Trends of Antibiotic Consumption in Korea According to National Reimbursement Data (2008-2012): A Population-Based Epidemiologic Study

Ten-year trends of antibiotics used for patients with pneumonia at long-term care hospitals in the Republic of Korea: An analysis based on national health insurance claims data

Aim

To determine the trends in the usage of antimicrobial drugs by patients with pneumonia with prescriptions from long-term care (LTC) hospitals in the Republic of Korea.

Method

This retrospective study was conducted from 2011 to 2022 using the National Health Insurance Review and Assessment Service claim data in Korea. We calculated antibiotic usage expressed as a daily defined dose (DDD) per 1000 patients per day (DID).

Results

The number of patients with pneumonia in LTC hospitals increased by 2.7 times, from 30,000 in 2011 to 79,000 in 2022. Furthermore, antibiotic consumption per episode by patients with pneumonia in LTC hospitals increased from 17.14 DDD in 2011 to 18.11 DDD in 2022. Among the Access, Watch, and Reserve classification groups, the Watch group showed the highest usage; further, the Access group showed a decreasing trend, whereas the Watch and Reserve groups showed an increasing trend (p < 0.01). In the Watch group, the most commonly used antibiotic was J01CR05 (piperacillin and beta-lactamase inhibitor), followed in order by J01DD04 (ceftriaxone), J01MA12 (levofloxacin), and J01DH02 (meropenem). In the Reserve group, J01XB01 (colistin) and J01AA12 (tigecycline) were commonly used.

Conclusion

The antibiotics prescribed for pneumonia in LTC hospitals have continuously increased the use of broad-spectrum antibiotics. Accordingly, appropriate use of antibiotics in LTC hospital settings and assessment of antibiotics used are warranted.

Assessment of the Safety and Probiotic Properties of Enterococcus faecium B13 Isolated from Fermented Chili

Enterococcus faecium B13, selected from fermentation chili, has been proven to promote animal growth by previous studies, but it belongs to opportunistic pathogens, so a comprehensive evaluation of its probiotic properties and safety is necessary. In this study, the probiotic properties and safety of B13 were evaluated at the genetic and phenotype levels in vitro and then confirmed in vivo. The genome of B13 contains one chromosome and two plasmids. The average nucleotide identity indicated that B13 was most closely related to the fermentation-plant-derived strain. The strain does not carry the major virulence genes of the clinical E. faecium strains but contains aac(6')-Ii, ant (6)-Ia, msrC genes. The strain had a higher tolerance to acid at pH 3.0, 4.0, and 0.3% bile salt and a 32.83% free radical DPPH clearance rate. It can adhere to Caco-2 cells and reduce the adhesion of E. coli to Caco-2 cells. The safety assessment revealed that the strain showed no hemolysis and did not exhibit gelatinase, ornithine decarboxylase, lysine decarboxylase, or tryptophanase activity. It was sensitive to twelve antibiotics but was resistant to erythromycin, rifampicin, tetracycline, doxycycline, and minocycline. Experiments in vivo have shown that B13 can be located in the ileum and colon and has no adverse effects on experiment animals. After 28 days of feeding, B13 did not remarkable change the α-diversity of the gut flora or increase the virulence genes. Our study demonstrated that E. faecium B13 may be used as a probiotic candidate.

Implementing antimicrobial stewardship: lessons and perspectives from a university-affiliated tertiary hospital in Korea

Antimicrobial stewardship programs (ASPs) can lower antibiotic use, decrease medical expenses, prevent the emergence of resistant bacteria, and enhance treatment for infectious diseases. This study summarizes the stepwise implementation and effects of ASPs in a single university-affiliated tertiary care hospital in Korea; it also presents future directions and challenges in resource-limited settings. At the study hospital, the core elements of the ASP such as leadership commitment, accountability, and operating system were established in 2000, then strengthened by the formation of the Antimicrobial Stewardship (AMS) Team in 2018. The actions of ASPs entail key components including a computerized restrictive antibiotic prescription system, prospective audit, post-prescription review through quantitative and qualitative intervention, and pharmacy-based interventions to optimize antibiotic usage. The AMS Team regularly tracked antibiotic use, the effects of interventions, and the resistance patterns of pathogens in the hospital. The reporting system was enhanced and standardized by participation in the Korea National Antimicrobial Use Analysis System, and educational efforts are ongoing. Stepwise implementation of the ASP and the efforts of the AMS Team have led to a substantial reduction in the overall consumption of antibiotics, particularly regarding injectables, and optimization of antibiotic use. Our experience highlights the importance of leadership, accountability, institution-specific interventions, and the AMS Team.

National Level Cross-Sectional Study on Antibiotic Use in Children during the Pre- and Early COVID-19 Eras

This study aimed to investigate national data for a quantitative evaluation of antibiotic usage in Korean children during the pre- and early COVID-19 period. This was a cross-sectional study from 2016 to 2021 of children <18 years, grouped by age (0, 1, 2-4, 5-11, and 12-17 years) and city/province. Systemic antibiotic prescriptions, days of administration, and population by age and region were collected. Days of therapy (DOT)/1000 pediatric inhabitant per day (PID) was used for antibiotic quantitative monitoring. A total of 257,088,265 antibiotic doses were prescribed to 170,309,944 children during the 6-year period. The highest DOT during the entire study period was observed in the 1-year age group, followed by the 2-4- and 0-year age groups. The highest DOT was observed in 2019, with 72.8 DOT/1000 PID in the 1-year age group, which fell to 34.7 DOT/1000 PID in 2020, however, DOT soon increased at similar rates to that in the pre-COVID-19 period. A higher DOT/1000 PID was observed for third-generation cephalosporins in 58.8% of the regions compared to beta-lactam/beta-lactamase inhibitors. To conclude, reductions in antibiotic use during the early COVID-19 pandemic period were not maintained. Further interventions are needed to decrease antibiotic overuse and misuse.

Evaluating the effectiveness of the Ministry of Health restriction policy on seasonal antibiotic consumption trends in Saudi Arabia, 2016-2020

Background: Understanding antibiotic consumption patterns over time is essential to optimize prescribing practices and minimizing antimicrobial resistance. This study aimed to determine whether the antibiotics restriction policy launched by the Saudi Ministry of Health in April 2018 has impacted antibiotic use by assessing changes and seasonal variations following policy enforcement. Methods: Quarterly sales data of J01 antibacterial for systemic use in standard units were obtained from the IQVIA-MIDAS database, spanning from the first quarter of 2016 to the last quarter of 2020. Antibiotics consumption was measured in defined daily doses per 1,000 inhabitant per day- in a quarter (DDDdq). A comparative analysis of antibiotic consumption pre- and post-policy periods introduction was conducted by computing the average consumption values for each period. Statistical comparison of the mean differences between the two periods were then made using independent samples t-test, Mann-Whitney U Test where needed. Time series analysis was employed to estimate the projected antibiotic consumption in the post-policy period if the restriction policy had not been implemented, which was then compared to actual consumption values to evaluate the effectiveness of the restriction policy. Results: During the pre-policy, there were seasonal trends of the total and oral antibiotic consumption through quarters, with higher consumption observed in the first and fourth quarters. In contrast, parenteral antibiotic consumption did not appear to follow a clear seasonal pattern. Following the restriction policy, there was a significant reduction in total and oral antibiotic use, with mean reductions of -96.9 DDDdq (p-value = 0.002) and -98 DDDdq (p-value = 0.002), respectively. Conversely, a significant increase in parenteral antibiotic consumption was observed with a mean increase of +1.4 DDDdq (p-value < 0.0001). The comparison between the forecasted and actual models showed that the actual antibiotics consumption for total, oral, and parenteral were lower than the corresponding forecasted values by 30%, 31%, and 34%, respectively. Conclusion: Overall, our analysis of antibiotics consumption from 2016 to 2020 displays great success for the policy implemented by the Saudi Ministry of Health in significantly reducing the total and oral use of antibiotics. However, future studies are needed to explore the increased consumption of the parenteral antibiotics as well as the persistent high consumption patterns during the fall and winter months even after the implementation of the restriction policy.

A dose-dependent increase in the risk of inflammatory bowel disease after exposure to broad-spectrum antibiotics: A national population study in Korea

BACKGROUND

The association between antibiotic use and risk of inflammatory bowel disease (IBD), particularly among adults, remains unclear. Furthermore, there is a scarcity of data among non-Western countries.

AIMS

To investigate the association and dose-response relationships between antibiotic use and subsequent IBD risk across all ages METHODS: This population-based case-control analysis used data from the Korean National Health Insurance Service database (2004-2018). We compared 68,633 patients with new-onset IBD to matched controls (n = 343,165) using multivariable conditional logistic regression analysis. We also examined the dose-response relationship using non-linear regression analysis, and separately analysed childhood-onset IBD (aged ≤14 years) risk following early-life antibiotic exposure.

RESULTS

The mean age at diagnosis was 45.2 ± 16.8 years. Antibiotic prescriptions between 2 and 5 years before diagnosis significantly increased the odds of developing IBD (adjusted odds ratio [OR], 1.24; 95% confidence interval [CI]: 1.21-1.27). Additionally, sensitivity analysis revealed an elevated risk up to 9 years before diagnosis. Broad-spectrum antibiotics increased IBD risk, independent of gastroenteritis. A distinct dose-response relationship was observed irrespective of the IBD subtype and study population (all p < 0.001). Furthermore, antibiotic exposure within the first year of life was linked with the risk of childhood-onset IBD (OR, 1.51; 95% CI: 1.25-1.82).

CONCLUSIONS

Broad-spectrum antibiotics dose-dependently increased the risk for IBD in the Korean population. Our findings provide a fundamental epidemiological basis for identifying antibiotic use as a significant risk factor for IBD across different environmental backgrounds.

Trends and seasonal variation of antibiotic consumption by community residents in Hefei, China, 2012-2016

OBJECTIVES

The aim of this study was to evaluate the trends and seasonal variations of antibiotic consumption by community residents in Hefei, China, over a 5-year period.

STUDY DESIGN

This was an ecological study.

METHODS

Data on antibiotic consumption by community residents in Hefei between 2012 and 2016 were collected from the Hefei Center for Disease Control and Prevention. Statistical analysis was carried out using Microsoft Excel 2021, SPSS 26.0 and R4.1.3. An interrupted time series (ITS) analysis was modelled to assess the impact of policies on antibiotic consumption trends.

RESULTS

Amoxicillin and cephalosporins accounted for 63.64% and 30.48%, respectively, of the total defined daily dose per 1000 inhabitant-days (DID) of antibiotics in 2016. The total consumption of antibiotics decreased from 6.92 DID in 2012 to 5.61 DID in 2016 (P_trend = 0.017). Seasonal analysis showed an average of 34.24% antibiotic consumption in the winter over the 5 years. The equation constructed by the ITS analysis was Y = 5.530 + 0.323X1 - 7.574X2 - 0.323X3 + ε.

CONCLUSION

Between 2012 and 2016, overall antibiotic consumption by community residents in Hefei decreased significantly. The impact of antibiotic policies, implemented between 2011 and 2013, started to appear in 2014 when the consumption of antibiotics decreased. This study has important policy implications for the use of antibiotics at the community level. Further studies on the trends of antibiotic consumption are required, and strategies should be designed to promote appropriate use of antibiotics.

Analysis of Changes in Antibiotic Use Patterns in Korean Hospitals during the COVID-19 Pandemic

With the onset of the coronavirus disease 2019 (COVID-19) pandemic, changes in patient care and antibiotic use have occurred in hospitals. The data of the National Health Insurance System's claims of inpatients from all hospitals in Korea between January 2019 and December 2020 were obtained from the Health Insurance Review & Assessment Service and analyzed. The trend in the use of all antibacterial agents in both hospitals declined for the total number of COVID-19 patients at the bottom 10% and those in the top 10%. Specifically, a decreasing trend in the use of broad-spectrum antibacterial agents predominantly prescribed for community-acquired cases and narrow-spectrum beta-lactam agents were observed in both hospitals. In the aftermath of the COVID-19 pandemic, the total use of antibacterial agents has gradually decreased among patients with pneumonia and those with severe COVID-19. In contrast, its use has increased gradually among those with mild to moderate COVID-19. A decreasing trend in overall antibiotic use was observed during the COVID-19 pandemic, and an increasing trend in antibiotic use was observed in patients with mild to moderate COVID-19 in Korean hospitals.

Trends in Using Antibiotics in the Era of National Health Insurance in the City of Manado

Introduction:

Antibiotic use needs to be monitored. Its irrational use causes resistance. Research aims to determine trends in antibiotic use.

Methods:

Observational research with retrospective data collection. Cross-sectional research design. Data about the availability of antibiotics from 2014 to 2017 in hospitals, health offices and PHCs in the city of Manado.

Results:

Trends of antibiotics used in PHC and health office in 2014–2017 were betalactam, macrolide, sulfamethoxazole-trimethoprim, and quinolone groups. Trends in secondary hospital were betalactam, sulfamethoxazole-trimethoprim, and quinolone groups. Trends in tertiary hospital are betalactam, quinolones, and other groups.

Conclusion:

Based on the data of five major antibiotics use in Manado City, there was a change in the pattern of antibiotic use, and this pattern tended to increase.

Stepwise Expansion of Antimicrobial Stewardship Programs and Its Impact on Antibiotic Use and Resistance Rates at a Tertiary Care Hospital in Korea

To optimize antibiotic use, the US CDC has outlined core elements of antimicrobial stewardship programs (ASP). However, they are difficult to implement in limited-resource settings. We report on the successful implementation of a series of ASP with insufficient number of infectious diseases specialists. We retrospectively collected data regarding antibiotic administration and culture results of all patients admitted to a tertiary care teaching hospital, Seoul National University Bundang Hospital (SNUBH), from January 2010 to December 2019. Trends of antibiotic use and antibiotic resistance rates were compared with those from Korean national data. Trend analyses were performed using nonparametric, two-sided, correlated seasonal Mann–Kendall tests. Total antibiotic agent usage has significantly decreased with ASP implementation at SNUBH since 2010. National claim data from tertiary care hospitals have revealed an increase in the use of all broad-spectrum antibiotics except for third-generation cephalosporins (3GC). In contrast, at SNUBH, glycopeptide and fluoroquinolone use gradually decreased, and 3GC and carbapenem use did not significantly change. Furthermore, the rate of colonization with methicillin-resistant Staphylococcus aureus showed a consistently decreasing trend, while that with 3GC- and fluoroquinolone-resistant Escherichia coli significantly increased. Unlike the national rate, the rate of colonization with antibiotic resistant-Klebsiella pneumoniae did not increase and that of 3GC- and fluoroquinolone-resistant Pseudomonas aeruginosa significantly decreased. Stepwise implementation of core ASP elements was effective in reducing antibiotic use despite a lack of sufficient manpower. Long-term multidisciplinary teamwork is necessary for successful and sustainable ASP implementation.

IMPORTANCE Antimicrobial stewardship programs aimed to optimize antibiotic use are difficult to implement in limited-resource settings. Our study indicates that stepwise implementation of core antimicrobial stewardship program elements was effective in reducing antibiotic use in a tertiary care hospital despite the lack of sufficient manpower.

Impact of the Expert Consensus on Carbapenem Consumption Trends and Patterns in Public Healthcare Institutes: An Interrupted Time Series Analysis, 2017-2020

Background: Carbapenems are considered the last line of defence against bacterial infections, but their high consumption and the resulting antibacterial resistance are an increasing global concern. In this context, the Chinese health authority issued an expert consensus on the clinical applications of carbapenems. However, the long- and short-term effects of the expert consensus on carbapenem use are not clear.

Methods: This study was conducted in Shaanxi, a northwest province of China. We collected all available carbapenem procurement data between January 2017 and December 2020 from the Provincial Drug Centralized Bidding Procurement System. A quasi-experimental interrupted time series analysis was used to evaluate the longitudinal effectiveness of expert consensus by measuring the change in the Defined Daily Dosesper 1,000 inhabitants per day (DID), the percentage of carbapenem expenditures to total antimicrobial expenditure, the total carbapenem expenditure, and the defined daily cost (DDDc). We used Stata SE version 15.0 for data analysis, and p < 0.05 was considered statistically significant.

Results: After the distribution of the expert consensus, the level (p = 0.769) and trend (p = 0.184) of DID decreased, but the differences were not statistically significant. The percentage of carbapenem expenditures to total antimicrobial expenditure decreased abruptly (p < 0.001) after the intervention, but the long-term trend was still upward. There was no statistically significant relationship between the release of the expert consensus and carbapenem expenditure in the long term, but there was a decreasing trend (p = 0.032). However, the expert consensus had a positive impact on the economic burden of carbapenem usage in patients, as the level (p < 0.001), and trend (p = 0.003) of DDDc significantly decreased.

Conclusion: The long-term effects of the distribution of the expert consensus on the use and expenditure of carbapenems in public health institutions in Shaanxi Province were not optimal. It is time to set up more administrative measures and scientific supervision to establish a specific index to limit the application of carbapenems.

Development of a Roadmap for the Antimicrobial Usage Monitoring System for Medical Institutions in Korea: a Delphi Study

Background

It is necessary to develop a roadmap for antimicrobial usage monitoring in order to perform monitoring of antimicrobial use at the national level properly. Therefore, this study aimed to develop a roadmap for establishing surveillance and monitoring of antimicrobial use in medical institutions at the national level.

Materials and Methods

A modified Delphi study was conducted, including 3 rounds of an online survey and a virtual meeting with 16 expert panels. The survey items were developed based on a literature review of the surveillance systems for antimicrobial use in 12 countries and interviews with experts. The questionnaire was designed to include both the surveillance and benchmarking systems.

Results

Regarding the scope of target institutions to be included in the surveillance system, medical institutions for sentinel surveillance had the highest proportion of agreement among the panels (75.0%, 9/12). For the benchmarking system, “tertiary- and secondary-care hospitals” were accepted as the scope of target institutions at the current moment. Furthermore, the National Health Insurance claims and prescription data of individual hospitals were considered appropriate data sources for the surveillance system. As for the measures to promote the participation of hospitals in the benchmarking system, “compensation through the establishment of antimicrobial management fees” and “set the participation in the program as a quality evaluation or accreditation index for hospital evaluation” were accepted.

Conclusion

This study provides a roadmap for establishing an antimicrobial use monitoring and benchmarking system for medical institutions at a national level in Korea.

Non-biomedical factors affecting antibiotic use in the community: a mixed-methods systematic review and meta-analysis

BACKGROUND

In the past two decades, human antibiotic consumption has increased globally, contributing to the emergence and spread of antimicrobial resistance and calling for urgent effective actions.

OBJECTIVES

To systematically identify and collate studies exploring non-biomedical factors influencing healthcare consumers' antibiotic use globally, in order to inform future interventions to improve antibiotic use practices.

METHODS

Data sources: PubMed, EMBASE, PsycINFO, and Cochrane.

STUDY ELIGIBILITY CRITERIA

Original and empirical studies that identified factors for healthcare consumers' antibiotic use.

PARTICIPANTS

Healthcare consumers. Assessment of risk of bias: Adapted BMJ survey appraisal tools, the Critical Appraisal Skills Programme checklist, and the Mixed Methods Appraisal Tool were utilised for quality assessment. Methods of data synthesis: The Social Ecological Framework and Health Belief Model were employed for data synthesis. We did random-effects meta-analyses to pool the odds ratios of risk factors for antibiotic use.

RESULTS

We included 71 articles for systematic review and analysis: 54 quantitative, nine qualitative, and eight mixed-methods studies. Prevalent non-prescription antibiotic uses and irresponsible prescriptions were reported globally, especially in low-to-middle income countries. Barriers to healthcare - wait time, transportation, stigmatization - influenced people's antibiotic use practices. Further, lack of oversight and regulation in the drug manufacturing and weak supply chain have led to the use of substandard or falsified antibiotics. Knowledge had mixed effects on antibiotic use behaviours. Meta-analyses identified pro-attitudes towards self-medication with antibiotics, relatives having medical backgrounds, older age, living in rural areas, and storing antibiotics at home to be risk factors for self-medication with antibiotics.

CONCLUSIONS

Non-prescription antibiotic use and irresponsible prescriptions in the community are prevalent in all WHO regions and largely driven by a mixed collection of non-biomedical factors specific to the respective setting. Future AMR strategies should incorporate implementation science approach for community-based complex interventions that addresses drivers of the target behaviours tailored to local contexts.

Impact of antibiotic usage on extended-spectrum β-lactamase producing Escherichia coli prevalence

An increase in antibiotic usage is considered to contribute to the emergence of antimicrobial resistance. Although experts are counting on the antimicrobial stewardship programs to reduce antibiotic usage, their effect remains uncertain. In this study, we aimed to evaluate the impact of antibiotic usage and forecast the prevalence of hospital-acquired extended spectrum β-lactamase (ESBL)—producing Escherichia coli (E. coli) using time-series analysis. Antimicrobial culture information of E. coli was obtained using a text processing technique that helped extract free-text electronic health records from standardized data. The antimicrobial use density (AUD) of antibiotics of interest was used to estimate the quarterly antibiotic usage. Transfer function model was applied to forecast relationship between antibiotic usage and ESBL-producing E. coli. Of the 1938 hospital-acquired isolates, 831 isolates (42.9%) were ESBL-producing E. coli. Both the proportion of ESBL-producing E. coli and AUD increased over time. The transfer model predicted that ciprofloxacin AUD is related to the proportion of ESBL-producing E. coli two quarters later. In conclusion, excessive use of antibiotics was shown to affect the prevalence of resistant organisms in the future. Therefore, the control of antibiotics with antimicrobial stewardship programs should be considered to restrict antimicrobial resistance.

Evaluation of Prescribing Patterns of Antibiotics Using Selected Indicators for Antimicrobial Use in Hospitals and the Access, Watch, Reserve (AWaRe) Classification by the World Health Organization

Objectives

Antibiotic resistance poses a significant threat to the world, and irrational use of antibiotics is a major contributing factor. Evaluation of antimicrobial use is underway with the help of indicators and the World Health Organization (WHO) classification of antibiotics into Access, Watch, and Reserve (AWaRe) categories. We aimed to evaluate the prescribing pattern of antibiotics using the AWaRe classification by the WHO and selected indicators for antimicrobial use in hospitals.

Materials and Methods

A total of 1.000 prescriptions were analyzed during the study for antibiotic prescribing patterns. Antibiotic consumption was calculated using defined daily dose (DDD) methodology. The prescribing pattern was evaluated using the WHO classification of antibiotics into the categories AWaRe and using selected indicators (hospital and prescribing) for antimicrobial use in hospitals.

Results

A total of 1.128 antibiotics were prescribed during the study. The 19-44 age group was prescribed a high number of antibiotics (n=510). Females were prescribed a high number of antibiotics compared with males (n=602). Azithromycin was the most commonly consumed antibiotic (14.97 DDD/1000/day). Four antibiotics from the Access category and five from the Watch category were prescribed in the study. The Watch category of antibiotics were consumed in a high number. There were no standard treatment guidelines in the hospital. In all, 98.0% of antibiotics were consistent with the hospital formulary and prescribed under generic names. The average number of antibiotics prescribed per patient was 1.12. The average duration of antimicrobial treatment was 5.24 days. The percentage of patients prescribed antimicrobials for pneumonia in accordance with treatment guidelines was 13.28%.

Conclusion

Irrational use of antibiotics exists in hospitals. There is a need to maintain standard treatment guidelines in the hospital because it prevents irrational use of antibiotics.

Antibiotics in surface water of East and Southeast Asian countries: A focused review on contamination status, pollution sources, potential risks, and future perspectives

This review provides focused insights into the contamination status, sources, and ecological risks associated with multiple classes of antibiotics in surface water from the East and Southeast Asia based on publications over the period 2007 to 2020. Antibiotics are ubiquitous in surface water of these countries with concentrations ranging from <1 ng/L to hundreds μg/L and median values from 10 to 100 ng/L. Wider ranges and higher maximum concentrations of certain antibiotics were found in surface water of the East Asian countries like China and South Korea than in the Southeast Asian nations. Environmental behavior and fate of antibiotics in surface water is discussed. The reviewed occurrence of antibiotics in their sources suggests that effluent from wastewater treatment plants, wastewater from aquaculture and livestock production activities, and untreated urban sewage are principal sources of antibiotics in surface water. Ecological risks associated with antibiotic residues were estimated for aquatic organisms and the prevalence of antibiotic resistance genes and antibiotic-resistant bacteria were reviewed. Such findings underline the need for synergistic efforts from scientists, engineers, policy makers, government managers, entrepreneurs, and communities to manage and reduce the burden of antibiotics and antibiotic resistance in water bodies of East and Southeast Asian countries.

Association Between Antibiotic Treatment and the Efficacy of Intravesical BCG Therapy in Patients With High-Risk Non-Muscle Invasive Bladder Cancer

Objective

To investigate the association between antibiotic therapy and the efficacy of intravesical BCG therapy in patients with high-risk non-muscle invasive bladder cancer (NMIBC).

Methods

This study involved the retrospective review of medical records of patients who underwent transurethral resection of bladder tumors for high-risk NMIBC followed by intravesical BCG therapy between 2008 and 2017. Patients were categorized as none, short- (2-6 days), and long-course use (≥7 days) based on the duration of antibiotic treatment concurrent with or initiated ≤30 days before BCG therapy. Oncologic outcomes, including recurrence-free survival and progression-free survival, were analyzed.

Results

Of the 276 patients enrolled in the study, 162 (58.7%) had pathologic T1 disease and 206 (80.2%) had high-grade disease. Concurrently with or prior to BCG therapy, 114 patients had (41.3%) received short-course antibiotic therapy, and 96 (34.8%) patients had received long-course antibiotics. The 5-year recurrence-free survival (62.2% vs 26.9%; log rank, p <0.001) and progression-free survival (79.6% vs. 53.3%; log rank, p=0.001) rates were significantly higher in patients who did not receive antibiotic therapy than in those treated with long-course antibiotics. Multivariable analysis revealed that antibiotic treatment for more than 7 days was independently associated with increased risks of recurrence (hazard ratio [HR], 2.45; 95% confidence interval [CI], 1.49-4.05; p < 0.001) and progression (HR, 3.68; 95% CI, 1.65-8.22 p = 0.001).

Conclusion

Long-course antibiotic treatment concurrently with or prior to intravesical BCG adversely influenced disease recurrence and progression outcomes in patients with high-risk NMIBC. Careful use of antibiotics may be required to enhance the efficacy of intravesical BCG therapy. Further mechanistic and prospective studies are warranted.

Correlation between Nosocomial Carriage of Vancomycin-Resistant Enterococci and Antimicrobial Use in Taiwan

A rapid increase of nosocomial vancomycin-resistant enterococci (VRE) from 23.3% in 2009 to 44.5% in 2018 among all the medical centers in Taiwan was found. The aim of the study was to explore the relationship between antimicrobial usage and prevalence of VRE. We conducted the study between January 2010 and December 2019 in a tertiary teaching hospital in Taiwan. Antibiotic consumption was expressed as defined daily doses (DDDs) per 1,000 patient-days (PDs). The trend in antibiotic consumption and VRE prevalence were analyzed by regression analysis with yearly data. Pearson's correlation analysis was used to determine the relationship between antibiotic consumption and the prevalence of VRE. The total consumption of antibiotics increased significantly from 450.6 DDDs/1,000 PDs in 2010 to 520.1 DDDs/1,000 PDs in 2019 (P = 0.013). Positive correlations were found between the prevalence of vancomycin-resistant Enterococcus faecium and the consumption of amoxicillin/clavulanate, vancomycin, and carbapenems, which included meropenem (P < 0.05). The increase in total VRE prevalence was significantly correlated with increased consumption of vancomycin and carbapenems, which included meropenem (P < 0.05). This 10-year study in a hospital demonstrated changes in antimicrobial use, which may have affected VRE prevalence in the hospital. We found a rise in nosocomial VRE prevalence was associated with the use of specific antimicrobial agents.

Trend of Antibiotic Usage for Hospitalized Community-acquired Pneumonia Cases in Korea Based on the 2010-2015 National Health Insurance Data

BACKGROUND

This study is to describe the changes in prescribing practices of antibiotics to treat community-acquired pneumonia (CAP) in Korea during 2010-2015.

METHODS

The claim database of the Health Insurance Review and Assessment Service in Korea was used to select adult patients (≥ 18 years of age) admitted between 2010 and 2015, with the International Classification of Diseases, Tenth Revision codes relevant to all-cause pneumonia for the first or second priority discharge diagnosis. The episodes with hospital-acquired or healthcare-associated pneumonia were excluded. Consumption of each antibiotic was converted to defined daily dose (DDD) per episode. The amount of antibiotic consumption was compared between patients with CAP aged < 65 years and those aged ≥ 65 years.

RESULTS

The average amount of antibiotic consumption per episode was 15.5 DDD, which remained stable throughout the study period (P = 0.635). Patients aged ≥ 65 years received more antibiotics than those aged < 65 years (15.7 vs. 15.3 DDD). Third-generation cephalosporin (4.9 DDD/episode, 31.4%) was the most commonly prescribed, followed by macrolide (2.7 DDD/episode, 17.1%) and beta-lactam/beta-lactamase inhibitor (BL/BLI) (2.1 DDD/episode, 13.6%). The consumption amount of fourth-generation cephalosporin (4th CEP) (P = 0.001), BL/BLI (P = 0.003) and carbapenem (P = 0.002) increased each year during the study period. The consumption of 4th CEP and carbapenem was doubled during 2010-2015.

CONCLUSION

The prescription of broad-spectrum antibiotics such as 4th CEP and carbapenem to treat CAP increased in Korea during 2010-2015.

Occurrence, Antimicrobial Resistance and Molecular Diversity of Enterococcus faecium in Processed Pork Meat Products in Korea

Because Enterococcus faecium is an important nosocomial pathogen and sentinel organism for tracking antimicrobial resistance, information on the contamination and antimicrobial resistance patterns of E. faecium in food are essential to public health and food safety. We analyzed the occurrence of E. faecium in retail pork meat products (n = 124), and antimicrobial resistance of 30 E. faecium isolates were examined against 14 antimicrobials using the broth dilution test and disc diffusion test. Rep-PCR-based molecular diversity was also analyzed using Deviersilab. The highest contamination of enterococci was observed for minced pork meat but most of the E. faecium was isolated from meatball-type frozen pork meat products (FP). Incidences of antimicrobial-resistant E. faecium against erythromycin, clindamycin and nitrofurantoin were 80%, 50% and 20%, respectively. No vancomycin-resistant enterococci were analyzed. Rep-PCR showed distinctive clusters with a similarity ≥ 98%, consisting of 18 E. faecium isolates from FP manufactured in seven companies. The analyzed data on the contamination and antimicrobial resistance patterns combined with molecular typing can be useful to derive risk management of antimicrobial-resistant enterococci in food.

Temporal association between carbapenems usage and antimicrobial resistance in gram-negative bacteria at a tertiary hospital in Nanjing, China

In this study, we investigated the temporal association between carbapenems usage and antimicrobial resistance among major Gram-negative bacteria, using the data of quarterly carbapenems consumptions and percentages of antibiotic resistance for Gram-negative bacteria from inpatients from 2013 to 2017 in a tertiary hospital from Jiangsu Province, China. First, carbapenems consumption showed an increasing trend in the past 5 years, accompanied with the rising rates of A. baumannii and P. aeruginosa resistance against imipenem. In A. baumannii, we identified correlations between carbapenems consumption and antimicrobial resistance against piperacillin/tazobactam, ceftazidime, ciprofloxacin and imipenem, respectively. Additionally, close correlations were observed between carbapenems consumption and antimicrobial resistance against ceftazidime and ciprofloxacin in E. coli. Our data indicated that a significant positive correlation between the usage of carbapenems and the rate of antimicrobial resistance among A. baumannii and E. coli, respectively. Carbapenems should be cautiously prescribed to prevent antimicrobial resistance outbreak in A. baumannii and E. coli.

Ten-year trends in antibiotic usage at a tertiary care hospital in Korea, 2004 to 2013

BACKGROUND/AIMS

This study was performed to evaluate trends in antibiotic usage at a tertiary care hospital in Korea.

METHODS

This study collated antibiotic prescription data and total patient days for inpatients at a tertiary care hospital in Korea between 2004 and 2013. The consumption of each class of antibiotic was converted to defined daily dose (DDD)/1,000 patient-days. We defined 3rd generation cephalosporins, 4th generation cephalosporins, β-lactam/β-lactamase inhibitors, and fluoroquinolones as broad-spectrum antibiotics; carbapenems, tigecycline, glycopeptides, oxazolidinone, and polymyxin were defined as antibiotics against multidrug-resistant (MDR) pathogens. Other antibiotic classes were defined as nonbroad-spectrum antibiotics.

RESULTS

Mean antibiotic consumption was 920.69 DDD/1,000 patient-days. The proportions of broad-spectrum antibiotics, antibiotics against MDR pathogens, and nonbroad-spectrum antibiotics were 41.8% (384.48/920.69), 3.5% (32.24/920.69), and 54.7% (503.97/920.69), respectively. Consumption of broad-spectrum antibiotics (coefficient for time 0.141; p = 0.049) and antibiotics against MDR pathogens (coefficient for time 0.185; p < 0.001) showed a significant increasing trend over the study period. Nonbroad-spectrum antibiotic consumption showed a significant decreasing trend over the study period (coefficient for time -2.601; p < 0.001).

CONCLUSION

Over the 10-year period, a stepwise increase in the consumption of broad-spectrum antibiotics and antibiotics against MDR pathogens was observed at a tertiary care hospital in Korea. Conversely, during the same period, nonbroad-spectrum antibiotic consumption showed a significant decreasing trend.

Antibiotic Utilization in Iran 2000-2016: Pattern Analysis and Benchmarking with Organization for Economic Co-operation and Development Countries

Objectives:

Antibiotic resistance is the main threat to health all over the world. The consumption of antibiotics is one of the factors causing the emergence of multidrug resistance. The purpose of this study was to recognize the patterns, trends, and changes of consumption in Iran and to compare them with those of Organization for Economic Co-operation and Development (OECD) countries.

Methods:

The data were collected from a national pharmaceutical wholesale data bank. Defined daily dose (DDD) or DDDs per 1000 inhabitants per day (DID) was calculated as a standard indicator for the consumption over 17 years.

Results:

Were benchmarked with the consumption of OECD countries. Drug utilization 90% (DU90%) method was used to assess the drug consumption pattern.

Findings:

The antibiotic consumption jumped up from 33.6 DID to 60 DID from 2000 to 2016. Compared to the average consumption of OECD countries, Iran has consumed antibiotics almost triple times. There were 9–11 chemical substances in the DU90% list during these years. Changes in DU90% list occurred within antibiotics classes during the study period. Although the total consumption growth was equal to 79% during these years, consumption of some pharmacological subgroups such as sulfonamide and aminoglycosides has decreased.

Conclusion:

Albeit the existence of surveillance system for health-related infectious diseases, the consumption of antibiotics has increased drastically, which illustrates the necessity of comprehensive and effective national antibiotic stewardship.

Searching for the Culprit Drugs for Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis from a Nationwide Claim Database in Korea

BACKGROUND

Ethnic differences exist in relation to culprit drugs for Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). We wanted to determine culprit drugs for SJS and TEN in Korean population.

OBJECTIVE

To evaluate culprit drugs for SJS and TEN by applying an algorithm for assessment of drug causality for epidermal necrolysis (ALDEN) in a nationwide administrative database.

METHODS

We used the claims database, which included claims data for the entire South Korean population. A retrospective cohort study was conducted by collecting subjects who were first diagnosed with SJS and TEN in 2011. All drugs prescribed to the subjects were reviewed and scored according to the ALDEN score. Drugs with an ALDEN score ≥2 were considered culprit drugs.

RESULTS

A total of 187 subjects were included in the culprit drug analysis; 33 very probable, 101 probable, and 57 possible culprit drugs were identified for SJS and TEN according to the ALDEN score. The most frequently suspected culprit drug was allopurinol (19 cases), followed by carbamazepine (17 cases), lamotrigine (13 cases), amoxicillin (9 cases), and dorzolamide (9 cases). Most cases (78.8%, 52 of 66) associated with the use of allopurinol, carbamazepine, lamotrigine, dorzolamide, and methazolamide occurred between 13 and 44 days after initiating the drug.

CONCLUSION

We applied the ALDEN score to the claims database to identify possible culprit drugs for SJS and TEN in South Korea. This approach could shed light on research and policymaking for drug adverse reactions.

Clinical efficacy of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry in patients with multidrug-resistant bacteremia: a single-center study in Korea

BACKGROUND/AIMS

Matrix-assisted laser desorption/ionization time-of-f light mass spectrometry (MALDI-TOF MS) is a new diagnostic tool for microorganism identification. The clinical usefulness of this approach has not been widely examined in Korea. This retrospective pre-post-intervention quasi-experimental study examined the effect of MALDI-TOF MS on patients with multidrug-resistant (MDR) bacteremia in the intensive care unit (ICU).

METHODS

All consecutive patients with MDR bacteremia in the ICU of a tertiary care hospital between March 2011 and February 2013 and between March 2014 and February 2016 were enrolled. MALDI-TOF MS was introduced between these periods. In the pre-intervention and intervention groups, microorganisms were identified by conventional means and by MALDI-TOF MS, respectively. The groups were compared in terms of time from venipuncture to microorganism identification and antimicrobial susceptibility test results.

RESULTS

In total, 187 patients (mean age, 61.0 years; 56.7% male) were enrolled. Of these, 97 and 90 were in the pre-intervention and intervention groups, respectively. The intervention group had a significantly shorter time from venipuncture to microorganism identification and antimicrobial susceptibility test results (82.5 ± 21.6 hours vs. 92.3 ± 40.4 hours, p = 0.038). The antibiotics were adjusted in 52 patients (26 each in the pre-intervention and intervention groups) based on these results. These groups did not differ in terms of time from venipuncture to antibiotic adjustment, and multivariate regression analysis showed that MALDI-TOF MS-based microorganism identification was not associated with 28-day mortality.

CONCLUSION

Our study showed that MALDI-TOF MS accelerated microorganism identification in patients with MDR bacteremia, but did not inf luence 28-day mortality.

Trend of antibiotics usage for acute pyelonephritis in Korea based on national health insurance data 2010-2014

BACKGROUND

The objective of this study is to describe the changes in prescribing practices of antibiotics to treat acute pyelonephritis (APN) in Korea.

METHODS

The claim data base of the Health Insurance Review and Assessment Service in Korea was used to select patients with ICD-10 codes N10 (acute tubulo-interstitial nephritis) or N12 (tubulo-interstitial nephritis, not specified as acute nor chronic) as the primary discharge diagnosis during 2010-2014. Consumption of each class of antibiotics was converted to Defined Daily Dose (DDD)/event.

RESULTS

Throughout the five-year period, the average antibiotic consumption were 11.3 DDD per inpatient event and 6.0 DDD per outpatient event. The annual average antibiotic consumption increased for inpatients (P = 0.002), but remained stable for outpatients (P = 0.066). The use of parenteral antibiotics increased for inpatients (P < 0.001), but decreased for outpatients (P = 0.017). As for the the antibiotic classes, 3rd generation cephalosporins (3rd CEPs) was the most commonly prescribed (41.4%) for inpatients, followed by fluoroquinolones (FQs) (28.5%); for outpatient, FQs (54.8%) was the most commonly prescribed, followed by 3rd CEPs (13.1%). The use of 3rd CEPs (P < 0.001), beta-lactam/beta-lactamase inhibitors (P = 0.007), and carbapenems (P < 0.001) increased substantially for the treatment of hospitalized APN patients. In particular, carbapenems use increased 3.1-fold over the 5 years.

CONCLUSIONS

Prescription of broad-spectrum antibiotics increased much for the treatment of APN in Korea during 2010-2014.

Antibiotic consumption in Shandong Province, China: an analysis of provincial pharmaceutical centralized bidding procurement data at public healthcare institutions, 2012-16

Objectives

To explore the trends of antibiotic consumption in public healthcare institutions through analysing the provincial centralized bidding procurement (CBP) data in Shandong, China.

Methods

The Shandong CBP system has been established since 2011, covering public healthcare institutions of 500 secondary and tertiary hospitals, 600 urban primary healthcare centres (PHCs) and 1600 rural PHCs. We collected all the antibiotic procurement records from the CBP system between 2012 and 2016. Antibiotic consumption data were calculated using Anatomical Therapeutic Chemical (ATC)/DDD methodology and normalized using DDD per 1000 inhabitants per day (DID).

Results

Overall antibiotic consumption increased from 12.859 DID in 2012 to 15.802 DID in 2014, then decreased to 13.802 DID in 2016. The top three antibiotics consumed in 2016 were penicillins (4.251 DID), quinolones (2.957 DID) and macrolides (2.057 DID). PHCs consumed 80% of the total antibiotics, of which rural PHCs accounted for 88%. Antibiotic consumption peaked in 2014 for rural PHCs and in 2015 for hospitals, and declined thereafter. In urban PHCs, the consumption steadily increased from 2012 to 2016.

Conclusions

Zero mark-up drug policies and national policies to improve rational use of antibiotic were associated with the reduction of antibiotic consumption in public healthcare institutions in Shandong Province. Regulations for antibiotic use in PHCs should be strengthened.

Procalcitonin-Guided Treatment on Duration of Antibiotic Therapy and Cost in Septic Patients (PRODA): a Multi-Center Randomized Controlled Trial

BACKGROUND

The objective of this study was to establish the efficacy and safety of procalcitonin (PCT)-guided antibiotic discontinuation in critically ill patients with sepsis in a country with a high prevalence of antimicrobial resistance and a national health insurance system.

METHODS

In a multi-center randomized controlled trial, patients were randomly assigned to a PCT group (stopping antibiotics based on a predefined cut-off range of PCT) or a control group. The primary end-point was antibiotic duration. We also performed a cost-minimization analysis of PCT-guided antibiotic discontinuation.

RESULTS

The two groups (23 in the PCT group and 29 in the control group) had similar demographic and clinical characteristics except for need for renal replacement therapy on ICU admission (46% vs. 14%; P = 0.010). In the per-protocol analysis, the median duration of antibiotic treatment for sepsis was 4 days shorter in the PCT group than the control group (8 days; interquartile range [IQR], 6-10 days vs. 14 days; IQR, 12-21 days; P = 0.001). However, main secondary outcomes, such as clinical cure, 28-day mortality, hospital mortality, and ICU and hospital stays were not different between the two groups. In cost evaluation, PCT-guided therapy decreased antibiotic costs by USD 30 (USD 241 in the PCT group vs. USD 270 in the control group). The results of the intention-to-treat analysis were similar to those obtained for the per-protocol analysis.

CONCLUSION

PCT-guided antibiotic discontinuation in critically ill patients with sepsis could reduce the duration of antibiotic use and its costs with no apparent adverse outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02202941.

[The Role of Pharmacists in Antimicrobial Stewardship]

Antimicrobial resistance (AMR) has been declared a global public health emergency, necessitating the involvement of the whole of society to address this increasingly serious threat. AMR causes prolonged illness, greater risk of infection spread, increased morbidity, and higher mortality rates, which result in increased expenses to the government, healthcare services, and individuals. Inappropriate use of antimicrobials has been indicated as the primary cause for the global expansion of AMR. Under these circumstances, various countries have formulated suitable national action plans to curb AMR. In Japan, the national action plan on AMR was announced in April 2016. Our previous study clarified that orally administered antimicrobials accounted for approximately 90% of total consumption: oral third-generation cephalosporins, macrolides, and fluoroquinolones accounted for approximately 77% of oral consumption. Therefore pharmacists must extend their support for the appropriate use of antimicrobials prescribed by attending physicians to not only hospitalized patients but also outpatients. "Choosing wisely," a US-based health education campaign, warns against unnecessary use of antimicrobials. Pharmacists should strive to disseminate the concept of "choosing wisely" in relation to other medicines, implement further interventions, and evaluate them. In this article, we present data on use of antimicrobials in Japan, and mention how pharmacists should be involved in enabling physicians choose antimicrobials wisely.

Trends in the use of antibiotics among Korean children

Inappropriate antibiotic use is the most important factor causing increased bacterial resistance to antibiotics, thus affecting patient outcomes. Multidrug-resistant bacteria have become a serious public health threat, causing significant morbidity and mortality worldwide. In Korea, the burden of antibioticresistant bacteria has become an important public health issue. There is increasing evidence of overuse and misuse of antibiotics in Korea, as observed in cohorts with large sample sizes. Antibiotic use among children should receive particular attention because of the frequency of community-associated infections among this population and the elevated risk of transmission. Recent studies from Korea have demonstrated that the use of broad-spectrum antibiotics, either for inpatient or outpatient treatment, has increased among many age groups, especially children. In this review, we aim to describe the patterns of antibiotic prescription and evaluate recent trends in antibiotic use among children. Coordinated efforts toward communication and education in order to address misunderstandings regarding antibiotic use, involving interprofessional antimicrobial stewardship programs, are required in the near future.

Trends and correlation between antibiotic usage and resistance pattern among hospitalized patients at university hospitals in Korea, 2004 to 2012: A nationwide multicenter study

The aim of this study was to evaluate the changing pattern of antibiotic usage and antimicrobial resistance of bacterial pathogens among hospitalized patients in Korea. We simultaneously investigated the correlation between antimicrobial resistance and antibiotic consumption.Data on total antibiotic prescriptions, patient days, and antimicrobial sensitivity tests among inpatients from 6 university hospitals in Korea in 2004, 2008, and 2012 were collected. The consumption of each antibiotic class was converted to defined daily dose/1000 patient-days by using the anatomical therapeutic chemical classification system by the World Health Organization. We defined third-generation cephalosporins (3rd CEPs), fourth-generation cephalosporins, beta-lactam/beta-lactamase inhibitors, and fluoroquinolones (FQs) as broad-spectrum antibiotics and carbapenems, tigecycline, glycopeptides, oxazolidinone, and polymyxin as antibiotics against multidrug-resistant (MDR) pathogens.A 15.1% decrease in total antibiotic consumption was observed in 2012 compared to that observed in 2004. In contrast, a 10.2% and 70.7% increase in broad-spectrum antibiotics and antibiotics against MDR pathogens were observed, respectively, in the same period. The resistance rate of Escherichia coli to 3rd CEPs (17.6% in 2004, 21.7% in 2008, and 33.8% in 2012, P <.001) and ciprofloxacin (37.5% in 2004, 38.7% in 2008, and 46.6% in 2012, P = .001) demonstrated a significantly increasing trend. Similarly, the resistance rate of Klebsiella pneumoniae to 3rd CEPs (34.3% in 2004, 33.7% in 2008, and 44.5% in 2012, P <.001) gradually increased. Resistance of Acinetobacter baumanii and Pseudomonas aeruginosa to imipenem significantly increased throughout the study period (A baumanii: 8.9% in 2004, 40.8% in 2008, and 65.3% in 2012, P <.001; P aeruginosa: 25.1% in 2004, 31.5% in 2008, and 29.7% in 2008, P = .050).The consumption of carbapenems and FQs demonstrated significant positive correlation for resistance of E coli or K pneumoniae to 3rd CEPs as well as E coli or K pneumoniae to ciprofloxacin. Increasing resistance of A baumanii to ciprofloxacin was significantly correlated with increasing consumption of FQs; increasing resistance of A baumanii to imipenem was significantly correlated with increasing consumption of carbapenems.In conclusion, overall antimicrobial resistance increased and consumption of broad-spectrum antibiotics and antibiotics against MDR pathogens subsequently increased in Korean hospitals.

Antibiotic consumption versus the prevalence of carbapenem-resistant Gram-negative bacteria at a tertiary hospital in China from 2011 to 2017

PURPOSE

China launched a 3-year rectification scheme on the clinical use of antibiotics in 2011, and a specific scheme on carbapenem use in February 2017. This study investigated the trends in and correlations between antibiotic consumption and the prevalence of carbapenem-resistant Gram-negative bacteria (CRGN) at a tertiary hospital during these years, particularly in carbapenem consumption.

METHODS

The data were collected calculated per quarter from 2011 to 2017. The trends in antibiotic consumption and resistance were analyzed by regression analysis, while Spearman correlation analysis was used to assess the correlations.

RESULT

The total consumption of antibiotics halved during the 7-year study period, from 770.15 DDDs/1000 PDs in quarter 1 of 2011 to 395.07 DDDs/1000 PDs in quarter 4 of 2017. Meantime, carbapenem consumption showed the significant increase, from 28.71 DDDs/1000 PDs to 49.2 DDDs/1000 PDs. The detection rates of CRGN (carbapenem-resistant Klebsiella pneumonia, Acinetobacter baumannii, and Pseudomonas aeruginosa) remained stable (P>0.05). The positive correlation was only discovered between the resistance rate of carbapenem-resistant K. pneumonia and the usage of carbapenems, which included meropenem and imipenem, with coefficients of 0.543, 0.537, and 0.497 (P<0.05), respectively. There was no more significant correlation in this study.

CONCLUSION

The total consumption of antibiotics reduced significantly in the analysed hospital, which could be related to the antimicrobial stewardship programme. However, the carbapenem consumption was increased. The specific index should be established to limit the application of carbapenems. This study identified the positive correlation between the detection rate of carbapenem-resistant K. pneumonia and carbapenem consumption. More research is needed to confirm the impact of restricting and appropriated use of carbapenems on the prevalence of CRGN.

Trends in polypharmacy over 12 years and changes in its social gradients in South Korea

Polypharmacy is associated with adverse drug reactions and represents an economic burden on the health insurance system. The objective of our study was to assess the trends in polypharmacy and its associated factors in South Korea. This cross-sectional study used a nationwide sampled database between 2002 and 2013, including outpatients of all ages who received at least 1 prescription in the same period. Polypharmacy was defined as the concomitant prescription of ≥6 distinct medications on a single prescription at least once without a given duration. The yearly prescribing trends were calculated and plotted. We conducted comparative analyses to identify the changes in social gradients of polypharmacy between the first 2 years, 2002‒2003, and the final 2 years, 2012‒2013. We repeated logistic regressions for pediatrics <20 years of age and adults ≥20 years of age to estimate the adjusted odds ratios (aOR) and 95% confidence intervals (CI). The distributions of polypharmacy in the respective periods were examined according to patient economic status (0 = most deprived and 10 = most affluent). The age-standardized prevalence of polypharmacy decreased from 65.8% in 2002 to 43.7% in 2013. Our study included 1,108,298 outpatients throughout 2002–2013. Pediatric patients aged 1–9 years had the highest number of medications among all age groups (mean: 5.1 ± 1.1 in 2002–2003 vs. 4.1 ± 1.1 in 2012–2013) in both periods. Changes in the association between deprivation and polypharmacy over 10 years were observed in adults (aOR = 0.68; 95% CI = 0.62–0.75 in 2002–2003 vs. 1.60; 95% CI = 1.54–1.66 in 2012–2013) and pediatrics (aOR = 0.60; 95% CI = 0.52–0.68 in 2002–2003 vs. 1.07; 95% CI = 1.01–1.14 in 2012–2013) compared with those in the most affluent patients. The high level of polypharmacy in pediatric patients is a public health concern that warrants policymaker attention.

Multidrug Resistance, Biofilm Formation, and Virulence of Escherichia coli Isolates from Commercial Meat and Vegetable Products

Escherichia coli is an important food safety and public health concern because of its pathogenicity and potential for antimicrobial resistance. E. coli isolates as food contaminants and their antimicrobial resistance, biofilm-forming ability, and virulence genes were analyzed to identify the potential of E. coli in food as a major transmission route for antimicrobial resistance and infectious agents. Among the 709 samples of minced meat and fresh vegetable products tested, 18.6% were positive for E. coli. One hundred nine (29.2%) out of 383 E. coli isolates were resistant to 1 or more of the 25 tested antimicrobials. Among the isolates from minced pork, the highest rate of resistance was observed for tetracycline (52.8%), followed by ampicillin (41.6%). The highest resistance rates against tetracycline were coincident with the high amount of tetracycline sold for veterinary use. Because penicillin is the most frequently used antimicrobial in humans, with 4.52 defined daily doses per 1000 people per day, the high rate of resistance to ampicillin (41.6%) supported the potential risk of E. coli food contaminants. However, only 1.3% of the isolates possessed the virulence genes commonly involved in foodborne outbreaks of E. coli. Sixty-seven isolates (17.5%) were multidrug-resistant (MDR), and the highest MDR was observed against 14 antimicrobials. Most of the MDR E. coli isolates showed biofilm-forming ability. Therefore, these isolates will have additional protection from environmental stresses, including antimicrobials. Given the importance of E. coli to food safety and public health, our results on the prevalence of antimicrobial resistance and virulence factors provide useful information for risk management options to protect public health.

Changes in Antimicrobial Usage Patterns in Korea: 12-Year Analysis Based on Database of the National Health Insurance Service-National Sample Cohort

National antimicrobial usage and prescription patterns during the 12 years from 2002 to 2013 were analyzed using the National Health Insurance Service-National Sample Cohort. Antimicrobial usage was analyzed by major illness, sex, age, area of residence, income rank, diagnosis, and type of medical institution for each year. Total antimicrobial prescriptions increased from 15.943 daily defined dose (DDD)/1,000 inhabitants/day in 2002 to 24.219 in 2013. In 2013, 72% of total prescriptions were administered in clinics. Antimicrobials were most frequently prescribed to children younger than 10 years, followed by adults aged 70 years or older and those aged 60-69 years. Penicillins and cephems were the most popular classes of antimicrobial used. In 2013, 48% of total antibiotic usage (11.683 DDD/1,000 inhabitants/day) was due to respiratory diseases. After the Korean government has implemented a series of healthcare policies, antibiotic prescription decreased for the treatment of upper respiratory infection, the causative agents are mostly viruses.

Temporal association between antibiotic use and resistance in Klebsiella pneumoniae at a tertiary care hospital

Background

β-Lactam/β-lactamase inhibitors (BLBLIs) were introduced into clinical practice as an alternative to carbapenems for treating multi-drug-resistant Klebsiella pneumoniae infections. However, little is known about the relationship between BLBLI treatment and antimicrobial resistance. In this study, we investigated the trends and the temporal association between antibiotic use and antimicrobial resistance in K. pneumoniae isolates obtained between 2012 and 2016.

Methods

Data regarding quarterly consumption (total number of prescriptions per quarter) of all BLBLIs, all third-generation cephalosporins, and all fluoroquinolones at a tertiary care hospital were obtained from the Korean Health Insurance Review and Assessment Service. Susceptibility data (isolation rate of antibiotic resistance per quarter) were obtained from the existing database of the same tertiary hospital. Regression analysis was used to analyze annual trends and cross-correlations to assess the temporal association on a quarterly basis between antibiotic consumption and antibiotic resistance in K. pneumoniae.

Results

The rate of resistance to piperacillin/tazobactam in K. pneumoniae significantly increased over the study period (p < 0.01). The consumption of all BLBLIs was also found to be significantly correlated with the rate of resistance to piperacillin/tazobactam (β = 0.66; p < 0.01), ceftazidime (β = 0.54; p = 0.02), and levofloxacin (β = - 0.60; p = 0.01) with two-quarter lags. Furthermore, the consumption of all third-generation cephalosporins was significantly correlated with rates of K. pneumoniae resistance to ceftazidime (β = 0.64; p < 0.01) with a two-quarter lag and levofloxacin (β = 0.50; p = 0.03) with a quarter lag. The consumption of all fluoroquinolones correlated with resistance rates to ceftazidime (β = 0.14; p < 0.01) with a two-quarter lag.

Conclusions

The rate of resistance to piperacillin/tazobactam in K. pneumoniae increased significantly over the study period and was significantly correlated with BLBLI consumption. While BLBLIs can potentially be utilized as an alternative to carbapenems, our findings reinforce concerns of resistance to these drugs. Further research is needed to understand the implications on resistance of utilizing BLBLIs as a carbapenem-sparing option.

Risk factors for poor outcome in community-onset Clostridium difficile infection

Background

A substantial portion of Clostridium difficile infection (CDI) cases occur in communities, and community-onset CDI (CO-CDI) can lead to serious complications including mortality. This study aimed to identify the risk factors for a poor outcome in CO-CDI.

Methods

We performed a retrospective review of all inpatients with CDI, in a 1300-bed tertiary-care hospital in Korea, from 2008 through 2015. CO-CDI was defined as CDI occurring within 48 h of admission. Poor outcome was defined as follows: 1) all-cause 30-day mortality, 2) in-hospital mortality, or 3) surgery due to CDI.

Results

Of a total 1256 CDIs occurring over 8 years, 152 (12.1%) cases were classified as CO-CDI and 23 (15.1%) had a poor outcome, including 22 (14.5%) cases of mortality and 2 (1.3%) cases of surgery. Patients with a poor outcome had a higher mean age than those without a poor outcome (75.8 vs. 69.6 years, p = 0.03). The proportion of men and prior proton pump inhibitor (PPI) use were significantly higher in the poor outcome group (65.2% vs. 41.9%, p = 0.04; 39.1% vs. 17.6%, p = 0.02, respectively). Multivariate binary logistic model showed that PPI use and anemia (hemoglobin < 10 g/dL) at presentation were significantly associated with a poor outcome (adjusted odds ratio [aOR], 3.76; 95% confidence interval [95CI], 1.26-11.21, aOR, 4.67; 95CI, 1.52-14.34, respectively).

Conclusions

Clinicians should not only be aware of the possibility of CDI in the community setting but also pay more attention to PPI-using elderly patients with anemia in consideration of a poor outcome.

A few antibiotics can represent the total hospital antibiotic consumption

Background

Appropriate antibiotic use has become an important issue. However, collecting data on the use of all antibiotics in a hospital is difficult without an advanced computerized system and dedicated staff. This paper examines if 1–3 antibiotics can satisfactorily represent the total antibiotic consumption at the hospital level.

Methods

We collected antibiotic data from six large university hospitals in Korea for some years between 2004 and 2012. Since the total antibiotics consist of a few chosen representative antibiotics and the rest, we used those chosen antibiotics along with additional variables constructed only with t (time) such as t, t², and t³ to capture the time trend and whether t belongs to each month or not to capture the monthly variations. The ordinary least squares method was used to explain the total antibiotic amount with these variables, and then the estimated model was employed to predict the use for 2013. To determine which antibiotics were the most representative in tracking general trends in antibiotic use over time, we tried various combinations of antibiotics to find the combination that best minimized the 2013 prediction error.

Results

We found that fluoroquinolones and aminoglycosides were the most representative, followed by beta-lactam/beta-lactamase inhibitors and 4th-generation and 3rd-generation cephalosporins. The mean prediction error over 12 months in 2013 with these few antibiotics was only 1–3% of the monthly antibiotic consumption amount.

Conclusions

The total antibiotic consumption amount at the hospital level can be represented sufficiently by a few antibiotics, such as fluoroquinolones and aminoglycosides, which means that hospitals can save resources by tracing only the usage of those few antibiotics instead of the entire inventory. Since the choice of fluoroquinolones and aminoglycosides is based solely on our Korean data, other hospitals may follow the same modelling methodology to find their own representative antibiotics.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3132-7) contains supplementary material, which is available to authorized users.

Consumption of antibiotics in Chinese public general tertiary hospitals (2011-2014): Trends, pattern changes and regional differences

Background

China has a high rate of antibiotic use. The Chinese Ministry of Health (MOH) established the Center for Antibacterial Surveillance (CAS) to monitor the use of antibacterial agents in hospitals in 2005. The purpose of this study was to identify trends, pattern changes and regional differences in antibiotic consumption in 151 public general tertiary hospitals across China from 2011–2014.

Materials and methods

Valid data for antibiotic use were collected quarterly, and the antibiotic consumption data were expressed as the defined daily dose (DDD) per 100 inpatient days (ID). We compared the patterns of antibiotic use in different classes and geographical clusters.

Results

Total antibiotic use significantly decreased (P = 0.018) from 75.86 DDD/100 ID in 2011 to 47.03 DDD/100 ID in 2014. The total consumption of flomoxef sodium and cefminox increased from 1.31 DDD/100 BD in 2011 to 8.6 DDD/100 BD in 2014. Cephalosporins were the most frequently used antibiotics in all regions. Third-generation cephalosporins accounted for more than 45% of the cephalosporins used. Carbapenem use substantially increased (P = 0.043). Penicillin combinations with inhibitors accounted for 50% of the penicillin used, and prescribed meropenem accounted for most of the carbapenems used in all regions in 2014. The subclasses in each antibiotic group were used differently between the seven regions, and the total hospital antibiotic use in 2014 differed significantly by region (P = 0.014).

Conclusion

Although the volume and intensity of total antibiotic use decreased, the antibiotic use patterns were not optimal, and broad-spectrum antibiotics were still the main classes. The aggregate data obtained during the study period reveal similar antibiotic consumption patterns in different regions. These findings provide useful information for improving the rational use of antibiotics. More detailed data on antibiotics linked to inpatient diseases need to be collected in future studies.

Epidemiology of drug hypersensitivity reactions using 6-year national health insurance claim data from Korea

Background Drug hypersensitivity reactions (DHRs) constitute a large portion of adverse drug reactions (ADRs), but studies for DHR incidence based on national data are scarce. Objective This study aimed to estimate the incidence and patterns of DHRs in a Korean population and the associated utilization of medical resources using the national claims data. Setting The retrospective cohort study performed using the national insurance claim database of the Health Insurance Review and Assessment (HIRA) in Korea. Methods The International Classification of Disease 10th revision code was used to identify DHRs with 20 drug induced DHR codes. The claim data with a diagnosis of DHR in the 2009-2014 periods were analyzed. Main outcome and measure The annual incidence and the 6-year incidence rates were calculated. Incidence rate coefficients were analyzed by sex, age, and year. DHRs following with visits of emergency department (ED) or intensive care unit (ICU) were assessed for utilization of medical resources and risk of ER or ICU visits by sex and age Results A total of 535,049 patients with 1,083,507 claims were assessed in the HIRA database for 6 years. DHR incidence was high in the elderly. The risk of ED and ICU visit with DHR was also higher in the elderly than in the young [highest relative risk, RR of ED 2.59 (1.65-4.07), ICU 5.04 (2.50-10.18)]. DHRs related to blood were high in the young age. Conclusion Incidence of DHRs in the real-world clinical practice was higher in the elderly and female. Clinical consequence was more severe in the elderly.

Epidemiology and treatment of antimicrobialresistant gram-negative bacteria in Korea

Antimicrobial resistance is becoming one of the greatest challenges to public health worldwide. Infections by antimicrobial-resistant organisms could result in the failure of treatment, increased medical costs, prolonged hospital stays, and an increased socioeconomic burden. Antimicrobial usage in Korea remains heavy, even after much effort to reduce their use. According to the Korean antimicrobial resistance surveillance system, the resistance rates of many bacteria are increasing. The resistance rate of Acinetobacter baumannii to imipenem in Korea increased to 85% in 2015, representing a major public threat. The reports of increased carbapenem resistance in Enterobacteriaceae are worrisome. More importantly, some carbapenem-resistant Enterobacteriaceae may result from the production of carbapenemases, which break down carbapenems. There are relatively few treatment options for extensively drug-resistant A. baumannii and carbapenem-resistant Enterobacteriaceae. Most reports are retrospective observational studies. Because there are little published data from randomized controlled trials, more data assessing antimicrobial treatment for extensively drug-resistant A. baumannii and carbapenem-resistant Enterobacteriaceae are needed to make treatment recommendations.

The first report of Japanese antimicrobial use measured by national database based on health insurance claims data (2011-2013): comparison with sales data, and trend analysis stratified by antimicrobial category and age group

Purpose

Our objective was to evaluate the utility of the national database (NDB) based on health insurance claims data for antimicrobial use (AMU) surveillance in medical institutions in Japan.

Methods

The population-weighted total AMU expressed as defined daily doses (DDDs) per 1000 inhabitants per day (DID) was measured by the NDB. The data were compared with our previous study measured by the sales data. Trend analysis of DID from 2011 to 2013 and subgroup analysis stratified by antimicrobial category and age group were performed.

Results

There was a significant linear correlation between the AMUs measured by the sales data and the NDB. Total oral and parenteral AMUs (expressed in DID) were 1.04-fold from 12.654 in 2011 to 13.202 in 2013 and 1.13-fold from 0.734 to 0.829, respectively. Percentage of oral form among total AMU was high with more than 94% during the study period. AMU in the children group (0–14 years) decreased from 2011 to 2013 regardless of dosage form, although the working age group (15–64 years) and elderly group (65 and above years) increased. Oral AMU in the working age group was approximately two-thirds of those in the other age groups. In contrast, parenteral AMU in the elderly group was extremely high compared to the other age groups.

Conclusions

The trend of AMU stratified by antimicrobial category and age group were successfully measured using the NDB, which can be a tool to monitor outcome indices for the national action plan on antimicrobial resistance.

Explaining family physicians' beliefs about antibiotic prescription

Background

Antibiotics are among those drugs prescribed abundantly in hospitals due to their high efficiency. However, excessive, non-logical and unnecessary use of antibiotics regardless of physicians' recommendations is considered as a challenge.

Objectives

The aim of this study was to explain family physicians' beliefs about antibiotic prescription in Ahvaz.

Methods

This study is part of a content-analysis qualitative research conducted in Ahvaz in 2016. Study subjects were selected according to purposive sampling and data collection continued to data saturation. Required data were collected using semi-structured in-depth interviews with participation of eight subjects. Data analysis was conducted along with conducting interviews using constant comparison analysis, and it continued to the last interview. Strength and accuracy of data were investigated by experts and participants.

Results

From data analysis, four major categories were extracted that were composed of 20 subcategories. They were 1) expected outcomes of antibiotics (perceived pros and cons); 2) perceived pressure to follow others' opinions; 3) the level of access to antibiotics; and 4) individual's perception for prescription.

Conclusion

Findings of this study showed that various factors affect physicians' decisions to prescribe antibiotics and it is emphasized to consider these factors.

Pediatric fluoroquinolone prescription in South Korea before and after a regulatory intervention: A nationwide study, 2007-2015

Objective

To investigate the impact of national implementation of age restriction on fluoroquinolone prescription in children and adolescents.

Methods

Data collected from the database of Health Insurance Review and Assessment Service in South Korea, a national health insurance system to analyze fluoroquinolone prescribing practice in children and adolescents younger than 18 years, between 2007 and 2015. The age restriction was implemented in December 2009. The annual prescription rate of FQ per 100,000 person-years was calculated and an autoregressive model was used to predict the prescription pattern if an intervention had not occurred.

Results

A total of 505,859 children received systemic fluoroquinolone during the study period—297,054 ciprofloxacin, and 208,805 levofloxacin. After implementation of the drug utilization review program, the annual prescription rate for ciprofloxacin declined by 97.5% (from 840 to 21 per 100,000 person-years, P < 0.001), and for levofloxacin by 96.4% (from 598 to 11 per 100,000 person-years, P < 0.001). The decline was more dramatic in the outpatient setting than in the inpatient setting for both drugs.

Conclusion

The dramatic and sustained decline in prescription number and change in prescription pattern after the regulatory action suggests that the implementation under drug utilization review program was successful in controlling excessive and inappropriate use of fluoroquinolones in children, possibly guiding towards more judicious and selective prescription behavior.

A Nation-Wide Epidemiological Study of Newly Diagnosed Primary Spine Tumor in the Adult Korean Population, 2009-2011

Objective

This 2009–2011 nation-wide study of adult Koreans was aimed to provide characteristics, medical utilization states, and survival rates for newly diagnosed patients with primary nonmalignant and malignant spine tumors.

Methods

Data for patients with primary spine tumors were selected from the Korean Health Insurance Review and Assessment Service database. The data included their age, sex, health insurance type, co-morbidities, medical cost, and hospital stay duration. Hospital stay duration and medical costs per person occurring in one calendar year were used. In addition, survival rates of patients with primary malignant spine tumors were evaluated.

Results

The incidence rate of a primary spine tumor increased with age, and the year of diagnosis (p≤0.0001). Average annual medical costs ranged from 1627 USD (pelvis & sacrum & coccyx tumors) to 6601 USD (spinal cord tumor) for primary nonmalignant spine tumor and from 12137 USD (spinal meningomas) to 20825 USD (pelvis & sacrum & coccyx tumors) for a primary malignant spine tumor. Overall survival rates for those with a primary malignant spine tumor were 87.0%, 75.3%, and 70.6% at 3, 12, and 24 months, respectively. The Cox regression model results showed that male sex, medicare insurance were significantly positive factors affecting survival after a diagnosis of primary malignant spine tumor.

Conclusion

Our study provides a detailed view of the characteristics, medical utilization states, and survival rates of patients newly diagnosed with primary spine tumors in Korea.

Effectiveness of Antibiotic Use Management in Tianjin (2011-2013): A Quasi-Experimental Study

BACKGROUND In this study we investigated changes in the status of antibiotic use in Tianjin since the implementation of the Antibiotic Stewardship Program (ASP) (2011-2013), as well as existing problems, strategies, and outcomes to promote rational clinical antibiotic use. MATERIAL AND METHODS A quasi-experimental study was performed to investigate situations of antibiotic use in secondary and tertiary general hospitals in Tianjin from April 2011 to 2013. Five major indicators were analyzed: percentage of antibiotic use in inpatient cases (%), antibacterial use density (AUD), proportion of prophylactic antibiotic application for type I surgical incision, compliance rate of medication administration 0.5-2.0 h before such procedures, and antibiotic prophylaxis for ≤24 h in patients receiving these surgeries. RESULTS There was a decrease in the percentage of antibiotic use across general hospitals (60.38% to 46.88%), in AUD (51.60% to 35.37%), and in the proportion of prophylactic antibiotic applications for type I incisions (86.67% to 25.08%). For patients undergoing these procedures, there was an increased compliance rate of medication administration of 0.5-2.0 h prior to surgery (86.38% to 100%), and of antibiotic prophylactic use for ≤24 h (40.30% to 96.37%). CONCLUSIONS Implementation of the ASP campaign has reduced irrational antibiotic use, promoted rational antibiotic use, and delayed antibiotic resistance.