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Ueda T, Takesue Y, Nakajima K, Ichiki K, Ishikawa K, Yamada K, Tsuchida T, Otani N, Takahashi Y, Ishihara M, Takubo S, Iijima K, Ikeuchi H, Uchino M, Kimura T. Correlation between Antimicrobial Resistance and the Hospital-Wide Diverse Use of Broad-Spectrum Antibiotics by the Antimicrobial Stewardship Program in Japan. Pharmaceutics 2023; 15:pharmaceutics15020518. [PMID: 36839839 PMCID: PMC9964530 DOI: 10.3390/pharmaceutics15020518] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/21/2023] [Accepted: 01/30/2023] [Indexed: 02/09/2023] Open
Abstract
Increased antibiotic use and antibiotic homogeneity cause selective pressure. This study investigated the correlation between antibiotic diversity and antimicrobial resistance (AMR) in Gram-negative organisms. The days of therapy/100 patient-days (DOT) for four broad-spectrum antibiotic classes were evaluated for 2015-2022. The antibiotic heterogeneity index (AHI) for the equal use of four classes (25%) and the modified AHI for the equal use of three classes (30%), excluding fluoroquinolones (10%), were measured (target: 1.0). Quarterly antibiotic use markers and the resistance rates against ≥2 anti-Pseudomonas antibiotics were compared. The DOT value was 9.94, and the relative DOT were 34.8% for carbapenems, 32.1% for piperacillin/tazobactam, 24.3% for fourth generation cephalosporins/ceftazidime/aztreonam, and 8.9% for fluoroquinolones. Although no correlation was found between the total DOT and the resistance rate for any bacterium, a significant negative correlation was found between the heterogeneity indices and resistance rates for Pseudomonas aeruginosa and Klebsiella pneumoniae. The significant cutoffs that discriminate the risk of resistance were 0.756 for the AHI and 0.889 for the modified AHI for K. pneumoniae. Antibiotic diversity is more important in preventing AMR than overall antibiotic use. The ideal ratio of broad-spectrum antibiotics should be studied for diversified use to prevent AMR.
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Affiliation(s)
- Takashi Ueda
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya 663-8501, Hyogo, Japan
| | - Yoshio Takesue
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya 663-8501, Hyogo, Japan
- Department of Clinical Infectious Diseases, Tokoname City Hospital, Tokoname 479-8510, Aichi, Japan
- Correspondence: ; Tel.: +81-0798-45-6689; Fax: +81-0798-45-6769
| | - Kazuhiko Nakajima
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya 663-8501, Hyogo, Japan
| | - Kaoru Ichiki
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya 663-8501, Hyogo, Japan
| | - Kaori Ishikawa
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya 663-8501, Hyogo, Japan
| | - Kumiko Yamada
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya 663-8501, Hyogo, Japan
| | - Toshie Tsuchida
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya 663-8501, Hyogo, Japan
| | - Naruhito Otani
- Department of Public Health, Hyogo College of Medicine, Nishinomiya 663-8501, Hyogo, Japan
| | - Yoshiko Takahashi
- Department of Pharmacy, Hyogo College of Medicine Hospital, Nishinomiya 663-8501, Hyogo, Japan
| | - Mika Ishihara
- Department of Pharmacy, Hyogo College of Medicine Hospital, Nishinomiya 663-8501, Hyogo, Japan
| | - Shingo Takubo
- Department of Pharmacy, Hyogo College of Medicine Hospital, Nishinomiya 663-8501, Hyogo, Japan
| | - Kosuke Iijima
- Department of Clinical Technology, Hyogo College of Medicine, Nishinomiya 663-8501, Hyogo, Japan
| | - Hiroki Ikeuchi
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya 663-8501, Hyogo, Japan
| | - Motoi Uchino
- Department of Inflammatory Bowel Disease, Hyogo College of Medicine, Nishinomiya 663-8501, Hyogo, Japan
| | - Takeshi Kimura
- Department of Pharmacy, Hyogo College of Medicine Hospital, Nishinomiya 663-8501, Hyogo, Japan
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Morosawa M, Ueda T, Nakajima K, Inoue T, Toyama M, Ogasiwa H, Doi M, Nozaki Y, Murakami Y, Ishii M, Takesue Y. Comparison of antibiotic use and antibiotic resistance between a community hospital and tertiary care hospital for evaluation of the antimicrobial stewardship program in Japan. PLoS One 2023; 18:e0284806. [PMID: 37093821 PMCID: PMC10124824 DOI: 10.1371/journal.pone.0284806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/06/2023] [Indexed: 04/25/2023] Open
Abstract
Assessment of risk-adjusted antibiotic use (AU) is recommended to evaluate antimicrobial stewardship programs (ASPs). We aimed to compare the amount and diversity of AU and antimicrobial susceptibility of nosocomial isolates between a 266-bed community hospital (CH) and a 963-bed tertiary care hospital (TCH) in Japan. The days of therapy/100 bed days (DOT) was measured for four classes of broad-spectrum antibiotics predominantly used for hospital-onset infections. The diversity of AU was evaluated using the modified antibiotic heterogeneity index (AHI). With 10% relative DOT for fluoroquinolones and 30% for each of the remaining three classes, the modified AHI equals 1. Multidrug resistance (MDR) was defined as resistance to ≥ 3 anti-Pseudomonas antibiotic classes. The DOT was significantly higher in the TCH than in the CH (10.85 ± 1.32 vs. 3.89 ± 0.93, p < 0.001). For risk-adjusted AU, the DOT was 6.90 ± 1.50 for acute-phase medical wards in the CH, and 8.35 ± 1.05 in the TCH excluding the hematology department. In contrast, the DOT of antibiotics for community-acquired infections was higher in the CH than that in the TCH. As quality assessment of AU, higher modified AHI was observed in the TCH than in the CH (0.832 ± 0.044 vs. 0.721 ± 0.106, p = 0.003), indicating more diverse use in the TCH. The MDR rate in gram-negative rods was 5.1% in the TCH and 3.4% in the CH (p = 0.453). No significant difference was demonstrated in the MDR rate for Pseudomonas aeruginosa and Enterobacteriaceae species between hospitals. Broad-spectrum antibiotics were used differently in the TCH and CH. However, an increased antibiotic burden in the TCH did not cause poor susceptibility, possibly because of diversified AU. Considering the different patient populations, benchmarking AU according to the facility type is promising for inter-hospital comparisons of ASPs.
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Affiliation(s)
- Mika Morosawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Department of Respiratory Medicine, Tokoname City Hospital, Tokoname, Aichi, Japan
| | - Takashi Ueda
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazuhiko Nakajima
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tomoko Inoue
- Department of Pharmacy, Tokoname City Hospital, Tokoname, Aichi, Japan
| | - Masanobu Toyama
- Department of Pharmacy, Tokoname City Hospital, Tokoname, Aichi, Japan
| | - Hitoshi Ogasiwa
- Department of Clinical Technology, Tokoname City Hospital, Tokoname, Aichi, Japan
| | - Miki Doi
- Department of Clinical Technology, Tokoname City Hospital, Tokoname, Aichi, Japan
| | - Yasuhiro Nozaki
- Department of Respiratory Medicine, Tokoname City Hospital, Tokoname, Aichi, Japan
| | - Yasushi Murakami
- Department of Respiratory Medicine, Tokoname City Hospital, Tokoname, Aichi, Japan
| | - Makoto Ishii
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshio Takesue
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
- Department of Clinical Infectious Diseases, Tokoname City Hospital, Tokoname, Japan
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Batchelder JI, Hare PJ, Mok WWK. Resistance-resistant antibacterial treatment strategies. FRONTIERS IN ANTIBIOTICS 2023; 2:1093156. [PMID: 36845830 PMCID: PMC9954795 DOI: 10.3389/frabi.2023.1093156] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Antibiotic resistance is a major danger to public health that threatens to claim the lives of millions of people per year within the next few decades. Years of necessary administration and excessive application of antibiotics have selected for strains that are resistant to many of our currently available treatments. Due to the high costs and difficulty of developing new antibiotics, the emergence of resistant bacteria is outpacing the introduction of new drugs to fight them. To overcome this problem, many researchers are focusing on developing antibacterial therapeutic strategies that are "resistance-resistant"-regimens that slow or stall resistance development in the targeted pathogens. In this mini review, we outline major examples of novel resistance-resistant therapeutic strategies. We discuss the use of compounds that reduce mutagenesis and thereby decrease the likelihood of resistance emergence. Then, we examine the effectiveness of antibiotic cycling and evolutionary steering, in which a bacterial population is forced by one antibiotic toward susceptibility to another antibiotic. We also consider combination therapies that aim to sabotage defensive mechanisms and eliminate potentially resistant pathogens by combining two antibiotics or combining an antibiotic with other therapeutics, such as antibodies or phages. Finally, we highlight promising future directions in this field, including the potential of applying machine learning and personalized medicine to fight antibiotic resistance emergence and out-maneuver adaptive pathogens.
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Affiliation(s)
- Jonathan I Batchelder
- Department of Molecular Biology and Biophysics, UConn Health, Farmington, CT, United States
| | - Patricia J Hare
- Department of Molecular Biology and Biophysics, UConn Health, Farmington, CT, United States.,School of Dental Medicine, University of Connecticut, Farmington, CT, United States
| | - Wendy W K Mok
- Department of Molecular Biology and Biophysics, UConn Health, Farmington, CT, United States
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Drug Efflux Pump Inhibitors: A Promising Approach to Counter Multidrug Resistance in Gram-Negative Pathogens by Targeting AcrB Protein from AcrAB-TolC Multidrug Efflux Pump from Escherichia coli. BIOLOGY 2022; 11:biology11091328. [PMID: 36138807 PMCID: PMC9495857 DOI: 10.3390/biology11091328] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/26/2022] [Accepted: 08/27/2022] [Indexed: 11/17/2022]
Abstract
Simple Summary Multidrug-resistant bacterial infections, especially that caused by Gram-negative bacteria, have posed serious health issues worldwide. Bacteria have different mechanisms that can confer multidrug resistance to bacteria, among these mechanisms are drug efflux pumps that play the main role in conferring multidrug resistance by recognizing then expelling a wide range of compounds, especially antibiotics, and reducing their concentration to sub-toxic levels. Small molecule inhibitors that target drug efflux pumps especially the AcrAB-TolC multidrug efflux pump, from E. coli, appear as a new promising and attractive approach that could increase the required accumulation of antimicrobials to eliminate bacteria as well as leading to reverse antibiotic resistance and prevent the development of resistance in clinically relevant bacterial pathogens and enhances the activity of antibiotics or prolong their effectiveness. Abstract Infections caused by multidrug resistance (MDR) of Gram-negative bacteria have become one of the most severe public health problems worldwide. The main mechanism that confers MDR to bacteria is drug efflux pumps, as they expel a wide range of compounds, especially antibiotics. Among the different types of drug efflux pumps, the resistance nodulation division (RND) superfamily confers MDR to various Gram-negative bacteria species. The AcrAB-TolC multidrug efflux pump, from E. coli, a member of RND, is the best-characterized example and an excellent model for understanding MDR because of an abundance of functional and structural data. Small molecule inhibitors that target the AcrAB-TolC drug efflux pump represent a new solution to reversing MDR in Gram-negative bacteria and restoring the efficacy of various used drugs that are clinically relevant to these pathogens, especially in the high shortage of drugs for multidrug-resistant Gram-negative bacteria. This review will investigate solutions of MDR in Gram-negative bacteria by studying the inhibition of the AcrAB-TolC multidrug efflux pump.
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Jayashree M, Singhi S, Ray P, Gautam V, Ratol S, Bharti S. Longitudinal comparative trial of antibiotic cycling and mixing on emergence of gram negative bacterial resistance in a pediatric medical intensive care unit. J Crit Care 2020; 56:243-248. [PMID: 31982698 DOI: 10.1016/j.jcrc.2020.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/10/2020] [Accepted: 01/12/2020] [Indexed: 01/19/2023]
Abstract
PURPOSE To compare antibiotic mixing vs. cycling with respect to acquisition of resistance and PICU mortality. MATERIALS AND METHODS Children between >1 month to 12 years admitted to a medical PICU were enrolled over three phases (baseline, mixing and cycling) with washout interval of 3 months following each antibiotic strategy. Following a baseline phase, empiric gram negative antibiotic protocol for suspected HCAI, was sequentially subjected to mixing and cycling using Latin Square methodology. Surveillance cultures were taken at admission, 48 h, weekly thereafter and within 2 days of PICU discharge. Acquisition of resistance and PICU mortality were primary and secondary outcomes respectively. RESULTS 778 children were enrolled; 99 baseline, 146 mixing, 362 cycling, and 171 during two washout phases. Proportion of children with acquired resistance at baseline (56.6%) was significantly higher than mixing (22.6%) and cycling (18.51%) (p < .0001). Adjusted hazards of acquired resistance (HR:0.82; 95% CI: 0.53-1.25, p = .352), and PICU mortality (RR1.07; 95% CI: 0.71-1.60, p = .72) were similar in cycling and mixing strategies. CONCLUSIONS Acquisition of resistance was significantly lower in both mixing and cycling as compared to baseline phase. Both were similar with respect to risk of antibiotic resistance as well as incidence of HCAI and PICU mortality.
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Affiliation(s)
| | - Sunit Singhi
- Department of Pediatrics, Advanced Pediatrics Centre, PGIMER, Chandigarh, India
| | - Pallab Ray
- Department of Medical Microbiology, PGIMER, Chandigarh, India
| | - Vikas Gautam
- Department of Medical Microbiology, PGIMER, Chandigarh, India
| | - Sukhsagar Ratol
- Department of Pediatrics, Advanced Pediatrics Centre, PGIMER, Chandigarh, India
| | - Sahul Bharti
- Build Healthy India Movement (Research based NGO), Chandigarh, India
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Hijazi K, Joshi C, Gould IM. Challenges and opportunities for antimicrobial stewardship in resource-rich and resource-limited countries. Expert Rev Anti Infect Ther 2019; 17:621-634. [PMID: 31282277 DOI: 10.1080/14787210.2019.1640602] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Inappropriate prescription practices, patient and provider knowledge and attitudes, variable availability of diagnostic and surveillance systems, and the unrestricted use of antimicrobials in animals and plants are contributory factors to the global crisis of antimicrobial resistance (AMR). Areas covered: Notwithstanding that interventions to revert AMR should be tailored to the socio-politico-economic landscape, there is a global consensus for the implementation and enhancement of antimicrobial stewardship strategies. Yet the implementation of Antimicrobial Stewardship Programs (ASPs) remains relatively limited within healthcare settings and faces complex challenges in resource-limited countries. The current review summarizes the limitations of current ASPs, translation challenges in resource-limited countries, and potential solutions. Expert opinion: Suboptimal ASP implementation in hospitals is multifactorial. Restriction of antimicrobial use should be informed by risk-benefit analyses, including the potential for substitute prescribing, and displacement of selection pressures. Thresholds in population use of antibiotics above which AMR increases may provide quantitative targets for ASPs. Horizontal and vertical collaborations involving policymakers and the general public are of paramount importance. While impactful prescribing changes require sustained engagement of the public and health-care professionals, we warn against over-estimating the benefits of behavioral interventions. We advocate for population-level stewardship interventions in addition to investment in structural factors that will aid ASP implementation.
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Affiliation(s)
- Karolin Hijazi
- a Institute of Dentistry, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen , Aberdeen , UK
| | - Chaitanya Joshi
- b Department of Medical Microbiology, Aberdeen Royal Infirmary , Aberdeen , UK
| | - Ian M Gould
- b Department of Medical Microbiology, Aberdeen Royal Infirmary , Aberdeen , UK
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Conlon-Bingham GM, Aldeyab M, Scott M, Kearney MP, Farren D, Gilmore F, McElnay J. Effects of Antibiotic Cycling Policy on Incidence of Healthcare-Associated MRSA and Clostridioides difficile Infection in Secondary Healthcare Settings. Emerg Infect Dis 2019; 25:52-62. [PMID: 30561306 PMCID: PMC6302607 DOI: 10.3201/eid2501.180111] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
This quasi-experimental study investigated the effect of an antibiotic cycling policy based on time-series analysis of epidemiologic data, which identified antimicrobial drugs and time periods for restriction. Cyclical restrictions of amoxicillin/clavulanic acid, piperacillin/tazobactam, and clarithromycin were undertaken over a 2-year period in the intervention hospital. We used segmented regression analysis to compare the effect on the incidence of healthcare-associated Clostridioides difficile infection (HA-CDI), healthcare-associated methicillin-resistant Staphylococcus aureus (HA-MRSA), and new extended-spectrum β-lactamase (ESBL) isolates and on changes in resistance patterns of the HA-MRSA and ESBL organisms between the intervention and control hospitals. HA-CDI incidence did not change. HA-MRSA incidence increased significantly in the intervention hospital. The resistance of new ESBL isolates to amoxicillin/clavulanic acid and piperacillin/tazobactam decreased significantly in the intervention hospital; however, resistance to piperacillin/tazobactam increased after a return to the standard policy. The results question the value of antibiotic cycling to antibiotic stewardship.
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8
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Redding LE, Lavigne S, Aceto H, Nolen-Walston R. Characterization of antimicrobial prescription frequency and diversity in a large animal veterinary medical teaching hospital. Prev Vet Med 2019; 168:66-74. [PMID: 31097125 DOI: 10.1016/j.prevetmed.2019.04.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/22/2019] [Accepted: 04/24/2019] [Indexed: 01/16/2023]
Abstract
Antimicrobials are commonly used in veterinary medicine for therapeutic and prophylactic purposes, but little is known about the frequency with which they are prescribed or the quantity administered, especially in large animals. Furthermore, there are no standardized metrics for characterizing antimicrobial use, which can lead to confusion when comparing antimicrobial use among different units (institution, clinical service, clinician). Because there is no gold standard metric, the most comprehensive characterization of antimicrobial use will be achieved using a variety of metrics. The goal of this study was to characterize antimicrobial use from 2013 to 2018 at a tertiary care teaching hospital for large animals using different metrics, including novel ones. We found that at least one antimicrobial was prescribed in 42% of visits and that antimicrobials were prescribed at a rate of 919 animal-defined daily doses (ADDs) per 1000 animal days. A median of 3.6 ADDs and a mean of 2 different classes of antimicrobial were prescribed per patient, and penicillin was the most commonly used antimicrobial. The prescription diversity, a metric accounting for richness and evenness (similarity of frequencies) of different types of antimicrobials, was 0.82, with 1.0 representing maximal richness and diversity. Antimicrobial use differed significantly by species and by organ system affected for all metrics, though in general antimicrobials were prescribed most frequently and with the largest amounts in animals presenting with integumentary or respiratory signs. Many of our findings were consistent with those of other studies examining antimicrobial use in the species represented in our patient population, but more research is needed to determine how to best characterize antimicrobial use and assess appropriateness of prescribing.
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Affiliation(s)
- Laurel E Redding
- University of Pennsylvania, School of Veterinary Medicine, Kennett Square, PA, USA.
| | - Sondra Lavigne
- University of Pennsylvania, School of Veterinary Medicine, Kennett Square, PA, USA
| | - Helen Aceto
- University of Pennsylvania, School of Veterinary Medicine, Kennett Square, PA, USA
| | - Rose Nolen-Walston
- University of Pennsylvania, School of Veterinary Medicine, Kennett Square, PA, USA
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9
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Moore S, Weiss B, Pascual JL, Kaplan LJ. Management of Acute Respiratory Failure in the Patient with Sepsis or Septic Shock. Surg Infect (Larchmt) 2018; 19:191-201. [PMID: 29360422 DOI: 10.1089/sur.2017.297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Sepsis and septic shock are each commonly accompanied by acute respiratory failure and the need for invasive as well as non-invasive ventilation throughout a patient's intensive care unit course. We explore the underpinnings of acute respiratory failure of pulmonary as well as non-pulmonary origin in the context of invasive and non-invasive management approaches. Both pharmacologic and non-pharmacologic adjuncts to ventilatory and oxygenation support are highlighted as well. Finally, rescue modalities are positioned within the intensivist's armamentarium for global care of support of the critically ill or injured patient with sepsis or septic shock.
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Affiliation(s)
- Sarah Moore
- 1 Department of Surgery, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Brian Weiss
- 2 Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Jose L Pascual
- 1 Department of Surgery, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Lewis J Kaplan
- 1 Department of Surgery, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania.,3 Corporal Michael J Crescenz VA Medical Center , Philadelphia, Pennsylvania
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10
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Yoshida M, Reyes SG, Tsuda S, Horinouchi T, Furusawa C, Cronin L. Time-programmable drug dosing allows the manipulation, suppression and reversal of antibiotic drug resistance in vitro. Nat Commun 2017; 8:15589. [PMID: 28593940 PMCID: PMC5472167 DOI: 10.1038/ncomms15589] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 04/11/2017] [Indexed: 12/30/2022] Open
Abstract
Multi-drug strategies have been attempted to prolong the efficacy of existing antibiotics, but with limited success. Here we show that the evolution of multi-drug-resistant Escherichia coli can be manipulated in vitro by administering pairs of antibiotics and switching between them in ON/OFF manner. Using a multiplexed cell culture system, we find that switching between certain combinations of antibiotics completely suppresses the development of resistance to one of the antibiotics. Using this data, we develop a simple deterministic model, which allows us to predict the fate of multi-drug evolution in this system. Furthermore, we are able to reverse established drug resistance based on the model prediction by modulating antibiotic selection stresses. Our results support the idea that the development of antibiotic resistance may be potentially controlled via continuous switching of drugs.
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Affiliation(s)
- Mari Yoshida
- WestCHEM, School of Chemistry, The University of Glasgow, Glasgow G12 8QQ, UK
| | | | - Soichiro Tsuda
- WestCHEM, School of Chemistry, The University of Glasgow, Glasgow G12 8QQ, UK
| | - Takaaki Horinouchi
- Quantitative Biology Center, RIKEN, 6-2-3 Furuedai, Suita, Osaka 565-0874, Japan
| | - Chikara Furusawa
- Quantitative Biology Center, RIKEN, 6-2-3 Furuedai, Suita, Osaka 565-0874, Japan
- Department of Physics, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Leroy Cronin
- WestCHEM, School of Chemistry, The University of Glasgow, Glasgow G12 8QQ, UK
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11
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Fitness costs associated with the acquisition of antibiotic resistance. Essays Biochem 2017; 61:37-48. [PMID: 28258228 DOI: 10.1042/ebc20160057] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 12/20/2016] [Accepted: 01/03/2017] [Indexed: 01/09/2023]
Abstract
Acquisition of antibiotic resistance is a relevant problem for human health. The selection and spread of antibiotic-resistant organisms not only compromise the treatment of infectious diseases, but also the implementation of different therapeutic procedures as organ transplantation, advanced surgery or chemotherapy, all of which require proficient methods for avoiding infections. It has been generally accepted that the acquisition of antibiotic resistance will produce a general metabolic burden: in the absence of selection, the resistant organisms would be outcompeted by the susceptible ones. If that was always true, discontinuation of antibiotic use would render the disappearance of resistant microorganisms. However, several studies have shown that, once resistance emerges, the recovery of a fully susceptible population even in the absence of antibiotics is not easy. In the present study, we review updated information on the effect of the acquisition of antibiotic resistance in bacterial physiology as well as on the mechanisms that allow the compensation of the fitness costs associated with the acquisition of resistance.
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12
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de With K, Allerberger F, Amann S, Apfalter P, Brodt HR, Eckmanns T, Fellhauer M, Geiss HK, Janata O, Krause R, Lemmen S, Meyer E, Mittermayer H, Porsche U, Presterl E, Reuter S, Sinha B, Strauß R, Wechsler-Fördös A, Wenisch C, Kern WV. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2017; 44:395-439. [PMID: 27066980 PMCID: PMC4889644 DOI: 10.1007/s15010-016-0885-z] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. Materials and methods A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. Conclusion The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.
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Affiliation(s)
- K de With
- Division of Infectious Diseases, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - F Allerberger
- Division Public Health, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - S Amann
- Hospital Pharmacy, Munich Municipal Hospital, Munich, Germany
| | - P Apfalter
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - H-R Brodt
- Department of Infectious Disease Medical Clinic II, Goethe-University Frankfurt, Frankfurt, Germany
| | - T Eckmanns
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - M Fellhauer
- Hospital Pharmacy, Schwarzwald-Baar Hospital, Villingen-Schwenningen, Germany
| | - H K Geiss
- Department of Hospital Epidemiology and Infectiology, Sana Kliniken AG, Ismaning, Germany
| | - O Janata
- Department for Hygiene and Infection Control, Danube Hospital, Vienna, Austria
| | - R Krause
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria
| | - S Lemmen
- Division of Infection Control and Infectious Diseases, University Hospital RWTH Aachen, Aachen, Germany
| | - E Meyer
- Institute of Hygiene and Environmental Medicine, Charité, University Medicine Berlin, Berlin, Germany
| | - H Mittermayer
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - U Porsche
- Department for Clinical Pharmacy and Drug Information, Landesapotheke, Landeskliniken Salzburg (SALK), Salzburg, Austria
| | - E Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - S Reuter
- Clinic for General Internal Medicine, Infectious Diseases, Pneumology and Osteology, Klinikum Leverkusen, Leverkusen, Germany
| | - B Sinha
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Strauß
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, University Hospital Erlangen, Erlangen, Germany
| | - A Wechsler-Fördös
- Department of Antibiotics and Infection Control, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - C Wenisch
- Medical Department of Infection and Tropical Medicine, Kaiser Franz Josef Hospital, Vienna, Austria
| | - W V Kern
- Division of Infectious Diseases, Department of Medicine, Freiburg University Medical Center, Freiburg, Germany
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Delmas CEL, Dussert Y, Delière L, Couture C, Mazet ID, Richart Cervera S, Delmotte F. Soft selective sweeps in fungicide resistance evolution: recurrent mutations without fitness costs in grapevine downy mildew. Mol Ecol 2017; 26:1936-1951. [DOI: 10.1111/mec.14006] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 01/30/2023]
Affiliation(s)
| | - Yann Dussert
- SAVE; Bordeaux Sciences Agro; INRA; 33140 Villenave d'Ornon France
| | - Laurent Delière
- SAVE; Bordeaux Sciences Agro; INRA; 33140 Villenave d'Ornon France
| | - Carole Couture
- SAVE; Bordeaux Sciences Agro; INRA; 33140 Villenave d'Ornon France
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14
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Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, Srinivasan A, Dellit TH, Falck-Ytter YT, Fishman NO, Hamilton CW, Jenkins TC, Lipsett PA, Malani PN, May LS, Moran GJ, Neuhauser MM, Newland JG, Ohl CA, Samore MH, Seo SK, Trivedi KK. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62:e51-77. [PMID: 27080992 PMCID: PMC5006285 DOI: 10.1093/cid/ciw118] [Citation(s) in RCA: 1806] [Impact Index Per Article: 225.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 12/11/2022] Open
Abstract
Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.
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Affiliation(s)
- Tamar F Barlam
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lilian M Abbo
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Conan MacDougall
- Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco
| | - Audrey N Schuetz
- Department of Medicine, Weill Cornell Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Edward J Septimus
- Department of Internal Medicine, Texas A&M Health Science Center College of Medicine, Houston
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Timothy H Dellit
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle
| | - Yngve T Falck-Ytter
- Department of Medicine, Case Western Reserve University and Veterans Affairs Medical Center, Cleveland, Ohio
| | - Neil O Fishman
- Department of Medicine, University of Pennsylvania Health System, Philadelphia
| | | | | | - Pamela A Lipsett
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland
| | - Preeti N Malani
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor
| | - Larissa S May
- Department of Emergency Medicine, University of California, Davis
| | - Gregory J Moran
- Department of Emergency Medicine, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Sylmar
| | | | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Missouri
| | - Christopher A Ohl
- Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Matthew H Samore
- Department of Veterans Affairs and University of Utah, Salt Lake City
| | - Susan K Seo
- Infectious Diseases, Memorial Sloan Kettering Cancer Center, New York, New York
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Evaluation of a Mixing versus a Cycling Strategy of Antibiotic Use in Critically-Ill Medical Patients: Impact on Acquisition of Resistant Microorganisms and Clinical Outcomes. PLoS One 2016; 11:e0150274. [PMID: 26982807 PMCID: PMC4794237 DOI: 10.1371/journal.pone.0150274] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 02/11/2016] [Indexed: 11/22/2022] Open
Abstract
Objective To compare the effect of two strategies of antibiotic use (mixing vs. cycling) on the acquisition of resistant microorganisms, infections and other clinical outcomes. Methods Prospective cohort study in an 8-bed intensive care unit during 35- months in which a mixing-cycling policy of antipseudomonal beta-lactams (meropenem, ceftazidime/piperacillin-tazobactam) and fluoroquinolones was operative. Nasopharyngeal and rectal swabs and respiratory secretions were obtained within 48h of admission and thrice weekly thereafter. Target microorganisms included methicillin-resistant S. aureus, vancomycin-resistant enterococci, third-generation cephalosporin-resistant Enterobacteriaceae and non-fermenters. Results A total of 409 (42%) patients were included in mixing and 560 (58%) in cycling. Exposure to ceftazidime/piperacillin-tazobactam and fluoroquinolones was significantly higher in mixing while exposure to meropenem was higher in cycling, although overall use of antipseudomonals was not significantly different (37.5/100 patient-days vs. 38.1/100 patient-days). There was a barely higher acquisition rate of microorganisms during mixing, but this difference lost its significance when the cases due to an exogenous Burkholderia cepacia outbreak were excluded (19.3% vs. 15.4%, OR 0.8, CI 0.5–1.1). Acquisition of Pseudomonas aeruginosa resistant to the intervention antibiotics or with multiple-drug resistance was similar. There were no significant differences between mixing and cycling in the proportion of patients acquiring any infection (16.6% vs. 14.5%, OR 0.9, CI 0.6–1.2), any infection due to target microorganisms (5.9% vs. 5.2%, OR 0.9, CI 0.5–1.5), length of stay (median 5 d for both groups) or mortality (13.9 vs. 14.3%, OR 1.03, CI 0.7–1.3). Conclusions A cycling strategy of antibiotic use with a 6-week cycle duration is similar to mixing in terms of acquisition of resistant microorganisms, infections, length of stay and mortality.
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16
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Alternating antibiotic treatments constrain evolutionary paths to multidrug resistance. Proc Natl Acad Sci U S A 2014; 111:14494-9. [PMID: 25246554 DOI: 10.1073/pnas.1409800111] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Alternating antibiotic therapy, in which pairs of drugs are cycled during treatment, has been suggested as a means to inhibit the evolution of de novo resistance while avoiding the toxicity associated with more traditional combination therapy. However, it remains unclear under which conditions and by what means such alternating treatments impede the evolution of resistance. Here, we tracked multistep evolution of resistance in replicate populations of Staphylococcus aureus during 22 d of continuously increasing single-, mixed-, and alternating-drug treatment. In all three tested drug pairs, the alternating treatment reduced the overall rate of resistance by slowing the acquisition of resistance to one of the two component drugs, sometimes as effectively as mixed treatment. This slower rate of evolution is reflected in the genome-wide mutational profiles; under alternating treatments, bacteria acquire mutations in different genes than under corresponding single-drug treatments. To test whether this observed constraint on adaptive paths reflects trade-offs in which resistance to one drug is accompanied by sensitivity to a second drug, we profiled many single-step mutants for cross-resistance. Indeed, the average cross-resistance of single-step mutants can help predict whether or not evolution was slower in alternating drugs. Together, these results show that despite the complex evolutionary landscape of multidrug resistance, alternating-drug therapy can slow evolution by constraining the mutational paths toward resistance.
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Cantón R, Horcajada JP, Oliver A, Garbajosa PR, Vila J. Inappropriate use of antibiotics in hospitals: the complex relationship between antibiotic use and antimicrobial resistance. Enferm Infecc Microbiol Clin 2014; 31 Suppl 4:3-11. [PMID: 24129283 DOI: 10.1016/s0213-005x(13)70126-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hospitals are considered an excellent compartment for the selection of resistant and multi-drug resistant (MDR) bacteria. The overuse and misuse of antimicrobial agents are considered key points fuelling this situation. Antimicrobial stewardship programs have been designed for better use of these compounds to prevent the emergence of resistant microorganisms and to diminish the upward trend in resistance. Nevertheless, the relationship between antibiotic use and antimicrobial resistance is complex, and the desired objectives are difficult to reach. Various factors affecting this relationship have been advocated including, among others, antibiotic exposure and mutant selection windows, antimicrobial pharmacodynamics, the nature of the resistance (natural or acquired, including mutational and that associated with horizontal gene transfer) and the definition of resistance. Moreover, antimicrobial policies to promote better use of these drugs should be implemented not only in the hospital setting coupled with infection control programs, but also in the community, which should also include animal and environmental compartments. Within hospitals, the restriction of antimicrobials, cycling and mixing strategies and the use of combination therapies have been used to avoid resistance. Nevertheless, the results have not always been favorable and resistant bacteria have persisted despite the theoretical benefits of these strategies. Mathematical models as well as microbiological knowledge can explain this failure, which is mainly related to the current scenario involving MDR bacteria and overcoming the fitness associated with resistance. New antimicrobials, rapid diagnostic and antimicrobial susceptibility testing and biomarkers will be useful for future antimicrobial stewardship interventions.
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Affiliation(s)
- Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Unidad de Resistencia a Antibióticos y Virulencia Bacteriana, Consejo Superior de Investigaciones Científicas, Madrid, Spain.
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18
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Pujol M, Delgado O, Puigventós F, Corzo JE, Cercenado E, Martínez JA. Evaluation of new antimicrobials for the hospital formulary. Policies restricting antibiotic use in hospitals. Enferm Infecc Microbiol Clin 2014; 31 Suppl 4:45-50. [PMID: 24129289 DOI: 10.1016/s0213-005x(13)70132-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In Spain, the inclusion of new antibiotics in hospital formularies is performed by the Infection Policy Committee or the Pharmacy and Therapeutic Committee, although now the decision is moving to a regional level. Criteria for the evaluation of new drugs include efficacy, safety and cost. For antimicrobial drugs evaluation it is necessary to consider local sensibility and impact in bacterial resistance to determinate the therapeutic positioning. There is compelling evidence that the use of antibiotics is associated with increasing bacterial resistance, and a great number of antibiotics are used incorrectly. In order to decrease the inappropriate use of antibiotics, several approaches have been proposed. Limiting the use of antimicrobials through formulary restrictions, often aimed at drugs with a specific resistance profile, shows benefits in improving antimicrobial susceptibilities and decreasing colonization by drug-resistant organisms. However, the restriction of one agent may result in the increased utilization of other agents. By using antibiotic cycling, the amount of antibiotics is maintained below the threshold where bacterial resistance develops, thus preserving highly efficient antibiotics. Unfortunately, cumulative evidence to date suggests that antibiotic cycling has limited efficacy in preventing antibiotic resistance. Finally, although there is still little clinical evidence available on antibiotic heterogeneity, the use of most of the existing antimicrobial classes could limit the emergence of resistance. This review summarizes information regarding antibiotic evaluation and available restrictive strategies to limit the use of antibiotics at hospitals with the aim of curtailing increasing antibiotic resistance.
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Affiliation(s)
- Miquel Pujol
- Servicio de Enfermedades Infecciosas, Hospital Universitario de Bellvitge, IDIBELL, Universitat de Barcelona, Barcelona, Spain.
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Abel zur Wiesch P, Kouyos R, Abel S, Viechtbauer W, Bonhoeffer S. Cycling empirical antibiotic therapy in hospitals: meta-analysis and models. PLoS Pathog 2014; 10:e1004225. [PMID: 24968123 PMCID: PMC4072793 DOI: 10.1371/journal.ppat.1004225] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 05/13/2014] [Indexed: 01/12/2023] Open
Abstract
The rise of resistance together with the shortage of new broad-spectrum antibiotics underlines the urgency of optimizing the use of available drugs to minimize disease burden. Theoretical studies suggest that coordinating empirical usage of antibiotics in a hospital ward can contain the spread of resistance. However, theoretical and clinical studies came to different conclusions regarding the usefulness of rotating first-line therapy (cycling). Here, we performed a quantitative pathogen-specific meta-analysis of clinical studies comparing cycling to standard practice. We searched PubMed and Google Scholar and identified 46 clinical studies addressing the effect of cycling on nosocomial infections, of which 11 met our selection criteria. We employed a method for multivariate meta-analysis using incidence rates as endpoints and find that cycling reduced the incidence rate/1000 patient days of both total infections by 4.95 [9.43–0.48] and resistant infections by 7.2 [14.00–0.44]. This positive effect was observed in most pathogens despite a large variance between individual species. Our findings remain robust in uni- and multivariate metaregressions. We used theoretical models that reflect various infections and hospital settings to compare cycling to random assignment to different drugs (mixing). We make the realistic assumption that therapy is changed when first line treatment is ineffective, which we call “adjustable cycling/mixing”. In concordance with earlier theoretical studies, we find that in strict regimens, cycling is detrimental. However, in adjustable regimens single resistance is suppressed and cycling is successful in most settings. Both a meta-regression and our theoretical model indicate that “adjustable cycling” is especially useful to suppress emergence of multiple resistance. While our model predicts that cycling periods of one month perform well, we expect that too long cycling periods are detrimental. Our results suggest that “adjustable cycling” suppresses multiple resistance and warrants further investigations that allow comparing various diseases and hospital settings. The rise of antibiotic resistance is a major concern for public health. In hospitals, frequent usage of antibiotics leads to high resistance levels; at the same time the patients are especially vulnerable. We therefore urgently need treatment strategies that limit resistance without compromising patient care. Here, we investigate two strategies that coordinate the usage of different antibiotics in a hospital ward: “cycling”, i.e. scheduled changes in antibiotic treatment for all patients, and “mixing”, i.e. random assignment of patients to antibiotics. Previously, theoretical and clinical studies came to different conclusions regarding the usefulness of these strategies. We combine meta-analyses of clinical studies and epidemiological modeling to address this question. Our meta-analyses suggest that cycling is beneficial in reducing the total incidence rate of hospital-acquired infections as well as the incidence rate of resistant infections, and that this is most pronounced at low baseline levels of resistance. We corroborate our findings with theoretical epidemiological models. When incorporating treatment adjustment upon deterioration of a patient's condition (“adjustable cycling”), we find that our theoretical model is in excellent accordance with the clinical data. With this combined approach we present substantial evidence that adjustable cycling can be beneficial for suppressing the emergence of multiple resistance.
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Affiliation(s)
- Pia Abel zur Wiesch
- Institute of Integrative Biology, ETH Zurich, Zurich, Switzerland
- Division of Global Health Equity, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Roger Kouyos
- Institute of Integrative Biology, ETH Zurich, Zurich, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Sören Abel
- Division of Infectious Diseases, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
| | - Wolfgang Viechtbauer
- Department of Psychiatry and Psychology, School for Mental Health and Neuroscience, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Imamovic L, Sommer MOA. Use of collateral sensitivity networks to design drug cycling protocols that avoid resistance development. Sci Transl Med 2014; 5:204ra132. [PMID: 24068739 DOI: 10.1126/scitranslmed.3006609] [Citation(s) in RCA: 278] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
New drug deployment strategies are imperative to address the problem of drug resistance, which is limiting the management of infectious diseases and cancers. We evolved resistance in Escherichia coli toward 23 drugs used clinically for treating bacterial infections and mapped the resulting collateral sensitivity and resistance profiles, revealing a complex collateral sensitivity network. On the basis of these data, we propose a new treatment framework--collateral sensitivity cycling--in which drugs with compatible collateral sensitivity profiles are used sequentially to treat infection and select against drug resistance development. We identified hundreds of such drug sets and demonstrated that the antibiotics gentamicin and cefuroxime can be deployed cyclically such that the treatment regimen selected against resistance to either drug. We then validated our findings with related bacterial pathogens. These results provide proof of principle for collateral sensitivity cycling as a sustainable treatment paradigm that may be generally applicable to infectious diseases and cancer.
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Affiliation(s)
- Lejla Imamovic
- Department of Systems Biology, Technical University of Denmark, DK-2800 Lyngby, Denmark
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Strategies to minimize antibiotic resistance. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2013; 10:4274-305. [PMID: 24036486 PMCID: PMC3799537 DOI: 10.3390/ijerph10094274] [Citation(s) in RCA: 221] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 09/02/2013] [Accepted: 09/03/2013] [Indexed: 02/07/2023]
Abstract
Antibiotic resistance can be reduced by using antibiotics prudently based on guidelines of antimicrobial stewardship programs (ASPs) and various data such as pharmacokinetic (PK) and pharmacodynamic (PD) properties of antibiotics, diagnostic testing, antimicrobial susceptibility testing (AST), clinical response, and effects on the microbiota, as well as by new antibiotic developments. The controlled use of antibiotics in food animals is another cornerstone among efforts to reduce antibiotic resistance. All major resistance-control strategies recommend education for patients, children (e.g., through schools and day care), the public, and relevant healthcare professionals (e.g., primary-care physicians, pharmacists, and medical students) regarding unique features of bacterial infections and antibiotics, prudent antibiotic prescribing as a positive construct, and personal hygiene (e.g., handwashing). The problem of antibiotic resistance can be minimized only by concerted efforts of all members of society for ensuring the continued efficiency of antibiotics.
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Heterogeneity of selection and the evolution of resistance. Trends Ecol Evol 2013; 28:110-8. [DOI: 10.1016/j.tree.2012.09.001] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 09/01/2012] [Accepted: 09/04/2012] [Indexed: 01/25/2023]
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Impact of antibiotic use on carbapenem resistance in Pseudomonas aeruginosa: is there a role for antibiotic diversity? Antimicrob Agents Chemother 2013; 57:1709-13. [PMID: 23357763 DOI: 10.1128/aac.01348-12] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In this study, we aimed to evaluate the relationship between the rates of resistance of Pseudomonas aeruginosa to carbapenems and the levels and diversity of antibiotic consumption. Data were retrospectively collected from 20 acute care hospitals across 3 regions of Switzerland between 2006 and 2010. The main outcome of the present study was the rate of resistance to carbapenems among P. aeruginosa. Putative predictors included the total antibiotic consumption and carbapenem consumption in defined daily doses per 100 bed days, the proportion of very broad-spectrum antibiotics used, and the Peterson index. The present study confirmed a correlation between carbapenem use and carbapenem resistance rates at the hospital and regional levels. The impact of diversifying the range of antibiotics used against P. aeruginosa resistance was suggested by (i) a positive correlation in multivariate analysis between the above-mentioned resistance and the proportion of consumed antibiotics having a very broad spectrum of activity (coefficient = 1.77; 95% confidence interval, 0.58 to 2.96; P < 0.01) and (ii) a negative correlation between the resistance and diversity of antibiotic use as measured by the Peterson homogeneity index (coefficient = -0.52; P < 0.05). We conclude that promoting heterogeneity plus parsimony in the use of antibiotics appears to be a valuable strategy for minimizing the spread of carbapenem resistance in P. aeruginosa in hospitals.
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Kees MG. [Strategies to avoid antibiotic resistance]. Med Klin Intensivmed Notfmed 2013; 108:125-30. [PMID: 23344520 DOI: 10.1007/s00063-012-0158-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 01/11/2013] [Indexed: 11/24/2022]
Abstract
Antibiotics are used very frequently in critically ill patients as a causal and often life-saving treatment; however, the high density of use of broad spectrum antibiotics contributes to a further deterioration in resistance trends, which makes a rational prescription behavior mandatory. This particularly includes measures which lead to the reduction of antibiotic use, i.e. rigorous indications, targeted de-escalation and limited duration. For optimal efficacy of a necessary treatment the integration of pharmacokinetic and pharmacodynamic principles can be helpful.
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Affiliation(s)
- M G Kees
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin.
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Antibiotic rotation for febrile neutropenic patients with hematological malignancies: clinical significance of antibiotic heterogeneity. PLoS One 2013; 8:e54190. [PMID: 23372683 PMCID: PMC3553165 DOI: 10.1371/journal.pone.0054190] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 12/07/2012] [Indexed: 11/19/2022] Open
Abstract
Background Our unit adopted the single administration of cefepime as the initial treatment for febrile episodes in neutropenic patients with hematological malignancies. However, recently, cefepime-resistant gram-negative bacteremia, including those with extended-spectrum β-lactamase (ESBL)-producers, was frequently observed in these patients. Therefore, we instituted a rotation of primary antibiotics for febrile neutropenic patients in an attempt to control antibiotic resistance. Methods This prospective trial was performed from August 2008 through March 2011 at our unit. After a pre-intervention period, in which cefepime was used as the initial agent for febrile neutropenia, 4 primary antibiotics, namely, piperacillin-tazobactam, ciprofloxacin, meropenem, and cefepime, were rotated at 1-month intervals over 20 months. Blood and surveillance cultures were conducted for febrile episodes, in order to assess the etiology, the resistance pattern (particularly to cefepime), and the prognosis. Results In this trial, 219 patients were registered. A 65.9% reduction in the use of cefepime occurred after the antibiotic rotation. In the surveillance stool cultures, the detection rate of cefepime-resistant gram-negative isolates, of which ESBL-producers were predominant, declined significantly after the intervention (8.5 vs 0.9 episodes per 1000 patient days before and after intervention respectively, P<0.01). Interestingly, ESBL-related bacteremia was not detected after the initiation of the trial (1.7 vs 0.0 episodes per 1000 patient days before and after intervention respectively, P<0.01). Infection-related mortality was comparable between the 2 periods. Conclusions We implemented a monthly rotation of primary antibiotics for febrile neutropenic patients. An antibiotic heterogeneity strategy, mainly performed as a cycling regimen, would be useful for controlling antimicrobial resistance among patients treated for febrile neutropenia.
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Gould IM, Bal AM. New antibiotic agents in the pipeline and how they can help overcome microbial resistance. Virulence 2013; 4:185-91. [PMID: 23302792 PMCID: PMC3654619 DOI: 10.4161/viru.22507] [Citation(s) in RCA: 181] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Bacterial resistance is a growing threat and yet few new antibiotics active against multi-resistant bacteria are being explored. A combination of falling profits, regulatory mechanisms and irrational and injudicious use of antibiotics has led to an alarming situation where some infections have no cure. In this article, we summarize the new developments that have been suggested to incentivize the pharmaceutical industries toward the field of infections. We also briefly mention the new compounds on the horizon and some newly approved compounds that might help us tide over this crisis.
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Multidrug therapy and evolution of antibiotic resistance: when order matters. Appl Environ Microbiol 2012; 78:6137-42. [PMID: 22729549 DOI: 10.1128/aem.01078-12] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The evolution of drug resistance among pathogenic bacteria has led public health workers to rely increasingly on multidrug therapy to treat infections. Here, we compare the efficacy of combination therapy (i.e., using two antibiotics simultaneously) and sequential therapy (i.e., switching two antibiotics) in minimizing the evolution of multidrug resistance. Using in vitro experiments, we show that the sequential use of two antibiotics against Pseudomonas aeruginosa can slow down the evolution of multiple-drug resistance when the two antibiotics are used in a specific order. A simple population dynamics model reveals that using an antibiotic associated with high costs of resistance first minimizes the chance of multidrug resistance evolution during sequential therapy under limited mutation supply rate. As well as presenting a novel approach to multidrug therapy, this work shows that costs of resistance not only influences the persistence of antibiotic-resistant bacteria but also plays an important role in the emergence of resistance.
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Abstract
PURPOSE OF REVIEW Antimicrobial stewardship is now recognized as a formal strategy for curbing the upward trend in antibiotic resistance. Literature on antimicrobial stewardship has focused on areas of strategic importance and operational delivery. A number of barriers have been recognized in the implementation of successful programs. These include lack of physician participation, lack of diagnostic facility, absence of formal mechanism of data collection, variation between countries, and lack of cooperative strategies. In this review, we suggest strategies to overcome these barriers. RECENT FINDINGS In the last few years, it has been recognized that an executive program is necessary for successful implementation of strategies to control the growing antibiotic resistance. Efforts have been made at higher levels of government through organizations such as the European Centre for Disease Prevention and Control. The need for community healthcare involvement has also been recognized. At a local level, strategies to promote cooperation between various committees (e.g. infection control and antimicrobial management teams) have been proposed and adopting antibiotic care bundles as part of patient safety and healthcare is being explored. SUMMARY We suggest that executive level planning, local cooperation, sustained education, emphasis on de-escalation, and use of care bundles could stem the tide of growing resistance.
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Perron GG, Lee AEG, Wang Y, Huang WE, Barraclough TG. Bacterial recombination promotes the evolution of multi-drug-resistance in functionally diverse populations. Proc Biol Sci 2011; 279:1477-84. [PMID: 22048956 DOI: 10.1098/rspb.2011.1933] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Bacterial recombination is believed to be a major factor explaining the prevalence of multi-drug-resistance (MDR) among pathogenic bacteria. Despite extensive evidence for exchange of resistance genes from retrospective sequence analyses, experimental evidence for the evolutionary benefits of bacterial recombination is scarce. We compared the evolution of MDR between populations of Acinetobacter baylyi in which we manipulated both the recombination rate and the initial diversity of strains with resistance to single drugs. In populations lacking recombination, the initial presence of multiple strains resistant to different antibiotics inhibits the evolution of MDR. However, in populations with recombination, the inhibitory effect of standing diversity is alleviated and MDR evolves rapidly. Moreover, only the presence of DNA harbouring resistance genes promotes the evolution of resistance, ruling out other proposed benefits for recombination. Together, these results provide direct evidence for the fitness benefits of bacterial recombination and show that this occurs by mitigation of functional interference between genotypes resistant to single antibiotics. Although analogous to previously described mechanisms of clonal interference among alternative beneficial mutations, our results actually highlight a different mechanism by which interactions among co-occurring strains determine the benefits of recombination for bacterial evolution.
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Affiliation(s)
- Gabriel G Perron
- Division of Biology, Imperial College London, Silwood Park Campus, Ascot SL5 7PY, UK.
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Cantón R, Ruiz-Garbajosa P. Co-resistance: an opportunity for the bacteria and resistance genes. Curr Opin Pharmacol 2011; 11:477-85. [DOI: 10.1016/j.coph.2011.07.007] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 07/18/2011] [Accepted: 07/19/2011] [Indexed: 11/28/2022]
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Cantón R, Morosini MI. Emergence and spread of antibiotic resistance following exposure to antibiotics. FEMS Microbiol Rev 2011; 35:977-91. [PMID: 21722146 DOI: 10.1111/j.1574-6976.2011.00295.x] [Citation(s) in RCA: 196] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Within a susceptible wild-type population, a small fraction of cells, even <10(-9) , is not affected when challenged by an antimicrobial agent. This subpopulation has mutations that impede antimicrobial action, allowing their selection during clinical treatment. Emergence of resistance occurs in the frame of a selective compartment termed a mutant selection window (MSW). The lower margin corresponds to the minimum inhibitory concentration of the susceptible cells, whereas the upper boundary, named the mutant prevention concentration (MPC), restricts the growth of the entire population, including that of the resistant mutants. By combining pharmacokinetic/pharmacodynamic concepts and an MPC strategy, the selection of resistant mutants can be limited. Early treatment avoiding an increase of the inoculum size as well as a regimen restricting the time within the MSW can reduce the probability of emergence of the resistant mutants. Physiological and, possibly, genetic adaptation in biofilms and a high proportion of mutator clones that may arise during chronic infections influence the emergence of resistant mutants. Moreover, a resistant population can emerge in a specific selective compartment after acquiring a resistance trait by horizontal gene transfer, but this may also be avoided to some extent when the MPC is reached. Known linkage between antimicrobial use and resistance should encourage actions for the design of antimicrobial treatment regimens that minimize the emergence of resistance. Emergence of a resistant bacterial subpopulation within a susceptible wild-type population can be restricted with a regimen using an antibiotic dose that is sufficiently high to inhibit both susceptible and resistant bacteria.
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Affiliation(s)
- Rafael Cantón
- Servicio de Microbiología and CIBER en Epidemiología y Salud Pública, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain.
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Nikaido H, Pagès JM. Broad-specificity efflux pumps and their role in multidrug resistance of Gram-negative bacteria. FEMS Microbiol Rev 2011; 36:340-63. [PMID: 21707670 DOI: 10.1111/j.1574-6976.2011.00290.x] [Citation(s) in RCA: 479] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Antibiotic resistance mechanisms reported in Gram-negative bacteria are causing a worldwide health problem. The continuous dissemination of 'multidrug-resistant' (MDR) bacteria drastically reduces the efficacy of our antibiotic 'arsenal' and consequently increases the frequency of therapeutic failure. In MDR bacteria, the overexpression of efflux pumps that expel structurally unrelated drugs contributes to the reduced susceptibility by decreasing the intracellular concentration of antibiotics. During the last decade, several clinical data have indicated an increasing involvement of efflux pumps in the emergence and dissemination of resistant Gram-negative bacteria. It is necessary to clearly define the molecular, functional and genetic bases of the efflux pump in order to understand the translocation of antibiotic molecules through the efflux transporter. The recent investigation on the efflux pump AcrB at its structural and physiological levels, including the identification of drug affinity sites and kinetic parameters for various antibiotics, may pave the way towards the rational development of an improved new generation of antibacterial agents as well as efflux inhibitors in order to efficiently combat efflux-based resistance mechanisms.
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Affiliation(s)
- Hiroshi Nikaido
- Department of Molecular and Cell Biology, University of California, Berkeley, CA, USA
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Abstract
Origins of antibiotic drug discovery are frequently traced to 1929 when Alexander Fleming recognized the antibacterial activity of a substance secreted by Penicillium notatum on a contaminated culture plate. However, the subsequent development of penicillin as a therapeutic agent was not realized until the early 1940s, after a consortium of academic and pharmaceutical scientists from England and the United States developed sufficiently advanced fermentation technology to produce high-purity penicillin in large enough quantities for medical supplies. It was at this time that the antibiotic era was truly successfully launched. During the following decade, unprecedented antibiotic research and development emerged in academic laboratories and the pharmaceutical industry, resulting in identification of most of the antibiotic classes currently used therapeutically. This short historical commentary describes some of these early events, beginning with a conference held at the New York Academy of Sciences in 1946, the first conference to focus entirely on the latest science related to the identification and characterization of antibacterial substances produced by microorganisms.
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Affiliation(s)
- Karen Bush
- Department of Biology, Indiana University, Bloomington, Indiana, USA.
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