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Jover-Sáenz A, Ramírez-Hidalgo M, Bellés Bellés A, Ribes Murillo E, Batlle Bosch M, Ribé Miró A, Mari López A, Cayado Cabanillas J, Piqué Palacín N, Garrido-Calvo S, Ortiz Valls M, Gracia Vilas MI, Gros Navés L, Javierre Caudevilla MJ, Montull Navarro L, Bañeres Argiles C, Vaqué Castilla P, Ichart Tomás JJ, Saura Codina M, Andreu Mayor E, Martorell Solé R, Vena Martínez A, Albalad Samper JM, Cano Marrón S, Soler Elcacho C, Rodríguez Garrocho A, Terrer Manrique G, Solé Curcó A, Escuin DDLR, Estadella Servalls MJ, Figueres Farreny AM, Montaña Esteban LM, Sanz Borrell L, Morales Valle A, Pallerola Planes M, Hamadi A, Pujol Aymerich F, Toribio Redondo F, Urgelés Castillón MC, Valgañon Palacios J, Olivart Parejo M, Torres-Puig-gros J. Effects of a Primary Care Antimicrobial Stewardship Program on Meticillin-Resistant Staphylococcus aureus Strains across a Region of Catalunya (Spain) over 5 Years. Antibiotics (Basel) 2024; 13:92. [PMID: 38247651 PMCID: PMC10812605 DOI: 10.3390/antibiotics13010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024] Open
Abstract
Primary care antimicrobial stewardship program (ASP) interventions can reduce the over-prescription of unnecessary antibiotics, but the impact on the reduction in bacterial resistance is less known, and there is a lack of available data. We implemented a prolonged educational counseling ASP in a large regional outpatient setting to assess its feasibility and effectiveness. Over a 5-year post-implementation period, which was compared to a pre-intervention period, a significant reduction in antibiotic prescriptions occurred, particularly those associated with greater harmful effects and resistance selection. There was also a decrease in methicillin-resistant Staphylococcus aureus (MRSA) strains and in their co-resistance to other antibiotics, particularly those with an ecological impact.
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Affiliation(s)
- Alfredo Jover-Sáenz
- Unidad Territorial Infección Nosocomial (UTIN), Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain;
| | - María Ramírez-Hidalgo
- Unidad Territorial Infección Nosocomial (UTIN), Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain;
| | - Alba Bellés Bellés
- Sección de Microbiología, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain;
| | - Esther Ribes Murillo
- Unidad de Farmacia de Atención Primaria, Institut Català de la Salut (ICS), 25007 Lleida, Spain;
| | - Meritxell Batlle Bosch
- Equipo de Atención Priamaria (EAP) Les Borges Blanques, 25400 Lleida, Spain; (M.B.B.); (A.R.M.)
| | - Anna Ribé Miró
- Equipo de Atención Priamaria (EAP) Les Borges Blanques, 25400 Lleida, Spain; (M.B.B.); (A.R.M.)
| | - Alba Mari López
- EAP Pla d’Urgell, 25001 Lleida, Spain; (A.M.L.); (J.C.C.); (N.P.P.)
| | | | | | | | | | | | | | | | | | | | | | - José Javier Ichart Tomás
- Servicio de Urgencias, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain; (J.J.I.T.); (M.S.C.)
| | - Mireia Saura Codina
- Servicio de Urgencias, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain; (J.J.I.T.); (M.S.C.)
| | | | | | - Ana Vena Martínez
- Servei de Geriatria, Hospital Universitari Santa Maria, 25198 Lleida, Spain;
| | | | - Susana Cano Marrón
- EAP Onze de Setembre, 25005 Lleida, Spain; (S.C.M.); (C.S.E.); (A.R.G.); (G.T.M.)
| | | | | | | | | | | | | | | | | | | | | | | | - Aly Hamadi
- EAP Balaguer, 25600 Lleida, Spain; (M.P.P.); (A.H.)
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Ng TM, Ang LW, Heng ST, Kwa ALH, Wu JE, Seah XFV, Lee SY, Seah J, Choo R, Lim PL, Thoon KC, Chlebicki MP, Somani J, Lee TH, Lye DC. Antibiotic utilisation and resistance over the first decade of nationally funded antimicrobial stewardship programmes in Singapore acute-care hospitals. Antimicrob Resist Infect Control 2023; 12:82. [PMID: 37612738 PMCID: PMC10464409 DOI: 10.1186/s13756-023-01289-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVE The aim of this study was to describe the time series of broad-spectrum antibiotic utilisation and incidence of antibiotic-resistant organisms during the implementation of antimicrobial stewardship programmes (ASP) in Singapore. METHODS An observational study was conducted using data from 2011 to 2020 in seven acute-care public hospitals. We applied joinpoint regressions to investigate changes in antibiotic utilisation rate and incidence density of antibiotic-resistant organisms. RESULTS Across the seven hospitals, quarterly broad-spectrum antibiotic utilisation rate remained stable. Half-yearly incidence density of antibiotic-resistant organisms with two joinpoints at first half (H1) of 2012 and second half (H2) of 2014 decreased significantly in the second and third period with a half-yearly percentage change (HPC) of -2.9% and - 0.5%, respectively. Across the five hospitals with complete data, half-yearly broad-spectrum antibiotic utilisation rate with one joinpoint decreased significantly from H1 of 2011 to H2 of 2018 (HPC - 4.0%) and H2 of 2018 to H2 2020 (HPC - 0.5%). Incidence density of antibiotic-resistant organisms decreased significantly in the two joinpoint periods from H1 of 2012 to H2 of 2014 (HPC - 2.7%) and H2 of 2014 to H2 of 2020 (HPC - 1.0%). Ceftriaxone with one joinpoint decreased significantly from H1 of 2011 to H1 of 2014 (HPC - 6.0%) and H1 of 2014 to H2 of 2020 (HPC - 1.8%) and ceftriaxone-resistant E. coli and K. pneumoniae decreased significantly in later periods, from H2 of 2016 to H2 of 2020 (HPC - 2.5%) and H1 of 2012 to H2 of 2015 (HPC - 4.6%) respectively. Anti-pseudomonal antibiotics with one joinpoint decreased significantly from H1 of 2011 to H2 of 2014 (HPC - 4.5%) and H2 of 2014 to H2 of 2020 (HPC - 0.8%) and that of quinolones with one joinpoint at H1 of 2015 decreased significantly in the first period. C. difficile with one joinpoint increased significantly from H1 of 2011 to H1 of 2015 (HPC 3.9%) and decreased significantly from H1 of 2015 to H2 of 2020 (HPC - 4.9%). CONCLUSIONS In the five hospitals with complete data, decrease in broad-spectrum antibiotic utilisation rate was followed by decrease in incidence density of antibiotic-resistant organisms. ASP should continue to be nationally funded as a key measure to combat antimicrobial resistance in acute care hospitals.
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Affiliation(s)
- Tat Ming Ng
- Tan Tock Seng Hospital, Singapore, Singapore.
| | - Li Wei Ang
- National Centre for Infectious Diseases, Singapore, Singapore
- Ministry of Health, Singapore, Singapore
| | | | - Andrea Lay-Hoon Kwa
- Singapore General Hospital, Singapore, Singapore
- Duke- National University of Singapore Medical School, Singapore, Singapore
| | - Jia En Wu
- National University Hospital, Singapore, Singapore
| | | | | | | | - Robin Choo
- Ng Teng Fong General Hospital, Singapore, Singapore
| | - Poh Lian Lim
- Tan Tock Seng Hospital, Singapore, Singapore
- National Centre for Infectious Diseases, Singapore, Singapore
- Ministry of Health, Singapore, Singapore
| | - Koh Cheng Thoon
- KK Women's and Children's Hospital, Singapore, Singapore
- Duke- National University of Singapore Medical School, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
| | | | - Jyoti Somani
- National University Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Tau Hong Lee
- Tan Tock Seng Hospital, Singapore, Singapore
- National Centre for Infectious Diseases, Singapore, Singapore
| | - David C Lye
- Tan Tock Seng Hospital, Singapore, Singapore
- National Centre for Infectious Diseases, Singapore, Singapore
- Yong Loo Lin School of Medicine, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
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Poku E, Cooper K, Cantrell A, Harnan S, Sin MA, Zanuzdana A, Hoffmann A. Systematic review of time lag between antibiotic use and rise of resistant pathogens among hospitalized adults in Europe. JAC Antimicrob Resist 2023; 5:dlad001. [PMID: 36694849 PMCID: PMC9856344 DOI: 10.1093/jacamr/dlad001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 12/28/2022] [Indexed: 01/21/2023] Open
Abstract
Background Antimicrobial resistance (AMR) causes substantial health and economic burden to individuals, healthcare systems and societies globally. Understanding the temporal relationship between antibiotic consumption and antibiotic resistance in hospitalized patients can better inform antibiotic stewardship activities and the time frame for their evaluation. Objectives This systematic review examined the temporal relationship between antibiotic use and development of antibiotic resistance for 42 pre-defined antibiotic and pathogen combinations in hospitalized adults in Europe. Methods Searches in MEDLINE, Embase, Cochrane Library and NIHR Centre for Reviews and Dissemination were undertaken from 2000 to August 2021. Pathogens of interest were Escherichia coli, Klebsiella pneumoniae, Streptococcus pneumoniae, Staphylococcus aureus, Enterococcus faecium, CoNS, Pseudomonas aeruginosa and Acinetobacter baumannii complex. Results Twenty-eight ecological studies and one individual-level study were included. Ecological studies were predominantly retrospective in design (19 studies) and of reasonable (20 studies) to high (8 studies) methodological quality. Of the eight pathogens of interest, no relevant data were identified for S. pneumoniae and CoNS. Across all pathogens, the time-lag data from the 28 ecological studies showed a similar pattern, with the majority of studies reporting lags ranging from 0 to 6 months. Conclusions Development of antibiotic resistance for the investigated antibiotic/pathogen combinations tends to occur over 0 to 6 months following exposure within European hospitals. This information could inform planning of antibiotic stewardship activities in hospital settings.
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Affiliation(s)
- Edith Poku
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katy Cooper
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sue Harnan
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Muna Abu Sin
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Arina Zanuzdana
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
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Aldeyab MA, Bond SE, Conway BR, Lee-Milner J, Sarma JB, Lattyak WJ. A Threshold Logistic Modelling Approach for Identifying Thresholds between Antibiotic Use and Methicillin-Resistant Staphylococcus aureus Incidence Rates in Hospitals. Antibiotics (Basel) 2022; 11:antibiotics11091250. [PMID: 36140029 PMCID: PMC9495804 DOI: 10.3390/antibiotics11091250] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/06/2022] [Accepted: 09/13/2022] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to demonstrate the utility of threshold logistic modelling, an innovative approach in identifying thresholds and risk scores in the context of population antibiotic use associated with methicillin-resistant Staphylococcus aureus (MRSA) incidence rates in hospitals. The study also aimed to assess the impact of exceeding those thresholds that resulted in increased MRSA rates. The study was undertaken in a 700-bed hospital in England between January 2015 and December 2021 (84 monthly observations). By employing the threshold logistic modelling approach, we: (i) determined the cut-off percentile value of MRSA incidence that defines a critical level of MRSA; (ii) identified thresholds for fluoroquinolone and co-amoxiclav use that would accelerate MRSA incidence rates and increase the probability of reaching critical incidence levels; (iii) enabled a better understanding of the effect of antibiotic use on the probability of reaching a critical level of resistant pathogen incidence; (iv) developed a near real-time performance monitoring feedback system; (v) provided risk scores and alert signals for antibiotic use, with the ability to inform hospital policies, and control MRSA incidence; and (vi) provided recommendations and an example for the management of pathogen incidence in hospitals. Threshold logistic models can help hospitals determine quantitative targets for antibiotic usage and can also inform effective antimicrobial stewardship to control resistance in hospitals. Studies should work toward implementing and evaluating the proposed approach prospectively, with the aim of determining the best counter-measures to mitigate the risk of increased resistant pathogen incidence in hospitals.
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Affiliation(s)
- Mamoon A. Aldeyab
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
- Correspondence:
| | - Stuart E. Bond
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
- Pharmacy Department, Mid Yorkshire Hospitals NHS Trust, Wakefield WF1 4DG, UK
| | - Barbara R. Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
- Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Jade Lee-Milner
- Pharmacy Department, Mid Yorkshire Hospitals NHS Trust, Wakefield WF1 4DG, UK
| | - Jayanta B. Sarma
- Department of Microbiology, Mid Yorkshire Hospitals NHS Trust, Wakefield WF1 4DG, UK
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Identifying Antibiotic Use Targets for the Management of Antibiotic Resistance Using an Extended-Spectrum β-Lactamase-Producing Escherichia coli Case: A Threshold Logistic Modeling Approach. Antibiotics (Basel) 2022; 11:antibiotics11081116. [PMID: 36009985 PMCID: PMC9405284 DOI: 10.3390/antibiotics11081116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/11/2022] [Accepted: 08/16/2022] [Indexed: 01/21/2023] Open
Abstract
The aim of this study was to develop a logistic modeling concept to improve understanding of the relationship between antibiotic use thresholds and the incidence of resistant pathogens. A combined approach of nonlinear modeling and logistic regression, named threshold logistic, was used to identify thresholds and risk scores in hospital-level antibiotic use associated with hospital-level incidence rates of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (E. coli). Threshold logistic models identified thresholds for fluoroquinolones (61.1 DDD/1000 occupied bed days (OBD)) and third-generation cephalosporins (9.2 DDD/1000 OBD) to control hospital ESBL-producing E. coli incidence. The 60th percentile of ESBL-producing E. coli was determined as the cutoff for defining high incidence rates. Threshold logistic analysis showed that for every one-unit increase in fluoroquinolones and third-generation cephalosporins above 61.1 and 9.2 DDD/1000 OBD levels, the average odds of the ESBL-producing E. coli incidence rate being ≥60th percentile of historical levels increased by 4.5% and 12%, respectively. Threshold logistic models estimated the risk scores of exceeding the 60th percentile of a historical ESBL-producing E. coli incidence rate. Threshold logistic models can help hospitals in defining critical levels of antibiotic use and resistant pathogen incidence and provide targets for antibiotic consumption and a near real-time performance monitoring feedback system.
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Identifying Targets for Antibiotic Use for the Management of Carbapenem-Resistant Acinetobacter baumannii (CRAb) in Hospitals-A Multi-Centre Nonlinear Time-Series Study. Antibiotics (Basel) 2022; 11:antibiotics11060775. [PMID: 35740181 PMCID: PMC9220031 DOI: 10.3390/antibiotics11060775] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/03/2022] [Accepted: 06/05/2022] [Indexed: 01/21/2023] Open
Abstract
Solutions are needed to inform antimicrobial stewardship (AMS) regarding balancing the access to effective antimicrobials with the need to control antimicrobial resistance. Theoretical and mathematical models suggest a non-linear relationship between antibiotic use and resistance, indicating the existence of thresholds of antibiotic use beyond which resistance would be triggered. It is anticipated that thresholds may vary across populations depending on host, environment, and organism factors. Further research is needed to evaluate thresholds in antibiotic use for a specific pathogen across different settings. The objective of this study is to identify thresholds of population antibiotic use associated with the incidence of carbapenem-resistant Acinetobacter baumannii (CRAb) across six hospital sites in Oman. The study was an ecological, multi-centre evaluation that involved collecting historical antibiotic use and CRAb incidence over the period from January 2015 to December 2019. By using non-linear time-series analysis, we identified different thresholds in the use of third-generation cephalosporins, piperacillin-tazobactam, aminoglycoside, and fluoroquinolones across participating hospitals. The identification of different thresholds emphasises the need for tailored analysis based on modelling data from each hospital. The determined thresholds can be used to set targets for each hospital AMS, providing a balance between access to these antibiotics versus controlling CRAb incidence.
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Cai L, Sun J, Yao F, Yuan Y, Zeng M, Zhang Q, Xie Q, Wang S, Wang Z, Jiao X. Antimicrobial resistance bacteria and genes detected in hospital sewage provide valuable information in predicting clinical antimicrobial resistance. THE SCIENCE OF THE TOTAL ENVIRONMENT 2021; 795:148815. [PMID: 34247085 DOI: 10.1016/j.scitotenv.2021.148815] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 06/27/2021] [Accepted: 06/29/2021] [Indexed: 02/05/2023]
Abstract
Extensive use of antibiotics is significantly associated with development of antibiotic-resistant (AR) bacteria. However, their causal relationships have not been adequately investigated, especially in human population and hospitals. Our aims were to understand clinical AR through revealing co-occurrence patterns between antibiotic-resistant bacteria and genes (ARB and ARGs), and their association with antibiotic use, and to consider impact of ARB and ARGs on environmental and human health. Antibiotic usage was calculated based on the actual consumption in our target hospital. ARB was identified by culture. In isolates collected from hospital sewage, bacterial-specific DNA sequences and ARGs were determined using metagenomics. Our data revealed that the use of culture-based single-indicator-strain approaches only captured ARB in 16.17% of the infectious samples. On the other hand, 1573 bacterial species and 885 types of ARGs were detected in the sewage. Furthermore, hospital use of antibiotics influenced the resistance profiles, but the strength varied among bacteria. From our metagenomics analyses, ARGs for aminoglycosides were the most common, followed by sulfonamide, tetracycline, phenicol, macrolides, and quinolones, comprising 82.6% of all ARGs. Association analyses indicated that 519 pairs of ARGs were significantly correlated with ARB species (r > 0.8). The co-occurrence patterns of bacteria-ARGs mirrored the AR in the clinic. In conclusion, our systematic investigation further emphasized that antibiotic usage in hospital significantly influenced the abundance and types of ARB and ARGs in dose- and time-dependent manners which, in turn, mirrored clinical AR. In addition, our data provide novel information on development of certain ARB with multiple antibiotic resistance. These ARB and ARGs from sewage can also be disseminated into the environment and communities to create health problems. Therefore, it would be helpful to use such data to develop improved predictive risk model of AR, to enhance effective use of antibiotics, and to reduce environmental pollution.
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Affiliation(s)
- Leshan Cai
- The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Jiayu Sun
- Department of Cell Biology and Genetics, Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Fen Yao
- Department of Pharmacology, Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Yumeng Yuan
- Department of Cell Biology and Genetics, Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Mi Zeng
- Department of Cell Biology and Genetics, Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Qiaoxin Zhang
- The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Qingdong Xie
- Department of Cell Biology and Genetics, Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Shiwei Wang
- Jiangsu Key Laboratory of Integrated Traditional Chinese and Western Medicine for Prevention and Treatment of Senile Diseases, Medical College of Yangzhou University, Yangzhou, Jiangsu 225000, China
| | - Zhen Wang
- Institute of Marine Sciences, Shantou University, Shantou 515063, China; Guangdong Provincial Key Laboratory of Marine Biotechnology, Shantou University, Shantou 515063, China
| | - Xiaoyang Jiao
- Department of Cell Biology and Genetics, Shantou University Medical College, Shantou, Guangdong 515041, China.
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Hamada Y, Ebihara F, Kikuchi K. A Strategy for Hospital Pharmacists to Control Antimicrobial Resistance (AMR) in Japan. Antibiotics (Basel) 2021; 10:1284. [PMID: 34827222 PMCID: PMC8614892 DOI: 10.3390/antibiotics10111284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 12/21/2022] Open
Abstract
In Japan, there is concern regarding the relation between the inappropriate use of antibiotics and antibiotic resistance (AMR). Increased bacterial resistance is due in part to the inappropriate use of antimicrobial agents. The support of the pharmacist becomes important, and there is growing interest in antimicrobial stewardship to promote the appropriate and safe use of antimicrobials needed for the optimal selection of drugs, doses, durations of therapy, therapeutic drug monitoring (TDM), and implementations of cost containment strategies in Japan. Pharmacists should strive to disseminate the concept of "choosing wisely" in relation to all medicines, implement further interventions, and put them into practice. In this article, we present data for antimicrobial stewardship and Japan's AMR action plan, focusing on how pharmacists should be involved in enabling physicians to choose antimicrobials wisely.
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Affiliation(s)
- Yukihiro Hamada
- Department of Pharmacy, Tokyo Women’s Medical University Hospital, Tokyo 162-8666, Japan;
| | - Fumiya Ebihara
- Department of Pharmacy, Tokyo Women’s Medical University Hospital, Tokyo 162-8666, Japan;
| | - Ken Kikuchi
- Department of Infectious Disease, Tokyo Women’s Medical University Hospital, Tokyo 162-8666, Japan;
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Hayajneh WA, Al-Azzam S, Yusef D, Lattyak WJ, Lattyak EA, Gould I, López-Lozano JM, Conway BR, Conlon-Bingham G, Aldeyab MA. Identification of thresholds in relationships between specific antibiotic use and carbapenem-resistant Acinetobacter baumannii (CRAb) incidence rates in hospitalized patients in Jordan. J Antimicrob Chemother 2021; 76:524-530. [PMID: 33152762 DOI: 10.1093/jac/dkaa463] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/06/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Antibiotic resistance is a major threat to public health worldwide. The relationship between the intensity of antibiotic use and resistance might not be linear, suggesting that there might be a threshold of antibiotic use, beyond which resistance would be triggered. OBJECTIVES To identify thresholds in antibiotic use, below which specific antibiotic classes have no significant measurable impact on the incidence of carbapenem-resistant Acinetobacter baumannii (CRAb), but above which their use correlates with an increase in the incidence of CRAb. METHODS The study took place at a tertiary teaching hospital in Jordan. The study was ecological in nature and was carried out retrospectively over the period January 2014 to December 2019. The outcome time series for this study was CRAb cases. The primary explanatory variables were monthly use of antibiotics and the use of alcohol-based hand rub (ABHR). Non-linear time-series methods were used to identify thresholds in antibiotic use. RESULTS Non-linear time-series analysis determined a threshold in third-generation cephalosporin and carbapenem use, where the maximum use of third-generation cephalosporins and carbapenems should not exceed 8 DDD/100 occupied bed days (OBD) and 10 DDD/100 OBD, respectively. ABHR had a significant reducing effect on CRAb cases even at lower usage quantities (0.92 L/100 OBD) and had the most significant effect when ABHR exceeded 3.4 L/100 OBD. CONCLUSIONS The identification of thresholds, utilizing non-linear time-series methods, can provide a valuable tool to inform hospital antibiotic policies through identifying quantitative targets that balance access to effective therapies with control of resistance. Further studies are needed to validate the identified thresholds, through being prospectively adopted as a target for antimicrobial stewardship programmes, and then to evaluate the impact on reducing CRAb incidence.
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Affiliation(s)
- Wail A Hayajneh
- Department of Paediatrics and Neonatology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Sayer Al-Azzam
- Clinical Pharmacy Department, Jordan University of Science and Technology, Irbid, Jordan
| | - Dawood Yusef
- Department of Paediatrics and Neonatology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | | | | | - Ian Gould
- Medical Microbiology Department, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK
| | | | - Barbara R Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK.,Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield, UK
| | | | - Mamoon A Aldeyab
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
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Tóth H, Buchholcz G, Fésüs A, Balázs B, Nagy JB, Majoros L, Szarka K, Kardos G. Evolution of the Gram-Negative Antibiotic Resistance Spiral over Time: A Time-Series Analysis. Antibiotics (Basel) 2021; 10:antibiotics10060734. [PMID: 34204497 PMCID: PMC8234935 DOI: 10.3390/antibiotics10060734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 11/16/2022] Open
Abstract
We followed up the interplay between antibiotic use and resistance over time in a tertiary-care hospital in Hungary. Dynamic relationships between monthly time-series of antibiotic consumption data (defined daily doses per 100 bed-days) and of incidence densities of Gram-negative bacteria (Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, and Acinetobacter baumannii) resistant to cephalosporins or carbapenems were followed using vector autoregressive models sequentially built of time-series ending in 2015, 2016, 2017, 2018, and 2019. Relationships with Gram-negative bacteria as a group were fairly stable across years. At species level, association of cephalosporin use and cephalosporin resistance of E. coli was shown in 2015–2017, leading to increased carbapenem use in these years. Association of carbapenem use and carbapenem resistance, as well as of carbapenem resistance and colistin use in case of A. baumannii, were consistent throughout; associations in case of Klebsiella spp. were rarely found; associations in case of P. aeruginosa varied highly across years. This highlights the importance of temporal variations in the interplay between changes in selection pressure and occurrence of competing resistant species.
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Affiliation(s)
- Hajnalka Tóth
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary; (H.T.); (A.F.); (B.B.); (J.B.N.); (L.M.); (K.S.)
- Doctoral School of Pharmaceutical Sciences, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary
- Ostalb Klinikum, Im Kälblesrain 1, D-73430 Aalen, Germany
| | - Gyula Buchholcz
- Central Clinical Pharmacy, Clinical Center, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary;
| | - Adina Fésüs
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary; (H.T.); (A.F.); (B.B.); (J.B.N.); (L.M.); (K.S.)
- Doctoral School of Pharmaceutical Sciences, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary
- Central Clinical Pharmacy, Clinical Center, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary;
| | - Bence Balázs
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary; (H.T.); (A.F.); (B.B.); (J.B.N.); (L.M.); (K.S.)
- Doctoral School of Pharmaceutical Sciences, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary
- Department of Metagenomics, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary
| | - József Bálint Nagy
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary; (H.T.); (A.F.); (B.B.); (J.B.N.); (L.M.); (K.S.)
- Doctoral School of Pharmaceutical Sciences, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary
| | - László Majoros
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary; (H.T.); (A.F.); (B.B.); (J.B.N.); (L.M.); (K.S.)
- Doctoral School of Pharmaceutical Sciences, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary
| | - Krisztina Szarka
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary; (H.T.); (A.F.); (B.B.); (J.B.N.); (L.M.); (K.S.)
- Doctoral School of Pharmaceutical Sciences, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary
| | - Gábor Kardos
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary; (H.T.); (A.F.); (B.B.); (J.B.N.); (L.M.); (K.S.)
- Department of Metagenomics, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary
- Correspondence: ; Tel.: +36-5225-5425
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11
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Borg MA, Suda D, Scicluna E, Brincat A, Zarb P. Universal admission screening: a potential game-changer in hospitals with high prevalence of MRSA. J Hosp Infect 2021; 113:77-84. [PMID: 33811962 DOI: 10.1016/j.jhin.2021.03.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/24/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Despite the perception that meticillin-resistant Staphylococcus aureus (MRSA) is now under control in high-income countries, global prevalence remains high, even increasing in some regions. Universal admission screening and decolonization has been instituted in some hospitals to attempt control but the practice remains controversial. METHODS In 2014, Mater Dei Hospital in Malta introduced a universal admission screening policy, utilizing a novel, centralized and customized approach to achieve high compliance and low cost. Admissions are screened nasally by designated staff using chromogenic media, irrespective of risk factors. Carriers are decolonized without concurrent isolation or contact precautions. In this study, longitudinal, quasi-experimental evaluation was undertaken using time series analysis to analyse the impact of the intervention on the proportion of MRSA among clinical S. aureus isolates (%MRSA) and incidence per 1000 bed-days. A cost-utility analysis was also attempted to identify approximate quality-adjusted life years (QALYs) gained. RESULTS A transfer function model approach concluded that the intervention had a significant effect on both %MRSA and incidence. Six years following its introduction, the screening programme had led to an overall 43% long-term reduction in %MRSA from pre-screening levels [R2=0.687; Bayesian information criterion (BIC)=4.063], translating to a decrease in incidence of approximately 0.56 cases/1000 bed-days (R2=0.633, BIC=-3.063). No correlation was identified with consumption of antibiotics or alcohol hand rub. The annual cost-benefit of the programme was calculated at €1058 per QALY gain per year. CONCLUSION The universal admission screening and decolonization intervention was successful and cost-effective in this high-endemicity setting. It facilitated improvement in the prevalence of MRSA, achieving reduction levels rarely reported by Mediterranean hospitals.
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Affiliation(s)
- M A Borg
- University of Malta, Msida, Malta; Mater Dei Hospital, Msida, Malta.
| | - D Suda
- University of Malta, Msida, Malta
| | | | | | - P Zarb
- University of Malta, Msida, Malta; Mater Dei Hospital, Msida, Malta
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12
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Guthrie JL, Teatero S, Hirai S, Fortuna A, Rosen D, Mallo GV, Campbell J, Pelude L, Golding G, Simor AE, Patel SN, McGeer A, Fittipaldi N. Genomic Epidemiology of Invasive Methicillin-Resistant Staphylococcus aureus Infections Among Hospitalized Individuals in Ontario, Canada. J Infect Dis 2021; 222:2071-2081. [PMID: 32432674 DOI: 10.1093/infdis/jiaa147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 04/03/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Prevention and control of methicillin-resistant Staphylococcus aureus (MRSA) infections remain challenging. In-depth surveillance integrating patient and isolate data can provide evidence to better inform infection control and public health practice. METHODS We analyzed MRSA cases diagnosed in 2010 (n = 212) and 2016 (n = 214) by hospitals in Ontario, Canada. Case-level clinical and demographic data were integrated with isolate characteristics, including antimicrobial resistance (AMR), classic genotyping, and whole-genome sequencing results. RESULTS Community-associated MRSA (epidemiologically defined) increased significantly from 23.6% in 2010 to 43.0% in 2016 (P < .001). The MRSA population structure changed over time, with a 1.5× increase in clonal complex (CC)8 strains and a concomitant decrease in CC5. The clonal shift was reflected in AMR patterns, with a decrease in erythromycin (86.7% to 78.4%, P = .036) and clindamycin resistance (84.3% to 47.9%, P < .001) and a >2-fold increase in fusidic acid resistance (9.0% to 22.5%, P < .001). Isolates within both CC5 and CC8 were relatively genetically diverse. We identified 6 small genomic clusters-3 potentially related to transmission in healthcare settings. CONCLUSIONS Community-associated MRSA is increasing among hospitalized individuals in Ontario. Clonal shifting from CC5 to CC8 has impacted AMR. We identified a relatively high genetic diversity and limited genomic clustering within these dominant CCs.
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Affiliation(s)
| | - Sarah Teatero
- Public Health Ontario, Toronto Laboratory, Toronto, Ontario, Canada
| | - Sotaro Hirai
- Department of Cell and Systems Biology, University of Toronto, Toronto, Ontario, Canada
| | - Alex Fortuna
- Public Health Ontario, Toronto Laboratory, Toronto, Ontario, Canada
| | - Daniel Rosen
- Public Health Ontario, Toronto Laboratory, Toronto, Ontario, Canada
| | - Gustavo V Mallo
- Public Health Ontario, Toronto Laboratory, Toronto, Ontario, Canada
| | - Jennifer Campbell
- National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Linda Pelude
- Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - George Golding
- National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Andrew E Simor
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Samir N Patel
- Public Health Ontario, Toronto Laboratory, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Allison McGeer
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Sinai Health System, Toronto, Ontario, Canada
| | - Nahuel Fittipaldi
- Public Health Ontario, Toronto Laboratory, Toronto, Ontario, Canada.,Department of Cell and Systems Biology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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13
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Kenyon C, Manoharan-Basil SS, Van Dijck C. Is There a Resistance Threshold for Macrolide Consumption? Positive Evidence from an Ecological Analysis of Resistance Data from Streptococcus pneumoniae, Treponema pallidum, and Mycoplasma genitalium. Microb Drug Resist 2021; 27:1079-1086. [PMID: 33596133 DOI: 10.1089/mdr.2020.0490] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
If we were to keep macrolide consumption below a certain threshold, would this reduce the probability of macrolide resistance emerging? No study that we are aware of has addressed this question. We, therefore, assessed at a country level if there was a macrolide consumption threshold for the selection of a prevalence of macrolide resistance of over 5% in Streptococcus pneumoniae, Treponema pallidum, and Mycoplasma genitalium. In this ecological-level analysis, we found evidence for a macrolide consumption threshold of 1.3 defined daily doses per 1,000 inhabitants per day (DID) for M. genitalium, 1.8 DID for T. pallidum, and 2.3 DID for S. pneumoniae. Our results provide further motivation for macrolide stewardship campaigns that strive to reduce macrolide consumption to levels below at least 2 DID.
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Affiliation(s)
- Chris Kenyon
- HIV/STI Unit, Institute of Tropical Medicine, Antwerp, Belgium.,Department of Medicine, Division of Infectious Diseases and HIV Medicine, University of Cape Town, Cape Town, South Africa
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14
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The Role of Uniform Meropenem Usage in Acinetobacter baumannii Clone Replacement. Antibiotics (Basel) 2021; 10:antibiotics10020127. [PMID: 33572723 PMCID: PMC7911629 DOI: 10.3390/antibiotics10020127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 01/19/2021] [Accepted: 01/26/2021] [Indexed: 01/01/2023] Open
Abstract
The dominant carbapenem resistant Acinetobacter baumannii harboring blaOXA-23-like carbapenemase was replaced by blaOXA-40-like carriers in a Hungarian tertiary-care center with high meropenem but relatively low imipenem use. We hypothesized that alterations in antibiotic consumption may have contributed to this switch. Our workgroup previous study examined the relation between resistance spiral and the antibiotic consumption, and the results suggest that the antibiotic usage provoked the increasing resistance in case of A. baumannii. We aimed at measuring the activity of imipenem and meropenem to compare the selection pressure exerted by the different carbapenems in time-kill assays. Strain replacement was confirmed by whole genome sequencing, core-genome multilocus sequence typing (cgMLST), and resistome analysis. Based on results of the time-kill assays, we found a significant difference between two different sequence-types (STs) in case of meropenem, but not in case of imipenem susceptibility. The newly emerged ST636 and ST492 had increased resistance level against meropenem compared to the previously dominant ST2 and ST49. On the other hand, the imipenem and colistin resistance profiles were similar. These results suggest, that the uniform meropenem usage may have contributed to A. baumannii strain replacement in our setting.
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15
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Kim EJ, Lee E, Kwak YG, Yoo HM, Choi JY, Kim SR, Shin MJ, Yoo SY, Cho NH, Choi YH. Trends in the Epidemiology of Candidemia in Intensive Care Units From 2006 to 2017: Results From the Korean National Healthcare-Associated Infections Surveillance System. Front Med (Lausanne) 2020; 7:606976. [PMID: 33392229 PMCID: PMC7773785 DOI: 10.3389/fmed.2020.606976] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 11/24/2020] [Indexed: 12/30/2022] Open
Abstract
Candidemia is an important healthcare-associated infection (HAI) in intensive care units (ICUs). However, limited research has been conducted on candidemia in the Republic of Korea. We aimed to analyze the secular trends in the incidence and distribution of candidemia in ICUs over 12-years using data from the Korean National Healthcare-Associated Infections Surveillance System (KONIS). KONIS was established in 2006 and has performed prospective surveillance of HAIs including bloodstream infections (BSIs) in ICUs. We evaluated the trends in the distribution of causative pathogens and the incidence of candidemia. From 2006 to 2017, 2,248 candidemia cases occurred in 9,184,264 patient-days (PDs). The pooled mean incidence rates of candidemia significantly decreased from 3.05 cases/10,000 PDs in 2006 to 2.5 cases/10,000 PDs in 2017 (P = 0.001). Nevertheless, the proportion of candidemia gradually increased from 15.2% in 2006 to 16.6% in 2017 (P = 0.001). The most frequent causative pathogen of BSIs from 2006 to 2012 was Staphylococcus aureus; however, Candida spp. emerged as the most frequent causative pathogen since 2013. C. albicans (39.9%) was the most common among Candida spp. causing BSIs, followed by Candida tropicalis (20.2%) and Candida parapsilosis (18.2%). The proportion of candidemia caused by C. glabrata significantly increased from 8.9% in 2006 to 17.9% in 2017 (P < 0.001). There was no significant change in the distribution of Candida spp. by year (P = 0.285). The most common source of BSIs was central lines associated BSI (92.5%). There was a significant increase in the proportion of candidemia by year in hospitals with organ transplant wards (from 18.9% in 2006 to 21.1% in 2017, P = 0.003), hospitals with <500 beds (from 2.7% in 2006 to 13.6% in 2017, P < 0.001), and surgical ICUs (from 16.2% in 2006 to 21.7% in 2017, P = 0.003). The proportion of candidemia has increased in Korea, especially in hospitals with <500 beds and surgical ICUs. Thus, appropriate infection control programs are needed.
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Affiliation(s)
- Eun Jin Kim
- Department of Infectious Diseases, Ajou University School of Medicine, Suwon, South Korea
| | - Eunyoung Lee
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, South Korea.,Office of Biostatistics, Medical Research Collaborating Center, Ajou Research Institute for Innovative Medicine, Ajou University Medical Center, Suwon, South Korea
| | - Yee Gyung Kwak
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Hyeon Mi Yoo
- Infection Control Office, Inje University Sanggye Paik Hospital, Seoul, South Korea
| | - Ji Youn Choi
- Infection Control Unit, Chung-Ang University Healthcare System, Seoul, South Korea
| | - Sung Ran Kim
- Infection Control Office, Korea University Guro Hospital, Seoul, South Korea
| | - Myoung Jin Shin
- Infection Control Office, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - So-Yeon Yoo
- Adjunct Assistant Professor, College of Nursing, The Catholic University of Korea, Seoul, South Korea
| | - Nan-Hyoung Cho
- Department of Infection Control, Gangnam Severance Hospital, Yonsei University, Seoul, South Korea
| | - Young Hwa Choi
- Department of Infectious Diseases, Ajou University School of Medicine, Suwon, South Korea
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16
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Toleman MS, Reuter S, Jamrozy D, Wilson HJ, Blane B, Harrison EM, Coll F, Hope RJ, Kearns A, Parkhill J, Peacock SJ, Török ME. Prospective genomic surveillance of methicillin-resistant Staphylococcus aureus (MRSA) associated with bloodstream infection, England, 1 October 2012 to 30 September 2013. ACTA ACUST UNITED AC 2020; 24. [PMID: 30696529 PMCID: PMC6351993 DOI: 10.2807/1560-7917.es.2019.24.4.1800215] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BackgroundMandatory reporting of methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI) has occurred in England for over 15years. Epidemiological information is recorded, but routine collection of isolates for characterisation has not been routinely undertaken. Ongoing developments in whole-genome sequencing (WGS) have demonstrated its value in outbreak investigations and for determining the spread of antimicrobial resistance and bacterial population structure. Benefits of adding genomics to routine epidemiological MRSA surveillance are unknown.AimTo determine feasibility and potential utility of adding genomics to epidemiological surveillance of MRSA.MethodsWe conducted an epidemiological and genomic survey of MRSA BSI in England over a 1-year period (1 October 2012--30 September 2013).ResultsDuring the study period, 903 cases of MRSA BSI were reported; 425 isolates were available for sequencing of which, 276 (65%) were clonal complex (CC) 22. Addition of 64 MRSA genomes from published outbreak investigations showed that the study genomes could provide context for outbreak isolates and supported cluster identification. Comparison to other MRSA genome collections demonstrated variation in clonal diversity achieved through different sampling strategies and identified potentially high-risk clones e.g. USA300 and local expansion of CC5 MRSA in South West England.ConclusionsWe demonstrate the potential utility of combined epidemiological and genomic MRSA BSI surveillance to determine the national population structure of MRSA, contextualise previous MRSA outbreaks, and detect potentially high-risk lineages. These findings support the integration of epidemiological and genomic surveillance for MRSA BSI as a step towards a comprehensive surveillance programme in England.
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Affiliation(s)
- Michelle S Toleman
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,Wellcome Sanger Institute, Hinxton, United Kingdom.,University of Cambridge, Department of Medicine, Cambridge, United Kingdom
| | - Sandra Reuter
- University of Freiburg, Institute for Infection Prevention and Hospital Epidemiology, Freiburg, Germany
| | | | - Hayley J Wilson
- University of Cambridge, Department of Medicine, Cambridge, United Kingdom
| | - Beth Blane
- University of Cambridge, Department of Medicine, Cambridge, United Kingdom
| | - Ewan M Harrison
- Wellcome Sanger Institute, Hinxton, United Kingdom.,University of Cambridge, Department of Medicine, Cambridge, United Kingdom
| | - Francesc Coll
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Russell J Hope
- Public Health England, National Infection Service, Colindale, London, United Kingdom
| | - Angela Kearns
- Public Health England, National Infection Service, Colindale, London, United Kingdom
| | | | - Sharon J Peacock
- London School of Hygiene and Tropical Medicine, London, United Kingdom.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,Wellcome Sanger Institute, Hinxton, United Kingdom.,University of Cambridge, Department of Medicine, Cambridge, United Kingdom
| | - M Estée Török
- Public Health England, Clinical Microbiology and Public Health Laboratory, Cambridge, United Kingdom.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,University of Cambridge, Department of Medicine, Cambridge, United Kingdom
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17
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Monnier AA, Tacconelli E, Årdal C, Cavaleri M, Gyssens IC. A case study on Staphylococcus aureus bacteraemia: available treatment options, antibiotic R&D and responsible antibiotic-use strategies. JAC Antimicrob Resist 2020; 2:dlaa034. [PMID: 34222996 PMCID: PMC8210125 DOI: 10.1093/jacamr/dlaa034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objectives This case study addresses: (i) antibiotic treatment options for Staphylococcus aureus bacteraemia (SAB), for both empirical and targeted therapy; (ii) the current status of and priorities for the antibiotic pipeline to ensure access of effective antibiotics for SAB; and (iii) strategies for responsible antibiotic use relevant to the clinical management of SAB. Methods Evidence to address the aims was extracted from the following information sources: (i) EUCAST and CLSI recommendations, summaries of product characteristics (SPCs), antibiotic treatment guidelines and the textbook Kucers’ The Use of Antibiotics; (ii) the www.clinicaltrial.gov database; and (iii) quality indicators for responsible antibiotic use. Results Current monotherapy treatment options for SAB include only three drug classes (β-lactams, glycopeptides and lipopeptides), of which two also cover MRSA bacteraemia (glycopeptides and lipopeptides). The analysis of the antibiotic pipeline and ongoing clinical trials revealed that several new antibiotics with S. aureus (including MRSA) coverage were developed in the past decade (2009–19). However, none belonged to a new antibiotic class or had superior effectiveness and their added clinical value for SAB remains to be proven. Responsible antibiotic use for the treatment of SAB was illustrated using 11 quality indicators. Conclusions Awareness of the problem of a limited antibiotic arsenal, together with incentives (e.g. push incentives), is needed to steer the R&D landscape towards the development of novel and effective antibiotics for treating SAB. In the meantime, responsible antibiotic use guided by quality indicators should preserve the effectiveness of currently available antibiotics for treating SAB.
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Affiliation(s)
- Annelie A Monnier
- Department of Internal Medicine and Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.,Faculty of Medicine, Research group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
| | - Evelina Tacconelli
- Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Christine Årdal
- Norwegian Institute of Public Health, Antimicrobial Resistance Centre, Oslo, Norway
| | | | - Inge C Gyssens
- Department of Internal Medicine and Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.,Faculty of Medicine, Research group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
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18
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Macdonald KE, Jordan CY, Crichton E, Barnes JE, Harkin GE, Hall LML, Jones JD. A retrospective analysis of the microbiology of diabetic foot infections at a Scottish tertiary hospital. BMC Infect Dis 2020; 20:218. [PMID: 32164543 PMCID: PMC7068857 DOI: 10.1186/s12879-020-4923-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 02/27/2020] [Indexed: 01/13/2023] Open
Abstract
Background This study represents the first Scottish retrospective analysis of the microbiology of diabetic foot infections (DFIs). The aims were to compare the microbiological profile of DFIs treated at a Scottish tertiary hospital to that in the literature, gather data regarding antimicrobial resistance and investigate potential trends between the microbiological results and nature or site of the clinical sample taken and age or gender of the patients. Methods A retrospective analysis of wound microbiology results was performed, data were obtained from one multidisciplinary outpatient foot clinic during the 12 months of the year 2017. Seventy-three patients and 200 microbiological investigations were included. In cases of soft tissue infection, the deepest part of a cleansed and debrided wound was sampled. In cases of osteomyelitis a bone biopsy was obtained. Factors influencing the pattern of microbial growth or prevalence of Staphylococcus aureus were investigated. Results Of the 200 microbiological investigations, 62% were culture positive, of which 37.9% were polymicrobial and 62.1% monomicrobial. Among the monomicrobial results (n = 77), most were Gram positive isolates (96.1%) and the most frequently isolated bacteria was S. aureus (84.4%). No methicillin-resistant S. aureus was reported. The prevalence of S. aureus in DFIs was associated with increasing age (p = 0.021), but no evidence of association with gender, anatomical sample site or sample material was found. Conclusion The microbiological profile of DFIs in Scotland resembles that reported elsewhere in the UK. In this context, Gram positive organisms, primarily S. aureus, are most frequently isolated from DFIs. The S. aureus isolates identified were largely susceptible to antibiotic therapy. An association between increasing patient age and the prevalence of S. aureus in DFIs was observed.
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Affiliation(s)
- Katherine E Macdonald
- Edinburgh Medical School: Biomedical Sciences, Infection Medicine, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Crispin Y Jordan
- Biomedical Teaching Organisation, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Doorway 3, Teviot Place, Edinburgh, EH8 9AG, UK
| | - Emma Crichton
- Diabetes and Endocrinology, Queen Elizabeth University Hospital, 1345 Govan Road, Govan, Glasgow, G51 4TF, UK
| | - Judith E Barnes
- Diabetes and Endocrinology, Queen Elizabeth University Hospital, 1345 Govan Road, Govan, Glasgow, G51 4TF, UK
| | - Gillian E Harkin
- Diabetes and Endocrinology, Queen Elizabeth University Hospital, 1345 Govan Road, Govan, Glasgow, G51 4TF, UK
| | - Lesley M L Hall
- Diabetes and Endocrinology, Queen Elizabeth University Hospital, 1345 Govan Road, Govan, Glasgow, G51 4TF, UK
| | - Joshua D Jones
- Edinburgh Medical School: Biomedical Sciences, Infection Medicine, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK. .,ZJU-UoE Institute, Zhejiang University School of Medicine, International Campus, Zhejiang University, 718 East Haizhou Road, Haining, Zhejiang, 314400, People's Republic of China.
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19
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Gould IM, Nebot C, Aldeyab M, López-Lozano JM. Comment on: 'Antibiotic footprint' as a communication tool to aid reduction of antibiotic consumption. J Antimicrob Chemother 2020; 75:784-785. [PMID: 31758689 DOI: 10.1093/jac/dkz496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ian M Gould
- Medical Microbiology Department, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK
| | - César Nebot
- Centro Universitario de la Defensa, Universidad Politécnica de Cartagena, San Javier, Spain
| | - Mamoon Aldeyab
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
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20
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Fuzi M, Rodriguez Baño J, Toth A. Global Evolution of Pathogenic Bacteria With Extensive Use of Fluoroquinolone Agents. Front Microbiol 2020; 11:271. [PMID: 32158437 PMCID: PMC7052298 DOI: 10.3389/fmicb.2020.00271] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/06/2020] [Indexed: 12/11/2022] Open
Abstract
It is well-established that the spread of many multidrug-resistant (MDR) bacteria is predominantly clonal. Interestingly the international clones/sequence types (STs) of most pathogens emerged and disseminated during the last three decades. Strong experimental evidence from multiple laboratories indicate that diverse fitness cost associated with high-level resistance to fluoroquinolones contributed to the selection and promotion of the international clones/STs of hospital-associated methicillin-resistant Staphylococcus aureus (HA-MRSA), extended-spectrum β-lactamase-(ESBL)-producing Klebsiella pneumoniae, ESBL-producing Escherichia coli and Clostridioides difficile. The overwhelming part of the literature investigating the epidemiology of the pathogens as a function of fluoroquinolone use remain in concordence with these findings. Moreover, recent in vitro data clearly show the potential of fluoroquinolone exposure to shape the clonal evolution of Salmonella Enteritidis. The success of the international clones/STs in all these species was linked to the strains' unique ability to evolve multiple energetically beneficial gyrase and topoisomerase IV mutations conferring high-level resistance to fluorquinolones and concomittantly permitting the acquisition of an extra resistance gene load without evoking appreciable fitness cost. Furthermore, by analyzing the clonality of multiple species, the review highlights, that in environments under high antibiotic exposure virulence factors play only a subsidiary role in the clonal dynamics of bacteria relative to multidrug-resistance coupled with favorable fitness (greater speed of replication). Though other groups of antibiotics should also be involved in selecting clones of bacterial pathogens the role of fluoroquinolones due to their peculiar fitness effect remains unique. It is suggested that probably no bacteria remain immune to the influence of fluoroquinolones in shaping their evolutionary dynamics. Consequently a more judicious use of fluoroquinolones, attuned to the proportion of international clone/ST isolates among local pathogens, would not only decrease resistance rates against this group of antibiotics but should also ameliorate the overall antibiotic resistance landscape.
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Affiliation(s)
- Miklos Fuzi
- Institute of Medical Microbiology, Semmelweis University, Budapest, Hungary
| | - Jesus Rodriguez Baño
- Unit of Infectious Diseases, Clinical Microbiology and Preventive Medicine, Department of Medicine, Hospital Universitario Virgen Macarena, University of Seville - Biomedicine Institute of Seville (IBiS), Seville, Spain
| | - Akos Toth
- Department of Bacteriology, Mycology and Parasitology, National Public Health Center, Budapest, Hungary
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21
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Resman F. Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy. Part II: Ten questions reflecting knowledge gaps and issues of controversy in the field of antimicrobial stewardship. Ther Adv Infect Dis 2020; 7:2049936120945083. [PMID: 32913648 PMCID: PMC7443983 DOI: 10.1177/2049936120945083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 06/30/2020] [Indexed: 01/15/2023] Open
Abstract
Regardless of one's opinion on antimicrobial stewardship programs (ASPs), it is hardly possible to work in hospital care and not be exposed to the term or its practical effects. Despite the term being relatively new, the number of publications in the field is vast, including several excellent reviews of general and specific aspects. Work in antimicrobial stewardship is complex, and include aspects not only of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name but a few. This review aims to take several of these aspects and the scientific evidence from antimicrobial stewardship studies and merge them into two questions: How should we design ASPs based on what we know today? and Which are the most essential unanswered questions regarding antimicrobial stewardship on a broader scale? This narrative review is written in two separate parts aiming to provide answers to the two questions. The first part, published separately, is written as a step-wise approach to designing a stewardship intervention based on the pillars of unmet need, feasibility, scientific evidence and necessary core elements. It is written mainly as a guide to someone new to the field. It is sorted into five distinct steps; (a) focusing on designing aims; (b) assessing performance and local barriers to rational antimicrobial use; (c) deciding on intervention technique; (d) practical, tailored design including core element inclusion; and (e) evaluation and sustainability. This second part formulates 10 critical questions on controversies in the field of antimicrobial stewardship. It is aimed at clinicians and researchers with stewardship experience and strives to promote discussion, not to provide answers.
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Affiliation(s)
- Fredrik Resman
- Clinical Infection Medicine, Department of
Translational Medicine, Lund University, Rut Lundskogs gata 3, plan 6, Malmö,
20502, Sweden
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Association between statewide adoption of the CDC's Core Elements of Hospital Antimicrobial Stewardship Programs and rates of methicillin-resistant Staphylococcus aureus bacteremia and Clostridioides difficile infection in the United States. Infect Control Hosp Epidemiol 2019; 41:430-437. [PMID: 31858919 DOI: 10.1017/ice.2019.352] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To measure the association between statewide adoption of the Centers for Disease Control and Prevention's (CDC's) Core Elements for Hospital Antimicrobial Stewardship Programs (Core Elements) and hospital-associated methicillin-resistant Staphylococcus aureus bacteremia (MRSA) and Clostridioides difficile infection (CDI) rates in the United States. We hypothesized that states with a higher percentage of reported compliance with the Core Elements have significantly lower MRSA and CDI rates. PARTICIPANTS All US states. DESIGN Observational longitudinal study. METHODS We used 2014-2016 data from Hospital Compare, Provider of Service files, Medicare cost reports, and the CDC's Patient Safety Atlas website. Outcomes were MRSA standardized infection ratio (SIR) and CDI SIR. The key explanatory variable was the percentage of hospitals that meet the Core Elements in each state. We estimated state and time fixed-effects models with time-variant controls, and we weighted our analyses for the number of hospitals in the state. RESULTS The percentage of hospitals reporting compliance with the Core Elements between 2014 and 2016 increased in all states. A 1% increase in reported ASP compliance was associated with a 0.3% decrease (P < .01) in CDIs in 2016 relative to 2014. We did not find an association for MRSA infections. CONCLUSIONS Increasing documentation of the Core Elements may be associated with decreases in the CDI SIR. We did not find evidence of such an association for the MRSA SIR, probably due to the short length of the study and variety of stewardship strategies that ASPs may encompass.
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Colson AR, Megiddo I, Alvarez-Uria G, Gandra S, Bedford T, Morton A, Cooke RM, Laxminarayan R. Quantifying uncertainty about future antimicrobial resistance: Comparing structured expert judgment and statistical forecasting methods. PLoS One 2019; 14:e0219190. [PMID: 31276536 PMCID: PMC6611586 DOI: 10.1371/journal.pone.0219190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 06/18/2019] [Indexed: 11/18/2022] Open
Abstract
The increase of multidrug resistance and resistance to last-line antibiotics is a major global public health threat. Although surveillance programs provide useful current and historical information on the scale of the problem, the future emergence and spread of antibiotic resistance is uncertain, and quantifying this uncertainty is crucial for guiding decisions about investment in antibiotics and resistance control strategies. Mathematical and statistical models capable of projecting future rates are challenged by the paucity of data and the complexity of the emergence and spread of resistance, but experts have relevant knowledge. We use the Classical Model of structured expert judgment to elicit projections with uncertainty bounds of resistance rates through 2026 for nine pathogen-antibiotic pairs in four European countries and empirically validate the assessments against data on a set of calibration questions. The performance-weighted combination of experts in France, Spain, and the United Kingdom projected that resistance for five pairs on the World Health Organization’s priority pathogens list (E. coli and K. pneumoniae resistant to third-generation cephalosporins and carbapenems and MRSA) would remain below 50% in 2026. In Italy, although upper bounds of 90% credible ranges exceed 50% resistance for some pairs, the medians suggest Italy will sustain or improve its current rates. We compare these expert projections to statistical forecasts based on historical data from the European Antimicrobial Resistance Surveillance Network (EARS-Net). Results from the statistical models differ from each other and from the judgmental forecasts in many cases. The judgmental forecasts include information from the experts about the impact of current and future shifts in infection control, antibiotic usage, and other factors that cannot be easily captured in statistical forecasts, demonstrating the potential of structured expert judgment as a tool for better understanding the uncertainty about future antibiotic resistance.
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Affiliation(s)
- Abigail R. Colson
- Department of Management Science, University of Strathclyde, Glasgow, Scotland, United Kingdom
- Center for Disease Dynamics, Economics & Policy, Washington, DC, United States of America
- * E-mail:
| | - Itamar Megiddo
- Department of Management Science, University of Strathclyde, Glasgow, Scotland, United Kingdom
- Center for Disease Dynamics, Economics & Policy, Washington, DC, United States of America
| | - Gerardo Alvarez-Uria
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, Andhra Pradesh, India
| | - Sumanth Gandra
- Department of Management Science, University of Strathclyde, Glasgow, Scotland, United Kingdom
- Center for Disease Dynamics, Economics & Policy, Washington, DC, United States of America
| | - Tim Bedford
- Department of Management Science, University of Strathclyde, Glasgow, Scotland, United Kingdom
| | - Alec Morton
- Department of Management Science, University of Strathclyde, Glasgow, Scotland, United Kingdom
| | - Roger M. Cooke
- Resources for the Future, Washington, DC, United States of America
- TU Delft, Delft, The Netherlands
| | - Ramanan Laxminarayan
- Department of Management Science, University of Strathclyde, Glasgow, Scotland, United Kingdom
- Center for Disease Dynamics, Economics & Policy, Washington, DC, United States of America
- Princeton Environmental Institute, Princeton University, Princeton, New Jersey, United States of America
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López-Lozano JM, Lawes T, Nebot C, Beyaert A, Bertrand X, Hocquet D, Aldeyab M, Scott M, Conlon-Bingham G, Farren D, Kardos G, Fésűs A, Rodríguez-Baño J, Retamar P, Gonzalo-Jiménez N, Gould IM. A nonlinear time-series analysis approach to identify thresholds in associations between population antibiotic use and rates of resistance. Nat Microbiol 2019; 4:1160-1172. [PMID: 30962570 DOI: 10.1038/s41564-019-0410-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 02/13/2019] [Indexed: 11/09/2022]
Abstract
Balancing access to antibiotics with the control of antibiotic resistance is a global public health priority. At present, antibiotic stewardship is informed by a 'use it and lose it' principle, in which antibiotic use by the population is linearly related to resistance rates. However, theoretical and mathematical models suggest that use-resistance relationships are nonlinear. One explanation for this is that resistance genes are commonly associated with 'fitness costs' that impair the replication or transmissibility of the pathogen. Therefore, resistant genes and pathogens may only gain a survival advantage where antibiotic selection pressures exceed critical thresholds. These thresholds may provide quantitative targets for stewardship-optimizing the control of resistance while avoiding over-restriction of antibiotics. Here, we evaluated the generalizability of a nonlinear time-series analysis approach for identifying thresholds using historical prescribing and microbiological data from five populations in Europe. We identified minimum thresholds in temporal relationships between the use of selected antibiotics and incidence rates of carbapenem-resistant Acinetobacter baumannii (Hungary), extended-spectrum β-lactamase-producing Escherichia coli (Spain), cefepime-resistant E. coli (Spain), gentamicin-resistant Pseudomonas aeruginosa (France) and methicillin-resistant Staphylococcus aureus (Northern Ireland) in different epidemiological phases. Using routinely generated data, our approach can identify context-specific quantitative targets for rationalizing population antibiotic use and controlling resistance. Prospective intervention studies that restrict antibiotic consumption are needed to validate these thresholds.
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Affiliation(s)
| | - Timothy Lawes
- The Wellcome Trust Liverpool-Glasgow Centre for Global Health Research, Liverpool, UK.
| | - César Nebot
- Centro Universitario de la Defensa de San Javier, Murcia, Spain
| | - Arielle Beyaert
- Departamento de Métodos Cuantitativos para la Economía y la Empresa, University of Murcia, Murcia, Spain
| | - Xavier Bertrand
- Laboratoire Chrono-environnement, Université de Bourgogne-Franche-Comté, Besançon, France.,Centre Hospitalier Régional Universitaire de Besançon, Besançon, France
| | - Didier Hocquet
- Laboratoire Chrono-environnement, Université de Bourgogne-Franche-Comté, Besançon, France.,Centre Hospitalier Régional Universitaire de Besançon, Besançon, France
| | - Mamoon Aldeyab
- School of Pharmacy and Pharmaceutical Science, Ulster University, Coleraine, UK
| | - Michael Scott
- Pharmacy Department, Northern Health and Social Care Trust and Regional Medicines Optimisation Innovation Centre, Antrim, UK
| | - Geraldine Conlon-Bingham
- Pharmacy Department, Northern Health and Social Care Trust and Regional Medicines Optimisation Innovation Centre, Antrim, UK
| | - David Farren
- Department of Medical Microbiology, Antrim Area Hospital, Antrim, UK
| | - Gábor Kardos
- Department of Medical Microbiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Adina Fésűs
- Clinical Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Jesús Rodríguez-Baño
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, Seville, Spain.,Department of Medicine, Instituto de Biomedicina de Sevilla, University of Sevilla, Seville, Spain
| | - Pilar Retamar
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, Seville, Spain.,Department of Medicine, Instituto de Biomedicina de Sevilla, University of Sevilla, Seville, Spain
| | | | - Ian M Gould
- Medical Microbiology Department, Aberdeen Royal Infirmary, Aberdeen, UK
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Pouwels KB, Hopkins S, Llewelyn MJ, Walker AS, McNulty CA, Robotham JV. Duration of antibiotic treatment for common infections in English primary care: cross sectional analysis and comparison with guidelines. BMJ 2019; 364:l440. [PMID: 30814052 PMCID: PMC6391655 DOI: 10.1136/bmj.l440] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the duration of prescriptions for antibiotic treatment for common infections in English primary care and to compare this with guideline recommendations. DESIGN Cross sectional study. SETTING General practices contributing to The Health Improvement Network database, 2013-15. PARTICIPANTS 931 015 consultations that resulted in an antibiotic prescription for one of several indications: acute sinusitis, acute sore throat, acute cough and bronchitis, pneumonia, acute exacerbation of chronic obstructive pulmonary disease (COPD), acute otitis media, acute cystitis, acute prostatitis, pyelonephritis, cellulitis, impetigo, scarlet fever, and gastroenteritis. MAIN OUTCOME MEASURES The main outcomes were the percentage of antibiotic prescriptions with a duration exceeding the guideline recommendation and the total number of days beyond the recommended duration for each indication. RESULTS The most common reasons for antibiotics being prescribed were acute cough and bronchitis (386 972, 41.6% of the included consultations), acute sore throat (239 231, 25.7%), acute otitis media (83 054, 8.9%), and acute sinusitis (76 683, 8.2%). Antibiotic treatments for upper respiratory tract indications and acute cough and bronchitis accounted for more than two thirds of the total prescriptions considered, and 80% or more of these treatment courses exceeded guideline recommendations. Notable exceptions were acute sinusitis, where only 9.6% (95% confidence interval 9.4% to 9.9%) of prescriptions exceeded seven days and acute sore throat where only 2.1% (2.0% to 2.1%) exceeded 10 days (recent guidance recommends five days). More than half of the antibiotic prescriptions were for longer than guidelines recommend for acute cystitis among females (54.6%, 54.1% to 55.0%). The percentage of antibiotic prescriptions exceeding the recommended duration was lower for most non-respiratory infections. For the 931 015 included consultations resulting in antibiotic prescriptions, about 1.3 million days were beyond the durations recommended by guidelines. CONCLUSION For most common infections treated in primary care, a substantial proportion of antibiotic prescriptions have durations exceeding those recommended in guidelines. Substantial reductions in antibiotic exposure can be accomplished by aligning antibiotic prescription durations with guidelines.
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Affiliation(s)
- Koen B Pouwels
- Modelling and Economics Unit, National Infection Service, Public Health England, London NW9 5EQ, UK
- Department of Health Sciences, Global Health, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Susan Hopkins
- Healthcare-Associated Infection and Antimicrobial Resistance Department, National Infection Service, Public Health England, London, UK
- Directorate of Infection, Royal Free London NHS Foundation Trust, London, UK
- National Institute for Health Research Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
| | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, Brighton, UK
- Department of Microbiology and Infection, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Ann Sarah Walker
- National Institute for Health Research Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
- Nuffield Department of Medicine, University of Oxford, UK
| | - Cliodna Am McNulty
- Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, Gloucester, UK
| | - Julie V Robotham
- Modelling and Economics Unit, National Infection Service, Public Health England, London NW9 5EQ, UK
- National Institute for Health Research Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
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27
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We need to consider collateral damage to resistomes when we decide how frequently to screen for chlamydia/gonorrhoea in preexposure prophylaxis cohorts. AIDS 2019; 33:155-157. [PMID: 30234609 DOI: 10.1097/qad.0000000000002020] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Numerous preexposure prophylaxis (PrEP) guidelines recommend three-monthly screening for gonorrhoea and chlamydia. To quantify the risk of antimicrobial resistance this may induce, we conducted a literature review of the incidence of gonorrhoea and chlamydia in PrEP studies that conducted 3-site, 3-monthly screening. We found that screening could result in macrolide consumption rates that exceed those in high macrolide consumption populations where consumption has been strongly associated with macrolide resistance.
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Tóth H, Fésűs A, Kungler-Gorácz O, Balázs B, Majoros L, Szarka K, Kardos G. Utilization of Vector Autoregressive and Linear Transfer Models to Follow Up the Antibiotic Resistance Spiral in Gram-negative Bacteria From Cephalosporin Consumption to Colistin Resistance. Clin Infect Dis 2018; 69:1410-1421. [DOI: 10.1093/cid/ciy1086] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/13/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Increasing antibiotic resistance may reciprocally affect consumption and lead to use of broader-spectrum alternatives; a vicious cycle that may gradually limit therapeutic options. Our aim in this study was to demonstrate this vicious cycle in gram-negative bacteria and show the utility of vector autoregressive (VAR) models for time-series analysis in explanatory and dependent roles simultaneously.
Methods
Monthly drug consumption data in defined daily doses per 100 bed-days and incidence densities of gram-negative bacteria (Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, and Acinetobacter baumannii) resistant to cephalosporins or to carbapenems were analyzed using VAR models. These were compared to linear transfer models used earlier.
Results
In case of all gram-negative bacteria, cephalosporin consumption led to increasing cephalosporin resistance, which provoked carbapenem use and consequent carbapenem resistance and finally increased colistin consumption, exemplifying the vicious cycle. Different species were involved in different ways. For example, cephalosporin-resistant Klebsiella spp. provoked carbapenem use less than E. coli, and the association between carbapenem resistance of P. aeruginosa and colistin use was weaker than that of A. baumannii. Colistin use led to decreased carbapenem use and decreased carbapenem resistance of P. aeruginosa but not of A. baumannii.
Conclusions
VAR models allow analysis of consumption and resistance series in a bidirectional manner. The reconstructed resistance spiral involved cephalosporin use augmenting cephalosporin resistance primarily in E. coli. This led to increased carbapenem use, provoking spread of carbapenem-resistant A. baumannii and consequent colistin use. Emergence of panresistance is fueled by such antibiotic-resistance spirals.
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Affiliation(s)
- Hajnalka Tóth
- Department of Medical Microbiology, Faculty of Medicine, Hungary
| | - Adina Fésűs
- Department of Medical Microbiology, Faculty of Medicine, Hungary
- Clinical Pharmacy, Faculty of Pharmacy, Clinical Center, University of Debrecen, Hungary
| | - Orsolya Kungler-Gorácz
- Department of Medical Microbiology, Faculty of Medicine, Hungary
- Clinical Pharmacy, Faculty of Pharmacy, Clinical Center, University of Debrecen, Hungary
| | - Bence Balázs
- Department of Medical Microbiology, Faculty of Medicine, Hungary
| | - László Majoros
- Department of Medical Microbiology, Faculty of Medicine, Hungary
| | - Krisztina Szarka
- Department of Medical Microbiology, Faculty of Medicine, Hungary
| | - Gábor Kardos
- Department of Medical Microbiology, Faculty of Medicine, Hungary
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Wurster JI, Bispo PJM, Van Tyne D, Cadorette JJ, Boody R, Gilmore MS. Staphylococcus aureus from ocular and otolaryngology infections are frequently resistant to clinically important antibiotics and are associated with lineages of community and hospital origins. PLoS One 2018; 13:e0208518. [PMID: 30521630 PMCID: PMC6283574 DOI: 10.1371/journal.pone.0208518] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 11/19/2018] [Indexed: 11/18/2022] Open
Abstract
Staphylococcus aureus is an important human pathogen that causes serious antibiotic-resistant infections. Its population structure is marked by the appearance and dissemination of successful lineages across different settings. To begin understanding the population structure of S. aureus causing ocular and otolaryngology infections, we characterized 262 isolates by antimicrobial sensitivity testing and multilocus sequence typing (MLST). Methicillin-resistant S. aureus were subjected to SCCmec typing and Panton-Valentine leukocidin (PVL) screening. Although we detected a high level of genetic diversity among methicillin-sensitive (MSSA) isolates, (63 sequence types—STs), the population was dominated by five lineages: ST30, ST5, ST8, ST15 and ST97. Resistance to penicillin, erythromycin and clindamycin was common among the major MSSA lineages, with fluctuations markedly impacted by genetic background. Isolates belonging to the predominant lineage, ST30, displayed high rates of resistance to penicillin (100%), erythromycin (71%), and clindamycin (63%). Overall, 21% of the isolates were methicillin-resistant (MRSA), with an apparent enrichment among otitis and orbital cellulitis isolates (>40%). MRSA isolates belonged to 14 STs grouped in 5 clonal complexes (CC), however, CC5 (56.1%) and CC8 (38.6%) dominated the population. Most CC5 strains were SCCmec type II, and resembled the hospital-adapted USA100 clone. CC8 strains were SCCmec type IV, and 86% were positive for the PVL toxin, common features of the community-acquired clone USA300. CC5 strains harboring a SCCmec type IV, typical for the USA800 clone, comprised 15.5% of the population. USA100 strains were highly resistant to clindamycin, erythromycin and levofloxacin (100%), while USA300 strains were frequently resistant to erythromycin (89%) but displayed lower rates of resistance to levofloxacin (39%) and clindamycin (17%). Our data demonstrate that the ocular and otolaryngology S. aureus populations are composed of strains that are commonly resistant to clinically relevant antibiotics, and are associated with the major epidemic clonal complexes of both community and hospital origins.
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Affiliation(s)
- Jenna I. Wurster
- Infectious Diseases Institute, Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States of America
| | - Paulo J. M. Bispo
- Infectious Diseases Institute, Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States of America
- * E-mail: (MSG); (PB)
| | - Daria Van Tyne
- Infectious Diseases Institute, Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States of America
- Department of Microbiology and Immunobiology, Harvard Medical School, Boston Massachusetts, United States of America
| | - James J. Cadorette
- Henry Whittier Porter Bacteriology Laboratory, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States of America
| | - Rick Boody
- Henry Whittier Porter Bacteriology Laboratory, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States of America
| | - Michael S. Gilmore
- Infectious Diseases Institute, Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, United States of America
- Department of Microbiology and Immunobiology, Harvard Medical School, Boston Massachusetts, United States of America
- * E-mail: (MSG); (PB)
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Comparison of subjective perception of safe antibiotic use between European Union states. HEALTH POLICY AND TECHNOLOGY 2018. [DOI: 10.1016/j.hlpt.2018.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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De la Rosa-Zamboni D, Ochoa SA, Laris-González A, Cruz-Córdova A, Escalona-Venegas G, Pérez-Avendaño G, Torres-García M, Suaréz-Mora R, Castellanos-Cruz C, Sánchrez-Flores YV, Vázquez-Flores A, Águila-Torres R, Parra-Ortega I, Klünder-Klünder M, Arellano-Galindo J, Hernández-Castro R, Xicohtencatl-Cortes J. Everybody hands-on to avoid ESKAPE: effect of sustained hand hygiene compliance on healthcare-associated infections and multidrug resistance in a paediatric hospital. J Med Microbiol 2018; 67:1761-1771. [PMID: 30372411 DOI: 10.1099/jmm.0.000863] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Hand hygiene is the most important strategy for preventing healthcare-associated infections (HCAIs); however, the impact of hand hygiene in middle-income countries has been poorly described. In this work, we describe the impact of the programme 'Let's Go for 100' on hand hygiene adherence, HCAIs rates and multidrug-resistant (MDR) bacteria, including the molecular typing of methicillin-resistant Staphylococcus aureus (MRSA) strains. METHODOLOGY A multimodal, hospital-wide hand hygiene programme was implemented from 2013. 'Let's Go for 100' involved all healthcare workers and encompassed education, awareness, visual reminders, feedback and innovative strategies. Monthly hand hygiene monitoring and active HCAI surveillance were performed in every ward. Molecular typing of MRSA was analysed by pulsed-field gel electrophoresis (PFGE).Results/Key findings. Hand hygiene adherence increased from 34.9 % during the baseline period to 80.6 % in the last 3 months of this study. The HCAI rate decreased from 7.54 to 6.46/1000 patient-days (P=0.004). The central line-associated bloodstream infection (CLABSIs) rate fell from 4.84 to 3.66/1000 central line-days (P=0.05). Negative correlations between hand hygiene and HCAIs rates were identified. The attack rate of MDR-ESKAPE group bloodstream infections decreased from 0.54 to 0.20/100 discharges (P=0.024). MRSA pulsotypes that were prevalent during the baseline period were no longer detected after the 5th quarter, although new strains were identified. CONCLUSIONS A multimodal hand hygiene programme in a paediatric hospital in a middle-income country was effective in improving adherence and reducing HCAIs, CLABSIs and MDR-ESKAPE bloodstream infections. Sustaining hand hygiene adherence at a level of >60 % for one year limited MRSA clonal transmission.
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Affiliation(s)
- Daniela De la Rosa-Zamboni
- 1Departamento de Epidemiología. Hospital Infantil de México Federico Gómez. Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - Sara A Ochoa
- 2Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez, Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - Almudena Laris-González
- 1Departamento de Epidemiología. Hospital Infantil de México Federico Gómez. Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - Ariadnna Cruz-Córdova
- 2Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez, Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - Gerardo Escalona-Venegas
- 2Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez, Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - Georgina Pérez-Avendaño
- 1Departamento de Epidemiología. Hospital Infantil de México Federico Gómez. Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - Margarita Torres-García
- 1Departamento de Epidemiología. Hospital Infantil de México Federico Gómez. Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - Roselia Suaréz-Mora
- 1Departamento de Epidemiología. Hospital Infantil de México Federico Gómez. Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - Carmen Castellanos-Cruz
- 3Laboratorio Central de Bacteriología, Hospital Infantil de México Federico Gómez, Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - Yadhira V Sánchrez-Flores
- 1Departamento de Epidemiología. Hospital Infantil de México Federico Gómez. Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - Adalberto Vázquez-Flores
- 1Departamento de Epidemiología. Hospital Infantil de México Federico Gómez. Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - Rosalinda Águila-Torres
- 1Departamento de Epidemiología. Hospital Infantil de México Federico Gómez. Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - Israel Parra-Ortega
- 3Laboratorio Central de Bacteriología, Hospital Infantil de México Federico Gómez, Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - Miguel Klünder-Klünder
- 4Subdirección de Investigación, Hospital Infantil de México Federico Gómez, Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - José Arellano-Galindo
- 5Departamento de Infectología, Hospital Infantil de México Federico Gómez, Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
| | - Rigoberto Hernández-Castro
- 6Departamento de Ecología de Agentes Patógenos, Hospital General Dr. Manuel Gea González, Tlalpan, 14080, Ciudad de México, México
| | - Juan Xicohtencatl-Cortes
- 2Laboratorio de Investigación en Bacteriología Intestinal, Hospital Infantil de México Federico Gómez, Dr. Márquez 162, Col. Doctores, Cuauhtémoc 06720. Ciudad de México, México
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Trends in Antibiotic Susceptibility in Staphylococcus aureus in Boston, Massachusetts, from 2000 to 2014. J Clin Microbiol 2017; 56:JCM.01160-17. [PMID: 29093105 PMCID: PMC5744217 DOI: 10.1128/jcm.01160-17] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 10/25/2017] [Indexed: 12/14/2022] Open
Abstract
The rate of infection by methicillin-resistant Staphylococcus aureus (MRSA) has declined over the past decade, but it is unclear whether this represents a decline in S. aureus infections overall. To evaluate the trends in the annual rates of infection by S. aureus subtypes and mean antibiotic resistance, we conducted a 15-year retrospective observational study at two tertiary care institutions in Boston, MA, of 31,753 adult inpatients with S. aureus isolated from clinical specimens. We inferred the gain and loss of methicillin resistance through genome sequencing of 180 isolates from 2016. The annual rates of infection by S. aureus declined from 2003 to 2014 by 4.2% (2.7% to 5.6%), attributable to an annual decline in MRSA of 10.9% (9.3% to 12.6%). Penicillin-susceptible S. aureus (PSSA) increased by 6.1% (4.2% to 8.1%) annually, and rates of methicillin-susceptible penicillin-resistant S. aureus (MSSA) did not change. Resistance in S. aureus decreased from 2000 to 2014 by 0.8 antibiotics (0.7 to 0.8). Within common MRSA clonal complexes, 3/14 MSSA and 2/21 PSSA isolates arose from the loss of resistance-conferring genes. Overall, in two tertiary care institutions in Boston, MA, a decline in S. aureus infections has been accompanied by a shift toward increased antibiotic susceptibility. The rise in PSSA makes penicillin an increasingly viable treatment option.
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Jamrozy D, Coll F, Mather AE, Harris SR, Harrison EM, MacGowan A, Karas A, Elston T, Estée Török M, Parkhill J, Peacock SJ. Evolution of mobile genetic element composition in an epidemic methicillin-resistant Staphylococcus aureus: temporal changes correlated with frequent loss and gain events. BMC Genomics 2017; 18:684. [PMID: 28870171 PMCID: PMC5584012 DOI: 10.1186/s12864-017-4065-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/15/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Horizontal transfer of mobile genetic elements (MGEs) that carry virulence and antimicrobial resistance genes mediates the evolution of methicillin-resistant Staphylococcus aureus, and the emergence of new MRSA clones. Most MRSA lineages show an association with specific MGEs and the evolution of MGE composition following clonal expansion has not been widely studied. RESULTS We investigated the genomes of 1193 S. aureus bloodstream isolates, 1169 of which were MRSA, collected in the UK and the Republic of Ireland between 2001 and 2010. The majority of isolates belonged to clonal complex (CC)22 (n = 923), which contained diverse MGEs including elements that were found in other MRSA lineages. Several MGEs showed variable distribution across the CC22 phylogeny, including two antimicrobial resistance plasmids (pWBG751-like and SAP078A-like, carrying erythromycin and heavy metal resistance genes, respectively), a pathogenicity island carrying the enterotoxin C gene and two phage types Sa1int and Sa6int. Multiple gains and losses of these five MGEs were identified in the CC22 phylogeny using ancestral state reconstruction. Analysis of the temporal distribution of the five MGEs between 2001 and 2010 revealed an unexpected reduction in prevalence of the two plasmids and the pathogenicity island, and an increase in the two phage types. This occurred across the lineage and was not correlated with changes in the relative prevalence of CC22, or of any sub-lineages within in. CONCLUSIONS Ancestral state reconstruction coupled with temporal trend analysis demonstrated that epidemic MRSA CC22 has an evolving MGE composition, and indicates that this important MRSA lineage has continued to adapt to changing selective pressure since its emergence.
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Affiliation(s)
- Dorota Jamrozy
- The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA UK
| | - Francesc Coll
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
| | - Alison E. Mather
- Department of Veterinary Medicine, University of Cambridge, Cambridge, CB3 0ES UK
| | - Simon R. Harris
- The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA UK
| | - Ewan M. Harrison
- Department of Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, CB2 0QQ UK
| | - Alasdair MacGowan
- British Society for Antimicrobial Chemotherapy, B1 3NJ, Birmingham, UK
| | - Andreas Karas
- Public Health England, Clinical Microbiology and Public Health Laboratory, Cambridge, CB21 5XA UK
| | - Tony Elston
- Colchester Hospital University NHS Foundation Trust, Colchester, CO4 5JL UK
| | - M. Estée Török
- Department of Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, CB2 0QQ UK
- Public Health England, Clinical Microbiology and Public Health Laboratory, Cambridge, CB21 5XA UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ UK
| | - Julian Parkhill
- The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA UK
| | - Sharon J. Peacock
- The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, Cambridge, CB10 1SA UK
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
- Department of Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, CB2 0QQ UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ UK
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Ceccato A, Ranzani OT, Torres A. Rapid identification of antimicrobial resistance patterns allows a faster antibiotic adequacy. Crit Care 2017; 21:208. [PMID: 28784143 PMCID: PMC5547525 DOI: 10.1186/s13054-017-1797-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Adrian Ceccato
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona - Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Villarroel 170, 08036 Barcelona, Spain
- Seccion Neumologia, Hospital Nacional Prof. Alejandro Posadas, Illia y Marconi s/n (1684), Palomar, Argentina
| | - Otavio T. Ranzani
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona - Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Villarroel 170, 08036 Barcelona, Spain
- Pulmonary Division, Heart Institute, Hospital das Clínicas, University of São Paulo, Av. Dr. Arnaldo, 455-Cerqueira César - CEP: 01246903, São Paulo, Brazil
| | - Antoni Torres
- Department of Pneumology, Institut Clinic de Respiratori, Hospital Clinic of Barcelona - Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona (UB) - SGR 911 - Ciber de Enfermedades Respiratorias (Ciberes, CB06/06/0028), Villarroel 170, 08036 Barcelona, Spain
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Heat map for data visualization in infection control epidemiology: An application describing the relationship between hospital-acquired infections, Simplified Acute Physiological Score II, and length of stay in adult intensive care units. Am J Infect Control 2017; 45:746-749. [PMID: 28549877 DOI: 10.1016/j.ajic.2017.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 02/10/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hospital-acquired infections (HAIs) in intensive care units (ICUs) are associated with increased length of stay (LOS). The objective of this study was to graphically describe by heat mapping LOS of patients hospitalized in ICUs related to the occurrence of HAI and severity at admission measured by the Simplified Acute Physiological Score II (SAPSII). METHODS Adult patients hospitalized in ICUs of Lyon University Hospitals (France) were included in an active standardized surveillance study of HAI from January 1, 1995-December 31, 2012. Surveillance included adult patients aged ≥18 years hospitalized ≥2 days. Patient follow-up ended at ICU discharge or death. LOS was calculated in days from differences between dates of entry and discharge from ICUs. HAIs recorded were pneumonia, bacteremia, and urinary tract infection. The heat map was designed with a spreadsheet software. RESULTS A total of 34,694 patients were analyzed. Among infected patients, 72.3% had 1 infected site (IS), 23% had 2 ISs, and 4.7% had 3 ISs. Median LOS was 24 days in infected patients (20.4 days among patients with 1 IS, 34.2 days among patients with 2 ISs, and 45.3 days among patients with 3 ISs) and 5 days in noninfected patients (P < .001). Two groups of multi-infected patients with long LOSs were identified with the heat map. CONCLUSIONS The heat map facilitated easy-to-implement semi-quantitative visualization of increasing LOS through the SAPSIIs and number of ISs.
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Evans ME, Kralovic SM, Simbartl LA, Jain R, Roselle GA. Eight years of decreased methicillin-resistant Staphylococcus aureus health care-associated infections associated with a Veterans Affairs prevention initiative. Am J Infect Control 2017; 45:13-16. [PMID: 28065327 DOI: 10.1016/j.ajic.2016.08.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/24/2016] [Accepted: 08/24/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Declines in methicillin-resistant Staphylococcus aureus (MRSA) health care associated infections (HAIs) were previously reported in Veterans Affairs acute care (2012), spinal cord injury (SCIU) (2011), and long-term-care facilities (LTCFs) (2012). Here we report continuing declines in infection rates in these settings through September 2015. METHODS Monthly data entered into a national database from 127 acute care facilities, 22 SCIUs, and 133 LTCFs were evaluated for trends using negative binomial regression. RESULTS There were 23,153,240 intensive care unit (ICU) and non-ICU, and 1,794,234 SCIU patient-days from October 2007-September 2015, and 22,262,605 LTCF resident-days from July 2009-September 2015. Admission nasal swabbing remained >92% in all 3 venues. Admission prevalence changed from 13.2%-13.5% in acute care, from 35.1%-32.0% in SCIUs, and from 23.1%-25.0% in LTCFs during the analysis periods. Monthly HAI rates fell 87.0% in ICUs, 80.1% in non-ICUs, 80.9% in SCIUs, and 49.4% in LTCFs (all P values < .0001 for trend). During September 2015, there were 2 MRSA HAIs reported in ICUs, 20 (with 3 in SCIUs) in non-ICUs, and 31 in LTCFs nationwide. CONCLUSIONS MRSA HAI rates declined significantly in acute care, SCIUs, and LTCFs over 8 years of the Veterans Affairs MRSA Prevention Initiative.
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Mendes ET, Ranzani OT, Marchi AP, da Silva MT, Filho JUA, Alves T, Guimarães T, Levin AS, Costa SF. Chlorhexidine bathing for the prevention of colonization and infection with multidrug-resistant microorganisms in a hematopoietic stem cell transplantation unit over a 9-year period: Impact on chlorhexidine susceptibility. Medicine (Baltimore) 2016; 95:e5271. [PMID: 27861350 PMCID: PMC5120907 DOI: 10.1097/md.0000000000005271] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Health care associated infections (HAIs) are currently among the major challenges to the care of hematopoietic stem cell transplantation (HSCT) patients. The objective of the present study was to evaluate the impact of 2% chlorhexidine (CHG) bathing on the incidence of colonization and infection with vancomycin-resistant Enterococcus (VRE), multidrug-resistant (MDR) gram-negative pathogens, and to evaluate their CHG minimum inhibitory concentration (MIC) after the intervention.A quasi-experimental study with duration of 9 years was conducted. VRE colonization and infection, HAI rates, and MDR gram-negative infection were evaluated by interrupted time series analysis. The antibacterial susceptibility profile and mechanism of resistance to CHG were analyzed in both periods by the agar dilution method in the presence or absence of the efflux pump inhibitor carbonyl cyanide-m-chlorophenyl hydrazone (CCCP) and presence of efflux pumps (qacA/E, qacA, qacE, cepA, AdeA, AdeB, and AdeC) by polymerase chain reaction (PCR).The VRE colonization and infection rates were significantly reduced in the postintervention period (P = 0.001). However, gram-negative MDR rates in the unit increased in the last years of the study. The CHG MICs for VRE increased during the period of exposure to the antiseptic. A higher MIC at baseline period was observed in MDR gram-negative strains. The emergence of a monoclonal Pseudomonas aeruginosa clone was observed in the second period.Concluding, CHG bathing was efficient regarding VRE colonization and infection, whereas no similar results were found with MDR gram-negative bacteria.
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Affiliation(s)
| | - Otavio T. Ranzani
- Pulmonary Division, Heart Institute, Hospital das Clínicas, University of São Paulo
| | | | | | | | | | - Thais Guimarães
- Department of Infectious, Diseases of Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | - Anna S. Levin
- Laboratory of Bacteriology, Department of Infectious Diseases
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Fuzi M. Dissimilar Fitness Associated with Resistance to Fluoroquinolones Influences Clonal Dynamics of Various Multiresistant Bacteria. Front Microbiol 2016; 7:1017. [PMID: 27458434 PMCID: PMC4935693 DOI: 10.3389/fmicb.2016.01017] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/15/2016] [Indexed: 01/24/2023] Open
Abstract
Fitness cost associated with resistance to fluoroquinolones was recently shown to vary across clones of methicillin-resistant Staphylococcus aureus and extended-spectrum β-lactamase-producing Klebsiella pneumoniae. The resulting dissimilar fitness should have influenced the clonal dynamics and thereby the rates of resistance for these pathogens. Moreover, a similar mechanism was recently proposed for the emergence of the H30 and H30R lineages of ESBL-producing E. coli and the major international clone (ribotype 027) of Clostridium difficile. Furthermore, several additional international clones of various multiresistant bacteria are suspect to have been selected by an analogous process. An ability to develop favorable mutations in the gyrase and topoisomerase IV genes seems to be a prerequisite for pathogens to retain fitness while showing high-level resistance to fluoroquinolones. Since, the consumption of other "non-fluoroquinolone" groups of antibiotics have also contributed to the rise in resistance rates a more judicious use of antibiotics in general and of fluoroquinolones in particular could ameliorate the international resistance situation.
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Affiliation(s)
- Miklos Fuzi
- Institute of Medical Microbiology, Semmelweis UniversityBudapest, Hungary
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Susceptibility to chlorhexidine amongst multidrug-resistant clinical isolates of Staphylococcus epidermidis from bloodstream infections. Int J Antimicrob Agents 2016; 48:86-90. [DOI: 10.1016/j.ijantimicag.2016.04.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/06/2016] [Accepted: 04/16/2016] [Indexed: 11/18/2022]
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Impact of patients' professional and educational status on perception of an antibiotic policy campaign: a pilot study at a university hospital. J Glob Antimicrob Resist 2016; 6:123-127. [PMID: 27530854 DOI: 10.1016/j.jgar.2016.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 04/18/2016] [Indexed: 11/20/2022] Open
Abstract
Antibiotics are overused in many European countries, particularly Greece, leading to emerging antimicrobial resistance with sustained high mortality among hospitalised patients. Limited data are available regarding factors influencing people's knowledge and the impact of public campaigns on antibiotic misuse. Patients' beliefs regarding antibiotics were investigated in the outpatient clinic of a university hospital in Athens, Greece. A questionnaire-based survey was conducted to examine patients' opinions on antibiotic use in the waiting room of the outpatient clinic. All participants read an illustrated pocket-sized leaflet endorsed by official authorities on the European Antibiotic Awareness Day (EAAD). Volunteers then completed a questionnaire containing information on demographics, knowledge on antibiotic use and overuse, and remarks on the quality of the leaflet's content. In a logistic regression analysis including age, sex, educational level and professional status of 605 eligible participants, women were more aware [odds ratio (OR)=3.2, 95% confidence interval (CI) 1.8-5.8; P<0.0001] and people with elementary education were less aware (OR=0.4, 95% CI 0.1-0.9; P=0.04) of antimicrobial misuse. Workers were also more aware than retired or unemployed people (P=0.007). However, only 16.0% of participants knew about the EAAD. All participants agreed on antibiotic misuse in Greece, mentioning patient accountability as the main cause (26.8%), an opinion more pronounced in highly educated individuals. In conclusion, targeted interventions taking into account variations in educational level and employee status should be considered in future scheduled educative campaigns on antibiotic overconsumption in highly prescribing antibiotic countries.
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The Role of Mathematical Modeling in Designing and Evaluating Antimicrobial Stewardship Programs. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2016. [DOI: 10.1007/s40506-016-0074-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Graves N, Page K, Martin E, Brain D, Hall L, Campbell M, Fulop N, Jimmeison N, White K, Paterson D, Barnett AG. Cost-Effectiveness of a National Initiative to Improve Hand Hygiene Compliance Using the Outcome of Healthcare Associated Staphylococcus aureus Bacteraemia. PLoS One 2016; 11:e0148190. [PMID: 26859688 PMCID: PMC4747462 DOI: 10.1371/journal.pone.0148190] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 01/14/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The objective is to estimate the incremental cost-effectiveness of the Australian National Hand Hygiene Inititiave implemented between 2009 and 2012 using healthcare associated Staphylococcus aureus bacteraemia as the outcome. Baseline comparators are the eight existing state and territory hand hygiene programmes. The setting is the Australian public healthcare system and 1,294,656 admissions from the 50 largest Australian hospitals are included. METHODS The design is a cost-effectiveness modelling study using a before and after quasi-experimental design. The primary outcome is cost per life year saved from reduced cases of healthcare associated Staphylococcus aureus bacteraemia, with cost estimated by the annual on-going maintenance costs less the costs saved from fewer infections. Data were harvested from existing sources or were collected prospectively and the time horizon for the model was 12 months, 2011-2012. FINDINGS No useable pre-implementation Staphylococcus aureus bacteraemia data were made available from the 11 study hospitals in Victoria or the single hospital in Northern Territory leaving 38 hospitals among six states and territories available for cost-effectiveness analyses. Total annual costs increased by $2,851,475 for a return of 96 years of life giving an incremental cost-effectiveness ratio (ICER) of $29,700 per life year gained. Probabilistic sensitivity analysis revealed a 100% chance the initiative was cost effective in the Australian Capital Territory and Queensland, with ICERs of $1,030 and $8,988 respectively. There was an 81% chance it was cost effective in New South Wales with an ICER of $33,353, a 26% chance for South Australia with an ICER of $64,729 and a 1% chance for Tasmania and Western Australia. The 12 hospitals in Victoria and the Northern Territory incur annual on-going maintenance costs of $1.51M; no information was available to describe cost savings or health benefits. CONCLUSIONS The Australian National Hand Hygiene Initiative was cost-effective against an Australian threshold of $42,000 per life year gained. The return on investment varied among the states and territories of Australia.
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Affiliation(s)
- Nicholas Graves
- Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Katie Page
- Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Elizabeth Martin
- Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - David Brain
- Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lisa Hall
- Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Megan Campbell
- Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Naomi Fulop
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Nerina Jimmeison
- School of Management, Queensland University of Technology, Brisbane, Australia
| | - Katherine White
- Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - David Paterson
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - Adrian G. Barnett
- Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
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Gould IM. Antibiotic Stewardship: What's Not To Like? Eur Urol 2016; 69:284-5. [DOI: 10.1016/j.eururo.2015.09.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 09/18/2015] [Indexed: 01/21/2023]
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Effects of national antibiotic stewardship and infection control strategies on hospital-associated and community-associated meticillin-resistant Staphylococcus aureus infections across a region of Scotland: a non-linear time-series study. THE LANCET. INFECTIOUS DISEASES 2015; 15:1438-49. [DOI: 10.1016/s1473-3099(15)00315-1] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 08/05/2015] [Accepted: 09/01/2015] [Indexed: 11/30/2022]
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Putting your money where your mouth is: Scotland's attack on MRSA pays off. THE LANCET. INFECTIOUS DISEASES 2015; 15:1369-70. [DOI: 10.1016/s1473-3099(15)00347-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 09/14/2015] [Indexed: 11/24/2022]
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Performance of BD Max StaphSR for Screening of Methicillin-Resistant Staphylococcus aureus Isolates among a Contemporary and Diverse Collection from 146 Institutions Located in Nine U.S. Census Regions: Prevalence of mecA Dropout Mutants. J Clin Microbiol 2015; 54:204-7. [PMID: 26537444 DOI: 10.1128/jcm.02047-15] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 10/27/2015] [Indexed: 01/01/2023] Open
Abstract
This study determined the performance of BD Max StaphSR and the rate of methicillin-resistant Staphylococcus aureus (MRSA) with an unrecognized staphylococcal cassette chromosome mec (SCCmec) right-extremity junction (MREJ) region among 907 methicillin-resistant S. aureus (MRSA) and 900 methicillin-susceptible S. aureus (MSSA) isolates. The rate of mecA/mecC dropout mutants was also evaluated. Only three MRSA isolates (99.7% sensitivity; 904/907) were classified as MSSA by the BD Max StaphSR assay, due to negative results for MREJ. Eight MSSA isolates (99.1% sensitivity; 892/900) were assigned as MRSA. However, six of these MSSA isolates had the mecA gene confirmed by PCR and sequencing (99.8% sensitivity; 898/900). Overall, 7.1% (64/900) of MSSA isolates showed results compatible with a mecA dropout genotype.
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