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Langford BJ, Bailey P, Livorsi DJ, Brown KA, Advani SD, Dodds Ashley E, Bearman G, Nori P. Five steps to high quality antimicrobial stewardship research. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e82. [PMID: 38751942 PMCID: PMC11094375 DOI: 10.1017/ash.2024.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 05/18/2024]
Abstract
The escalating threat of antimicrobial resistance (AMR) necessitates impactful, reproducible, and scalable antimicrobial stewardship strategies. This review addresses the critical need to enhance the quality of antimicrobial stewardship intervention research. We propose five considerations for authors planning and evaluating antimicrobial stewardship initiatives. Antimicrobial stewards should consider the following mnemonic ABCDE: (A) plan Ahead using implementation science; (B) Be clear and thoroughly describe the intervention by using the TidIER checklist; (C) Use a Checklist to comprehensively report study components; (D) Select a study Design carefully; and (E) Assess Effectiveness and implementation by selecting meaningful outcomes. Incorporating these recommendations will help strengthen the evidence base of antimicrobial stewardship literature and support optimal implementation of strategies to mitigate AMR.
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Affiliation(s)
- Bradley J. Langford
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Daniel J. Livorsi
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Kevin A. Brown
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Elizabeth Dodds Ashley
- Division of Infectious Diseases, Duke University School of Medicine and Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA
| | - Gonzalo Bearman
- Healthcare Infection Prevention Program, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Priya Nori
- Department of Medicine, Division of Infectious Diseases, Montefiore Medical Center, Bronx, NY, USA
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Elias C, Raad M, Rasoanandrasana S, Raherinandrasana AH, Andriananja V, Raberahona M, Moore CE, Randria M, Raskine L, Vanhems P, Babin FX. Implementation of an antibiotic resistance surveillance tool in Madagascar, the TSARA project: a prospective, observational, multicentre, hospital-based study protocol. BMJ Open 2024; 14:e078504. [PMID: 38508637 PMCID: PMC10953040 DOI: 10.1136/bmjopen-2023-078504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 03/08/2024] [Indexed: 03/22/2024] Open
Abstract
INTRODUCTION Antimicrobial resistance (AMR) has become a significant public health threat. Without any interventions, it has been modelled that AMR will account for an estimated 10 million deaths annually by 2050, this mainly affects low/middle-income countries. AMR has a systemic negative perspective affecting the overall healthcare system down to the patient's personal outcome. In response to this issue, the WHO urged countries to provide antimicrobial stewardship programmes (ASPs). ASPs in hospitals are a vital component of national action plans for AMR, and have been shown to significantly reduce AMR, in particular in low-income countries such as Madagascar.As part of an ASP, AMR surveillance provides essential information needed to guide medical practice. We developed an AMR surveillance tool-Technique de Surveillance Actualisée de la Résistance aux Antimicrobiens (TSARA)-with the support of the Mérieux Foundation. TSARA combines bacteriological and clinical information to provide a better understanding of the scope and the effects of AMR in Madagascar, where no such surveillance tool exists. METHODS AND ANALYSIS A prospective, observational, hospital-based study was carried out for data collection using a standardised data collection tool, called TSARA deployed in 2023 in 10 hospitals in Madagascar participating in the national Malagasy laboratory network (Réseau des Laboratoires à Madagascar (RESAMAD)). Any hospitalised patient where the clinician decided to take a bacterial sample is included. As a prospective study, individual isolate-level data and antimicrobial susceptibility information on pathogens were collected routinely from the bacteriology laboratory and compiled with clinical information retrieved from face-to-face interviews with the patient and completed using medical records where necessary. Analysis of the local ecology, resistance rates and antibiotic prescription patterns were collected. ETHICS AND DISSEMINATION This protocol obtained ethical approval from the Malagasy Ethical Committee n°07-MSANP/SG/AGMED/CNPV/CERBM on 24 January 2023. Findings generated were shared with national health stakeholders, microbiologists, members of the RESAMAD network and the Malagasy academic society of infectious diseases.
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Affiliation(s)
- Christelle Elias
- Service Hygiène et Epidémiologie, Hospices Civils de Lyon, Lyon, France
- Public Health, Epidemiology & Evolutionary Ecology of Infectious Diseases (PHE3ID) team, Centre International de Recherche en Infectiologie (CIRI), Inserm U1111, CNRS UMR5308, ENS de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Mathieu Raad
- Direction des Opérations Internationales, Fondation Mérieux, Lyon, France
| | | | | | | | - Mihaja Raberahona
- Service des Maladies Infectieuses, Hôpital Befelatanana, Antananarivo, Madagascar
| | - Catrin E Moore
- Centre for Neonatal and Paediatric Infection, St. George's, University of London, London, UK
| | - Mamy Randria
- Service de Biologie, Hôpital Befelatanana, Antananarivo, Madagascar
| | - Laurent Raskine
- Direction des Opérations Internationales, Fondation Mérieux, Lyon, France
| | - Philippe Vanhems
- Service Hygiène et Epidémiologie, Hospices Civils de Lyon, Lyon, France
- Public Health, Epidemiology & Evolutionary Ecology of Infectious Diseases (PHE3ID) team, Centre International de Recherche en Infectiologie (CIRI), Inserm U1111, CNRS UMR5308, ENS de Lyon, Université Claude Bernard Lyon 1, Lyon, France
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Abdel Hadi H, Eltayeb F, Al Balushi S, Daghfal J, Ahmed F, Mateus C. Evaluation of Hospital Antimicrobial Stewardship Programs: Implementation, Process, Impact, and Outcomes, Review of Systematic Reviews. Antibiotics (Basel) 2024; 13:253. [PMID: 38534688 DOI: 10.3390/antibiotics13030253] [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: 01/20/2024] [Revised: 02/21/2024] [Accepted: 02/29/2024] [Indexed: 03/28/2024] Open
Abstract
Antimicrobial Stewardship Programs (ASP) were introduced in healthcare as a public health priority to promote appropriate prescribing of antimicrobials, to reduce adverse events related to antimicrobials, as well as to control the escalating challenges of antimicrobial resistance. To deliver aimed outcome objectives, ASPs involve multiple connected implementation process measures. A systematic review was conducted to evaluate both concepts of ASPs. Guided by PRISMA frames, published systematic reviews (SR) focusing on ASPs restricted to secondary and tertiary healthcare were evaluated over the past 10 years involving all age groups. Out of 265 identified SR studies, 63 met the inclusion criteria. The majority were conducted in Europe and North America, with limited studies from other regions. In the reviewed studies, all age groups were examined, although they were conducted mainly on adults when compared to children and infants. Both process and outcomes measures of ASPs were examined equally and simultaneously through 25 different concepts, dominated by efficacy, antimicrobial resistance, and economic impact, while information technology as well as role of pharmacy and behavioral factors were equally examined. The main broad conclusions from the review were that, across the globe, ASPs demonstrated effectiveness, proved efficacy, and confirmed efficiency, while focused evaluation advocated that developed countries should target medium- and small-sized hospitals while developing countries should continue rolling ASPs across healthcare facilities. Additionally, the future of ASPs should focus on embracing evolving information technology to bridge the gaps in knowledge, skills, and attitude, as well as to enhance appropriate decision making.
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Affiliation(s)
- Hamad Abdel Hadi
- Communicable Diseases Centre, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster LA1 4YW, UK
| | - Faiha Eltayeb
- Division of Microbiology, Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar
| | - Sara Al Balushi
- Communicable Diseases Centre, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar
| | - Joanne Daghfal
- Communicable Diseases Centre, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar
| | - Faraz Ahmed
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster LA1 4YW, UK
| | - Ceu Mateus
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster LA1 4YW, UK
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Ruiz Ramos J, Santolaya Perrín MR, González Del Castillo J, Candel FJ, Quirós AM, López-Contreras González J, Jiménez AJ, Suárez-Lledó Grande A. Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department. FARMACIA HOSPITALARIA 2024; 48:57-63. [PMID: 37481455 DOI: 10.1016/j.farma.2023.06.011] [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: 03/03/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/24/2023] Open
Abstract
OBJECTIVE To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department. METHODS A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritization level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritization order and rated the new indicators in the same manner as in the first round. RESULTS 61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analyzing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority. CONCLUSIONS The experts agreed on a panel of ASP indicators adapted to the emergency services prioritized by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.
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Affiliation(s)
- Jesús Ruiz Ramos
- Servicio de Farmacia, Hospital Santa Creu y San Pau, Barcelona, España.
| | | | | | - Francisco Javier Candel
- Unidad de Enfermedades Infecciosas, Hospital Clínico Universitario San Carlos, Madrid, España
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Ruiz-Ramos J, Santolaya-Perrín MR, González-Del-Castillo J, Candel FJ, Martín-Quirós A, López-Contreras-González J, Julián-Jiménez A, Suárez-Lledó-Grande A. [Translated article] Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department. FARMACIA HOSPITALARIA 2024; 48:T57-T63. [PMID: 38148256 DOI: 10.1016/j.farma.2023.11.006] [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: 03/03/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 12/28/2023] Open
Abstract
OBJECTIVE To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department. METHODS A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritisation level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritisation order and rated the new indicators in the same manner as in the first round. RESULTS 61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analysing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority. CONCLUSIONS The experts agreed on a panel of ASP Indicators adapted to the emergency services prioritised by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.
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Affiliation(s)
- Jesús Ruiz-Ramos
- Servicio de Farmacia, Hospital Santa Creu y San Pau, Catalonia, Spain.
| | | | | | - Francisco Javier Candel
- Infectious diseases-Clinical Microbiology, Hospital Clínico Universitario San Carlos, Madrid, Spain
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Assenholm Kristensen M, Skov Abrantes J, Jensen HI, Backer Mogensen C, Søndergaard J, Kjølseth Møller J. The association between socioeconomic factors and the success of decolonization treatment among individuals diagnosed with methicillin-resistant Staphylococcus aureus: A cohort study from 2007 to 2020. Infect Control Hosp Epidemiol 2023; 44:1620-1628. [PMID: 37017132 PMCID: PMC10587379 DOI: 10.1017/ice.2023.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/14/2022] [Accepted: 02/02/2023] [Indexed: 04/06/2023]
Abstract
OBJECTIVES To examine associations between socioeconomic factors and (1) adherence to methicillin-resistant Staphylococcus aureus (MRSA) posttreatment follow-up swab sampling after 1 and 6 months and (2) successful decolonization treatment. DESIGN Cohort study with 2 years of follow-up. Data on patients diagnosed with MRSA were extracted from a regional MRSA database and national registries. We used a cluster-based logistic regression model to estimate the adjusted odds ratios (aOR) and 95% confidence interval (CI) for associations between socioeconomic factors and decolonization treatment. SETTING Danish primary health care. RESULTS The rate of adherence to posttreatment follow-up swab sampling among 2,536 cases 1 month after decolonization treatment was 66% (95% CI, 64%-68%), and it decreased to 30% (95% CI, 28%-32%) after 6 months. Living in intermediate municipalities (76-159 inhabitants/km2) or having retired were associated with completed posttreatment follow-up swabs 1 month after decolonization treatment: aOR, 1.40 (95% CI, 1.2-1.74) and aOR, 2.67 (95% CI, 1.16-6.13), respectively. The rate of successful decolonization treatment 2 years after initiating treatment was 36% (95% CI, 34%-38%). Factors associated with successful decolonization treatment included individuals with higher education (aOR, 1.62; 95% CI, 1.22-2.15), early retirees (aOR, 1.63; 95% CI, 1.12-2.38), those living in intermediate municipalities (ie, 160-900+ inhabitants/km2; aOR, 1.35; 95% CI, 1.08-1.68), and those living in predominantly urban municipalities (ie, 160-900+ inhabitants/km2; aOR, 2.04; 95% CI, 1.5-2.76). CONCLUSIONS Disparities in the effect of decolonization treatment and adherence to MRSA follow-up sampling among MRSA-positive individuals appear to be largely explained by the level of education, area of residence, and employment status.
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Affiliation(s)
- Mette Assenholm Kristensen
- Department of Clinical Microbiology, Lillebaelt Hospital, University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Julia Skov Abrantes
- Department of Quality, Lillebaelt Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Hanne Irene Jensen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Anesthesiology and Intensive Care, Lillebaelt Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Christian Backer Mogensen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Emergency Medicine, Hospital Sønderjylland, University Hospital of Southern Denmark, Aabenraa, Denmark
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark,Odense, Denmark
| | - Jens Kjølseth Møller
- Department of Clinical Microbiology, Lillebaelt Hospital, University Hospital of Southern Denmark, Vejle, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Greco M, Caruso PF, Angelotti G, Aceto R, Coppalini G, Martinetti N, Albini M, Bash LD, Carvello M, Piccioni F, Monzani R, Montorsi M, Cecconi M. REVersal of nEuromusculAr bLocking Agents in Patients Undergoing General Anaesthesia (REVEAL Study). J Clin Med 2023; 12:jcm12020563. [PMID: 36675492 PMCID: PMC9866312 DOI: 10.3390/jcm12020563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023] Open
Abstract
Background: Neuromuscular blocking agent (NMBA) monitoring and reversals are key to avoiding residual curarization and improving patient outcomes. Sugammadex is a NMBA reversal with favorable pharmacological properties. There is a lack of real-world data detailing how the diffusion of sugammadex affects anesthetic monitoring and practice. Methods: We conducted an electronic health record analysis study, including all adult surgical patients undergoing general anesthesia with orotracheal intubation, from January 2016 to December 2019, to describe changes and temporal trends of NMBAs and NMBA reversals administration. Results: From an initial population of 115,046 surgeries, we included 37,882 procedures, with 24,583 (64.9%) treated with spontaneous recovery from neuromuscular block and 13,299 (35.1%) with NMBA reversals. NMBA reversals use doubled over 4 years from 25.5% to 42.5%, mainly driven by sugammadex use, which increased from 17.8% to 38.3%. Rocuronium increased from 58.6% (2016) to 94.5% (2019). Factors associated with NMBA reversal use in the multivariable analysis were severe obesity (OR 3.33 for class II and OR 11.4 for class III obesity, p-value < 0.001), and high ASA score (OR 1.47 for ASA III). Among comorbidities, OSAS, asthma, and other respiratory diseases showed the strongest association with NMBA reversal administration. Conclusions: Unrestricted availability of sugammadex led to a considerable increase in pharmacological NMBA reversal, with rocuronium use also rising. More research is needed to determine how unrestricted and safer NMBA reversal affects anesthesia intraoperative monitoring and practice.
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Affiliation(s)
- Massimiliano Greco
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Correspondence:
| | - Pier Francesco Caruso
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
| | | | - Romina Aceto
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Giacomo Coppalini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Nicolò Martinetti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Marco Albini
- IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | | | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Surgery, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Federico Piccioni
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Roberta Monzani
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Marco Montorsi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Surgery, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
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Gabay O, Cherki T, Tsaban G, Bichovsky Y, Nesher L. The Safety and Impact of Raising the Urine Culture Reporting Threshold in Hospitalized Patients. J Clin Med 2022; 11:jcm11237014. [PMID: 36498590 PMCID: PMC9740109 DOI: 10.3390/jcm11237014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/21/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022] Open
Abstract
Objective: To assess the impact of changing the reporting threshold policy of positive urine cultures in hospitalized non-pregnant adults from 104 CFU/mL to 105 CFU/mL on the unwarranted use of antibiotics and patient safety. Setting: A 1100-bed tertiary-care hospital in southern Israel. Methods: As an intervention, we changed urine culture reporting policy for patients admitted to general medical wards. If culture grew ≥105 CFU/mL, it was reported with pathogen and antibiotic susceptibility data, if it grew ≤104 CFU/mL, it was reported as "low growth". The withheld information was available upon request. We retrospectively collected data on all patients in a four-month period following the intervention and report using STROBE guidelines. Results: 7808 patients were admitted, in whom 3523 urine cultures were obtained. A total of 496 grew a pathogen, 51 were excluded (candida spp. positive, history of urinary surgery, obtained from catheter). A total of 300 were reported as positive and 145 were reported as low-growth. A higher rate of patients in the low-growth group were not treated with antibiotics 45/145(31%) vs. 56/300(18.7%) in the positive group p = 0.015 and the antibiotic duration of treatment was shorter by day 5 (IQR 0.9) vs. 6 (IQR 0.9) p = 0.015. No between-group difference was observed in recurrent admission rates, pyelonephritis within 30 days, bacteremia or all-cause mortality. Conclusions: Changing the reporting threshold of positive urine culture results from 104 CFU/mL to 105 CFU/mL in hospitalized patients reduced the number of patients who were unnecessarily treated for asymptomatic bacteriuria without negatively impacting patient safety. We urge microbiological laboratories to consider this change in threshold as part of an antimicrobial stewardship program.
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Abe FC, Kodaira K, Motta CDCB, Barberato-Filho S, Silva MT, Guimarães CC, Martins CC, Lopes LC. Antimicrobial resistance of microorganisms present in periodontal diseases: A systematic review and meta-analysis. Front Microbiol 2022; 13:961986. [PMID: 36262326 PMCID: PMC9574196 DOI: 10.3389/fmicb.2022.961986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 09/01/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe aim of this study was to estimate the antimicrobial resistance in microorganisms present in periodontal diseases.MethodsA systematic review was conducted according to the PRISMA statement. The MEDLINE (PubMed/Ovid), EMBASE, BVS, CINAHL, and Web of Science databases were searched from January 2011 to December 2021 for observational studies which evaluated the antimicrobial resistance in periodontal diseases in permanent dentition. Studies that allowed the antimicrobial consumption until the time of sample collection, studies that used laboratory acquired strains, studies that only characterized the microbial strain present, assessment of cellular morphological changes, sequencing system validation, and time series were excluded. Six reviewers, working in pairs and independently, selected titles, abstracts, and full texts extracting data from all studies that met the eligibility criteria: characteristics of patients, diagnosis of infection, microbial species assessed, antimicrobial assessed, identification of resistance genes, and virulence factors. “The Joanna Briggs Institute” critical appraisal for case series was adapted to assess the risk of bias in the included studies.ResultsTwenty-four studies (N = 2.039 patients) were included. Prevotella and Porphyromonas species were the most cited microorganisms in the included studies, and the virulence factors were related to Staphylococcus aureus. The antimicrobial reported with the highest frequency of resistance in the included studies was ampicillin (39.5%) and ciprofloxacin showed the lowest frequency of resistance (3.4%). The most cited genes were related to macrolides. The quality of the included studies was considered critically low.ConclusionNo evidence was found regarding the profile of antimicrobial resistance in periodontal diseases, requiring further research that should focus on regional population studies to address this issue in the era of increasing antimicrobial resistance.Clinical relevanceThe knowledge about the present microorganism in periodontal diseases and their respective antimicrobial resistance profiles should guide dentists in prescribing complementary therapy for these infections.Systematic review registration[http://dx.doi.org/10.1097/MD.0000000000013158], identifier [CRD42018077810].
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Affiliation(s)
- Flávia Casale Abe
- Department of Pharmaceutical Sciences, University of Sorocaba, Sorocaba, Brazil
| | - Katia Kodaira
- Department of Pharmaceutical Sciences, University of Sorocaba, Sorocaba, Brazil
| | | | | | | | | | | | - Luciane Cruz Lopes
- Department of Pharmaceutical Sciences, University of Sorocaba, Sorocaba, Brazil
- *Correspondence: Luciane Cruz Lopes,
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The 2021 Dutch Working Party on Antibiotic Policy (SWAB) guidelines for empirical antibacterial therapy of sepsis in adults. BMC Infect Dis 2022; 22:687. [PMID: 35953772 PMCID: PMC9373543 DOI: 10.1186/s12879-022-07653-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The Dutch Working Party on Antibiotic Policy (SWAB) in collaboration with relevant professional societies, has updated their evidence-based guidelines on empiric antibacterial therapy of sepsis in adults. METHODS Our multidisciplinary guideline committee generated ten population, intervention, comparison, and outcome (PICO) questions relevant for adult patients with sepsis. For each question, a literature search was performed to obtain the best available evidence and assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The quality of evidence for clinically relevant outcomes was graded from high to very low. In structured consensus meetings, the committee formulated recommendations as strong or weak. When evidence could not be obtained, recommendations were provided based on expert opinion and experience (good practice statements). RESULTS Fifty-five recommendations on the antibacterial therapy of sepsis were generated. Recommendations on empiric antibacterial therapy choices were differentiated for sepsis according to the source of infection, the potential causative pathogen and its resistance pattern. One important revision was the distinction between low, increased and high risk of infection with Enterobacterales resistant to third generation cephalosporins (3GRC-E) to guide the choice of empirical therapy. Other new topics included empirical antibacterial therapy in patients with a reported penicillin allergy and the role of pharmacokinetics and pharmacodynamics to guide dosing in sepsis. We also established recommendations on timing and duration of antibacterial treatment. CONCLUSIONS Our multidisciplinary committee formulated evidence-based recommendations for the empiric antibacterial therapy of adults with sepsis in The Netherlands.
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Loganathan A, Nachimuthu R. Antibiotic resistance, biofilm forming ability, and clonal profiling of clinical isolates of Staphylococcus aureus from southern and northeastern India. ASIAN BIOMED 2022; 16:191-199. [PMID: 37551171 PMCID: PMC10321179 DOI: 10.2478/abm-2022-0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Staphylococcus aureus is a pathogen endemic in India and sometimes deadly for patients in intensive care units. Objectives To determine the antibiotic-resistance pattern, biofilm forming ability, and clonal type of S. aureus from isolates collected in Tamil Nadu (south) and the Mizoram (northeast) regions of India. Methods We collected S. aureus isolates from diagnostic laboratories in Tamil Nadu and Mizoram. An antibiotic susceptibility test was performed according to Clinical Laboratory and Standards Institute methods. Antibiotic-resistant determinants such as mecA, mecC, blaZ, vanA, vanB, and vanC were confirmed by polymerase chain reaction (PCR). All isolates were further studied for biofilm forming ability. Enterobacterial repetitive intergenic consensus (ERIC)-PCR was used for clonal analysis. Results A study of 206 clinical isolates showed 52.9% prevalence of methicillin-resistant S. aureus in Tamil Nadu and 49.4% in Mizoram. Minimum inhibitory concentration tests showed a high prevalence of 67% oxacillin resistance in isolates from Tamil Nadu and 49% in isolates from Mizoram. PCR showed 53% mecA in Tamil Nadu and 49% mecA in Mizoram. Vancomycin-intermediate resistance S. aureus (VISA) prevalence was lower in isolates from Tamil Nadu (4%) and Mizoram (5%). All methicillin-resistant S. aureus (MRSA) isolates formed biofilms. Clonal analysis revealed a genetic relatedness between the isolates. Conclusions The prevalence of MRSA is high in the regions studied, with most of the clinical isolates being multidrug resistant. Adopting appropriate community-based preventive measures and establishing antimicrobial stewardship is highly recommended to minimize the dissemination in antibiotic resistance.
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Affiliation(s)
- Archana Loganathan
- Department of Bio-Medical Sciences, School of Bio Sciences and Technology, Vellore Institute of Technology, Vellore, Tamil Nadu632014, India
| | - Ramesh Nachimuthu
- Department of Bio-Medical Sciences, School of Bio Sciences and Technology, Vellore Institute of Technology, Vellore, Tamil Nadu632014, India
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12
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Greco M, De Corte T, Ercole A, Antonelli M, Azoulay E, Citerio G, Morris AC, De Pascale G, Duska F, Elbers P, Einav S, Forni L, Galarza L, Girbes ARJ, Grasselli G, Gusarov V, Jubb A, Kesecioglu J, Lavinio A, Delgado MCM, Mellinghoff J, Myatra SN, Ostermann M, Pellegrini M, Povoa P, Schaller SJ, Teboul JL, Wong A, De Waele JJ, Cecconi M. Clinical and organizational factors associated with mortality during the peak of first COVID-19 wave: the global UNITE-COVID study. Intensive Care Med 2022; 48:690-705. [PMID: 35596752 PMCID: PMC9123859 DOI: 10.1007/s00134-022-06705-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/13/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To accommodate the unprecedented number of critically ill patients with pneumonia caused by coronavirus disease 2019 (COVID-19) expansion of the capacity of intensive care unit (ICU) to clinical areas not previously used for critical care was necessary. We describe the global burden of COVID-19 admissions and the clinical and organizational characteristics associated with outcomes in critically ill COVID-19 patients. METHODS Multicenter, international, point prevalence study, including adult patients with SARS-CoV-2 infection confirmed by polymerase chain reaction (PCR) and a diagnosis of COVID-19 admitted to ICU between February 15th and May 15th, 2020. RESULTS 4994 patients from 280 ICUs in 46 countries were included. Included ICUs increased their total capacity from 4931 to 7630 beds, deploying personnel from other areas. Overall, 1986 (39.8%) patients were admitted to surge capacity beds. Invasive ventilation at admission was present in 2325 (46.5%) patients and was required during ICU stay in 85.8% of patients. 60-day mortality was 33.9% (IQR across units: 20%-50%) and ICU mortality 32.7%. Older age, invasive mechanical ventilation, and acute kidney injury (AKI) were associated with increased mortality. These associations were also confirmed specifically in mechanically ventilated patients. Admission to surge capacity beds was not associated with mortality, even after controlling for other factors. CONCLUSIONS ICUs responded to the increase in COVID-19 patients by increasing bed availability and staff, admitting up to 40% of patients in surge capacity beds. Although mortality in this population was high, admission to a surge capacity bed was not associated with increased mortality. Older age, invasive mechanical ventilation, and AKI were identified as the strongest predictors of mortality.
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Affiliation(s)
- Massimiliano Greco
- grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy ,grid.417728.f0000 0004 1756 8807IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Thomas De Corte
- grid.5342.00000 0001 2069 7798Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium ,grid.410566.00000 0004 0626 3303Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Ari Ercole
- grid.5335.00000000121885934Cambridge Centre for Artificial Intelligence in Medicine, University of Cambridge, Cambridge, UK ,grid.120073.70000 0004 0622 5016University of Cambridge Division of Anaesthesia, Addenbrooke’s Hospital, Hills Road, Cambridge, UK
| | - Massimo Antonelli
- grid.8142.f0000 0001 0941 3192Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy ,grid.8142.f0000 0001 0941 3192Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Elie Azoulay
- grid.508487.60000 0004 7885 7602Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital, Paris University, Paris, France ,grid.508487.60000 0004 7885 7602Université de Paris, Paris, France
| | - Giuseppe Citerio
- grid.7563.70000 0001 2174 1754School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy ,Department Neuroscience, Neurointensive Care, ASST-Monza, Monza, Italy
| | - Andy Conway Morris
- grid.5335.00000000121885934Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Division of Immunology, Department of Pathology, University of Cambridge, Cambridge, UK ,grid.120073.70000 0004 0622 5016JVF Intensive Care Unit, Addenbrookes Hospital, Cambridge, UK
| | - Gennaro De Pascale
- grid.8142.f0000 0001 0941 3192Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy ,grid.8142.f0000 0001 0941 3192Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Frantisek Duska
- grid.4491.80000 0004 1937 116XDepartment of Anaesthesia and Intensive Care, Third Faculty of Medicine, Charles University, Prague, Czech Republic ,grid.412819.70000 0004 0611 1895FNKV University Hospital in Prague, Prague, Czech Republic
| | - Paul Elbers
- grid.12380.380000 0004 1754 9227Department of Intensive Care Medicine, Laboratory of Critical Care Computational Intelligence, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sharon Einav
- grid.414505.10000 0004 0631 3825General Intensive Care Unit of the Shaare Zedek Medical Center, Jerusalem, Israel ,grid.9619.70000 0004 1937 0538Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Lui Forni
- grid.5475.30000 0004 0407 4824Department of Critical Care, Royal Surrey Hospital and Faculty of Experimental Medicine, University of Surrey, Guildford, UK
| | - Laura Galarza
- grid.470634.2Intensive Care Unit, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - Armand R. J. Girbes
- grid.12380.380000 0004 1754 9227Department of Intensive Care Medicine, Research VUmc Intensive Care (REVIVE), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Sciences (ACS), Amsterdam Infection and Immunity Institute (AI&II), UMC, Location VUmc, VU Amsterdam, Amsterdam, The Netherlands
| | - Giacomo Grasselli
- grid.414818.00000 0004 1757 8749Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy ,grid.4708.b0000 0004 1757 2822Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Vitaly Gusarov
- grid.510503.2Pirogov National Medical and Surgical Center, Moscow, 105203 Russian Federation
| | - Alasdair Jubb
- grid.5335.00000000121885934Division of Anaesthesia, University of Cambridge Department of Medicine, Cambridge, UK ,grid.24029.3d0000 0004 0383 8386Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals, Cambridge, UK ,grid.498239.dCancer Research UK-Cambridge Institute, Cambridge, UK
| | - Jozef Kesecioglu
- grid.5477.10000000120346234Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Andrea Lavinio
- grid.24029.3d0000 0004 0383 8386Neurosciences and Trauma Critical Care Unit (NCCU), Anaesthesia Medical Examiner and Clinical Lead Organ Donation-Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Maria Cruz Martin Delgado
- grid.488600.20000 0004 1777 7270Intensive Care Unit, Hospital Universitario de Torrejón, Madrid, Spain ,grid.449795.20000 0001 2193 453XUniversidad Francisco de Vitoria, Madrid, Spain
| | - Johannes Mellinghoff
- grid.12477.370000000121073784School of Sports and Health Sciences, University of Brighton, Brighton, UK
| | - Sheila Nainan Myatra
- grid.450257.10000 0004 1775 9822Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marlies Ostermann
- grid.420545.20000 0004 0489 3985Department of Critical Care, King’s College London, Guy’s & St Thomas’ Hospital, London, UK
| | - Mariangela Pellegrini
- Intensive Care Unit, AnOpIVA, Akademiska sjukhuset, Uppsala, Sweden ,grid.8993.b0000 0004 1936 9457Hedenstierna Laboratory, Department of Surgical Science, Uppsala University, Uppsala, Sweden
| | - Pedro Povoa
- grid.10772.330000000121511713CHRC, CEDOC, NOVA Medical School, New University of Lisbon, Lisbon, Portugal ,grid.414462.10000 0001 1009 677XPolyvalent Intensive Care Unit, Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal ,grid.7143.10000 0004 0512 5013Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Stefan J. Schaller
- grid.7468.d0000 0001 2248 7639Department of Anesthesiology and Operative Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany ,grid.6936.a0000000123222966School of Medicine, Klinikum rechts der Isar, Department of Anesthesiology and Intensive Care, Technical University of Munich, Munich, Germany
| | - Jean-Louis Teboul
- grid.413784.d0000 0001 2181 7253Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, AP-HP Université Paris-Saclay, Inserm UMR S_999, Le Kremlin-Bicêtre, France
| | - Adrian Wong
- grid.46699.340000 0004 0391 9020Department of Critical Care, King’s College Hospital, London, UK
| | - Jan J. De Waele
- grid.5342.00000 0001 2069 7798Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium ,grid.410566.00000 0004 0626 3303Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Maurizio Cecconi
- grid.452490.eDepartment of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy ,grid.417728.f0000 0004 1756 8807IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
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O'Riordan F, Shiely F, Byrne S, O'Brien D, Ronayne A, Fleming A. Antimicrobial use and antimicrobial resistance in Enterobacterales and Enterococcus faecium: a time series analysis. J Hosp Infect 2021; 120:57-64. [PMID: 34780809 DOI: 10.1016/j.jhin.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 11/02/2021] [Accepted: 11/06/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Irish and European antimicrobial resistance (AMR) surveillance data have highlighted increasing AMR in Enterobacterales and vancomycin resistance in Enterococcus faecium (VRE). Antimicrobial consumption (AC) in Irish hospital settings is also increasing. METHODS A retrospective time series analysis (TSA) was conducted to evaluate the trends and possible relationship between AC of selected antimicrobials and AMR in Enterobacterales and vancomycin resistance in E. faecium, from January 2017 to December 2020. RESULTS Increased AC was seen with ceftriaxone (p= 0.0006), piperacillin/tazobactam (p = 0.03) and meropenem (p = 0.05), while ciprofloxacin and gentamicin use trended downwards. AMR rates in E. coli, K. pneumoniae and other Enterobacterales were largely stable, an increase in ertapenem resistance in the latter from 0.58% in 2017 to 5.19% in 2020 (p= 0.003) being the main concern. The proportion of E. faecium that was VRE did not changed significantly (64% in 2017; 53% in 2020, p = 0.1). TSA identified a correlation between piperacillin/tazobactam use and the decreasing rate of ceftriaxone resistance in E. coli. CONCLUSION Our data suggest that hospital antimicrobial stewardship programme is largely containing, but not reducing AMR in key nosocomial pathogens. An increase in AC following the COVID-19 pandemic appears as yet to have had no impact on AMR rates.
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Affiliation(s)
- F O'Riordan
- Pharmacy Department, Mercy University Hospital, Grenville Place, Cork, Ireland; Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland.
| | - F Shiely
- HRB Clinical Research Facility Cork, Mercy University Hospital, Grenville Place, Cork, Ireland; School of Public Health, University College Cork, Cork, Ireland
| | - S Byrne
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - D O'Brien
- Department of Microbiology, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - A Ronayne
- Department of Microbiology, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - A Fleming
- Pharmacy Department, Mercy University Hospital, Grenville Place, Cork, Ireland; Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
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14
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Schönherr SG, Ranft D, Lippmann N, Lübbert C. Changes in antibiotic consumption, AMR and Clostridioides difficile infections in a large tertiary-care center following the implementation of institution-specific guidelines for antimicrobial therapy: A nine-year interrupted time series study. PLoS One 2021; 16:e0258690. [PMID: 34648594 PMCID: PMC8516227 DOI: 10.1371/journal.pone.0258690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/01/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Institution-specific guidelines (ISGs) within the framework of antimicrobial stewardship programs offer locally tailored decision support taking into account local pathogen and resistance epidemiology as well as national and international guidelines. OBJECTIVES To assess the impact of ISGs for antimicrobial therapy on antibiotic consumption and subsequent changes in resistance rates and Clostridioides difficile infections (CDIs). METHODS The study was conducted at the Leipzig University Hospital, a 1,451-bed tertiary-care medical center, and covered the years 2012 to 2020. Since 2014, ISGs were provided to optimize empirical therapies, appropriate diagnostics, and antimicrobial prophylaxis. We used interrupted time series analysis (ITSA) and simple linear regression to analyze changes in antimicrobial consumption, resistance and CDIs. RESULTS Over the study period, 1,672,200 defined daily doses (DDD) of antibiotics were dispensed, and 85,645 bacterial isolates as well as 2,576 positive C. difficile cultures were collected. Total antimicrobial consumption decreased by 14% from 2012 to 2020, without clear impact of the deployment of ISGs. However, implementation of ISGs was associated with significant decreases in the use of substances that were rarely recommended (e.g., fluoroquinolones). Over the whole study period, we observed declining resistance rates to most antibiotic classes of up to 25% in Enterobacterales, staphylococci, and Pseudomonas aeruginosa. Switching from ceftriaxone to cefotaxime was associated with reduced resistance to third-generation cephalosporins. The number of CDI cases fell by 65%, from 501 in 2012 to 174 in 2020. CONCLUSIONS Well-implemented ISGs can have a significant, immediate, and lasting impact on the prescription behavior. ISGs might thereby contribute to reduce resistance rates and CDI incidences in the hospital setting.
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Affiliation(s)
- Sebastian G. Schönherr
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine II, Leipzig University Hospital, Leipzig, Germany
| | - Donald Ranft
- Hospital Pharmacy, Leipzig University Hospital, Leipzig, Germany
| | - Norman Lippmann
- Institute for Medical Microbiology and Virology, Leipzig University Hospital, Leipzig, Germany
- Interdisciplinary Center for Infectious Diseases (ZINF), Leipzig University Hospital, Leipzig, Germany
| | - Christoph Lübbert
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine II, Leipzig University Hospital, Leipzig, Germany
- Interdisciplinary Center for Infectious Diseases (ZINF), Leipzig University Hospital, Leipzig, Germany
- Department of Infectious Diseases/Tropical Medicine, Nephrology and Rheumatology, Hospital St. Georg, Leipzig, Germany
- * E-mail:
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15
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Zhu NJ, Rawson TM, Mookerjee S, Price JR, Davies F, Otter J, Aylin P, Hope R, Gilchrist M, Shersing Y, Holmes A. Changing Patterns of Bloodstream Infections in the Community and Acute Care Across 2 Coronavirus Disease 2019 Epidemic Waves: A Retrospective Analysis Using Data Linkage. Clin Infect Dis 2021; 75:e1082-e1091. [PMID: 34596212 PMCID: PMC9402624 DOI: 10.1093/cid/ciab869] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND We examined community- and hospital-acquired bloodstream infections (BSIs) in coronavirus disease 2019 (COVID-19) and non-COVID-19 patients across 2 epidemic waves. METHODS We analyzed blood cultures of patients presenting to a London hospital group between January 2020 and February 2021. We reported BSI incidence, changes in sampling, case mix, healthcare capacity, and COVID-19 variants. RESULTS We identified 1047 BSIs from 34 044 blood cultures, including 653 (62.4%) community-acquired and 394 (37.6%) hospital-acquired. Important pattern changes were seen. Community-acquired Escherichia coli BSIs remained below prepandemic level during COVID-19 waves, but peaked following lockdown easing in May 2020, deviating from the historical trend of peaking in August. The hospital-acquired BSI rate was 100.4 per 100 000 patient-days across the pandemic, increasing to 132.3 during the first wave and 190.9 during the second, with significant increase in elective inpatients. Patients with a hospital-acquired BSI, including those without COVID-19, experienced 20.2 excess days of hospital stay and 26.7% higher mortality, higher than reported in prepandemic literature. In intensive care, the BSI rate was 421.0 per 100 000 intensive care unit patient-days during the second wave, compared to 101.3 pre-COVID-19. The BSI incidence in those infected with the severe acute respiratory syndrome coronavirus 2 Alpha variant was similar to that seen with earlier variants. CONCLUSIONS The pandemic have impacted the patterns of community- and hospital-acquired BSIs, in COVID-19 and non-COVID-19 patients. Factors driving the patterns are complex. Infection surveillance needs to consider key aspects of pandemic response and changes in healthcare practice.
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Affiliation(s)
- Nina J Zhu
- Correspondence: N. J. Zhu, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Hospital, Du Cane Road, London, W12 0NN, UK ()
| | - Timothy M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom,Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom,Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
| | - Siddharth Mookerjee
- Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom
| | - James R Price
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom,Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom
| | - Frances Davies
- Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom
| | - Jonathan Otter
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom,Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom
| | - Paul Aylin
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom,Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdomand
| | - Russell Hope
- Division of Healthcare Associated Infection and Antimicrobial Resistance, Public Health England, London, United Kingdom
| | - Mark Gilchrist
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom,Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom,Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
| | - Yeeshika Shersing
- Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom
| | - Alison Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom,Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom,Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
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16
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Silvestro E, Marino R, Cusenza F, Pruccoli G, Denina M, De Intinis G, Licciardi F, Garazzino S, Scolfaro C. Antimicrobial stewardship experience in paediatrics: first-year activity report. Eur J Clin Microbiol Infect Dis 2021; 40:1727-1735. [PMID: 33745086 DOI: 10.1007/s10096-021-04222-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/08/2021] [Indexed: 11/24/2022]
Abstract
Antimicrobial resistance is one of the most relevant threats in public health worldwide. Strategies as antimicrobial stewardship programs, aiming to preserve our antibiotic armamentarium, have been implemented since 2007 in adult and paediatric patients. We aim to describe the first experience of a paediatric antimicrobial stewardship program. We conducted a retrospective observational study in a tertiary care children's hospital. A team composed of a microbiologist, an infectious diseases physician, and a paediatrician led the project. All positive blood and cerebrospinal fluid cultures and other biological samples yielding multi-drug-resistant bacteria were collected and reviewed through a prospective-audit-with-feedback strategy. We recorded patient characteristics and worth monitoring prescribed antibiotics. The antimicrobial stewardship audit could end in intervention (step-up/step-down and broadening/narrowing) or recommendation(s). We then checked out wards staff compliance. The team performed 192 interventions out of 584 reviews, mostly suggesting discontinuation of antibiotics (in 76.0% of cases and 39.7% of running molecules). The antibiotic spectrum was more likely tapered than expanded (p < 0.0001), and we ordered more narrow-spectrum antibiotic molecules than local medical staff straightaway did (p = 0.0113). Interventions were most likely needed in case of documented infections (p < 0.0001) and in surgical patients (p = 0.0002). In 85.9% of interventions, ward teams fully agreed with our argument. This study demonstrated an antimicrobial stewardship program to be a suitable method for improving the appropriateness of antimicrobial use in hospitalized children.
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Affiliation(s)
- Erika Silvestro
- Department of Paediatrics, Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Piazza Polonia, 94, 10126, Turin, TO, Italy.
| | - Raffaella Marino
- Department of Paediatrics, Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Piazza Polonia, 94, 10126, Turin, TO, Italy
| | - Francesca Cusenza
- Department of Paediatrics, Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Piazza Polonia, 94, 10126, Turin, TO, Italy
| | - Giulia Pruccoli
- Department of Paediatrics, Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Piazza Polonia, 94, 10126, Turin, TO, Italy
| | - Marco Denina
- Department of Paediatrics, Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Piazza Polonia, 94, 10126, Turin, TO, Italy
| | - Gianfranco De Intinis
- Microbiology and Virology Unit, AOU Città Della Salute e Della Scienza di Torino, Turin, Italy
| | - Francesco Licciardi
- Department of Paediatrics, Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Piazza Polonia, 94, 10126, Turin, TO, Italy
| | - Silvia Garazzino
- Department of Paediatrics, Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Piazza Polonia, 94, 10126, Turin, TO, Italy
| | - Carlo Scolfaro
- Department of Paediatrics, Infectious Diseases Unit, Regina Margherita Children's Hospital, University of Turin, Piazza Polonia, 94, 10126, Turin, TO, Italy
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Impact of an Antibiotic Stewardship Program on the Incidence of Resistant Escherichia coli: A Quasi-Experimental Study. Antibiotics (Basel) 2021; 10:antibiotics10020179. [PMID: 33578840 PMCID: PMC7916635 DOI: 10.3390/antibiotics10020179] [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: 01/15/2021] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 11/24/2022] Open
Abstract
Infections caused by multidrug-resistant Gram-negative bacteria increase hospitalizations and mortality rates; antibiotic pressure increases resistance rates. We evaluated the impact of the antibiotics stewardship program (ASP) on Escherichia coli resistance rates, evaluating all antibiotic use and patients with positive cultures hospitalized between 2011 and 2018. Data on antibiotics were collected quarterly as the defined daily dose (DDD)/100 days hospitalization. In 2014, an intervention was introduced, targeting the reduction of overall antibiotic use as well as specifically targeting quinolones and other broad-spectrum antibiotics. Using interrupted time series analysis (ITS), we compared the rates and trends of antibiotic use and resistant E. coli. We included 6001 patients, 3182 pre-ASP and 2819 post-ASP. We observed significant changes in absolute numbers as well as in trends for use of DDD/100 days of all antibiotics by 31% from 76 to 52, and by 52% from 10.4 to 4.9 for quinolones. ITS demonstrated that before the ASP intervention, there was a slope pattern for increased E. coli resistance to antibiotics. This slope was reversed following the intervention for quinolones −1.52, aminoglycosides −2.04, and amoxicillin clavulanate (amox/clav) −1.76; the effect of the intervention was observed as early as three months after the intervention and continued to decrease over time until the end of the study, at 48 months. We conclude that the ASP can positively impact the resistance rate of Gram-negative infections over time, regardless of the targeted combination of antibiotics, if the overall use is reduced.
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18
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Shafat T, Shimoni O, Nikonov A, Nesher L. The Kinetics of an Antibiotic Stewardship Intervention: A Quasi-Experimental Study. Infect Dis Ther 2021; 10:613-619. [PMID: 33515415 PMCID: PMC7954991 DOI: 10.1007/s40121-021-00403-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/13/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Little is known about the kinetics and different phases of a successful antibiotic stewardship program (ASP) intervention. Methods We analyzed the trends of quarterly antibiotic use measured in defined daily dose (DDD)/100 days hospitalization using the Joinpoint Regression Program and interrupted time series analysis to objectively identify shifts in the trends of antibiotic use. We correlated these changes in trends with the introduction of a hospital-wide ASP intervention. Results The ASP intervention reduced the overall antibiotic use by 33%, from a prior steady state of 76.5 DDD/100 days hospitalization to a post-intervention steady state of 51.2 DDD/100 days hospitalization (p < 0.001). We identified four distinct phases in the trends: prior steady state (A), early intervention (B), accelerated phase (C), and post steady state (D). From A to B a change of slope (−1.46) [SE 0.37, 95% CI −2.23, −0.69 (p = 0.002)]; B to C, a further decrease of slope (−4.70) [SE 0.64, 95% CI −6.03, −3.37 (p = 0.001)]; between periods C and D, straightening out of the slope (+ 6.84) [SE 0.55, 95% CI 5.70, 7.98 (p < 0.001)] to a new post-intervention steady state. It took 1.5 years after completion of the intervention to reach the new steady state. Conclusions We demonstrate that ASP interventions require time to achieve the maximal effect. Successful interventions require physicians to adapt new prescribing behaviors and gain confidence in the change; this adaptation can be a prolonged process and might even take years after the introduction of the ASP. These factors should be considered when planning and implementing ASP interventions.
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Affiliation(s)
- Tali Shafat
- Infectious Disease Institute, Soroka University Medical Center, Beer Sheba, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel.,Clinical Research Center, Soroka University Medical Center, Beer Sheba, Israel
| | - Orly Shimoni
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel.,Pharmacy Services, Soroka University Medical Center, Beer Sheba, Israel
| | - Anna Nikonov
- Pharmacy Services, Soroka University Medical Center, Beer Sheba, Israel
| | - Lior Nesher
- Infectious Disease Institute, Soroka University Medical Center, Beer Sheba, Israel. .,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel.
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19
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Paulson CM, Handley JF, Dilworth TJ, Persells D, Prusi RY, Brummitt CF, Torres KM, Skrupky LP. Impact of a Systematic Pharmacist-Initiated Antibiotic Time-Out Intervention for Hospitalized Adults. J Pharm Pract 2020; 35:388-395. [PMID: 33353452 DOI: 10.1177/0897190020980616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Antibiotic time-outs (ATO) are a recommended antimicrobial stewardship action, but data assessing their impact are lacking. This study investigated the impact of a systematic, pharmacist initiated ATO intervention. METHODS This pre-post study included inpatients on hospitalist and intensivist services receiving empiric antibiotics for ≥48 hours. The ATO was initiated by pharmacists after 48 hours of empiric therapy and the outcome was documented including antibiotic indication, plan, and duration. An electronic medical record (EMR) alert facilitated ATO completion and pharmacists and prescribers received education prior to implementation. The primary outcome was EMR documentation of an antibiotic plan by 72 hours. Secondary outcomes included antibiotic utilization and antibiotic therapy modifications by 2 hours. RESULTS 399 patients were included, 199 pre- and 200 post-intervention. The most common indications were pneumonia (32%), intra-abdominal infection (20%) and urinary tract infection (19%), with no between-group differences. EMR documentation of an antibiotic plan significantly improved in the post-intervention group (19% vs. 79%, p<0.0001) as did modifications to antibiotic therapy. The median duration of in-hospital antibiotic therapy was similar between groups (4.0 vs. 4.0 days, p = 0.2499). Approximately 45% of patients in each group received discharge antibiotics and median duration of discharge antibiotic therapy prescribed was reduced (7 vs. 5 days in the pre- and post-intervention groups, respectively; p = 0.0140). DISCUSSION Implementation of pharmacist initiated ATO was associated with improvements in supporting EMR documentation and antibiotic therapy modifications. These findings highlight an important role in which pharmacists can serve as part of a collaborative antibiotic stewardship team.
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Affiliation(s)
- Calley M Paulson
- Department of Pharmacy Services, 577980Advocate Aurora Health, Aurora BayCare Medical Center, Green Bay, WI, USA
| | - Jillian F Handley
- Department of Pharmacy Services, 577980Advocate Aurora Health, Milwaukee, WI, USA
| | - Thomas J Dilworth
- Department of Pharmacy Services, 577980Advocate Aurora Health, Milwaukee, WI, USA
| | - Dan Persells
- Department of Pharmacy Services, 577980Advocate Aurora Health, Milwaukee, WI, USA
| | - Rachael Y Prusi
- Department of Education, University of Chicago Medicine, Chicago, IL, USA
| | | | - Katherine M Torres
- Department of Infectious Disease, Aurora Medical Group, Green Bay, WI, USA
| | - Lee P Skrupky
- Department of Education, 6915Mayo Clinic, Rochester, Minnesota, USA
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20
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Zhang H, Guo Y, Prosperi M, Bian J. An ontology-based documentation of data discovery and integration process in cancer outcomes research. BMC Med Inform Decis Mak 2020; 20:292. [PMID: 33317497 PMCID: PMC7734720 DOI: 10.1186/s12911-020-01270-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/17/2020] [Indexed: 01/24/2023] Open
Abstract
Background To reduce cancer mortality and improve cancer outcomes, it is critical to understand the various cancer risk factors (RFs) across different domains (e.g., genetic, environmental, and behavioral risk factors) and levels (e.g., individual, interpersonal, and community levels). However, prior research on RFs of cancer outcomes, has primarily focused on individual level RFs due to the lack of integrated datasets that contain multi-level, multi-domain RFs. Further, the lack of a consensus and proper guidance on systematically identify RFs also increase the difficulty of RF selection from heterogenous data sources in a multi-level integrative data analysis (mIDA) study. More importantly, as mIDA studies require integrating heterogenous data sources, the data integration processes in the limited number of existing mIDA studies are inconsistently performed and poorly documented, and thus threatening transparency and reproducibility. Methods Informed by the National Institute on Minority Health and Health Disparities (NIMHD) research framework, we (1) reviewed existing reporting guidelines from the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) network and (2) developed a theory-driven reporting guideline to guide the RF variable selection, data source selection, and data integration process. Then, we developed an ontology to standardize the documentation of the RF selection and data integration process in mIDA studies. Results We summarized the review results and created a reporting guideline—ATTEST—for reporting the variable selection and data source selection and integration process. We provided an ATTEST check list to help researchers to annotate and clearly document each step of their mIDA studies to ensure the transparency and reproducibility. We used the ATTEST to report two mIDA case studies and further transformed annotation results into sematic triples, so that the relationships among variables, data sources and integration processes are explicitly standardized and modeled using the classes and properties from OD-ATTEST. Conclusion Our ontology-based reporting guideline solves some key challenges in current mIDA studies for cancer outcomes research, through providing (1) a theory-driven guidance for multi-level and multi-domain RF variable and data source selection; and (2) a standardized documentation of the data selection and integration processes powered by an ontology, thus a way to enable sharing of mIDA study reports among researchers.
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Affiliation(s)
- Hansi Zhang
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 2197 Mowry Road, Suite 122, PO Box 100177, Gainesville, FL, 32610-0177, USA
| | - Yi Guo
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 2197 Mowry Road, Suite 122, PO Box 100177, Gainesville, FL, 32610-0177, USA.,Cancer Informatics & eHealth Core, University of Florida Health Cancer Center, Gainesville, FL, USA
| | - Mattia Prosperi
- Department of Epidemiology, College of Medicine & College of Public Health and Health Professions, University of Florida, Gainesville, FL, USA
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 2197 Mowry Road, Suite 122, PO Box 100177, Gainesville, FL, 32610-0177, USA. .,Cancer Informatics & eHealth Core, University of Florida Health Cancer Center, Gainesville, FL, USA.
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21
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Ardura-Garcia C, Mozun R, Pedersen ESL, Otth M, Mallet MC, Goutaki M, Kuehni CE. Paediatric cohort studies on lower respiratory diseases and their reporting quality: systematic review of the year 2018. Eur Respir J 2020; 56:13993003.00168-2020. [PMID: 32457199 DOI: 10.1183/13993003.00168-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/19/2020] [Indexed: 11/05/2022]
Abstract
The paediatric respiratory research community uses cohort studies extensively. However, the landscape of these studies and their quality of reporting has not been assessed.We performed a systematic review of publications on cohort studies reporting on paediatric lower respiratory problems published in 2018. We searched MEDLINE and Embase and extracted data on study and journal characteristics. We assessed the number of items of the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist that a random sample (100 papers) reported. We analysed factors associated with the STROBE score and with the most poorly reported items, using Poisson and logistic regression.Of the 21 319 records identified, 369 full-text articles met our inclusion criteria. Most papers studied asthma aetiology through birth cohorts and were based in Europe or North America. The reporting quality was insufficient: 15% reported the 22 STROBE items; median (interquartile range) score 18 (16-21). The most poorly reported items were sources of bias, sample size, statistical methods, descriptive results and generalisability. None of the study or journal factors were associated with the STROBE score.We need a joint effort of editors, reviewers and authors to improve the reporting quality of paediatric cohort studies on respiratory problems.
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Affiliation(s)
| | - Rebeca Mozun
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Eva S L Pedersen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Maria Otth
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Division of Haematology-Oncology, Dept of Paediatrics, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Myrofora Goutaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland
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22
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Shaghaghian S, Astaneh B. Adherence to the Strengthening the Reporting of Observational Studies in Epidemiology Statement in Observational Studies Published in Iranian Medical Journals. IRANIAN JOURNAL OF PUBLIC HEALTH 2020; 49:1520-1529. [PMID: 33083329 PMCID: PMC7554393 DOI: 10.18502/ijph.v49i8.3896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Although much medical knowledge comes from observational research, such studies are more prone to confounding and bias than others. This study was conducted to evaluate the adherence of the observational studies published in Iranian medical journals to the STROBE (strengthening the reporting of observational studies in epidemiology) statement. Methods In this cross-sectional study, we selected 150 articles of Iranian medical journals, using multistage sampling from Aug 2016 to Jun 2017. The reported items of the STROBE statement in the articles was determined and considered as the adherence of the articles to the statement. The adherence of the articles with different characteristics was compared. Results The adherence of the articles to the statement varied from 24% to 68% with a mean score of 48%±9%. The lowest mean scores were found in the Result (36%) and Method (49%) sections. The adherence was significantly better in the articles published in the journals indexed in PubMed or Web of Knowledge (ISI) databases (P<0.001) and those written by cooperation of the authors from other countries (P=0.044). Conclusion The evaluated articles in our study had not adequately reported the items recommended by the STROBE statement. This indicates deficiency in key elements for readers to assess the validity and applicability of a study.
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Affiliation(s)
- Soheila Shaghaghian
- Department of Medical Journalism, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Behrooz Astaneh
- Department of Medical Journalism, School of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
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De Bus L, Depuydt P, Steen J, Dhaese S, De Smet K, Tabah A, Akova M, Cotta MO, De Pascale G, Dimopoulos G, Fujitani S, Garnacho-Montero J, Leone M, Lipman J, Ostermann M, Paiva JA, Schouten J, Sjövall F, Timsit JF, Roberts JA, Zahar JR, Zand F, Zirpe K, De Waele JJ. Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure: the DIANA study. Intensive Care Med 2020; 46:1404-1417. [PMID: 32519003 PMCID: PMC7334278 DOI: 10.1007/s00134-020-06111-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 05/11/2020] [Indexed: 01/10/2023]
Abstract
Purpose The DIANA study aimed to evaluate how often antimicrobial de-escalation (ADE) of empirical treatment is performed in the intensive care unit (ICU) and to estimate the effect of ADE on clinical cure on day 7 following treatment initiation. Methods Adult ICU patients receiving empirical antimicrobial therapy for bacterial infection were studied in a prospective observational study from October 2016 until May 2018. ADE was defined as (1) discontinuation of an antimicrobial in case of empirical combination therapy or (2) replacement of an antimicrobial with the intention to narrow the antimicrobial spectrum, within the first 3 days of therapy. Inverse probability (IP) weighting was used to account for time-varying confounding when estimating the effect of ADE on clinical cure. Results Overall, 1495 patients from 152 ICUs in 28 countries were studied. Combination therapy was prescribed in 50%, and carbapenems were prescribed in 26% of patients. Empirical therapy underwent ADE, no change and change other than ADE within the first 3 days in 16%, 63% and 22%, respectively. Unadjusted mortality at day 28 was 15.8% in the ADE cohort and 19.4% in patients with no change [p = 0.27; RR 0.83 (95% CI 0.60–1.14)]. The IP-weighted relative risk estimate for clinical cure comparing ADE with no-ADE patients (no change or change other than ADE) was 1.37 (95% CI 1.14–1.64). Conclusion ADE was infrequently applied in critically ill-infected patients. The observational effect estimate on clinical cure suggested no deleterious impact of ADE compared to no-ADE. However, residual confounding is likely. Electronic supplementary material The online version of this article (10.1007/s00134-020-06111-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Liesbet De Bus
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
| | - Pieter Depuydt
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Johan Steen
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, C. Heymanslaan 10, Ghent, Belgium
- Renal Division, Ghent University Hospital, C. Heymanslaan 10, Ghent, Belgium
| | - Sofie Dhaese
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Ken De Smet
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Alexis Tabah
- Intensive Care Unit, Redcliffe and Caboolture Hospitals, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Murat Akova
- Departmant of Infectious Diseases and Clinical Microbiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Menino Osbert Cotta
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Gennaro De Pascale
- Dipartimento Di Scienza Dell'Emergenza, Anestesiologiche e della Rianimazione - UOC Di Anestesia, Rianimazione, Terapia Intensiva e Tossicologia Clinica - Istituto di Anestesia e Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, Athens, Greece
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Shigeki Fujitani
- Emergency Medicine and Critical Care Medicine, St. Marianna University Hospital, Kawasaki-City, Kanagawa, Japan
| | - Jose Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
- Instituto de Biomedicina de Sevilla (IBIS), Seville, Spain
| | - Marc Leone
- Service d'Anesthésie et de Réanimation, Hôpital NordAssistance Publique Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Jeffrey Lipman
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - José-Artur Paiva
- Emergency and Intensive Care Department, Centro Hospitalar Universitário São João EPE, Porto, Portugal
- Faculdade de Medicina da Universidade Do Porto, Grupo de Infecção E Sépsis, Porto, Portugal
| | - Jeroen Schouten
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare, IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fredrik Sjövall
- Department of Intensive Care and Perioperative Medicine, Skane University Hospital, Malmö, Sweden
- Mitochondrial Medicine, Lund University, Lund, Sweden
| | - Jean-François Timsit
- Sorbonne Paris Cité, IAME, UMR 1137, Université de Paris, Paris, France
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard Hospital, 75018, Paris, France
| | - Jason A Roberts
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jean-Ralph Zahar
- INSERM, IAME UMR 1137, University of Paris, Paris, France
- Microbiology, Infection Control Unit, GH Paris Seine Saint-Denis, APHP, Bobigny, France
| | - Farid Zand
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kapil Zirpe
- Grant Medical Foundation, Ruby Hall Clinic, Pune, Maharashtra, India
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
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Cazer CL, Eldermire ERB, Lhermie G, Murray SA, Scott HM, Gröhn YT. The effect of tylosin on antimicrobial resistance in beef cattle enteric bacteria: A systematic review and meta-analysis. Prev Vet Med 2020; 176:104934. [PMID: 32109782 PMCID: PMC7197392 DOI: 10.1016/j.prevetmed.2020.104934] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Tylosin is a commonly used in-feed antimicrobial and is approved in several countries to reduce the incidence of liver abscesses in beef cattle. Macrolides are critically important antimicrobials in human health and used to treat some foodborne bacterial diseases, such as Campylobacter jejuni and Salmonella. Feeding tylosin could select for resistant enteric bacteria in cattle, which could contaminate beef products at slaughter and potentially cause foodborne illness. We conducted a systematic review and meta-analysis to evaluate the impact of feeding tylosin to cattle on phenotypic and genotypic resistance in several potential zoonotic enteric bacteria: Enterococcus species, Escherichia coli, Salmonella enterica subspecies enterica, and Campylobacter species. This review was registered with PROSPERO (#CRD42018085949). RESULTS Eleven databases were searched for primary research studies that fed tylosin at approved doses to feedlot cattle and tested bacteria of interest for phenotypic or genotypic resistance. We screened 1,626 citations and identified 13 studies that met the inclusion criteria. Enterococcus species were tested in seven studies, Escherichia coli was isolated in five studies, three studies reported on Salmonella, and two studies reported on Campylobacter species. Most studies relied on phenotypic antimicrobial susceptibility testing and seven also reported resistance gene testing. A random-effects meta-analyses of erythromycin-resistant enterococci from four studies had significant residual heterogeneity. Only two studies were available for a meta-analysis of tylosin-resistant enterococci. A semi-quantitative analysis demonstrated an increase in macrolide-resistant enterococci after long durations of tylosin administration (>100 days). Semi-quantitative analyses of other bacteria-antimicrobial combinations revealed mixed results, but many comparisons found no effect of tylosin administration. However, about half of these no-effect comparisons did not record the cumulative days of tylosin administration or the time since the last dose. CONCLUSIONS When fed at approved dosages for typical durations, tylosin increases the proportion of macrolide-resistant enterococci in the cattle gastrointestinal tract, which could pose a zoonotic risk to human beef consumers. Feeding tylosin for short durations may mitigate the impact on macrolide-resistant enterococci and further studies are encouraged to determine the effect of minimizing or eliminating tylosin use in beef cattle. There may also be an impact on other bacteria and other antimicrobial resistances but additional details or data are needed to strengthen these comparisons. We encourage authors of antimicrobial-resistance studies to follow reporting guidelines and publish details of all comparisons to strengthen future meta-analyses.
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Affiliation(s)
- Casey L Cazer
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA.
| | - Erin R B Eldermire
- Flower-Sprecher Veterinary Library, Cornell University College of Veterinary Medicine, USA.
| | - Guillaume Lhermie
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA.
| | - Sarah A Murray
- Department of Veterinary Pathobiology, Texas A&M College of Veterinary Medicine, USA.
| | - H Morgan Scott
- Department of Veterinary Pathobiology, Texas A&M College of Veterinary Medicine, USA.
| | - Yrjö T Gröhn
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA.
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Resman F. Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy Part I: step-wise design of an antimicrobial stewardship program. Ther Adv Infect Dis 2020; 7:2049936120933187. [PMID: 32612826 PMCID: PMC7307277 DOI: 10.1177/2049936120933187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/11/2020] [Indexed: 12/27/2022] Open
Abstract
Regardless of one's opinion of 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 includes not only aspects of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name a few. This review aims to take several of these aspects and the scientific evidence of 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. This first part 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. The second part, published separately, formulates ten 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
- Department of Translational Medicine, Clinical
Infection Medicine, Lund University, Rut Lundskogs Gata 3, Plan 6, Malmö, 20502,
Sweden
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26
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Antibiorésistance : outils pour une recherche translationnelle efficace. Therapie 2020; 75:1-6. [DOI: 10.1016/j.therap.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 12/02/2019] [Indexed: 11/23/2022]
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27
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Ploy MC, Andremont A, Valtier B, Le Jeunne C. Antibiotic resistance: Tools for effective translational research. Therapie 2019; 75:7-12. [PMID: 31987590 DOI: 10.1016/j.therap.2019.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
The rising emergence of bacterial resistances has led to a crisis which threatens human, animal and environmental health. The impact of the emergency is enormous in terms of public health and economics. Although there is a global awareness of the warnings and programmes supporting innovative actions to combat fight against antibiotic resistance, it must be admitted that proposed new antibiotics fail to find the economic profitability necessary for them to reach the market and become available for patients and the community. Moreover, it is necessary to develop tools/indicators to define effective interventions against antibiotic resistance. The work of the think-tank reported in this article concentrated on two aspects of translational research: - prevention and the impact on health of the antibiotic resistance issue, and - the specific requirements of clinical research leading to innovation in the fight against antibiotic resistance. This article, which reflects the thoughts of a group of French experts, proposes directly operational solutions which could be rapidly implemented and radically transform the quality and quantity of our resources available for the combat.
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Affiliation(s)
- Marie-Cécile Ploy
- Inserm, U1092, RESINFIT, CHU de Limoges, university Limoges, 87000 Limoges, France.
| | | | | | - Claire Le Jeunne
- Service de médecine interne, site Cochin, centre université de Paris, AP-HP, 75014 Paris, France
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Abstract
Antimicrobial stewardship improves patient care and reduces antimicrobial resistance, inappropriate use, and adverse outcomes. Despite high-profile mandates for antimicrobial stewardship programs across the healthcare continuum, descriptive data, and recommendations for dedicated resources, including appropriate physician, pharmacist, data analytics, and administrative staffing support, are not robust. This review summarizes the current literature on antimicrobial stewardship staffing and calls for the development of minimum staffing recommendations.
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Abbara S, Domenech de Cellès M, Batista R, Mira JP, Poyart C, Poupet H, Casetta A, Kernéis S. Variable impact of an antimicrobial stewardship programme in three intensive care units: time-series analysis of 2012-2017 surveillance data. J Hosp Infect 2019; 104:150-157. [PMID: 31605739 DOI: 10.1016/j.jhin.2019.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/29/2019] [Accepted: 10/01/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Preprescription authorization (PPA) and postprescription review with feedback (PPRF) were successively implemented in 2012 and 2016 in our 1500-bed hospital. AIM The impact of PPA and PPRF on carbapenems use and resistance levels of Pseudomonas aeruginosa was assessed in three intensive care units (ICUs). METHODS Carbapenems use (in DDDs/1000 occupied bed-days) and resistance of P. aeruginosa (percentage of non-susceptible (I+R) isolates to imipenem and/or meropenem) were analysed using a controlled interrupted time-series method. Two periods were compared: 2012-2015 (PPA) and 2016-2017 (PPA+PPRF). Models were adjusted on the annual incidence of extended-spectrum β-lactamase-producing enterobacteriacae. FINDINGS Carbapenem use was stable over the PPA period in all ICUs, with a significant change of slope over the PPA+PPRF period only in ICU1 (β2 = -12.8, 95% confidence interval (CI) = -19.5 to -6.1). There was a switch from imipenem to meropenem during the PPA period in all three units. Resistances of P. aeruginosa were stable over the study period in ICU1 and ICU2, and significantly decreased over the PPA+PPRF period in ICU3 (β2 = -0.18, CI = -0.3 to -0.03). CONCLUSION In real-life conditions and with the same antimicrobial stewardship programme (AMSP) led by a single team, the impact of PPRF was heterogeneous between ICUs. Factors driving the impact of AMSPs should be further assessed in comparable settings through real-life data, to target where they could prove cost-effective.
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Affiliation(s)
- S Abbara
- INSERM, UMR 1181, Biostatistics, Biomathematics, Pharmacoepidemiology, and Infectious Diseases (B2PHI), Paris, France; Institut Pasteur, B2PHI, Paris, France; Versailles Saint-Quentin University, UMR 1181, B2PHI, Montigny-le-Bretonneux, France; Antimicrobial Stewardship Team, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre-Site Cochin, Paris, France.
| | - M Domenech de Cellès
- INSERM, UMR 1181, Biostatistics, Biomathematics, Pharmacoepidemiology, and Infectious Diseases (B2PHI), Paris, France; Institut Pasteur, B2PHI, Paris, France; Versailles Saint-Quentin University, UMR 1181, B2PHI, Montigny-le-Bretonneux, France
| | - R Batista
- Pharmacy, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France
| | - J P Mira
- Medical Intensive Care Unit, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France; Université Paris Descartes, Sorbonne Paris cité, Paris, France
| | - C Poyart
- Université Paris Descartes, Sorbonne Paris cité, Paris, France; Department of Bacteriology, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France
| | - H Poupet
- Department of Bacteriology, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France
| | - A Casetta
- Infection Control Team, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre - Site Cochin, Paris, France
| | - S Kernéis
- INSERM, UMR 1181, Biostatistics, Biomathematics, Pharmacoepidemiology, and Infectious Diseases (B2PHI), Paris, France; Institut Pasteur, B2PHI, Paris, France; Versailles Saint-Quentin University, UMR 1181, B2PHI, Montigny-le-Bretonneux, France; Université Paris Descartes, Sorbonne Paris cité, Paris, France; Antimicrobial Stewardship Team, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires Paris Centre-Site Cochin, Paris, France
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Schweitzer VA, van Werkhoven CH, Rodríguez Baño J, Bielicki J, Harbarth S, Hulscher M, Huttner B, Islam J, Little P, Pulcini C, Savoldi A, Tacconelli E, Timsit JF, van Smeden M, Wolkewitz M, Bonten MJM, Walker AS, Llewelyn MJ. Optimizing design of research to evaluate antibiotic stewardship interventions: consensus recommendations of a multinational working group. Clin Microbiol Infect 2019; 26:41-50. [PMID: 31493472 DOI: 10.1016/j.cmi.2019.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antimicrobial stewardship interventions and programmes aim to ensure effective treatment while minimizing antimicrobial-associated harms including resistance. Practice in this vital area is undermined by the poor quality of research addressing both what specific antimicrobial use interventions are effective and how antimicrobial use improvement strategies can be implemented into practice. In 2016 we established a working party to identify the key design features that limit translation of existing research into practice and then to make recommendations for how future studies in this field should be optimally designed. The first part of this work has been published as a systematic review. Here we present the working group's final recommendations. METHODS An international working group for design of antimicrobial stewardship intervention evaluations was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). The group comprised clinical and academic specialists in antimicrobial stewardship and clinical trial design from six European countries. Group members completed a structured questionnaire to establish the scope of work and key issues to develop ahead of a first face-to-face meeting that (a) identified the need for a comprehensive systematic review of study designs in the literature and (b) prioritized key areas where research design considerations restrict translation of findings into practice. The working group's initial outputs were reviewed by independent advisors and additional expertise was sought in specific clinical areas. At a second face-to-face meeting the working group developed a theoretical framework and specific recommendations to support optimal study design. These were finalized by the working group co-ordinators and agreed by all working group members. RESULTS We propose a theoretical framework in which consideration of the intervention rationale the intervention setting, intervention features and the intervention aims inform selection and prioritization of outcome measures, whether the research sets out to determine superiority or non-inferiority of the intervention measured by its primary outcome(s), the most appropriate study design (e.g. experimental or quasi- experimental) and the detailed design features. We make 18 specific recommendation in three domains: outcomes, objectives and study design. CONCLUSIONS Researchers, funders and practitioners will be able to draw on our recommendations to most efficiently evaluate antimicrobial stewardship interventions.
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Affiliation(s)
- V A Schweitzer
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - C H van Werkhoven
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - J Rodríguez Baño
- Unit of Infectious Diseases, Clinical Microbiology and Preventive Medicine, Department of Medicine, Hospital Universitario Virgen Macarena, Universidad de Sevilla and Biomedicine Institute of Sevilla (IBiS), Seville, Spain
| | - J Bielicki
- Paediatric Infectious Disease Research Group, St George's University of London, London, UK
| | - S Harbarth
- Department of Infectious Diseases and Infection Control, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - M Hulscher
- Scientific Centre for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - B Huttner
- Department of Infectious Diseases and Infection Control, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - J Islam
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | - P Little
- Department of Primary Care Research, University of Southampton, Southampton, UK
| | - C Pulcini
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, APEMAC, Université de Lorraine, Nancy, France
| | - A Savoldi
- Infectious Diseases, Department of Diagnostic and Public Health, Verona, Italy; University Hospital, Internal Medicine, Tuebingen University, Germany
| | - E Tacconelli
- Infectious Diseases, Department of Diagnostic and Public Health, Verona, Italy; University Hospital, Internal Medicine, Tuebingen University, Germany
| | - J-F Timsit
- Medical and Infectious Diseases ICU, Bichat University Hospital, AP-HP, Paris, France; UMR 1137, Infection Antimicrobials Modelling Evolution, Paris Diderot University, Paris, France
| | - M van Smeden
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M Wolkewitz
- Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - M J M Bonten
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - A S Walker
- MRC Clinical Trials Unit, University College London, London, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M J Llewelyn
- Department of Primary Care Research, University of Southampton, Southampton, UK.
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Cross ELA, Sivyer K, Islam J, Santillo M, Mowbray F, Peto TEA, Walker AS, Yardley L, Llewelyn MJ. Adaptation and implementation of the ARK (Antibiotic Review Kit) intervention to safely and substantially reduce antibiotic use in hospitals: a feasibility study. J Hosp Infect 2019; 103:268-275. [PMID: 31394146 DOI: 10.1016/j.jhin.2019.07.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 07/30/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antimicrobial stewardship initiatives in secondary care depend on clinicians undertaking antibiotic prescription reviews but decisions to limit antibiotic treatment at review are complex. AIM To assess the feasibility and acceptability of implementing ARK (Antibiotic Review Kit), a behaviour change intervention made up of four components (brief online tool, prescribing decision aid, regular data collection and feedback process, and patient leaflet) to support stopping antibiotic treatment when it is safe to do so among hospitalized patients; before definitive evaluation through a stepped-wedge cluster-randomized controlled trial. METHODS Acceptability of the different intervention elements was assessed for a period of 12 weeks by uptake of the online tool, adoption of the decision aid into prescribing practice, and rates of decisions to stop antibiotics at review (assessed through repeated point-prevalence surveys). Patient perceptions of the information leaflet were assessed through a brief questionnaire. FINDINGS All elements of the intervention were successfully introduced into practice. A total of 132 staff encompassing a broad range of prescribers and non-prescribers completed the online tool (19.4 per 100 acute beds), including 97% (32/33) of the pre-specified essential clinical staff. Among 588 prescription charts evaluated in seven point-prevalence surveys over the 12-week implementation period, 82% overall (76-90% at each survey) used the decision aid. The median antibiotic stop rate post implementation was 36% (range: 29-40% at each survey) compared with 9% pre implementation (P < 0.001). CONCLUSION ARK provides a feasible and acceptable mechanism to support stopping antibiotics safely at post-prescription reviews in an acute hospital setting.
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Affiliation(s)
- E L A Cross
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - K Sivyer
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - J Islam
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - M Santillo
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - F Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - T E A Peto
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Biomedical Centre, Oxford, UK
| | - A S Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Biomedical Centre, Oxford, UK
| | - L Yardley
- School of Psychological Science, University of Bristol, Bristol, UK
| | - M J Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK.
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Pagels CM, McCreary EK, Rose WE, Dodds Ashley ES, Bookstaver PB, Dilworth TJ. Designing antimicrobial stewardship initiatives to enhance scientific dissemination. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
| | - Erin K. McCreary
- University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Warren E. Rose
- School of Pharmacy, University of Wisconsin-Madison; Madison Wisconsin
| | | | - P. Brandon Bookstaver
- Department of Clinical Pharmacy & Outcomes Sciences; University of South Carolina College of Pharmacy; Columbia South Carolina
| | - Thomas J. Dilworth
- Department of Pharmacy Services; Aurora St. Luke's Medical Center; Milwaukee Wisconsin
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Turner P, Fox-Lewis A, Shrestha P, Dance DAB, Wangrangsimakul T, Cusack TP, Ling CL, Hopkins J, Roberts T, Limmathurotsakul D, Cooper BS, Dunachie S, Moore CE, Dolecek C, van Doorn HR, Guerin PJ, Day NPJ, Ashley EA. Microbiology Investigation Criteria for Reporting Objectively (MICRO): a framework for the reporting and interpretation of clinical microbiology data. BMC Med 2019; 17:70. [PMID: 30922309 PMCID: PMC6440102 DOI: 10.1186/s12916-019-1301-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 03/06/2019] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND There is a pressing need to understand better the extent and distribution of antimicrobial resistance on a global scale, to inform development of effective interventions. Collation of datasets for meta-analysis, mathematical modelling and temporo-spatial analysis is hampered by the considerable variability in clinical sampling, variable quality in laboratory practice and inconsistencies in antimicrobial susceptibility testing and reporting. METHODS The Microbiology Investigation Criteria for Reporting Objectively (MICRO) checklist was developed by an international working group of clinical and laboratory microbiologists, infectious disease physicians, epidemiologists and mathematical modellers. RESULTS In keeping with the STROBE checklist, but applicable to all study designs, MICRO defines items to be included in reports of studies involving human clinical microbiology data. It provides a concise and comprehensive reference for clinicians, researchers, reviewers and journals working on, critically appraising, and publishing clinical microbiology datasets. CONCLUSIONS Implementation of the MICRO checklist will enhance the quality and scientific reporting of clinical microbiology data, increasing data utility and comparability to improve surveillance, grade data quality, facilitate meta-analyses and inform policy and interventions from local to global levels.
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Affiliation(s)
- Paul Turner
- Cambodia-Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Andrew Fox-Lewis
- Cambodia-Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Poojan Shrestha
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Infectious Diseases Data Observatory, Oxford, UK
| | - David A. B. Dance
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People’s Democratic Republic
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Tri Wangrangsimakul
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Tomas-Paul Cusack
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People’s Democratic Republic
- National Infection Service, Public Health England, London, UK
| | - Clare L. Ling
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Jill Hopkins
- Cambodia-Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Tamalee Roberts
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People’s Democratic Republic
| | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ben S. Cooper
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Susanna Dunachie
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Catrin E. Moore
- Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Christiane Dolecek
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - H. Rogier van Doorn
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Philippe J. Guerin
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Infectious Diseases Data Observatory, Oxford, UK
| | - Nicholas P. J. Day
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Elizabeth A. Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Myanmar Oxford Clinical Research Unit, Yangon, Myanmar
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Sharp MK, Tokalić R, Gómez G, Wager E, Altman DG, Hren D. A cross-sectional bibliometric study showed suboptimal journal endorsement rates of STROBE and its extensions. J Clin Epidemiol 2019; 107:42-50. [PMID: 30423373 DOI: 10.1016/j.jclinepi.2018.11.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/10/2018] [Accepted: 11/06/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The STrengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement provides guidance on reporting observational studies. Many extensions have been created for specialized methods or fields. We determined endorsement prevalence and typology by journals in extension-related fields. STUDY DESIGN AND SETTING A published protocol defined search strategies to identify journals publishing observational studies (2007-2017) across seven fields relating to STROBE extensions. We extracted text regarding STROBE, seven STROBE extensions, reporting guidelines Consolidated Standards of Reporting Trials and Preferred Reporting Items for Systematic Reviews and Meta-Analyses, and transparent reporting documents/groups: International Committee of Medical Journal Editors, Committee on Publication Ethics (COPE), and the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) networks. Relationships between endorsing STROBE, endorsing other guidelines, and journal impact factor were tested using chi square and Mann-Whitney tests. RESULTS Of 257 unique journals, 12 (5%) required STROBE on submission, 22 (9%) suggested use, 12 (5%) recommended a "relevant guideline," 72 (28%) mentioned it indirectly (via editorial policies or International Committee of Medical Journal Editors recommendations), and 139 (54%) did not mention STROBE. The relevant extension was required by 2 (<1%) journals; 4 (1%) suggested use. STROBE endorsement was not associated with journal impact indices but was with Consolidated Standards of Reporting Trials and Preferred Reporting Items for Systematic Reviews and Meta-Analyses endorsements. CONCLUSION Reporting guideline endorsement rates are low; information is vague and scattered. Unambiguous language is needed to improve adherence to reporting guidelines and increase the quality of reporting.
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Affiliation(s)
- Melissa K Sharp
- Department of Psychology, University of Split, Faculty of Humanities and Social Sciences, Split, Croatia; INSERM, U1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Methods of Therapeutic Evaluation of Chronic Diseases Team (METHODS), Paris, F-75014 France; Paris Descartes University, Sorbonne Paris Cité, France.
| | | | - Guadalupe Gómez
- Universitat Politècnica de Catalunya-BarcelonaTech, Departament d'Estadística i Investigació Operativa, Barcelona, Spain
| | - Elizabeth Wager
- Sideview, Buckinghamshire, UK; University of Split, School of Medicine, Split, Croatia
| | - Douglas G Altman
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Darko Hren
- Department of Psychology, University of Split, Faculty of Humanities and Social Sciences, Split, Croatia
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Hansen MP, Scott AM, McCullough A, Thorning S, Aronson JK, Beller EM, Glasziou PP, Hoffmann TC, Clark J, Del Mar CB. Adverse events in people taking macrolide antibiotics versus placebo for any indication. Cochrane Database Syst Rev 2019; 1:CD011825. [PMID: 30656650 PMCID: PMC6353052 DOI: 10.1002/14651858.cd011825.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Macrolide antibiotics (macrolides) are among the most commonly prescribed antibiotics worldwide and are used for a wide range of infections. However, macrolides also expose people to the risk of adverse events. The current understanding of adverse events is mostly derived from observational studies, which are subject to bias because it is hard to distinguish events caused by antibiotics from events caused by the diseases being treated. Because adverse events are treatment-specific, rather than disease-specific, it is possible to increase the number of adverse events available for analysis by combining randomised controlled trials (RCTs) of the same treatment across different diseases. OBJECTIVES To quantify the incidences of reported adverse events in people taking macrolide antibiotics compared to placebo for any indication. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Acute Respiratory Infections Group Specialised Register (2018, Issue 4); MEDLINE (Ovid, from 1946 to 8 May 2018); Embase (from 2010 to 8 May 2018); CINAHL (from 1981 to 8 May 2018); LILACS (from 1982 to 8 May 2018); and Web of Science (from 1955 to 8 May 2018). We searched clinical trial registries for current and completed trials (9 May 2018) and checked the reference lists of included studies and of previous Cochrane Reviews on macrolides. SELECTION CRITERIA We included RCTs that compared a macrolide antibiotic to placebo for any indication. We included trials using any of the four most commonly used macrolide antibiotics: azithromycin, clarithromycin, erythromycin, or roxithromycin. Macrolides could be administered by any route. Concomitant medications were permitted provided they were equally available to both treatment and comparison groups. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and collected data. We assessed the risk of bias of all included studies and the quality of evidence for each outcome of interest. We analysed specific adverse events, deaths, and subsequent carriage of macrolide-resistant bacteria separately. The study participant was the unit of analysis for each adverse event. Any specific adverse events that occurred in 5% or more of any group were reported. We undertook a meta-analysis when three or more included studies reported a specific adverse event. MAIN RESULTS We included 183 studies with a total of 252,886 participants (range 40 to 190,238). The indications for macrolide antibiotics varied greatly, with most studies using macrolides for the treatment or prevention of either acute respiratory tract infections, cardiovascular diseases, chronic respiratory diseases, gastrointestinal conditions, or urogynaecological problems. Most trials were conducted in secondary care settings. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin.Most studies (89%) reported some adverse events or at least stated that no adverse events were observed.Gastrointestinal adverse events were the most commonly reported type of adverse event. Compared to placebo, macrolides caused more diarrhoea (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.34 to 2.16; low-quality evidence); more abdominal pain (OR 1.66, 95% CI 1.22 to 2.26; low-quality evidence); and more nausea (OR 1.61, 95% CI 1.37 to 1.90; moderate-quality evidence). Vomiting (OR 1.27, 95% CI 1.04 to 1.56; moderate-quality evidence) and gastrointestinal disorders not otherwise specified (NOS) (OR 2.16, 95% CI 1.56 to 3.00; moderate-quality evidence) were also reported more often in participants taking macrolides compared to placebo.The number of additional people (absolute difference in risk) who experienced adverse events from macrolides was: gastrointestinal disorders NOS 85/1000; diarrhoea 72/1000; abdominal pain 62/1000; nausea 47/1000; and vomiting 23/1000.The number needed to treat for an additional harmful outcome (NNTH) ranged from 12 (95% CI 8 to 23) for gastrointestinal disorders NOS to 17 (9 to 47) for abdominal pain; 19 (12 to 33) for diarrhoea; 19 (13 to 30) for nausea; and 45 (22 to 295) for vomiting.There was no clear consistent difference in gastrointestinal adverse events between different types of macrolides or route of administration.Taste disturbances were reported more often by participants taking macrolide antibiotics, although there were wide confidence intervals and moderate heterogeneity (OR 4.95, 95% CI 1.64 to 14.93; I² = 46%; low-quality evidence).Compared with participants taking placebo, those taking macrolides experienced hearing loss more often, however only four studies reported this outcome (OR 1.30, 95% CI 1.00 to 1.70; I² = 0%; low-quality evidence).We did not find any evidence that macrolides caused more cardiac disorders (OR 0.87, 95% CI 0.54 to 1.40; very low-quality evidence); hepatobiliary disorders (OR 1.04, 95% CI 0.27 to 4.09; very low-quality evidence); or changes in liver enzymes (OR 1.56, 95% CI 0.73 to 3.37; very low-quality evidence) compared to placebo.We did not find any evidence that appetite loss, dizziness, headache, respiratory symptoms, blood infections, skin and soft tissue infections, itching, or rashes were reported more often by participants treated with macrolides compared to placebo.Macrolides caused less cough (OR 0.57, 95% CI 0.40 to 0.80; moderate-quality evidence) and fewer respiratory tract infections (OR 0.70, 95% CI 0.62 to 0.80; moderate-quality evidence) compared to placebo, probably because these are not adverse events, but rather characteristics of the indications for the antibiotics. Less fever (OR 0.73, 95% 0.54 to 1.00; moderate-quality evidence) was also reported by participants taking macrolides compared to placebo, although these findings were non-significant.There was no increase in mortality in participants taking macrolides compared with placebo (OR 0.96, 95% 0.87 to 1.06; I² = 11%; low-quality evidence).Only 24 studies (13%) provided useful data on macrolide-resistant bacteria. Macrolide-resistant bacteria were more commonly identified among participants immediately after exposure to the antibiotic. However, differences in resistance thereafter were inconsistent.Pharmaceutical companies supplied the trial medication or funding, or both, for 91 trials. AUTHORS' CONCLUSIONS The macrolides as a group clearly increased rates of gastrointestinal adverse events. Most trials made at least some statement about adverse events, such as "none were observed". However, few trials clearly listed adverse events as outcomes, reported on the methods used for eliciting adverse events, or even detailed the numbers of people who experienced adverse events in both the intervention and placebo group. This was especially true for the adverse event of bacterial resistance.
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Affiliation(s)
| | - Anna M Scott
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Amanda McCullough
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Sarah Thorning
- Gold Coast Hospital and Health ServiceGCUH LibraryLevel 1, Block E, GCUHSouthportQueenslandAustralia4215
| | - Jeffrey K Aronson
- Oxford UniversityNuffield Department of Primary Care Health SciencesOxfordOxonUKOX26GG
| | - Elaine M Beller
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Paul P Glasziou
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Tammy C Hoffmann
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Justin Clark
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
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Chatterjee A, Modarai M, Naylor NR, Boyd SE, Atun R, Barlow J, Holmes AH, Johnson A, Robotham JV. Quantifying drivers of antibiotic resistance in humans: a systematic review. THE LANCET. INFECTIOUS DISEASES 2018; 18:e368-e378. [PMID: 30172580 DOI: 10.1016/s1473-3099(18)30296-2] [Citation(s) in RCA: 184] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 03/26/2018] [Accepted: 05/01/2018] [Indexed: 02/06/2023]
Abstract
Mitigating the risks of antibiotic resistance requires a horizon scan linking the quality with the quantity of data reported on drivers of antibiotic resistance in humans, arising from the human, animal, and environmental reservoirs. We did a systematic review using a One Health approach to survey the key drivers of antibiotic resistance in humans. Two sets of reviewers selected 565 studies from a total of 2819 titles and abstracts identified in Embase, MEDLINE, and Scopus (2005-18), and the European Centre for Disease Prevention and Control, the US Centers for Disease Control and Prevention, and WHO (One Health data). Study quality was assessed in accordance with Cochrane recommendations. Previous antibiotic exposure, underlying disease, and invasive procedures were the risk factors with most supporting evidence identified from the 88 risk factors retrieved. The odds ratios of antibiotic resistance were primarily reported to be between 2 and 4 for these risk factors when compared with their respective controls or baseline risk groups. Food-related transmission from the animal reservoir and water-related transmission from the environmental reservoir were frequently quantified. Uniformly quantifying relationships between risk factors will help researchers to better understand the process by which antibiotic resistance arises in human infections.
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Affiliation(s)
- Anuja Chatterjee
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK.
| | - Maryam Modarai
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
| | - Nichola R Naylor
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
| | - Sara E Boyd
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK; Imperial College London Healthcare NHS Trust, London, UK; Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Rifat Atun
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK; Department of Global Health and Population, and Department of Health Policy and Management, Harvard University, Boston, MA, USA
| | - James Barlow
- Centre for Health Economics & Policy Innovation, Imperial College Business School, London, UK
| | - Alison H Holmes
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK; Imperial College London Healthcare NHS Trust, London, UK
| | - Alan Johnson
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK; Department of Healthcare-Associated Infections and Antimicrobial Resistance, National Infection Service, Public Health England, London, UK
| | - Julie V Robotham
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK; Modelling and Economics Unit, National Infection Service, Public Health England, London, UK
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Systematic review of the use of time series data in the study of antimicrobial consumption and Pseudomonas aeruginosa resistance. J Glob Antimicrob Resist 2018; 15:69-73. [DOI: 10.1016/j.jgar.2018.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/30/2018] [Accepted: 06/05/2018] [Indexed: 11/22/2022] Open
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An analysis of reporting quality of prospective studies examining community antibiotic use and resistance. Trials 2018; 19:656. [PMID: 30482238 PMCID: PMC6258384 DOI: 10.1186/s13063-018-3040-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 11/03/2018] [Indexed: 12/22/2022] Open
Abstract
Background Antibiotic resistance is a global problem, but the relationship between antibiotic use and resistance development and decay is not well understood. This knowledge is best provided by prospective studies, but to be useful they must be both conducted and reported well. Little is known about the reporting quality of these studies. This study aimed to assess the quality of reporting in prospective studies that investigated antibiotic resistance following antibiotic exposure in community-based individuals. Methods The quality of reporting of prospective studies (17 randomised trials, eight cohort studies) identified in a systematic review of the relationship between antibiotic use and resistance were assessed independently by two researchers using checklists (one for trials, one for cohort studies) developed from existing reporting guidelines for these designs and this field. Results The mean percentage (SD, minimum-maximum) of mandatory items that were adequately described by the included studies was 59% for trials (14%, 36–84%) and 52% for cohort studies (17%, 13–70%). Most studies adequately described the study background and rationale, the type, combination, and duration of the antibiotic intervention, and the sampling procedures followed to isolate resistant bacteria. Most studies did not report the incident numbers of resistant and susceptible isolates analysed at each time point. Blinding and sample size calculation was inadequately reported in almost half of the trials and all cohort studies. Conclusions The quality of reporting in prospective studies investigating the association between antibiotic exposure in the community and isolation of resistance isolates is variable. Some details were missing in more than half of the studies, which precludes a complete risk of bias assessment and accurate interpretation and synthesis of results. Electronic supplementary material The online version of this article (10.1186/s13063-018-3040-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Melissa K Sharp
- Department of Psychology, Faculty of Humanities and Social Sciences, University of Split, Split, Croatia, INSERM, U1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Methods of therapeutic evaluation of chronic diseases Team (METHODS), Paris, France, Paris Descartes University, Sorbonne Paris Cité, France, ; Department of Psychology, Faculty of Humanities and Social Sciences, University of Split, Split, Croatia Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
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Pulcini C, Beovic B, Howard P, Mendelson M. Human resources estimates and funding for antibiotic stewardship teams are urgently needed: authors' response. Clin Microbiol Infect 2018; 24:557. [DOI: 10.1016/j.cmi.2018.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 01/13/2018] [Indexed: 01/28/2023]
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Harder T, Eckmanns T, Schmidt N, Kern W, Sin MA. Human resources estimates for antibiotic stewardship teams: evidence-based approaches for recommendations are needed. Clin Microbiol Infect 2018; 24:554-556. [DOI: 10.1016/j.cmi.2017.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 10/18/2022]
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McGettigan P, Roderick P, Kadam A, Pollock A. Threats to global antimicrobial resistance control: Centrally approved and unapproved antibiotic formulations sold in India. Br J Clin Pharmacol 2018; 85:59-70. [PMID: 29397576 DOI: 10.1111/bcp.13503] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Revised: 12/08/2017] [Accepted: 12/24/2017] [Indexed: 11/26/2022] Open
Abstract
AIMS Rising antimicrobial resistance (AMR) is a global health crisis. India has among the highest resistance rates and antibiotic consumption internationally. Extensive use of fixed-dose combination (FDC) antibiotics and of unapproved formulations are claimed contributory factors but there has been no systematic examination of formulations or volumes sold. The aim of the present study was to investigate the regulatory approval status and sales volumes of systemic antibiotics marketed in India. METHODS This was an ecological study using regulatory records in India, the UK and the US to determine the approval status in each country of systemic antibiotic FDCs and single-drug formulations (SDFs) sold in India. Pharmatrac® sales data were used to determine the formulations and volumes sold (2007-2012), branded-product numbers and manufacturers. RESULTS Of 118 systemic antibiotic FDC formulations sold in India, 43 (36%) were approved but 75 (64%) had no record of regulatory approval; four (3%) formulations were approved in the UK and/or US. Almost half of formulations (58/118; 49%) comprised dual antimicrobials, most unapproved in India (43/58; 74%), and many were pharmacologically problematic. In contrast, 80/86 (93%) SDFs were approved in India and over two-thirds in the UK and/or US. Total antibiotic sales increased by 26%, from 2056 million units (2007-08) to 2583 million units (2011-12). FDC sales rose by 38% vs. 20% for SDFs. By 2011-12, FDCs comprised one-third of sales (872 million units). Over one-third of FDCs sold (300.26 million units; 34.5%) were of unapproved formulations. Multinational companies manufactured unapproved formulations and accounted for 19% of all FDC and SDF sales annually. CONCLUSIONS Sales in India of antibiotic FDCs, including unapproved formulations, are rising. In the context of increasing AMR rates nationally and globally, unapproved antibiotic FDCs undermine India's national AMR strategy and should be banned from sale.
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Affiliation(s)
- Patricia McGettigan
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, EC1M 6BQ, UK
| | - Peter Roderick
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
| | - Abhay Kadam
- Lakshya Society for Public Health Education and Research, Pune, Maharashtra, India
| | - Allyson Pollock
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
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Pulcini C, Huttner A. CMI policy on antimicrobial stewardship research. Clin Microbiol Infect 2018; 24:91-92. [DOI: 10.1016/j.cmi.2017.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 11/04/2017] [Indexed: 12/18/2022]
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Sharp MK, Utrobičić A, Gómez G, Cobo E, Wager E, Hren D. The STROBE extensions: protocol for a qualitative assessment of content and a survey of endorsement. BMJ Open 2017; 7:e019043. [PMID: 29061635 PMCID: PMC5665297 DOI: 10.1136/bmjopen-2017-019043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) Statement was developed in response to inadequate reporting of observational studies. In recent years, several extensions to STROBE have been created to provide more nuanced field-specific guidance for authors. The content and the prevalence of extension endorsement have not yet been assessed. Accordingly, there are two aims: (1) to classify changes made in the extensions to identify strengths and weaknesses of the original STROBE checklist and (2) to determine the prevalence and typology of endorsement by journals in fields related to extensions. METHODS AND ANALYSIS Two independent researchers will assess additions in each extension. Additions will be coded as 'field specific' (FS) or 'not field specific' (NFS). FS is defined as particularly relevant information for a single field and guidance provided generally cannot be extrapolated beyond that field. NFS is defined as information that reflects epidemiological or methodological tenets and can be generalised to most, if not all, types of observational research studies. Intraclass correlation will be calculated to measure reviewers' concordance. On disagreement, consensus will be sought. Individual additions will be grouped by STROBE checklist items to identify the frequency and distribution of changes.Journals in fields related to extensions will be identified through National Library of Medicine PubMed Broad Subject Terms, screened for eligibility and further distilled via Ovid MEDLINE® search strategies for observational studies. Text describing endorsement will be extracted from each journal's website. A classification scheme will be created for endorsement types and the prevalence of endorsement will be estimated. Analyses will use NVivo V.11 and SAS University Edition. ETHICS AND DISSEMINATION This study does not require ethical approval as it does not involve human participants. This study has been preregistered on Open Science Framework.
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Affiliation(s)
- Melissa K Sharp
- Department of Psychology, Faculty of Humanities and Social Sciences, University of Split, Split, Croatia
- Sorbonne Paris Cité, Pierre Louis Doctoral School: Epidemiology and Biomedical Sciences, Université Paris Descartes, Paris, France
| | - Ana Utrobičić
- School of Medicine, University of Split, Split, Croatia
| | - Guadalupe Gómez
- Departament d'Estadística i Investigació Operativa, Universitat Politecnica de Catalunya, Barcelona, Catalunya, Spain
| | - Erik Cobo
- Departament d'Estadística i Investigació Operativa, Universitat Politecnica de Catalunya, Barcelona, Catalunya, Spain
| | - Elizabeth Wager
- School of Medicine, University of Split, Split, Croatia
- Sideview, Buckinghamshire, UK
| | - Darko Hren
- Department of Psychology, Faculty of Humanities and Social Sciences, University of Split, Split, Croatia
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Toma M, Davey PG, Marwick CA, Guthrie B. A framework for ensuring a balanced accounting of the impact of antimicrobial stewardship interventions. J Antimicrob Chemother 2017; 72:3223-3231. [DOI: 10.1093/jac/dkx312] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Birkegård AC, Halasa T, Græsbøll K, Clasen J, Folkesson A, Toft N. Association between selected antimicrobial resistance genes and antimicrobial exposure in Danish pig farms. Sci Rep 2017; 7:9683. [PMID: 28852034 PMCID: PMC5575052 DOI: 10.1038/s41598-017-10092-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 08/03/2017] [Indexed: 11/08/2022] Open
Abstract
Bacterial antimicrobial resistance (AMR) in pigs is an important public health concern due to its possible transfer to humans. We aimed at quantifying the relationship between the lifetime exposure of antimicrobials and seven antimicrobial resistance genes in Danish slaughter pig farms. AMR gene levels were quantified by qPCR of total-community DNA in faecal samples obtained from 681 batches of slaughter pigs. The lifetime exposure to antimicrobials was estimated at batch level for the piglet, weaner, and finisher periods individually for the sampled batches. We showed that the effect of antimicrobial exposure on the levels of AMR genes was complex and unique for each individual gene. Several antimicrobial classes had both negative and positive correlations with the AMR genes. From 10-42% of the variation in AMR gene levels could be explained in the final regression models, indicating that antimicrobial exposure is not the only important determinant of the AMR gene levels.
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Affiliation(s)
- Anna Camilla Birkegård
- Division for Diagnostics & Scientific Advice, National Veterinary Institute, Technical University of Denmark, Kemitorvet Building 204, 2800 Kgs. Lyngby, Denmark.
| | - Tariq Halasa
- Division for Diagnostics & Scientific Advice, National Veterinary Institute, Technical University of Denmark, Kemitorvet Building 204, 2800 Kgs. Lyngby, Denmark
| | - Kaare Græsbøll
- Division for Diagnostics & Scientific Advice, National Veterinary Institute, Technical University of Denmark, Kemitorvet Building 204, 2800 Kgs. Lyngby, Denmark
| | - Julie Clasen
- Division for Diagnostics & Scientific Advice, National Veterinary Institute, Technical University of Denmark, Kemitorvet Building 204, 2800 Kgs. Lyngby, Denmark
| | - Anders Folkesson
- Division for Diagnostics & Scientific Advice, National Veterinary Institute, Technical University of Denmark, Kemitorvet Building 204, 2800 Kgs. Lyngby, Denmark
| | - Nils Toft
- Division for Diagnostics & Scientific Advice, National Veterinary Institute, Technical University of Denmark, Kemitorvet Building 204, 2800 Kgs. Lyngby, Denmark
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Surgical site infection with extended-spectrum β-lactamase-producing Enterobacteriaceae after cardiac surgery: incidence and risk factors. Clin Microbiol Infect 2017; 24:283-288. [PMID: 28698036 DOI: 10.1016/j.cmi.2017.07.004] [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: 02/17/2017] [Revised: 06/27/2017] [Accepted: 07/01/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the incidence, microbiology and risk factors for sternal wound infection (SWI) with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) following cardiac surgery. METHODS We performed a retrospective analysis between January 2006 and December 2015 of prospective surveillance of a cohort of patients with cardiac surgery at a single centre (Paris, France). SWI was defined as the need for reoperation due to sternal infection. All patients with an initial surgery under extracorporeal circulation and diagnosed with an SWI caused by Enterobacteriaceae isolates were included. We compared patients infected with at least one ESBL-PE with those with SWI due to other Enterobacteriaceae by logistic regression analysis. RESULTS Of the 11 167 patients who underwent cardiac surgery, 412 (3.7%) developed SWI, among which Enterobacteriaceae were isolated in 150 patients (36.5%), including 29 ESBL-PE. The main Enterobacteriaceae (n = 171) were Escherichia coli in 49 patients (29%) and Enterobacter cloacae in 26 (15%). Risk factors for SWI with ESBL-PE in the multivariate logistic regression were previous intensive care unit admission during the preceding 6 months (adjusted odds ratio (aOR) 12.2; 95% CI 3.3-44.8), postoperative intensive care unit stay before surgery for SWI longer than 5 days (aOR 4.6; 95% CI 1.7-11.9) and being born outside France (aOR 3.2; 95% CI 1.2-8.3). CONCLUSIONS Our results suggest that SWI due to ESBL-PE was associated with preoperative and postoperative unstable state, requiring an intensive care unit stay longer than the usual 24 or 48 postoperative hours, whereas being born outside France may indicate ESBL-PE carriage before hospital admission.
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Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2017. [PMID: 28629876 DOI: 10.1016/s1473-3099(17)30325-0] [Citation(s) in RCA: 464] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Antibiotic stewardship programmes have been shown to reduce antibiotic use and hospital costs. We aimed to evaluate evidence of the effect of antibiotic stewardship on the incidence of infections and colonisation with antibiotic-resistant bacteria. METHODS For this systematic review and meta-analysis, we searched PubMed, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Web of Science for studies published from Jan 1, 1960, to May 31, 2016, that analysed the effect of antibiotic stewardship programmes on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infections in hospital inpatients. Two authors independently assessed the eligibility of trials and extracted data. Studies involving long-term care facilities were excluded. The main outcomes were incidence ratios (IRs) of target infections and colonisation per 1000 patient-days before and after implementation of antibiotic stewardship. Meta-analyses were done with random-effect models and heterogeneity was calculated with the I2 method. FINDINGS We included 32 studies in the meta-analysis, comprising 9 056 241 patient-days and 159 estimates of IRs. Antibiotic stewardship programmes reduced the incidence of infections and colonisation with multidrug-resistant Gram-negative bacteria (51% reduction; IR 0·49, 95% CI 0·35-0·68; p<0·0001), extended-spectrum β-lactamase-producing Gram-negative bacteria (48%; 0·52, 0·27-0·98; p=0·0428), and meticillin-resistant Staphylococcus aureus (37%; 0·63, 0·45-0·88; p=0·0065), as well as the incidence of C difficile infections (32%; 0·68, 0·53-0·88; p=0·0029). Antibiotic stewardship programmes were more effective when implemented with infection control measures (IR 0·69, 0·54-0·88; p=0·0030), especially hand-hygiene interventions (0·34, 0·21-0·54; p<0·0001), than when implemented alone. Antibiotic stewardship did not affect the IRs of vancomycin-resistant enterococci and quinolone-resistant and aminoglycoside-resistant Gram-negative bacteria. Significant heterogeneity between studies was detected, which was partly explained by the type of interventions and co-resistance patterns of the target bacteria. INTERPRETATION Antibiotic stewardship programmes significantly reduce the incidence of infections and colonisation with antibiotic-resistant bacteria and C difficile infections in hospital inpatients. These results provide stakeholders and policy makers with evidence for implementation of antibiotic stewardship interventions to reduce the burden of infections from antibiotic-resistant bacteria. FUNDING German Center for Infection Research.
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de Kraker MEA, Abbas M, Huttner B, Harbarth S. Good epidemiological practice: a narrative review of appropriate scientific methods to evaluate the impact of antimicrobial stewardship interventions. Clin Microbiol Infect 2017; 23:819-825. [PMID: 28571767 DOI: 10.1016/j.cmi.2017.05.019] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/15/2017] [Accepted: 05/17/2017] [Indexed: 12/30/2022]
Abstract
AIMS In this narrative review, we provide a framework for assessing the quality of evidence provided by studies investigating antimicrobial stewardship (AMS) interventions, and inform the design and planning stage for future AMS evaluation studies to determine the best strategies to keep antimicrobial resistance at bay. SOURCES Cochrane/Pubmed. CONTENT As AMS is mostly applied in a complex, real-world setting, bias and random time effects can jeopardize the validity of causal inference. The most important risks include simultaneously implemented infection prevention strategies and regression to the mean. Inclusion of homogeneous intervention and control arms, through randomization of the intervention, can limit these risks. However, contamination can play an important role for AMS; therefore, randomization at cluster-level, instead of randomization at individual-level, is recommended. It can be challenging to identify enough representative clusters, and implementation of a cluster-RCT (cRCT) can be costly. Controlled interrupted time series (ITS) design has a high validity as well, and is relatively straightforward to implement, although time-varying confounding should be considered. Independent of the study design, it is crucial to include multiple process, clinical outcome, microbiological and financial measures, to be able to detect possible, unintended consequences. IMPLICATIONS Future studies assessing the impact of new AMS strategies should produce compelling evidence by opting for cRCTs, or ITS including a control arm. Furthermore, a holistic view of intended and unintended consequences should be reported, and a detailed process evaluation should be provided to adequately inform implementation of successful AMS strategies to battle the rising burden of AMR.
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Affiliation(s)
- M E A de Kraker
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | - M Abbas
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - B Huttner
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - S Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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