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

Relationship between the appropriateness of antibiotic treatment and clinical outcomes/medical costs of patients with community-acquired acute pyelonephritis: a multicenter prospective cohort study

BACKGROUND

Inappropriate use of antibiotics not only increases antibiotic resistance as collateral damage but also increases clinical failure rates and medical costs. The purpose of this study was to determine the relationship between the appropriateness of antibiotic prescription and outcomes of community-acquired acute pyelonephritis (CA-APN).

METHODS

A multicenter prospective cohort study was conducted at eight hospitals in Korea between September 2017 and August 2018. All hospitalized patients aged ≥ 19 years who were diagnosed with CA-APN on admission were recruited. The appropriateness of empirical and definitive antibiotics, as well as the appropriateness of antibiotic treatment duration and route of administration, was evaluated in accordance with the guideline and expert opinions. Clinical outcomes and medical costs were compared between patients who were administered antibiotics 'appropriately' and 'inappropriately.'

RESULTS

A total of 397 and 318 patients were eligible for the analysis of the appropriateness of empirical and definitive antibiotics, respectively. Of them, 10 (2.5%) and 18 (5.7%) were administered 'inappropriately' empirical and definitive antibiotics, respectively. Of the 119 patients whose use of both empirical and definitive antibiotics was classified as 'optimal,' 57 (47.9%) received antibiotics over a longer duration than that recommended; 67 (56.3%) did not change to oral antibiotics on day 7 of hospitalization, even after stabilization of the clinical symptoms. Patients who were administered empirical antibiotics 'appropriately' had shorter hospitalization days (8 vs. 10 days, P = 0.001) and lower medical costs (2381.9 vs. 3235.9 USD, P = 0.002) than those who were administered them 'inappropriately.' Similar findings were observed for patients administered both empirical and definitive antibiotics 'appropriately' and those administered either empirical or definitive antibiotics 'inappropriately'.

CONCLUSIONS

Appropriate use of antibiotics leads to better outcomes, including reduced hospitalization duration and medical costs.

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

Background

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

Materials and Methods

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

Results

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

Conclusion

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

Quantitative Evaluation of the Economic Impact of Antimicrobial Resistance on the Treatment of Community-Acquired Acute Pyelonephritis in Korea

Background

Materials and Methods

Results

Conclusion

Trends and Patterns of Antibiotics Use in China's Urban Tertiary Hospitals, 2016-19

Objectives: This study aimed to identify the trends in antibiotics utilization and patients costs, evaluating the effect of the policy and exploring factors associated with the irrational use of antibiotics. Methods: Based on the Cooperation Project Database of Hospital Prescriptions, data were collected from 89 tertiary hospitals in nine cities in China during 2016-2019. The study sample consisted of prescription records with antibiotics for 3,422,710 outpatient and emergency visits and 26, 118, 436 inpatient hospitalizations. Results: For outpatients, the proportion of treated with antibiotics declined from 14.72 to 13.92% significantly (p < 0.01). The proportion of antibiotic costs for outpatients decreased from 5.79 to 4.45% significantly (p < 0.01). For emergency patients, the proportion of treated with antibiotics increased from 39.31 to 43.45% significantly (p < 0.01). The proportion of antibiotic costs for emergency patients decreased from 36.44 to 34.69%, with no significant change (p = 0.87). For inpatients, the proportion of treated with antibiotics increased from 23.82 to 27.25% significantly (p < 0.01). The proportion of antibiotic costs for outpatients decreased from 18.09 to 17.19% with no statistical significance (p = 0.89). Other β-lactam antibacterials (1,663.03 ten thousand DDD) far exceeded other antibiotics categories. Stablely ranked first, followed by Macrolides, lincosamide and streptogramins (965.74 ten thousand DDD), Quinolone antibacterials (710.42 ten thousand DDD), and β-lactam antibacterials, penicillins (497.01 ten thousand DDD). Conclusions: The proportion of treated with antibiotics for outpatients and inpatients meet the WHO standards. The antibiotics use varied by different survey areas, clinical departments, patient gender, patient age and antibiotics categories. More efforts should focus on improving the appropriateness of antibiotics use at the individual level.

Impact of agr Functionality on the Outcome of Patients with Methicillin-Susceptible Staphylococcus aureus Bacteremia

Dysfunctional accessory gene regulator (agr) is associated with unfavorable outcomes in invasive methicillin-resistant Staphylococcus aureus infections. However, it is unknown whether this association persists in methicillin-susceptible Staphylococcus aureus bacteremia (MSSA-B). This study evaluated the association between agr dysfunction and mortality in patients with MSSA-B. This retrospective cohort study included MSSA-B patients (≥15 years) enrolled from June 2014 to June 2019 and retrospectively collected their demographic and clinical information. Stored causative strains were measured for agr functionality by δ-hemolysin production assays. Among 244 MSSA-B patients, 91 (37.3%) and 153 (62.7%) had dysfunctional and functional agr MSSA-B, respectively. Ninety-day mortality occurred in 18.7% and 17.6% dysfunctional and functional groups, respectively (P = 0.97). Kaplan-Meier analysis showed that mortality due to dysfunctional agr MSSA-B was not significantly higher (P = 0.82). Age, sites, the severity of infection, and comorbidity adjusted hazard ratio (aHR) of the dysfunctional group for 90-day mortality was 1.303 (95% confidence interval [CI], 0.698 to 2.436, P = 0.41). Mortality due to MSSA-B with sequential organ failure assessment (SOFA) scores of 2 to 5 was significantly higher in the dysfunctional group (P = 0.03), and the dysfunctional agr aHR for 90-day mortality was 3.260 (95% CI, 1.050 to 10.118, P = 0.04). The agr dysfunction of causative organisms can have a significant effect on the outcomes of MSSA-B in patients with moderate severity (SOFA scores 2 to 5).

IMPORTANCE Few studies have examined the association between methicillin-susceptible Staphylococcus aureus (MSSA) infection and accessory gene regulator (agr) functionality. We evaluated the association between agr dysfunction and mortality in patients with MSSA bacteremia. Dysfunctional agr is associated with lower survival in MSSA bacteremia patients with moderately severe sequential organ failure assessment (SOFA) scores of 2 to 5. We found that the agr functionality of causative organisms may have an effect on patients’ outcomes in MSSA like in methicillin-resistant S. aureus.

Xanthogranulomatous pyelonephritis: a focus on microbiological and antibiotic resistance profiles

BACKGROUND

Xanthogranulomatous pyelonephritis (XGP) is an inflammatory condition of the kidney and its treatment most often involves a combination of antibiotics and nephrectomy. This study aimed to define the clinical features and management of XGP, focusing on microbiological aspects and antibiotic therapy.

METHODS

We performed a retrospective study of 27 cases of XGP diagnosed between January 2001 and January 2020 to analyse their clinical and management characteristics. In addition, a literature review was conducted of XGP case series covering the period from 2000-2020. We searched PubMed for case series through April 2020 without language restrictions. Studies reporting case series of XGP (more than ten cases) were included if they were relevant to this study.

RESULTS

Twenty-seven patients were diagnosed with XGP, and 26 of them were histologically proven to have XGP. A total of 81.5% of the patients were female and the mean age was 59.6 years (SD 19.2). The most frequent symptoms were flank pain (70.4%) and fever (59.3%), while 77.8% of patients had renal stones. Proteus mirabilis was detected in the urine culture in 18.5% of patients, followed by detection of Escherichia coli in 14.8% of patients. The computed tomography (CT) findings included perirenal (29.6%) or pararenal (29.6%) involvement in the majority of patients. Twenty-six patients underwent nephrectomy. Piperacillin/tazobactam and ceftriaxone were the most commonly prescribed antibiotics for treatment. The reported piperacillin/tazobactam and ceftriaxone resistance rates were 14.3% and 16.6%, respectively. Twenty-six case series were included in the literature review, reporting 693 cases in total.

CONCLUSION

We found well-established characteristics of XGP patients among series in terms of previous history, clinical, laboratory and imaging findings, and operative and postoperative outcomes. It is important to know the clinical presentation and potential severity of XGP, as well as the most frequently involved microorganisms and their antibiotic resistance profiles, to select the most appropriate antibiotic therapy.

Comparison of antimicrobial resistances and clinical features in community-onset Escherichia coli and Klebsiella pneumoniae bacteremia

BACKGROUND/AIMS

The aim of this study was to compare antimicrobial resistance, clinical features, and outcomes of community-onset Escherichia coli (COEC) and Klebsiella pneumoniae (COKP) bacteremia.

METHODS

The medical records of patients diagnosed with E. coli or K. pneumoniae bacteremia in the emergency department of a 750-bed secondary care hospital in Daegu, Korea from January 2010 to December 2016 were retrospectively reviewed.

RESULTS

A total of 866 patients with COEC bacteremia and 299 with COKP bacteremia were enrolled. COEC bacteremia, compared to COKP bacteremia, had higher rates of 3rd generation cephalosporin (3GC) (18.8% vs. 8.4%, p < 0.001) and f luoroquinolone (FQ) (30.4% vs. 8.0%, p < 0.001) resistance. The patients with COKP bacteremia had higher Charlson comorbidity indices (CCI) (1.8 ± 2.0 vs. 1.5 ± 1.8, p = 0.035), Pittsburgh bacteremia scores (PBS) (2.0 ± 2.6 vs. 1.3 ± 1.8, p < 0.001), and 30-day mortality (14.44% vs. 8.8%, p = 0.008) than the patients with COEC bacteremia. Age younger than 70 years, male sex, polymicrobial infections, pneumonia, intra-abdominal infection, PBS ≥ 2, and Foley catheter insertion were independent predictive factors for COKP bacteremia compared to COEC bacteremia in the multivariate analysis. CCI, PBS, and intensive care unit admission were independent risk factors for 30-day mortality in the multivariate analysis.

CONCLUSION

3GCs and FQs are still useful for the empirical treatment of patients with probable COKP bacteremia. The patients with COKP bacteremia had worse outcomes because of its greater severity and more frequent underlying comorbidities.

Comparison of the clinical characteristics of community-acquired acute pyelonephritis between male and female patients

BACKGROUND

Community-acquired acute pyelonephritis (CA-APN) is relatively rare in men. This study aimed to compare the clinical characteristics of CA-APN between male and female patients.

METHODS

We prospectively collected the clinical and microbiological data of hospitalized CA-APN patients aged ≥19 years in South Korea from March 2010 to February 2011 in 11 hospitals and from September 2017 to August 2018 in 8 hospitals. Only the first episodes of APN of each patient during the study period were included.

RESULTS

From 2010 to 2011, 573 patients from 11 hospitals were recruited, and from 2017 to 2018, 340 patients were recruited from 8 hospitals. Among them, 5.9% (54/913) were male. Male patients were older (66.0 ± 15.2 vs. 55.3 ± 19.0 years, P < 0.001), had a higher Charlson comorbidity index (1.3 ± 1.5 vs. 0.7 ± 1.2, P = 0.027), and had a higher proportion of structural problems in the urinary tract (40.7% vs. 6.1%, P < 0.001) than female patients. Moreover, the total duration of antibiotic treatment was longer (21.8 ± 17.8 d vs. 17.3 ± 9.4 d, P = 0.001) and the proportion of carbapenem usage was higher (24.1% vs. 9.5%, P = 0.001) in men than in women. Male patients were hospitalized for longer durations than female patients (median, 10 d vs. 7 d, P < 0.001).

CONCLUSIONS

Male CA-APN patients were older and had more comorbidities than female CA-APN patients. In addition, male patients received antibiotic treatment for a longer duration than female patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Changes in Clinical Characteristics of Community-Acquired Acute Pyelonephritis and Antimicrobial Resistance of Uropathogenic Escherichia coli in South Korea in the Past Decade

This study examined changes in the clinical characteristics of community-acquired acute pyelonephritis (CA-APN) in South Korea between the period 2010–2011 and 2017–2018. We recruited all CA-APN patients aged ≥19 years who visited eight hospitals in South Korea from September 2017 to August 2018, prospectively. Data collected were compared with those from the previous study in 2010–2012, with the same design and participation from 11 hospitals. A total of 617 patients were enrolled and compared to 818 patients’ data collected in 2010–2011. Escherichia coli was the most common causative pathogen of CA-APN in both periods (87.3% vs. 86.5%, p = 0.680). E. coli isolates showed significantly higher antimicrobial resistance against fluoroquinolone (32.0% vs. 21.6%, p < 0.001), cefotaxime (33.6% vs. 8.3%, p < 0.001), and trimethoprim/sulfamethoxazole (37.5% vs. 29.2%, p = 0.013) in 2017–2018 than in 2010–2011. Total duration of antibiotic treatment increased from 16.55 ± 9.68 days in 2010–2011 to 19.12 ± 9.90 days in 2017–2018 (p < 0.001); the duration of carbapenem usage increased from 0.59 ± 2.87 days in 2010–2011 to 1.79 ± 4.89 days in 2010–2011 (p < 0.001). The median hospitalization was higher for patients in 2017–2018 than in 2010–2011 (9 vs. 7 days, p < 0.001). In conclusion, antimicrobial resistance of E. coli to almost all antibiotic classes, especially third generation cephalosporin, increased significantly in CA-APN in South Korea. Consequently, total duration of antibiotic treatment, including carbapenem usage, increased.

Differences in antibiotic usage patterns for acute pyelonephritis according to hospital type and region in the Republic of Korea: A population-based study

This study aimed to determine the differences in antibiotic usage patterns in the treatment of acute pyelonephritis according to hospital type and region in Korea.The claims database of the Health Insurance Review and Assessment Service in Korea was used to select patients with the International Classification of Diseases, Tenth Revision code N10 (acute tubulo-interstitial nephritis) or N12 (tubulo-interstitial nephritis, neither acute nor chronic) as the primary discharge diagnosis in 2010-2014. Usage of each class of antibiotics was expressed as the defined daily dose (DDD)/event.The average antibiotic usage per inpatient event was 11.3 DDD. The average antibiotic usage was the highest among patients admitted to tertiary hospitals (13.8 DDD), followed by those admitted to secondary hospitals (11.5 DDD), clinics (10.0 DDD), and primary hospitals (9.8 DDD). According to the geographic analyses, third-generation cephalosporins were highly prescribed in some southern regions; fluoroquinolones and aminoglycosides were highly prescribed in some centrally located regions of the Korean peninsula. The hotspots for carbapenem usage included Seoul and Gyeonggi province cluster and Busan cluster: these regions include the capital city and the second biggest city in Korea, respectively.In conclusion, the antibiotic usage patterns for acute pyelonephritis in Korea differ according to the hospital type and region.

Development of Antibiotic Classification for Measuring Antibiotic Usage in Korean Hospitals Using a Modified Delphi Method

In 2019, a project designed to develop a system for measuring and comparing antibiotic usage in hospitals was launched in Korea. As part of this project, we developed a means to classify antibiotic usage in Korean hospitals using a modified Delphi method. In results, the following categories of antibiotic classification were accepted for use in Korean hospitals: 1) broad-spectrum antibacterial agents predominantly used for hospital-onset infections in adults, 2) broad-spectrum antibacterial agents predominantly used for community-acquired infections in adults, 3) antibacterial agents predominantly used for resistant gram-positive infections in adults, 4) narrow-spectrum beta-lactam agents in adults, 5) antibacterial agents predominantly used for extensive antibiotic resistant gram-negative bacteria in adults, and 6) total antibacterial agents.