The Global Alliance for Infections in Surgery: defining a model for antimicrobial stewardship-results from an international cross-sectional survey

A qualitative study on factors influencing health workers' uptake of a pilot surgical antibiotic prophylaxis stewardship programme in selected Georgian hospitals

Antimicrobial misuse in surgical antibiotic prophylaxis (SAP) can include the inappropriate use of broad-spectrum antibiotics or prolonged dosing. In 2021, a pilot antimicrobial stewardship programme (ASP) was launched in Georgia, which involved developing and adapting SAP guidelines, establishing an interprofessional SAP prescribing approach, collecting surgical site infection (SSI) data via routinely collected data and telephonic patient follow-ups, and providing surgical unit staff with prescribing feedback and training on antimicrobial resistance (AMR) and antimicrobial stewardship (AMS). ASP introduction was staggered across ten hospitals over three years. This study explored behavioural determinants of surgical teams' ASP uptake in five hospitals where the ASP was introduced or about to be introduced. Findings primarily concerned epidemiologists' and nurses' ASP-related behaviour. Those at ASP non-introduced hospitals were less involved in the SAP prescribing process, had lower AMR awareness, and lacked professional development opportunities. Those at ASP-introduced hospitals exhibited higher AMR knowledge and felt ASP participation boosted confidence, facilitated work, and furnished key professional development. Results indicate interprofessional collaboration on SAP prescribing supported ASP uptake across teams, and investment in health worker training and administrative encouragement ensured effective ASP participation and implementation. Findings highlight the crucial role of epidemiologists in SAP and illustrate a need for developing Georgian nurses' AMR competencies as a vehicle to address public AMR knowledge gaps. Longer-term ASP uptake will need to consider the regulatory context in which hospitals lack access to national-level SSI data and feedback on SSI reporting but are fined for reporting non-compliance. Despite resource limitations and a small sample size, the study engaged all pilot ASP health workers. Respondents' inexperience of qualitative research participation and ensuant hesitation limited exploration of motivational factors supporting health workers' ASP uptake, which could be explored in further research.

Epidemiological analysis of intra-abdominal infections in Italy from the Italian register of complicated intra-abdominal infections-the IRIS study: a prospective observational nationwide study

BACKGROUND

Intra-abdominal infections (IAIs) are common and severe surgical emergencies associated with high morbidity and mortality. In recent years, there has been a worldwide increase in antimicrobial resistance associated with intra-abdominal infections, responsible for a significant increase in mortality rates. To improve the quality of treatment, it is crucial to understand the underlying local epidemiology, clinical implications, and proper management of antimicrobial resistance, for both community- and hospital-acquired infections. The IRIS study (Italian Register of Complicated Intra-abdominal InfectionS) aims to investigate the epidemiology and initial management of complicated IAIs (cIAIs) in Italy.

MATERIAL AND METHOD

This is a prospective, observational, nationwide (Italy), multicentre study. approved by the coordinating centre ethic committee (Local Research Ethics Committee of Pisa (Prot n 56478//2019). All consecutively hospitalized patients (older than 16 years of age) with diagnosis of cIAIs undergoing surgery, interventional drainage or conservative treatment have been included.

RESULTS

4530 patients included from 23 different Italian hospitals. Community Acquired infection represented the 70.9% of all the cases. Among appendicitis, we found that 98.2% of the cases were community acquired (CA) and 1.8% Healthcare-associated (HA) infections. We observed that CA represented the 94.2% and HA 5.8% of Gastro Duodenal perforation cases. The majority of HA infections were represented by colonic perforation and diverticulitis (28.3%) followed by small bowel occlusion (19%) and intestinal ischemia (18%). 27.8% of patients presented in septic shock. Microbiological Samples were collected from 3208 (70.8%) patients. Among 3041 intrabdominal sample 48.8% resulted positive. The major pathogens involved in intra-abdominal infections were found to be E.coli (45.6%). During hospital stay, empiric antimicrobial therapy was administered in 78.4% of patients. Amoxicillin/clavulanate was the most common antibiotic used (in 30.1% appendicitis, 30% bowel occlusion, 30.5% of cholecystitis, 51% complicated abdominal wall hernia, 55% small bowel perforation) followed by piperacillin/tazobactam (13.3% colonic perforation and diverticulitis, 22.6% cholecystitis, 24.2% intestinal ischemia, 28.6% pancreatitis). Empiric antifungal therapy was administered in 2.6% of patients with no sign of sepsis, 3.1% of patients with clinical sign of sepsis and 4.1% of patients with septic shock. Azoles was administered in 49.2% of patients that received empiric antifungal therapy. The overall mortality rate was 5.13% (235/4350). 16.5% of patients required ICU (748/4350). In accordance with mortality, it is important to highlight that 35.7% of small bowel perforation, 27.6% of colonic perforation and diverticulitis, 25.6% of intestinal ischemia and 24.6% of gastroduodenal complications required ICU.

CONCLUSION

Antibiotic stewardship programs and correct antimicrobial and antimycotic prescription campaigns are necessary to ulteriorly improve the adequacy of drug usage and reduce the resistances burden. This will help in improving the care and the cure of the next generations.

The Global Burden of Sepsis and Septic Shock

A dysregulated host response to infection causes organ dysfunction in sepsis and septic shock, two potentially fatal diseases. They continue to be major worldwide health burdens with high rates of morbidity and mortality despite advancements in medical care. The goal of this thorough review was to present a thorough summary of the current body of knowledge about the prevalence of sepsis and septic shock worldwide. Using widely used computerized databases, a comprehensive search of the literature was carried out, and relevant studies were chosen in accordance with predetermined inclusion and exclusion criteria. A narrative technique was used to synthesize the data that were retrieved. The review's conclusions show how widely different locations and nations differ in terms of sepsis and septic shock's incidence, prevalence, and fatality rates. Compared to high-income countries (HICs), low- and middle-income countries (LMICs) are disproportionately burdened more heavily. We talk about risk factors, comorbidities, and difficulties in clinical management and diagnosis in a range of healthcare settings. The review highlights the need for more research, enhanced awareness, and context-specific interventions in order to successfully address the global burden of sepsis and septic shock.

Antibiotic Stewardship in Surgical Departments

Antimicrobial resistance (AMR) has emerged as one of the leading public health threats of the 21st century. New evidence underscores its significance in patients' morbidity and mortality, length of stay, as well as healthcare costs. Globally, the factors that contribute to antimicrobial resistance include social and economic determinants, healthcare governance, and environmental interactions with impact on humans, plants, and animals. Antimicrobial stewardship (AS) programs have historically overlooked surgical teams as they considered them more difficult to engage. This review aims to summarize the evolution and significance of AS in surgical wards, including the surgical intensive care unit (SICU) and the role of diagnostic stewardship (DS). The contribution of AS team members is presented. The new diagnostic modalities and the new technologies including artificial intelligence (AI) are also reviewed.

Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action

Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or "golden rules," for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice.

Back to Nature: Medicinal Plants as Promising Sources for Antibacterial Drugs in the Post-Antibiotic Era

Undoubtedly, the advent of antibiotics in the 19th century had a substantial impact, increasing human life expectancy. However, a multitude of scientific investigations now indicate that we are currently experiencing a phase known as the post-antibiotic era. There is a genuine concern that we might regress to a time before antibiotics and confront widespread outbreaks of severe epidemic diseases, particularly those caused by bacterial infections. These investigations have demonstrated that epidemics thrive under environmental stressors such as climate change, the depletion of natural resources, and detrimental human activities such as wars, conflicts, antibiotic overuse, and pollution. Moreover, bacteria possess a remarkable ability to adapt and mutate. Unfortunately, the current development of antibiotics is insufficient, and the future appears grim unless we abandon our current approach of generating synthetic antibiotics that rapidly lose their effectiveness against multidrug-resistant bacteria. Despite their vital role in modern medicine, medicinal plants have served as the primary source of curative drugs since ancient times. Numerous scientific reports published over the past three decades suggest that medicinal plants could serve as a promising alternative to ineffective antibiotics in combating infectious diseases. Over the past few years, phenolic compounds, alkaloids, saponins, and terpenoids have exhibited noteworthy antibacterial potential, primarily through membrane-disruption mechanisms, protein binding, interference with intermediary metabolism, anti-quorum sensing, and anti-biofilm activity. However, to optimize their utilization as effective antibacterial drugs, further advancements in omics technologies and network pharmacology will be required in order to identify optimal combinations among these compounds or in conjunction with antibiotics.

Antibiotic stewardship team in a Tunisian university hospital: A four-year experience

BACKGROUND

Association between antibiotic use and antimicrobial resistance has been demonstrated in several studies; hence the importance of antibiotic stewardship programs (ASPs) to reduce the burden of this resistance.

AIM

To describe the antibiotic stewardship team (AST) interventions in a Tunisian university hospital.

METHODS

a cross-sectional study was conducted in the infectious diseases department in Sousse-Tunisia between 2016 and 2020. Hospital and private practice doctors have been informed of the existence of an antibiotic stewardship team. Interventions consisted of some helps to antibiotic therapy (i.e.; prescription, change or discontinuation) and/or diagnosis (i.e.; further investigations).

RESULTS

Two thousand five hundred and fourteen interventions were made including 2288 (91%) in hospitalized patients, 2152 (86%) in university hospitals and 1684 (67%) in medical wards. The most common intervention consisted of help to antibiotic therapy (80%). The main sites of infections were skin and soft tissues (28%) and urinary tract (14%). Infections were microbiologically documented in 36% of cases. The most frequently isolated microorganisms were Enterobactriaceae (41%). Antibiotic use restriction was made in 44% of cases including further investigations (16%), antibiotic de-escalation (11%), no antibiotic prescription (9%) and antibiotic discontinuation (8%). In cases where antibiotics have been changed (N=475), the intervention was associated with an overall decrease in the prescription of broad-spectrum antibiotics from 61% to 50% with a decrease in the prescription of third generation cephalosporins from 22% to 15%.

CONCLUSIONS

The majority of antibiotic stewardship team's interventions were made in hospitalized patients, university hospitals and medical wards. These interventions resulted in an overall and broad-spectrum antibiotic use reduction.

Comparison of Duration and Empiric Antibiotic Choice of Post-Operative Treatment in Abdominal Sepsis

Background: Although abdominal foci are the second most common source of sepsis, only few studies focus on the optimal length of post-operative antibiotic therapy in critically ill patients with abdominal sepsis. The aim of this study was to compare the outcomes of short versus long antibiotic therapy as well as broad-spectrum penicillin versus carbapenem in patients with abdominal sepsis. Patients and Methods: We performed a single center retrospective study in patients with abdominal sepsis who underwent emergency surgery. The study was conducted in a tertiary hospital in Germany during 2016-2018. We reviewed the duration of post-operative antibiotic therapy and the initially used agent, comparing patients treated shorter or longer than seven days with or without source control. Depending on the empirically given antibiotic, a subgroup analysis was conducted comparing patients treated with piperacillin-tazobactam versus carbapenems. Results: Longer duration of post-operative antibacterial treatment (>7 days) was not substantially advantageous. The group with a longer course of antibiotic therapy had more severe post-operative complications (82.4% [n = 61] vs. 62.5% [n = 20]; p = 0.01) requiring longer critical care support (18 days vs. 11 days; p = 0.027), prolonging the length of stay (28 days vs. 20 days; p = 0.044). Surgical re-interventions were more frequent in the long-course arm (70.3% vs. 40.6%; p = 0.004). The subgroup analysis comparing piperacillin-tazobactam versus carbapenems confirmed more severe complications (86.3% vs. 67.5%; p = 0.04) for the carbapenem arm. Conclusions: Post-surgical continuation of antibiotic agents beyond seven days was observed with more post-operative complications and delayed recovery. Piperacillin-tazobactam seems to be a potent alternative for patients with abdominal sepsis.

It is time to define an organizational model for the prevention and management of infections along the surgical pathway: a worldwide cross-sectional survey

BACKGROUND

The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness.

METHODS

A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days.

RESULTS

Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations.

CONCLUSION

Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened.

Retrospective Cohort Analysis of the Effect of Antimicrobial Stewardship on Postoperative Antibiotic Therapy in Complicated Intra-Abdominal Infections: Short-Course Therapy Does Not Compromise Patients’ Safety

Background: Recent evidence suggests that short-course postoperative antibiotic therapy (PAT) of intra-abdominal infections is non-inferior considering clinical outcomes. The aim of this study was to compare the outcome of short vs. long PAT in complicated intra-abdominal infections (cIAIs) without sepsis. Methods: We performed a single center-quality improvement study at a 1500 bed sized university hospital in Bavaria, Germany, with evaluation of the length of antibiotic therapy after emergency surgery on cIAIs with adequate source control during 2016 to 2018. We reviewed a total of 260 cases (160 short duration vs. 100 long duration). The antibiotic prescribing quality was assessed by our in-house antimicrobial stewardship team (AMS). Results: No significant differences of patient characteristics were observed between short and long PAT. The frequency of long PAT declined during the observation period from 48.1% to 26.3%. Prolongation of PAT was not linked with any clinical benefits, on the contrary clinical outcome of patients receiving longer regimes were associated with higher postoperative morbidity. AMS identified additional educational targets to improve antibiotic prescribing quality on general wards like unnecessary postoperative switches of antibiotic regimes, e.g., unrequired switches to oral antibiotics as well as prolongation of PAT due to elevated CRP. Conclusion: Short-course antibiotic therapy after successful surgical source control in cIAIs is safe, and long-duration PAT has no beneficial effects.

A genomic data resource for predicting antimicrobial resistance from laboratory-derived antimicrobial susceptibility phenotypes

Antimicrobial resistance (AMR) is a major global health threat that affects millions of people each year. Funding agencies worldwide and the global research community have expended considerable capital and effort tracking the evolution and spread of AMR by isolating and sequencing bacterial strains and performing antimicrobial susceptibility testing (AST). For the last several years, we have been capturing these efforts by curating data from the literature and data resources and building a set of assembled bacterial genome sequences that are paired with laboratory-derived AST data. This collection currently contains AST data for over 67 000 genomes encompassing approximately 40 genera and over 100 species. In this paper, we describe the characteristics of this collection, highlighting areas where sampling is comparatively deep or shallow, and showing areas where attention is needed from the research community to improve sampling and tracking efforts. In addition to using the data to track the evolution and spread of AMR, it also serves as a useful starting point for building machine learning models for predicting AMR phenotypes. We demonstrate this by describing two machine learning models that are built from the entire dataset to show where the predictive power is comparatively high or low. This AMR metadata collection is freely available and maintained on the Bacterial and Viral Bioinformatics Center (BV-BRC) FTP site ftp://ftp.bvbrc.org/RELEASE_NOTES/PATRIC_genomes_AMR.txt.

Assessing the impact of the Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) on hospital antimicrobial stewardship programmes: results of a worldwide survey

BACKGROUND

The Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) provides a methodology to support hospitals worldwide in collecting antimicrobial use data. We aim to evaluate the impact of the Global-PPS on local antimicrobial stewardship (AMS) programmes and assess health care professionals' educational needs and barriers for implementing AMS.

METHODS

A cross-sectional survey was disseminated within the Global-PPS network. The target audience consisted of hospital healthcare workers, involved in local surveillance of antimicrobial consumption and resistance. This included contacts from hospitals that already participated in the Global-PPS or were planning to do so. The survey contained 24 questions that addressed the hospital's AMS activities, experiences conducting the PPS, as well as the learning needs and barriers for implementing AMS.

RESULTS

A total of 248 hospitals from 74 countries participated in the survey, of which 192 had already conducted the PPS at least once. The survey response rate was estimated at 25%. In 96.9% of these 192 hospitals, Global-PPS participation had led to the identification of problems related to antimicrobial prescribing. In 69.3% at least one of the hospital's AMS components was initiated as a result of Global-PPS findings. The level of AMS implementation varied across regions. Up to 43.1% of all hospitals had a formal antimicrobial stewardship strategy, ranging from 10.8% in Africa to 60.9% in Northern America. Learning needs of hospitals in high-income countries and in low-and middle-income countries were largely similar and included general topics (e.g. 'optimising antibiotic treatment'), but also PPS-related topics (e.g. 'translating PPS results into meaningful interventions'). The main barriers to implementing AMS programmes were a lack of time (52.7%), knowledge on good prescribing practices (42.0%), and dedicated funding (39.9%). Hospitals in LMIC more often reported unavailability of prescribing guidelines, insufficient laboratory capacity and suboptimal use of the available laboratory services.

CONCLUSIONS

Although we observed substantial variation in the level of AMS implementation across regions, the Global-PPS has been very useful in informing stewardship activities in many participating hospitals. More is still to be gained in guiding hospitals to integrate the PPS throughout AMS activities, building on existing structures and processes.

How Antibiotics Stewardship Can Be Safely Implemented in Patients with Septic Shock?

In critically ill patients with sepsis and septic shock, the need for prompt and adequate antibiotic therapy is balanced by the risk of excessive antibiotic exposure that leads to emergence of multidrug-resistant pathogens. As such, antibiotic stewardship programs propose a set of operating rules from antibiotic treatment initiation to de-escalation and finally cessation. In this review, we will describe the rationale for early antibiotic treatment in septic patients, how to optimize initial antibiotic treatment, rules for early treatment discontinuation in pathogen-negative sepsis, and optimal duration of antimicrobial therapy.

3D Laparoscopic common bile duct exploration with primary repair by absorbable barbed suture is safe and feasible

BACKGROUND AND AIM

Endoscopic retrograde cholangiopancreatography (ERCP), with interval laparoscopic cholecystectomy (LC), is the most common treatment approach for common bile duct (CBD) stones. However, recent studies show that single-stage laparoscopic CBD exploration (LCBDE) is safe and feasible. Three-dimensional (3D) laparoscopy enhances depth perception and facilitates intracorporeal suturing. The application of 3D technology for LCBDE is emerging, and we report our case series of 3D LCBDE.

METHODS

We audited the 27 consecutive 3D LCBDE performed from July 2017 to January 2020. We have a liberal policy for magnetic resonance cholangiopancreatography (MRCP) in patients with deranged liver function tests (LFT). All CBD explorations were done through choledochotomy with a 5 mm flexible choledochoscope and primarily repaired with an absorbable barbed suture without a stent or T-tube.

RESULTS

The mean age of patients was 68 (range 44-91) years, and 12 (44%) were male. The indications for surgery were choledocholithiasis 67% (n=18), cholangitis 22% (n=6), and gallstone pancreatitis 11% (n=3). About 67% (n=18) had pre-operative ERCP. About 37% (n=10) had pre-operative biliary stent. Pre-operative MRCP was done in 74% (n=20), and the mean diameter of CBD was 14.5 mm (range 7-30). The median operative time was 160 (range 80-265) min. The operative drain was inserted in 18 patients. One patient each (4%) had a bile leak and a retained stone. There was no open conversion, readmission, or mortality.

CONCLUSION

3D LCBDE with primary repair by an absorbable barbed suture is safe and feasible.

RELEVANCE FOR PATIENTS

This paper emphasized that one stage LCBDE should be a treatment option which is comparable with two stage ERCP followed by LC to treat CBD stones. In addition, 3D technology and barbed sutures use in LCBDE are safe and useful.

Assessment of Knowledge, Attitude, and Practice of Antibiotic Use among the Population of Boyolali, Indonesia: A Cross-Sectional Study

Misuse and overuse of antibiotics are potential causes of the increasing prevalence of antibiotic resistance (ABR). Having information about the knowledge, attitude, and practices concerning antibiotics use by the public might help control ABR growth. Therefore, this cross-sectional study aimed to investigate the levels and associated factors of knowledge, attitude, and practice (KAP) of antibiotics use among the public. A questionnaire was designed and validated, which consisted of a total of 51 questions with four sections: demographics (6), knowledge (20), attitude (12), and practice (13) to measure KAP. Univariate analysis (using Mann-Whitney U and Kruskal-Wallis analysis) was applied to assess the differences in the mean scores of KAP. Linear regression analysis was performed to identify factors associated with KAP. Finally, using Spearman analysis we have examined the correlation between responses to the KAP. The sample size of this study was 575, with a 99.96% response rate. Regarding knowledge, 73.12% of respondents stated that antibiotics could be used to treat viral infections, and 63.35% of respondents answered that antibiotics could reduce fever. Concerning attitude, 50% of respondents had considered stopping taking antibiotics as soon as symptoms had disappeared. In analyzing practice, we found 40% of respondents obtained antibiotics from a pharmacy without a prescription from a physician, a nurse, or a midwife. Statistical analysis revealed that KAP about antibiotic use was significantly associated with gender, area of residence, level of education, and monthly income (p < 0.05). Our findings concluded that men, respondents with low income, those with low-level education, and those living in rural areas are more prone to excessive use of antibiotics without knowing the adverse effects of improper use and how it can contribute to high ABR. So it is urgently necessary to strengthen policies on antibiotics use, including drug provision, distribution, and sales. In addition, people with low KAP should be a priority consideration in education outreach initiatives.

Barriers-enablers-ownership approach: a mixed methods analysis of a social intervention to improve surgical antibiotic prescribing in hospitals

OBJECTIVES

To assess an intervention for surgical antibiotic prophylaxis (SAP) improvement within surgical teams focused on addressing barriers and fostering enablers and ownership of guideline compliance.

DESIGN

The Queensland Surgical Antibiotic Prophylaxis (QSAP) study was a multicentre, mixed methods study designed to address barriers and enablers to SAP compliance and facilitate engagement in self-directed audit/feedback and assess the efficacy of the intervention in improving compliance with SAP guidelines. The implementation was assessed using a 24-month interrupted time series design coupled with a qualitative evaluation.

SETTING

The study was undertaken at three hospitals (one regional, two metropolitan) in Australia.

PARTICIPANTS

SAP-prescribing decisions for 1757 patients undergoing general surgical procedures from three health services were included. Six bimonthly time points, pre-implementation and post implementation of the intervention, were measured. Qualitative interviews were performed with 29 clinical team members. SAP improvements varied across site and time periods.

INTERVENTION

QSAP embedded ownership of quality improvement in SAP within surgical teams and used known social influences to address barriers to and enablers of optimal SAP prescribing.

RESULTS

The site that reported senior surgeon engagement showed steady and consistent improvement in prescribing over 24 months (prestudy and poststudy). Multiple factors, including resource issues, influenced engagement and sites/time points where these were present had no improvement in guideline compliance.

CONCLUSIONS

The barriers-enablers-ownership model shows promise in its ability to facilitate prescribing improvements and could be expanded into other areas of antimicrobial stewardship. Senior ownership was a predictor of success (or failure) of the intervention across sites and time periods. The key role of senior leaders in change leadership indicates the critical need to engage other specialties in the stewardship agenda. The influence of contextual factors in limiting engagement clearly identifies issues of resource distributions/inequalities within health systems as limiting antimicrobial optimisation potential.

[Antibiotics Stewardship Team Recommendations - An Analysis under Routine Conditions in a University Hospital]

AIM

To evaluate recommendations of an antibiotic stewardship (ABS) team during routine weekly visits and to analyse their implementation and reasons for non-implementation by the ward physicians.

METHODS

Multiprofessional ABS Rounds (members: infectiology, microbiology, pharmacy and hospital epidemiology) were accompanied by an observer in nine intensive and peripheral wards of a university hospital (1451 beds) for eight weeks. The recommendations of the ABS team were prospectively analysed, and when these were not implemented, ward physicians in charge were asked to give reasons for non-implementation.

RESULTS

A total of 262 patients were visited in the course of 359 ABS visits. A median of four physicians and one pharmacist (Q25/Q75: 4/6) participated in the ABS rounds. In 177/359 (49%) of visits, at least one recommendation for anti-infective therapy was given; the total number of recommendations made was 210. The most frequent (38%, 80/210) recommendations were related to the prescribed therapy duration. The more different the professional groups participating in the ABS rounds, the larger was the number of recommendations given (p=0.016; odds ratio=1.018 (1.003-1.033)). 62/210 (30%) of the ABS recommendations were not implemented by the ward physicians in charge. The most frequent reason (32%: 20/62) for this was the deliberate decision by the physicians to deviate from the recommended therapy.

CONCLUSIONS

The high recommendation rate of 50% demonstrates the need for optimizing therapy by the ABS teams in routine practice. The larger the number of different specialists participating in single visits, the larger was the number of recommendations. Reasons for the lack of implementations need to be critically examined by both the ABS team and the ward physicians in charge.

Priorities in peritonitis

PURPOSE OF REVIEW

Timely and adequate management are the key priorities in the care of peritonitis. This review focuses on the cornerstones of the medical support: source control and antiinfective therapies.

RECENT FINDINGS

Peritonitis from community-acquired or healthcare-associated origins remains a frequent cause of admission to the ICU. Each minute counts for initiating the proper management. Late diagnosis and delayed medical care are associated to dramatically increased mortality rates. The diagnosis of peritonitis can be difficult in these ICU cases. The signs of organ failures are more relevant than biological surrogates. A delayed source control and a late anti-infective therapy are of critical importance. The quality of source control and medical management are other key elements of the prognosis. The conventional rules applied for sepsis are applicable for peritonitis, including hemodynamic support and anti-infective therapy. Growing proportions of multidrug resistant pathogens are reported from surgical samples, mainly related to Gram-negative bacteria. The increasing complexity in the care of these critically ill patients is a strong incentive for a multidisciplinary approach.

SUMMARY

Early clinical diagnosis, timely and adequate source control and antiinfective therapy are the essential pillars of the management of peritonitis in ICU patients.

Antibiotic stewardship in UK surgical departments: challenges and possible solutions

Antibiotics are one of the most widely used classes of drugs within hospitals in the UK. They have a wide range of uses within all surgical specialties, both as preoperative prophylaxis and for treatment of acute surgical conditions. Antimicrobial resistance has increasingly been seen as a major issue, as the production of new antibiotics has decreased and overall use worldwide has increased. With the COVID-19 pandemic increasing concerns about antimicrobial resistance, there is an ever-increasing need for action. This article examines the particular challenges of antibiotic stewardship in surgical departments within the UK, and outlines possible solutions for improving adherence and reducing the risk of antimicrobial resistance in the future.

What Promotes Surgeon Practice Change? A Scoping Review of Innovation Adoption in Surgical Practice

OBJECTIVE

The goal of this scoping review was to summarize the literature on facilitators and barriers to surgical practice change. This information can inform research to implement best practices and evaluate new surgical innovations.

BACKGROUND

In an era of accelerated innovations, surgeons face the difficult decision to either acknowledge and implement or forgo new advances. Although changing surgical practice to align with evidence is an imperative of health systems, evidence-based guidelines have not translated into consistent change. The literature on practice change is limited and has largely focused on synthesizing information on methods and trials to evaluate innovative surgical interventions. No reviews to date have grounded their analysis within an implementation science framework.

METHODS

A systematic review of the literature on surgical practice change was performed. Abstracts and full-text articles were reviewed for relevance using inclusion and exclusion criteria and data were extracted from each article. Cited facilitators and barriers were then mapped across domains within the implementation science Theoretical Domains Framework and expanded to the Capability, Opportunity, Motivation, and Behavior model.

RESULTS

Components of the Capability, Opportunity, Motivation, and Behavior model were represented across the Theoretical Domains Framework domains and acted as both facilitators and barriers to practice change depending on the circumstances. Domains that most affected surgical practice change, in order, were: opportunity (environmental context and resources and social influences), capability (knowledge and skills), and motivation (beliefs about consequences and reinforcement).

CONCLUSIONS

Practice change is predicated on a conducive environment with adequate resources, but once that is established, the surgeon's individual characteristics, including skills, motivation, and reinforcement determine the likelihood of successful change. Deficiencies in the literature underscore the need for further study of resource interventions and the role of surgical team dynamics in the adoption of innovation. A better understanding of these areas is needed to optimize our ability to disseminate and implement best practices in surgery.

Defining the Scope of Antimicrobial Stewardship Interventions on the Prescription Quality of Antibiotics for Surgical Intra-Abdominal Infections

Background: The aim of this study was to assess the impact of antimicrobial stewardship interventions on surgical antibiotic prescription behavior in the management of non-elective surgical intra-abdominal infections, focusing on postoperative antibiotic use, including the appropriateness of indications. Methods: A single-center quality improvement study with retrospective evaluation of the impact of antimicrobial stewardship measures on optimizing antibacterial use in intra-abdominal infections requiring emergency surgery was performed. The study was conducted in a tertiary hospital in Germany from January 1, 2016, to January 30, 2020, three years after putting a set of antimicrobial stewardship standards into effect. Results: 767 patients were analyzed (n = 495 in 2016 and 2017, the baseline period; n = 272 in 2018, the antimicrobial stewardship period). The total days of therapy per 100 patient days declined from 47.0 to 42.2 days (p = 0.035). The rate of patients receiving postoperative therapy decreased from 56.8% to 45.2% (p = 0.002), comparing both periods. There was a significant decline in the rate of inappropriate indications (17.4% to 8.1 %, p = 0.015) as well as a significant change from broad-spectrum to narrow-spectrum antibiotic use (28.8% to 6.5%, p ≤ 0.001) for postoperative therapy. The significant decline in antibiotic use did not affect either clinical outcomes or the rate of postoperative wound complications. Conclusions: Postoperative antibiotic use for intra-abdominal infections could be significantly reduced by antimicrobial stewardship interventions. The identification of inappropriate indications remains a key target for antimicrobial stewardship programs.

Is the Isolation of Pseudomonas aeruginosa Associated with Outcomes from Intra-Abdominal Infection? No, But the Receipt of an Empiric Anti-Pseudomonal Agent Is

Background: Pseudomonas aeruginosa is isolated at variable rates from intra-abdominal infections (IAI). Not all recommended empiric regimens for IAI include anti-Pseudomonas aeruginosa activity, for example, ceftriaxone and metronidazole. We hypothesized that within an adult population, Pseudomonas aeruginosa is a relatively rare isolate and has no association with mortality, and thus, empiric therapy with anti-Pseudomonas aeruginosa activity is not warranted. Patients and Methods: All IAI with positive cultures treated between 1997 and 2017 at a single institution were analyzed. This data set was divided into two cohorts, namely, those with cultures positive for Pseudomonas aeruginosa and those without. Demographics and in-hospital mortality were compared by Student t-test and χ² analysis. Predictors of isolation of Pseudomonas aeruginosa and in-hospital mortality were done by logistic regression (LR) analysis. Results: In total, 2,420 IAIs were identified, 104 (4.3%) with Pseudomonas aeruginosa and 2,316 (95.7%) without. Major demographic differences between patients with Pseudomonas aeruginosa and those without included a higher rate of health-care-associated infections (87/104, 83.7% vs. 621/2316, 26.8%; p = 0.02), a higher rate of intensive care unit (ICU)-acquired infections (23/104, 22.1% vs. 329/2316, 14.2%; p = 0.04) and a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (17.7 ± 0.8 vs. 14.5 ± 0.2; p < 0.0001). There was an increased rate of Pseudomonas aeruginosa isolation with increasing APACHE II score. Independent predictors of isolation of Pseudomonas aeruginosa by LR included APACHE II score and days of hospitalization prior to diagnosis. Crude in-hospital mortality was similar between groups: Pseudomonas aeruginosa 14/104 (13.5%) and 276/2316 (11.9%), p = 0.79. After controlling for age, gender, APACHE II, prior transfusion, immunosuppression status, solid organ transplant status, healthcare-association, and days of hospitalization prior to diagnosis, the isolation of Pseudomonas aeruginosa was not associated with mortality. Conclusion: Pseudomonas aeruginosa is infrequently isolated and overall not associated with mortality. Nonetheless, there may be a population that merits empiric anti-Pseudomonas aeruginosa therapy: those with APACHE II ≥20 or a significant length of hospitalization prior to diagnosis.

Open-label, single-centre, cluster-randomised controlled trial to Evaluate the Potential Impact of Computerisedantimicrobial stewardship (EPIC) on the antimicrobial use after cardiovascular surgeries: EPIC trial study original protocol

INTRODUCTION

Inappropriate antimicrobial use increases the prevalence of antimicrobial-resistant bacteria. Surgeons are reluctant to implement recommendations of guidelines in clinical practice. Antimicrobial stewardship (AMS) is effective in antimicrobial management, but it remains labour intensive. The computerised decision support system (CDSS) has been identified as an effective way to enable key elements of AMS in clinical settings. However, insufficient evidence is available to evaluate the efficacy of computerised AMS in surgical settings.

METHODS AND ANALYSIS

The Evaluate of the Potential Impact of Computerised AMS trial is an open-label, single-centre, two-arm, cluster-randomised, controlled trial, which aims to determine whether a multicomponent CDSS intervention reduces overall antimicrobial use after cardiovascular surgeries compared with usual clinical care in a specialty hospital with a big volume of cardiovascular surgeries. Eighteen cardiovascular surgical teams will be randomised 1:1 to either the intervention or the control arm. The intervention will consist of (1) re-evaluation alerts and decision support for the duration of antimicrobial treatment decision, (2) re-evaluation alerts and decision support for the choice of antimicrobial, (3) quality control audit and feedback. The primary outcome will be the overall systemic antimicrobial use measured in days of therapy (DOT) per admission and DOT per 1000 patient-days over the whole intervention period (6 months). Secondary outcomes include a series of indices to evaluate antimicrobial use, microbial resistance, perioperative infection outcomes, patient safety, resource consumption, and user compliance and satisfaction.

ETHICS AND DISSEMINATION

The Ethics Committee in Fuwai Hospital approved this study (2020-1329). The results of the trial will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04328090.

A survey of Chinese pharmacists participating in anti-infective therapy and its related information technology support

WHAT IS KNOWN AND OBJECTIVE

Anti-infective therapy is the major daily work for most clinical pharmacists in China, and information technology (IT) support for them is very important. However, the current situation of pharmacists' roles in anti-infective therapy and related IT support are seldom reported. The aim of the study was to investigate the current situation of pharmacists participating in anti-infective therapy and the corresponding hospital IT support, which may help identify and solve related problems and facilitate pharmacists to play better roles.

METHODS

A 15-item questionnaire was distributed online to clinical pharmacists from Chinese hospitals. Pharmacists answered the questions on the WeChat platform. Data were analysed using descriptive statistics.

RESULTS AND DISCUSSION

A total of 272 valid questionnaires were returned, and the respondents were from 27 provinces (or autonomous regions or municipalities) of China covering over 15 specialties. Most of the respondents (76.1%) were from tertiary hospitals and 72.4% of all the respondents participated in anti-infective therapy. They mainly performed drug selection (95.4%), dose adjustment (88.8%) and adverse drug reaction monitoring (84.8%) for anti-infective therapy, in ways such as consultation (71.1%), drug consult (86.3%) and prescription evaluation (88.8%). Most pharmacists (93.0%) thought that the modules of anti-infective therapy in hospital IT system needed to be advanced, in the aspects of doctor-pharmacist interaction, convenience for pharmacists to control drug expenses and integration of multi-functions for anti-infective therapy.

WHAT IS NEW AND CONCLUSION

The roles of Chinese clinical pharmacists in anti-infective therapy are becoming increasingly clear, and establishing smart, pharmacist-friendly and highly-integrated electronic interfaces will facilitate the establishment of pharmacist-driven anti-infective therapy team, thus improving work efficiency and user experience.

Impact of Antimicrobial Stewardship Interventions on Appropriateness of Surgical Antibiotic Prophylaxis: How to Improve

Surgical site infections (SSIs) are the most common healthcare-associated infections. The appropriate use of Surgical Antibiotic Prophylaxis (SAP) is a key component to reduce SSIs, while its inappropriate application is a major cause of some emerging infections and selects for antibiotic resistance. We describe an Antimicrobial Stewardship (AMS) intervention on SAP appropriateness. The prospective study was conducted in an Italian hospital, in 12 main surgical units, and was organized in three subsequent phases, as follows. Phase 0: Definition of hospital evidence-based guidelines and a new workflow to optimize the process of ordering, dispensing, administering and documenting the SAP. Phase 1: We analysed 2059 elective surgical cases from January to June 2018 for three SAP parameters of appropriateness: indication, choice and dose. Phase 2: In July 2018, an audit was performed to analyse the results; we reviewed 1781 elective surgical procedures from July to December 2018 looking for the same three SAP appropriateness parameters. The comparative analysis between phases 1 and 2 demonstrated that the correct indication, the correct dose and the overall compliance significantly improved (p-value 0.00128, p-value < 2.2·10¹⁶ and p-value < 5.6·10¹² respectively). Our prospective study demonstrates a model of successful antimicrobial stewardship intervention that improves appropriateness on SAP.

Adherence to Guideline-Based Antibiotic Prophylaxis in Gynecology among Alabama Providers

OBJECTIVES

Surgical site infection (SSI) is a preventable cause of postoperative morbidity. The appropriate use of perioperative antibiotics for prevention of SSIs is a well-established quality metric. Little is known about the adherence to guidelines-based antibiotic prophylaxis among Alabama obstetricians and gynecologists. Our aims were to determine their adherence to guidelines-based antibiotic prophylaxis and identify the factors that are predictive of nonadherence.

METHODS

Online, self-administered survey of Alabama obstetricians and gynecologists.

RESULTS

Providers reported not providing the indicated antibiotics and/or giving nonindicated antibiotics in almost all surgical scenarios. The exceptions included hysterectomies, in which almost all (96%) providers routinely gave indicated antibiotics. No providers reported giving antibiotics during intrauterine device placement or endometrial biopsies, which is appropriate. The only factor predictive of inappropriate antibiotic use was the absence of a standing antibiotic protocol.

CONCLUSIONS

Alabama gynecologic surgeons can and should improve their compliance with guidelines-based antibiotic prophylaxis. More research is needed to determine which interventions would improve adherence in this provider population; our study suggests that the implementation of a standing antibiotic protocol may be a reasonable first step.

A proposal for a comprehensive approach to infections across the surgical pathway

Despite evidence supporting the effectiveness of best practices in infection prevention and management, many healthcare workers fail to implement them and evidence-based practices tend to be underused in routine practice. Prevention and management of infections across the surgical pathway should always focus on collaboration among all healthcare workers sharing knowledge of best practices. To clarify key issues in the prevention and management of infections across the surgical pathway, a multidisciplinary task force of experts convened in Ancona, Italy, on May 31, 2019, for a national meeting. This document represents the executive summary of the final statements approved by the expert panel.

Antimicrobial Stewardship Programs Are Required in a Department of Surgery: "How" Is the Question A Quasi-Experimental Study: Results after Three Years

Objective: Our aim was to describe our antimicrobial stewardship program and the methodology based on the results in a surgical department. Methods: Our study was a quasi-experimental study conducted from January 1, 2009, through September 30, 2017. The site was the General and Digestive Surgery Department in a public primary referral center, the University Hospital of Getafe (Madrid, Spain). We implemented the antimicrobial stewardship program following a prospective audit and feedback model, with a surgeon incorporated into the manaagement group. We studied the deaths and 30-day re-admission rates, length of stay, prevalence of gram-negative bacilli, meropenem resistance, and days of treatment with meropenem. Results: After three years of the program, we recorded a significant decrease in Pseudomonas aeruginosa prevalence, a significant increase in Klebsiella pneumoniae prevalence, a decrease in meropenem resistance, and a reduction in meropenem days of treatment. Conclusions: Antimicrobial stewardship programs have a desirable effect on patients. In our experience, the program team should be led by a staff from the particular department. When human resources are limited, the sustainability, efficiency, and effectiveness of interventions are feasible only with adequate computer support. Finally, but no less important, the necessary feedback between the prescribers and the team must be based on an ad hoc method such as that provided by statistical control charts, a median chart in our study.

Fungal Isolates in Peritoneal Fluid Culture Do Not Impact Peri-Operative Outcomes of Peptic Ulcer Perforation

Background: Fungal isolates from peritoneal fluid sampling in patients with perforated peptic ulcer (PPU) is not uncommon and its management unclear. This study aims to evaluate whether the presence of fungus in peritoneal fluid cultures is a predictor of morbidity and mortality after laparotomy for PPU. Method: This is a single-center retrospective study including adult patients with perforated gastric and duodenal ulcers over a 10-year period (January 2004 to January 2014). Evaluation of predictors contributing to fungal growth was conducted using multiple logistic regression analysis. Operative factors and 30-day mortality and morbidity outcomes were compared against fungal growth using a multivariable generalized linear mixed model analysis. Results: The median age was 58 (interquartile range [IQR] 44-70) years with 110 (20.3%) females. In addition to hypertension and hyperlipidemia, diabetes mellitus (13.5%), ischemic heart disease (2.6%), and heart failure (2.4%) were common. Fungus was cultured from peritoneal fluid in 209 (38.6%) patients. Median American Society of Anesthesiology (ASA) score was 2 (IQR 2-3) and median Mannheim peritonitis index (MPI) score was 15 (IQR 10-20). Free air was detected in 323 (59.6%) patients and 52 (9.6%) patients had gastrectomy. Median length of stay was 7 (IQR 6-11) days. All-cause complications were seen in 53 (9.8%) patients, of whom 37 patients (6.8%) developed intra-abdominal collection, 20 patients (3.7%) had anastomotic leakage, and 12 patients (2.2%) required repeat operation. Thirty-day mortality was seen in 47 (8.7%) patients. Multivariable analysis showed age (median age, 64; IQR 53-74) as a predictor of fungal growth (p < 0.001) but fungal growth not a predictor of adverse peri-operative outcomes. Conclusion: Fungal isolates in peritoneal fluid cultures are more likely to occur in older patients who have PPU. Presence of fungal isolates does not impact peri-operative outcomes.

Post-operative abdominal infections: epidemiology, operational definitions, and outcomes

Postoperative abdominal infections are an important and heterogeneous health challenge in intensive care units (ICU) and encompass postoperative infectious processes developing within the abdominal cavity that may be caused by either bacterial or fungal pathogens. In this narrative review, we discuss postoperative bacterial and fungal abdominal infections, covering also multidrug-resistant (MDR) pathogens. We also cover clinically preeminent aspects such as the definition of postoperative abdominal infections, which still remains difficult owing to their heterogeneity in patient characteristics, clinical presentation, ecology and antimicrobial treatment. With regard to treatment, modifiable factors such as source control and antimicrobial therapy play a key role in influencing the prognosis of postoperative abdominal infections, but several conditions may hamper their correct application; thus efforts should necessarily be devoted towards improving their appropriateness and timing. Hot topics regarding the characteristics and management of postoperative abdominal infections are discussed in this narrative review.

Antibiotic use in surgical units of selected hospitals in Ghana: a multi-centre point prevalence survey

Background

Improper use of antibiotics leads to the emergence of resistant microorganisms as well as drug toxicity, increased healthcare costs, morbidity and mortality. Globally, an estimated 25–68% of hospitalized patients receive suboptimal antibiotic regimes. Information on the extent of this problem in Ghana is currently limited, particularly in surgical units. To strategize for interventions, we estimated the antibiotic use prevalence in surgical departments in a country-wide point prevalence survey (PPS) in Ghana.

Methods

Between October 2016 and December 2016, we conducted a cross-sectional multi-center country-wide PPS. This involved an audit of in-patients’ records from all units/departments of ten systematically selected hospitals in Ghana. Data were collected with a standardized questionnaire, adopted from the European Centre for Disease Prevention and Control. In this report, we present data on antibiotic use from the surgical units.

Results

Of 2107 eligible patients included in the PPS, 540 patients were identified in surgical units, of which 70.7% (382/540) received antibiotic therapy. A total of 636 antibiotic prescriptions were issued to these surgical patients; 224 (58.6%) for treatment, including 50 for treatment of hospital-acquired infections, and 144 (37.7%) for prophylaxis (medical and surgical). Median duration of antibiotic therapy prior to the survey was 5 days (interquartile range (IQR): 3-8 days). Surgical prophylaxis was administered for longer than the recommended one day in 107 of 144 (88.4%) patients. The choice of antibiotics was largely similar for community- and hospital-acquired infections as well as for prophylaxis. Only 3.7% of patients had microbiological analysis done on clinical samples.

Conclusion

We found a high prevalence of antibiotic use, with the choice of antibiotics, in some cases, inconsistent with the country’s treatment guidelines. Antibiotics were administered for long duration including antibiotics for prophylactic purposes and the majority was started without supporting microbiological analysis. Prescription practices that encourage rational use of antibiotics guided by microbiology and enforcement of antibiotic policy guidelines should be the target for future interventions.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7162-x) contains supplementary material, which is available to authorized users.

Ectopic retained gallstone causing an abdominal wall abscess

A 67-year-old lady was managed with percutaneous cholecystostomy for severe acute cholecystitis with septic shock. An interval laparoscopic subtotal cholecystectomy was done at 8 weeks. Her post-operative phase was complicated by intra-abdominal abscess requiring radiologically guided percutaneous drain insertion. Five days following the removal of the drain, she presented with a right abdominal wall abscess. A computerized tomography scan showed an abdominal wall ectopically-retained gallstone. The gallstone was retrieved along with drainage of abscess.

The effect of re-audit and education on antibiotic prescribing practice at Causeway Hospital, Northern Ireland

BACKGROUND

Antimicrobial resistance is a growing global problem. There has been increasing emphasis on promoting antimicrobial stewardship. Accurate completion of antibiotic prescriptions, such as documentation of clinical indication and a stop/review date, helps promote antimicrobial stewardship.

AIMS

To investigate the impact of educational interventions on the completeness of antibiotic prescriptions at Causeway Hospital surgical unit.

METHODS

Inpatient drug prescription charts were audited to monitor the completeness of antibiotic prescriptions on the surgical unit. Two educational interventions were implemented, with a subsequent prospective re-audit carried out.

RESULTS

The completion of (1) "Stop date/Review date", (2) "What infection are you treating?", (3) "Cultures sent?", (4) "Printed name", (5) "Professional number", and (6) "Bleep number" fields within the inpatient drug charts increased noticeably in the re-audit. A paired t test, comparing all of the initial audit completion proportions with the re-audit completion proportions, demonstrated a statistically significant improvement (p < 0.05).

CONCLUSIONS

Educational interventions led to an improvement in the completeness of antibiotic prescriptions. This highlights the important role that continued audit and education play in the promotion of antimicrobial stewardship.

Point-of-care diagnostics: needs of African health care workers and their role combating global antimicrobial resistance

Point-of-care tests (POCTs) offer the opportunity for increased diagnostic capacity in resource-limited settings, where there is lack of electricity, technical capacity, reagents, and infrastructure. Understanding how POCTs are currently used and determining what health care workers (HCWs) need is key to development of appropriate tests. In 2016, we undertook an email survey of 7584 HCWs who had received training at the Infectious Diseases Institute, Uganda, in a wide variety of courses. HCWs were contacted up to three times and asked to complete the survey using Qualtrics software. Of 555 participants answering the survey (7.3% response rate), 62% completed. Ninety-one percent were from Uganda and 50.3% were male. The most commonly-used POCTs were pregnancy tests (74%), urine dipstick (71%), syphilis rapid test (66%), and Gram stain (41%). The majority (74%) practiced syndromic diagnosis for sexually transmitted infections/HIV. Lack of availability of POCTs, increased patient wait time, and lack of training were the leading barriers for POCT use. Increasing POCT availability and training could improve uptake of POCTs for sexually transmitted infections in Africa and decrease syndromic management. This could reduce overtreatment and slow the emergence of antibiotic resistance. This is the first published email survey of HCWs in Uganda; mechanisms to increase the response rate should be evaluated.

Status of antimicrobial stewardship programmes in Nigerian tertiary healthcare facilities: Findings and implications

OBJECTIVES

The problem of antimicrobial resistance (AMR) is increasing worldwide, with health-related and economic consequences. This is a concern in Africa, including Nigeria, the most populous country in Africa, with its high rates of infectious diseases. Approaches to reducing AMR include instigating antimicrobial stewardship programmes (ASPs) in hospitals. Currently, no information is available regarding the extent of ASPs in Nigerian hospitals. Consequently, the objective was to address this starting in tertiary hospitals.

METHODS

This was a cross-sectional, questionnaire-based study among tertiary healthcare facilities. Tertiary hospitals were chosen initially since if there are concerns in these training hospitals, such concerns will likely to be exacerbated in other hospitals.

RESULTS

Completed questionnaires were received from 17 of 25 tertiary healthcare facilities across five of the six geopolitical regions of Nigeria. Ten (59%), four (24%), two (12%) and one (6%) respondents were in internal medicine, infectious diseases, medical microbiology and clinical pharmacology, respectively. Only six healthcare facilities (35%) had a formal organisational structure and a team responsible for ASP. Facility-specific treatment recommendations, based on local AMR patterns, were available in only four facilities (24%). Policies on approval for prescribing specified antimicrobials and formal procedures for reviewing their appropriateness after 48h were present in only two facilities (12%). A cumulative antimicrobial susceptibility report for the previous year was available in only two facilities (12%), and only one facility routinely monitored antimicrobial use.

CONCLUSION

Significant inadequacies in the availability of ASPs were observed. This needs to be urgently addressed to reduce AMR rates in Nigeria.

Prevalence of integrons 1, 2, 3 associated with antibiotic resistance in Pseudomonas aeruginosa isolates from Northwest of Iran

Background: The presence of Class 1, 2 and 3 integrons in clinical isolates of Pseudomonas aeruginosa with multi-drug resistance phenotype has rendered the organism as a new concern. Objective: This study aimed to investigate the prevalence of Class 1, 2 and 3 integrons in multi-drug resistant clinical isolates of Pseudomonas aeruginosa collected from hospitals in the city of Tabriz

Materials and Methods: A total of 200 P. aeruginosa non-duplicated clinical isolates were collected from inpatients and outpatients in different wards of hospitals from May to November 2016. The bacteria were identified by conventional microbiological methods. Antibiotic susceptibility test was performed by disk diffusion method and the presence of integrons was analyzed by polymerase chain reaction (PCR).

Results: Colistin was the most effective antibiotic, while 98% of the isolates were resistant to cefotaxime. Fifty-three percent of the isolates were recorded as multi-drug resistant (MDR) phenotype; however, 27.5% of the isolates were resistant to more than 8 antibiotics. In this study, 55 (27.5%), 51 (25.5%), and 30 (15%) clinical isolates of P. aeruginosa were positive for Class 1, 2 and 3 integrons, respectively. aac(6)II in Class I integrons and dfrA1 in ClassII and aacA7 in Class II integrons were the most prevalent genes. Resistance to aminoglycosides were the most common genes harbored by integrons.

Conclusion: The results of this study showed that the prevalence of Class 1, 2 and 3 in integron genes in most P. aeruginosa strains islated from different parts and equipment used in the hospital. The role of these transferable genetic agents has been proven in the creation of resistance. Therefore, it is essential to use management practices to optimize the use of antibiotics, preferably based on the results of antibiogram and trace coding genes for antibiotic resistance.

[Perception of surgeons on the use of antimicrobial stewardships programs]

INTRODUCTION

The misuse and overuse of antimicrobials can contribute to an increase in antimicrobial resistance, increasing the risk of infections caused by drug-resistant bacteria. Most common surgical pathologies are infectious (either primary or as a complication), often being over-treated. Exploring the perception of surgeons on the use of implementing Antimicrobial stewardship programs (ASPs) is relevant in order to adapt the program to local context.

OBJECTIVE

To determine the perception of surgeons on the management of infections and antibiotic (AB) prescription in a General Surgery Department (GSD).

METHODS

A cross-sectional and descriptive study was conducted using an anonymous questionnaire that was distributed to assess the aspects related to AB management.

RESULTS

A total of 42 questionnaires were completed, with a 65% response rate. The large majority (75%) considered that antimicrobial resistance was an important problem. The main situations considered with medium/high margin of improvement were: time from taking the specimen to receiving the results (70%), use of a wide spectrum AB, and excessive duration (88% and 89%), dose adjustment according to renal function (81%), unnecessary prolongation of intravenous AB treatment (87%) and excessive duration of it (89%), preference for intravenous AB administration until discharge of the patient (73%). There were also difficulties in ASP implementation, as well as established and solid AB patterns (84%) and the heterogeneity of the GSD (84%).

CONCLUSIONS

Organisational aspects of the GSD constitute one of the problems to implement the ASPs. A specific multidisciplinary team has been constituted to address different training aspects. This will also serve as a forum of discussion of certain complex patients with difficulties in antibiotic management.

A Global Declaration on Appropriate Use of Antimicrobial Agents across the Surgical Pathway

This declaration, signed by an interdisciplinary task force of 234 experts from 83 different countries with different backgrounds, highlights the threat posed by antimicrobial resistance and the need for appropriate use of antibiotic agents and antifungal agents in hospitals worldwide especially focusing on surgical infections. As such, it is our intent to raise awareness among healthcare workers and improve antimicrobial prescribing. To facilitate its dissemination, the declaration was translated in different languages.