1
|
Menting SGP, Redican E, Murphy J, Bucholc M. Primary Care Antibiotic Prescribing and Infection-Related Hospitalisation. Antibiotics (Basel) 2023; 12:1685. [PMID: 38136719 PMCID: PMC10740527 DOI: 10.3390/antibiotics12121685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/15/2023] [Accepted: 11/16/2023] [Indexed: 12/24/2023] Open
Abstract
Inappropriate prescribing of antibiotics has been widely recognised as a leading cause of antimicrobial resistance, which in turn has become one of the most significant threats to global health. Given that most antibiotic prescriptions are issued in primary care settings, investigating the associations between primary care prescribing of antibiotics and subsequent infection-related hospitalisations affords a valuable opportunity to understand the long-term health implications of primary care antibiotic intervention. A narrative review of the scientific literature studying associations between primary care antibiotic prescribing and subsequent infection-related hospitalisation was conducted. The Web of Science database was used to retrieve 252 potentially relevant studies, with 23 of these studies included in this review (stratified by patient age and infection type). The majority of studies (n = 18) were published in the United Kingdom, while the remainder were conducted in Germany, Spain, Denmark, New Zealand, and the United States. While some of the reviewed studies demonstrated that appropriate and timely antibiotic prescribing in primary care could help reduce the need for hospitalisation, excessive antibiotic prescribing can lead to antimicrobial resistance, subsequently increasing the risk of infection-related hospitalisation. Few studies reported no association between primary care antibiotic prescriptions and subsequent infection-related hospitalisation. Overall, the disparate results in the extant literature attest to the conflicting factors influencing the decision-making regarding antibiotic prescribing and highlight the necessity of adopting a more patient-focussed perspective in stewardship programmes and the need for increased use of rapid diagnostic testing in primary care.
Collapse
Affiliation(s)
| | - Enya Redican
- School of Psychology, Ulster University, Coleraine BT52 1SA, UK
| | - Jamie Murphy
- School of Psychology, Ulster University, Coleraine BT52 1SA, UK
| | - Magda Bucholc
- School of Computing, Engineering and Intelligent Systems, Ulster University, Derry-Londonderry BT48 7JL, UK
| |
Collapse
|
2
|
Jamrozik E, Heriot GS. Ethics and antibiotic resistance. Br Med Bull 2022; 141:4-14. [PMID: 35136968 PMCID: PMC8935610 DOI: 10.1093/bmb/ldab030] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 11/28/2021] [Accepted: 12/02/2021] [Indexed: 11/13/2022]
Abstract
INTRODUCTION OR BACKGROUND Antibiotic resistance raises ethical issues due to the severe and inequitably distributed consequences caused by individual actions and policies. SOURCES OF DATA Synthesis of ethical, scientific and clinical literature. AREAS OF AGREEMENT Ethical analyses have focused on the moral responsibilities of patients to complete antibiotic courses, resistance as a tragedy of the commons and attempts to limit use through antibiotic stewardship. AREAS OF CONTROVERSY Each of these analyses has significant limitations and can result in self-defeating or overly narrow implications for policy. GROWING POINTS More complex analyses focus on ethical implications of ubiquitous asymptomatic carriage of resistant bacteria, non-linear outcomes within and between patients over time and global variation in resistant disease burdens. AREAS TIMELY FOR DEVELOPING RESEARCH Neglected topics include the harms of antibiotic use, including off-target effects on the human microbiome, and the lack of evidence guiding most antibiotic prescription decisions.
Collapse
Affiliation(s)
- Euzebiusz Jamrozik
- The Ethox Centre and Wellcome Centre for Ethics and Humanities, Nuffield Department of Population Health, University of Oxford. Old Road Campus, Oxford OX3 7LF, UK.,Monash Bioethics Centre, Monash University, Wellington Rd, Clayton, 3800, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, University of Melbourne, 300 Grattan St, Parkville, 3050, Victoria, Australia
| | - George S Heriot
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, 300 Grattan St, Parkville, 3050, Victoria, Australia
| |
Collapse
|
3
|
Krockow EM, Tarrant C, Colman AM. Prosociality in the social dilemma of antibiotic prescribing. Curr Opin Psychol 2021; 44:164-169. [PMID: 34662776 DOI: 10.1016/j.copsyc.2021.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/06/2021] [Accepted: 09/06/2021] [Indexed: 01/21/2023]
Abstract
Antibiotic prescribing can be conceptualised as a social dilemma in which the overuse of antibiotics, to minimise immediate risks to individual patients, results in a sub-optimal outcome for society (antimicrobial resistance) and increased risks to all patients in the long run. Doctors face the challenge of balancing the interests of individual patients against the collective good when prescribing antibiotics. While evidence suggests that doctors tend to prioritise individual interests over those of the collective, the conventional interpretation of such decisions as selfish may be inappropriate because most doctors are motivated by prosocial concerns about their patients. This review of antibiotic decision research provides a more nuanced understanding of prosociality in the context of the social dilemma of antibiotic prescribing.
Collapse
Affiliation(s)
- Eva M Krockow
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, University Road, Leicester, LE1 7RK, United Kingdom.
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, University Road, Leicester, LE1 7RK, United Kingdom
| | - Andrew M Colman
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, University Road, Leicester, LE1 7RK, United Kingdom
| |
Collapse
|
4
|
Khan MS, Durrance-Bagale A, Mateus A, Sultana Z, Hasan R, Hanefeld J. What are the barriers to implementing national antimicrobial resistance action plans? A novel mixed-methods policy analysis in Pakistan. Health Policy Plan 2021; 35:973-982. [PMID: 32743655 DOI: 10.1093/heapol/czaa065] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2020] [Indexed: 12/25/2022] Open
Abstract
Despite political commitment to address antimicrobial resistance (AMR), countries are facing challenges to implementing policies to reduce inappropriate use of antibiotics. Critical factors to the success of policy implementation in low- and middle-income countries (LMIC), such as capacity for enforcement, contestation by influential stakeholders and financial interests, have been insufficiently considered. Using Pakistan as a case study representing a populous country with extremely high antibiotic usage, we identified 195 actors who affect policies on antibiotic use in humans and animals through a snowballing process and interviewed 48 of these who were nominated as most influential. We used a novel card game-based methodology to investigate policy actors' support for implementation of different regulatory approaches addressing actions of frontline healthcare providers and antibiotic producers across the One Health spectrum. We found that there was only widespread support for implementing hard regulations (prohibiting certain actions) against antibiotic suppliers with little power-such as unqualified/informal healthcare providers and animal feed producers-but not to target more powerful groups such as doctors, farmers and pharmaceutical companies. Policy actors had limited knowledge to develop implementation plans to address inappropriate use of antibiotics in animals, even though this was recognized as a critical driver of AMR. Our results indicate that local political and economic dynamics may be more salient to policy actors influencing implementation of AMR national action plans than solutions presented in global guidelines that rely on implementation of hard regulations. This highlights a disconnect between AMR action plans and the local contexts where implementation takes place. Thus if the global strategies to tackle AMR are to become implementable policies in LMIC, they will need greater appreciation of the power dynamics and systemic constraints that relate to many of the strategies proposed.
Collapse
Affiliation(s)
- Mishal S Khan
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Anna Durrance-Bagale
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Ana Mateus
- Department of Pathobiology and Population Sciences, Royal Veterinary College, London WC1H 9SH, UK
| | - Zia Sultana
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi 74800, Pakistan
| | - Rumina Hasan
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi 74800, Pakistan.,Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Johanna Hanefeld
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| |
Collapse
|
5
|
Lambregts M, Rump B, Ropers F, Sijbom M, Petrignani M, Visser L, de Vries M, de Boer M. Antimicrobial guidelines in clinical practice: incorporating the ethical perspective. JAC Antimicrob Resist 2021; 3:dlab074. [PMID: 34235435 PMCID: PMC8254525 DOI: 10.1093/jacamr/dlab074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/23/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Guidelines on antimicrobial therapy are subject to periodic revision to anticipate changes in the epidemiology of antimicrobial resistance and new scientific knowledge. Changing a policy to a broader spectrum has important consequences on both the individual patient level (e.g. effectiveness, toxicity) and population level (e.g. emerging resistance, costs). By combining both clinical data evaluation and an ethical analysis, we aim to propose a comprehensive framework to guide antibiotic policy dilemmas. Methods A preliminary framework for decision-making on antimicrobial policy was constructed based on existing literature and panel discussions. Antibiotic policy themes were translated into specific elements that were fitted into this framework. The adapted framework was evaluated in two moral deliberation groups. The moral deliberation sessions were analysed using ATLAS.ti statistical software to categorize arguments and evaluate completeness of the final framework. Results The final framework outlines the process of data evaluation, ethical deliberation and decision-making. The first phase is a factual data exploration. In the second phase, perspectives are weighed and the policy of moral preference is formulated. Judgments are made on three levels: the individual patient, the patient population and society. In the final phase, feasibility, implementation and re-evaluation are addressed. Conclusions The proposed framework facilitates decision-making on antibiotic policy by structuring existing data, identifying knowledge gaps, explicating ethical considerations and balancing interests of the individual and current and future generations.
Collapse
Affiliation(s)
- Merel Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Babette Rump
- National Institute of Public Health and the Environment, Centre for Infectious Diseases Control (RIVM-LCI), Antonie van Leeuwenhoeklaan 9, 3721MA, Bilthoven, The Netherlands
| | - Fabienne Ropers
- Department of Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Center, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - Martijn Sijbom
- Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Mariska Petrignani
- Department of Infectious Diseases, Haaglanden Municipal Health Service, Westeinde 128, 2512HE Den Haag, The Netherlands
| | - Leo Visser
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Martine de Vries
- Leiden University Medical Center, Department of Medical Ethics and Law, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Mark de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| |
Collapse
|
6
|
Korang SK, Safi S, Nava C, Gordon A, Gupta M, Greisen G, Lausten-Thomsen U, Jakobsen JC. Antibiotic regimens for early-onset neonatal sepsis. Cochrane Database Syst Rev 2021; 5:CD013837. [PMID: 33998666 PMCID: PMC8127574 DOI: 10.1002/14651858.cd013837.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Neonatal sepsis is a major cause of morbidity and mortality. It is the third leading cause of neonatal mortality globally constituting 13% of overall neonatal mortality. Despite the high burden of neonatal sepsis, high-quality evidence in diagnosis and treatment is scarce. Possibly due to the diagnostic challenges of sepsis and the relative immunosuppression of the newborn, many neonates receive antibiotics for suspected sepsis. Antibiotics have become the most used therapeutics in neonatal intensive care units. The last Cochrane Review was updated in 2004. Given the clinical importance, an updated systematic review assessing the effects of different antibiotic regimens for early-onset neonatal sepsis is needed. OBJECTIVES To assess the beneficial and harmful effects of different antibiotic regimens for early-onset neonatal sepsis. SEARCH METHODS We searched the following electronic databases: CENTRAL (2020, Issue 8); Ovid MEDLINE; Embase Ovid; CINAHL; LILACS; Science Citation Index EXPANDED and Conference Proceedings Citation Index - Science on 12 March 2021. We searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We included RCTs comparing different antibiotic regimens for early-onset neonatal sepsis. We included participants from birth to 72 hours of life at randomisation. DATA COLLECTION AND ANALYSIS Three review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We used the GRADE approach to assess the certainty of evidence. Our primary outcome was all-cause mortality, and our secondary outcomes were: serious adverse events, respiratory support, circulatory support, nephrotoxicity, neurological developmental impairment, necrotising enterocolitis, and ototoxicity. Our primary time point of interest was at maximum follow-up. MAIN RESULTS We included five RCTs (865 participants). All trials were at high risk of bias. The certainty of the evidence according to GRADE was very low. The included trials assessed five different comparisons of antibiotics. We did not conduct any meta-analyses due to lack of relevant data. Of the five included trials one trial compared ampicillin plus gentamicin with benzylpenicillin plus gentamicin; one trial compared piperacillin plus tazobactam with amikacin; one trial compared ticarcillin plus clavulanic acid with piperacillin plus gentamicin; one trial compared piperacillin with ampicillin plus amikacin; and one trial compared ceftazidime with benzylpenicillin plus gentamicin. None of the five comparisons found any evidence of a difference when assessing all-cause mortality, serious adverse events, circulatory support, nephrotoxicity, neurological developmental impairment, or necrotising enterocolitis; however, none of the trials were near an information size that could contribute significantly to the evidence of the comparative benefits and risks of any particular antibiotic regimen. None of the trials assessed respiratory support or ototoxicity. The benefits and harms of different antibiotic regimens remain unclear due to the lack of well-powered trials and the high risk of systematic errors. AUTHORS' CONCLUSIONS Current evidence is insufficient to support any antibiotic regimen being superior to another. Large RCTs assessing different antibiotic regimens in early-onset neonatal sepsis with low risk of bias are warranted.
Collapse
Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chiara Nava
- Neonatal Intensive Care Unit, Ospedale "A. Manzoni", Lecco, Italy
| | - Adrienne Gordon
- Neonatology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Munish Gupta
- Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ulrik Lausten-Thomsen
- Pediatric and Neonatal Intensive Care Unit, Paris South University Hospitals Le Kremlin-Bicêtre, Paris, France
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
7
|
Korang SK, Safi S, Nava C, Greisen G, Gupta M, Lausten-Thomsen U, Jakobsen JC. Antibiotic regimens for late-onset neonatal sepsis. Cochrane Database Syst Rev 2021; 5:CD013836. [PMID: 33998665 PMCID: PMC8127057 DOI: 10.1002/14651858.cd013836.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Neonatal sepsis is a major cause of morbidity and mortality. It is the third leading cause of neonatal mortality globally constituting 13% of overall neonatal mortality. Despite the high burden of neonatal sepsis, high-quality evidence in diagnosis and treatment is scarce. Due to the diagnostic challenges of sepsis and the relative immunosuppression of the newborn, many neonates receive antibiotics for suspected sepsis. Antibiotics have become the most used therapeutics in neonatal intensive care units, and observational studies in high-income countries suggest that 83% to 94% of newborns treated with antibiotics for suspected sepsis have negative blood cultures. The last Cochrane Review was updated in 2005. There is a need for an updated systematic review assessing the effects of different antibiotic regimens for late-onset neonatal sepsis. OBJECTIVES To assess the beneficial and harmful effects of different antibiotic regimens for late-onset neonatal sepsis. SEARCH METHODS We searched the following electronic databases: CENTRAL (2021, Issue 3); Ovid MEDLINE; Embase Ovid; CINAHL; LILACS; Science Citation Index EXPANDED and Conference Proceedings Citation Index - Science on 12 March 2021. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We included RCTs comparing different antibiotic regimens for late-onset neonatal sepsis. We included participants older than 72 hours of life at randomisation, suspected or diagnosed with neonatal sepsis, meningitis, osteomyelitis, endocarditis, or necrotising enterocolitis. We excluded trials that assessed treatment of fungal infections. DATA COLLECTION AND ANALYSIS Three review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We used the GRADE approach to assess the certainty of evidence. Our primary outcome was all-cause mortality, and our secondary outcomes were: serious adverse events, respiratory support, circulatory support, nephrotoxicity, neurological developmental impairment, necrotising enterocolitis, and ototoxicity. Our primary time point of interest was at maximum follow-up. MAIN RESULTS We included five RCTs (580 participants). All trials were at high risk of bias, and had very low-certainty evidence. The five included trials assessed five different comparisons of antibiotics. We did not conduct a meta-analysis due to lack of relevant data. Of the five included trials one trial compared cefazolin plus amikacin with vancomycin plus amikacin; one trial compared ticarcillin plus clavulanic acid with flucloxacillin plus gentamicin; one trial compared cloxacillin plus amikacin with cefotaxime plus gentamicin; one trial compared meropenem with standard care (ampicillin plus gentamicin or cefotaxime plus gentamicin); and one trial compared vancomycin plus gentamicin with vancomycin plus aztreonam. None of the five comparisons found any evidence of a difference when assessing all-cause mortality, serious adverse events, circulatory support, nephrotoxicity, neurological developmental impairment, or necrotising enterocolitis; however, none of the trials were near an information size that could contribute significantly to the evidence of the comparative benefits and risks of any particular antibiotic regimen. None of the trials assessed respiratory support or ototoxicity. The benefits and harms of different antibiotic regimens remain unclear due to the lack of well-powered trials and the high risk of systematic errors. AUTHORS' CONCLUSIONS Current evidence is insufficient to support any antibiotic regimen being superior to another. RCTs assessing different antibiotic regimens in late-onset neonatal sepsis with low risks of bias are warranted.
Collapse
Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chiara Nava
- Neonatal Intensive Care Unit, Ospedale "A. Manzoni", Lecco, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Munish Gupta
- Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ulrik Lausten-Thomsen
- Pediatric and Neonatal Intensive Care Unit, Paris South University Hospitals Le Kremlin-Bicêtre, Paris, France
| | - Janus C Jakobsen
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
8
|
Ancillotti M. An Effort Worth Making: A Qualitative Study of How Swedes Respond to Antibiotic Resistance. Public Health Ethics 2021; 14:1-11. [PMID: 34234840 PMCID: PMC8254642 DOI: 10.1093/phe/phaa033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Due to the alarming rise of antibiotic resistance, medically unwarranted use of antibiotics has assumed new moral significance. In this paper, a thematic content analysis of focus group discussions was conducted to explore lay people's views on the moral challenges posed by antibiotic resistance. The most important finding is that lay people are morally sensitive to the problems entailed by antibiotic resistance. Participants saw the decreasing availability of effective antibiotics as a problem of justice. This involves individual as well as collective moral responsibility. Yet, holding agents responsible for their use of antibiotics involves varying degrees of demandingness. In our discussion, these findings are related to the contemporary ethical debate on antibiotic resistance and two proposals for the preservation of antibiotic effectiveness are compared to and evaluated against participants' views.
Collapse
|
9
|
Korang SK, Safi S, Gupta M, Greisen G, Lausten-Thomsen U, Jakobsen JC. Antibiotic regimens for late-onset neonatal sepsis. Hippokratia 2021. [DOI: 10.1002/14651858.cd013836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812; Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
- Pediatric Department; Holbaek Sygehus; Holbaek Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research; Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Munish Gupta
- Neonatology; Beth Israel Deaconess Medical Center; Boston USA
| | - Gorm Greisen
- Department of Neonatology; Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Ulrik Lausten-Thomsen
- Pediatric and Neonatal Intensive Care Unit; Paris South University Hospitals Le Kremlin-Bicêtre; Paris France
| | - Janus C Jakobsen
- Cochrane Hepato-Biliary Group; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet; Copenhagen Denmark
- Department of Cardiology; Holbaek Hospital; Holbaek Denmark
- Department of Regional Health Research, the Faculty of Health Sciences; University of Southern Denmark; Holbaek Denmark
| |
Collapse
|
10
|
Korang SK, Safi S, Gupta M, Gordon A, Greisen G, Lausten-Thomsen U, Jakobsen JC. Antibiotic regimens for early-onset neonatal sepsis. Hippokratia 2021. [DOI: 10.1002/14651858.cd013837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812; Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
- Pediatric Department; Holbaek Sygehus; Holbaek Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research; Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Munish Gupta
- Neonatology; Beth Israel Deaconess Medical Center; Boston USA
| | | | - Gorm Greisen
- Department of Neonatology; Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Ulrik Lausten-Thomsen
- Pediatric and Neonatal Intensive Care Unit; Paris South University Hospitals Le Kremlin-Bicêtre; Paris France
| | - Janus C Jakobsen
- Cochrane Hepato-Biliary Group; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet; Copenhagen Denmark
- Department of Cardiology; Holbaek Hospital; Holbaek Denmark
- Department of Regional Health Research, the Faculty of Health Sciences; University of Southern Denmark; Holbaek Denmark
| |
Collapse
|
11
|
Bettinger B, Benneyan JC, Mahootchi T. Antibiotic stewardship from a decision-making, behavioral economics, and incentive design perspective. APPLIED ERGONOMICS 2021; 90:103242. [PMID: 32861088 DOI: 10.1016/j.apergo.2020.103242] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 06/11/2023]
Abstract
Antibiotic-resistant infections cause over 20 thousand deaths and $20 billion annually in the United States. Antibiotic prescribing decision making can be described as a "tragedy of the commons" behavioral economics problem, for which individual best interests affecting human decision-making lead to suboptimal societal antibiotic overuse. In 2015, the U.S. federal government announced a $1.2 billion National Action Plan to combat resistance and reduce antibiotic use by 20% in inpatient settings and 50% in outpatient settings by 2020. We develop and apply a behavioral economics model based on game theory and "tragedy of the commons" concepts to help illustrate why rational individuals may not practice ideal stewardship and how to potentially structure three specific alternate approaches to accomplish these objectives (collective cooperative management, usage taxes, resistance penalties), based on Ostrom's economic governance principles. Importantly, while each approach can effectively incentivize ideal stewardship, the latter two do so with 10-30% lower utility to all providers. Encouraging local or state-level self-managed cooperative stewardship programs thus is preferred to national taxes and penalties, in contrast with current trends and with similar implications in other countries.
Collapse
Affiliation(s)
| | - James C Benneyan
- Healthcare Systems Engineering Institute, Northeastern University, Boston MA, USA.
| | | |
Collapse
|
12
|
Vu TLH, Vu QD, Hoang BL, Nguyen TCT, Ta TDN, Nadjm B, van Doorn HR. Factors influencing choices of empirical antibiotic treatment for bacterial infections in a scenario-based survey in Vietnam. JAC Antimicrob Resist 2020; 2:dlaa087. [PMID: 33210086 PMCID: PMC7653509 DOI: 10.1093/jacamr/dlaa087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 09/07/2020] [Indexed: 12/28/2022] Open
Abstract
Background Antimicrobial stewardship (AMS) programmes have been implemented around the world to guide rational use of antibiotics but implementation is challenging, particularly in low- and middle-income countries, including Vietnam. Understanding factors influencing doctors’ prescribing choices for empirical treatment can help design AMS interventions in these settings. Objectives To understand doctors’ choices of antibiotics for empirical treatment of common bacterial infections and the factors influencing decision-making. Methods We conducted a cross-sectional survey among medical professionals applying for a postgraduate programme at Hanoi Medical University, Vietnam. We used a published survey developed for internal medicine doctors in Canada. The survey was self-administered and included four clinical scenarios: (i) severe undifferentiated sepsis; (ii) mild undifferentiated sepsis; (iii) severe genitourinary infection; and (iv) mild genitourinary infection. Results A total of 1011/1280 (79%), 683/1188 (57.5%), 718/1157 (62.1%) and 542/1062 (51.0%) of the participants selected combination therapy for empirical treatment in scenarios 1, 2, 3 and 4, respectively. Undifferentiated sepsis (OR 1.82, 95% CI 1.46–2.27 and 2.18, 1.51–3.16 compared with genitourinary) and severe infection (1.33, 1.24–1.43 and 1.38, 1.21–1.58 compared with mild) increased the likelihood of choosing a combination therapy and a carbapenem regimen, respectively. Participants with higher acceptable minimum threshold for treatment coverage and young age were also more likely to prescribe carbapenems. Conclusions Decision-making in antibiotic prescribing among doctors in Vietnam is influenced by both disease-related characteristics and individual factors, including acceptable minimum treatment coverage. These findings are useful for tailoring AMS implementation in Vietnam and other, similar settings.
Collapse
Affiliation(s)
- Thi Lan Huong Vu
- Oxford University Clinical Research Unit, 78 Giai Phong, Hanoi, Vietnam
| | - Quoc Dat Vu
- Hanoi Medical University, 1 Ton That Tung, Hanoi, Vietnam
| | - Bao Long Hoang
- Oxford University Clinical Research Unit, 78 Giai Phong, Hanoi, Vietnam
| | - Thi Cam Tu Nguyen
- Oxford University Clinical Research Unit, 78 Giai Phong, Hanoi, Vietnam
| | | | - Behzad Nadjm
- Oxford University Clinical Research Unit, 78 Giai Phong, Hanoi, Vietnam
| | | |
Collapse
|
13
|
Hernando-Amado S, Coque TM, Baquero F, Martínez JL. Antibiotic Resistance: Moving From Individual Health Norms to Social Norms in One Health and Global Health. Front Microbiol 2020; 11:1914. [PMID: 32983000 PMCID: PMC7483582 DOI: 10.3389/fmicb.2020.01914] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022] Open
Abstract
Antibiotic resistance is a problem for human health, and consequently, its study had been traditionally focused toward its impact for the success of treating human infections in individual patients (individual health). Nevertheless, antibiotic-resistant bacteria and antibiotic resistance genes are not confined only to the infected patients. It is now generally accepted that the problem goes beyond humans, hospitals, or long-term facility settings and that it should be considered simultaneously in human-connected animals, farms, food, water, and natural ecosystems. In this regard, the health of humans, animals, and local antibiotic-resistance-polluted environments should influence the health of the whole interconnected local ecosystem (One Health). In addition, antibiotic resistance is also a global problem; any resistant microorganism (and its antibiotic resistance genes) could be distributed worldwide. Consequently, antibiotic resistance is a pandemic that requires Global Health solutions. Social norms, imposing individual and group behavior that favor global human health and in accordance with the increasingly collective awareness of the lack of human alienation from nature, will positively influence these solutions. In this regard, the problem of antibiotic resistance should be understood within the framework of socioeconomic and ecological efforts to ensure the sustainability of human development and the associated human-natural ecosystem interactions.
Collapse
Affiliation(s)
- Sara Hernando-Amado
- Centro Nacional de Biotecnología, Consejo Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| | - Teresa M. Coque
- Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) and Centro de Investigación Biomédica en Red Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Fernando Baquero
- Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) and Centro de Investigación Biomédica en Red Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - José L. Martínez
- Centro Nacional de Biotecnología, Consejo Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| |
Collapse
|
14
|
Porras-Povedano M, Santacruz-Hamer V, Muñoz-Collado E, Ramírez-Pulido R. [Ethical aspects of specific precautions programs in patients infected or colonised by multidrug-resistant microorganisms in a hospital setting]. J Healthc Qual Res 2020; 35:159-165. [PMID: 32404291 DOI: 10.1016/j.jhqr.2020.03.006] [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: 10/30/2019] [Revised: 01/28/2020] [Accepted: 03/09/2020] [Indexed: 10/24/2022]
Abstract
The approach to public health, patient safety and quality of care has led to analysing health situations or problems from a population perspective, in a wide way and giving priority to factors that can normally be left in the background from a clinical point of view. For years, the problem of the use and abuse of antimicrobials, the increase and diffusion of microorganisms resistant to them, cross-transmission, and healthcare related infections have been prioritised both nationally and internationally. To combat these problems, various strategies are being developed and put into practice, from the policies of rational use and optimization of antimicrobials, surveillance, and control of infections related to health care, to training information and awareness strategies. One of the pillars of surveillance and control is the correct application of standard and specific precautions, which within the framework of these comprehensive programs aim to control the transmission of microorganisms of special microbiological and/or epidemiological interest through a series of measures. In hospitals, the application of these precautions (single room, barrier measures, restrictions on access to rooms, waste management…) in patients infected or colonised by these microorganisms can have different repercussions, both for patients and the professionals that attend them, and it is considered pertinent that the protocols and/or programs of specific precautions explicitly include the analysis of the ethical aspects in their preparation, implementation, and monitoring.
Collapse
|
15
|
Moral Responsibility and the Justification of Policies to Preserve Antimicrobial Effectiveness. ETHICS AND DRUG RESISTANCE: COLLECTIVE RESPONSIBILITY FOR GLOBAL PUBLIC HEALTH 2020. [DOI: 10.1007/978-3-030-27874-8_9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Abstract
Restrictive policies that limit antimicrobial consumption, including therapeutically justified use, might be necessary to tackle the problem of antimicrobial resistance. We argue that such policies would be ethically justified when forgoing antimicrobials constitutes a form of easy rescue for an individual. These are cases of mild and self-limiting infections in otherwise healthy patients whose overall health is not significantly compromised by the infection. In such cases, restrictive policies would be ethically justified because they would coerce individuals into fulfilling a moral obligation they independently have. However, to ensure that such justification is the strongest possible, states also have the responsibility to ensure that forgoing antimicrobials is as easy as possible for patients by implementing adequate compensation measures.
Collapse
|
16
|
Korang SK, Safi S, Gluud C, Lausten-Thomsen U, Jakobsen JC. Antibiotic regimens for neonatal sepsis - a protocol for a systematic review with meta-analysis. Syst Rev 2019; 8:306. [PMID: 31805993 PMCID: PMC6896287 DOI: 10.1186/s13643-019-1207-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 10/22/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Sepsis is a major cause of morbidity and mortality among neonates and infants. Antibiotics are a central part of the first line treatment for sepsis in neonatal intensive care units worldwide. However, the evidence on the clinical effects of the commonly used antibiotic regimens for sepsis in neonates remains scarce. This systematic review aims to assess the efficacy and harms of antibiotic regimens for neonatal sepsis. METHODS Electronic searches will be conducted in MEDLINE, Embase, The Cochrane Library, CINAHL, ZETOC and clinical trial registries (clinicaltrials.gov and ISRCTN). We will include randomised controlled trials of different antibiotic regimens for sepsis of neonates and infants. Eligible interventions will be any antibiotic regimen. Two reviewers will independently screen, select, and extract data. The methodological quality of individual studies will be appraised following Cochrane methodology. Primary outcomes will be 'all-cause mortality' and 'serious adverse events'. Secondary outcomes will be 'need for respiratory support', 'need for circulatory support', 'neurodevelopmental impairment', ototoxicity, nephrotoxicity and necrotizing enterocolitis. We plan to perform a meta-analysis with trial sequential analysis. DISCUSSION This is the study protocol for a systematic review on the effects of different antibiotic regimens for neonatal sepsis. The results of this systematic review intent to adequately inform stakeholders or health care professionals in the field of neonatal sepsis, and to aid appropriate development of treatment guidelines. SYSTEMATIC REVIEW REGISTRATION PROSPERO reference number: CRD42019134300.
Collapse
Affiliation(s)
- Steven Kwasi Korang
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ulrik Lausten-Thomsen
- Department of Neonatology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
| |
Collapse
|
17
|
Tarrant C, Colman A, Chattoe-Brown E, Jenkins D, Mehtar S, Perera N, Krockow E. Optimizing antibiotic prescribing: collective approaches to managing a common-pool resource. Clin Microbiol Infect 2019; 25:1356-1363. [DOI: 10.1016/j.cmi.2019.03.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/08/2019] [Accepted: 03/10/2019] [Indexed: 12/18/2022]
|
18
|
Abstract
Public health policies often require individuals to make personal sacrifices for the sake of protecting other individuals or the community at large. Such requirements can be more or less demanding for individuals. This paper examines the implications of demandingness for public health ethics and policy. It focuses on three possible public health policies that pose requirements that are differently demanding: vaccination policies, policy to contain antimicrobial resistance, and quarantine and isolation policies. Assuming the validity of the ‘demandingness objection’ in ethics, we argue that states should try to pose requirements that individuals would have an independent moral obligation to fulfil, and therefore that are not too demanding. In such cases, coercive measures are ethically justified, especially if the interventions also entail some benefits to the individuals; this is, for example, the case of vaccination policies. When public health policies need to require individuals to do something that is too demanding to constitute an independent moral obligation, states have an obligation to either provide incentives to give individuals non-moral reasons to fulfil a certain requirement – as in the case of policies that limit antibiotic prescriptions – or to compensate individuals for being forced to do something that is too demanding to constitute an independent moral obligation – as in the case of quarantine and isolation policies.
Collapse
Affiliation(s)
- Alberto Giubilini
- Oxford Martin School and Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
| | - Julian Savulescu
- Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics and Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
- Murdoch Children’s Research Institute, Melbourne (Visiting Professorial Fellow), Melbourne, Australia
| |
Collapse
|
19
|
Colman AM, Krockow EM, Chattoe-Brown E, Tarrant C. Medical prescribing and antibiotic resistance: A game-theoretic analysis of a potentially catastrophic social dilemma. PLoS One 2019; 14:e0215480. [PMID: 31002685 PMCID: PMC6474592 DOI: 10.1371/journal.pone.0215480] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/02/2019] [Indexed: 01/08/2023] Open
Abstract
The availability of antibiotics presents medical practitioners with a prescribing dilemma. On the one hand, antibiotics provide a safe and effective treatment option for patients with bacterial infections, but at a population level, over-prescription reduces their effectiveness by facilitating the evolution of bacteria that are resistant to antibiotic medication. A game-theoretic investigation, including analysis of equilibrium strategies, evolutionarily stability, and replicator dynamics, reveals that rational doctors, motivated to attain the best outcomes for their own patients, will prescribe antibiotics irrespective of the level of antibiotic resistance in the population and the behavior of other doctors, although they would achieve better long-term outcomes if their prescribing were more restrained. Ever-increasing antibiotic resistance may therefore be inevitable unless some means are found of modifying the payoffs of this potentially catastrophic social dilemma.
Collapse
Affiliation(s)
- Andrew M. Colman
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, United Kingdom
- * E-mail:
| | - Eva M. Krockow
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Edmund Chattoe-Brown
- Department of Media, Communication and Sociology, University of Leicester, Leicester, United Kingdom
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| |
Collapse
|
20
|
Boyd R, Richerson PJ, Meinzen-Dick R, De Moor T, Jackson MO, Gjerde KM, Harden-Davies H, Frischmann BM, Madison MJ, Strandburg KJ, McLean AR, Dye C. Tragedy revisited. Science 2018; 362:1236-1241. [PMID: 30545871 DOI: 10.1126/science.aaw0911] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Robert Boyd
- School of Human Evolution and Social Change, Arizona State University, Tempe, AZ, USA.
| | - Peter J Richerson
- Department of Environmental Science and Policy, University of California, Davis, CA, USA.
| | | | | | - Matthew O Jackson
- Stanford University, Stanford, CA, USA. .,Sante Fe Insitute, Santa Fe, NM, USA.,Canadian Institute For Advanced Research, Toronto, ON, Canada
| | - Kristina M Gjerde
- IUCN Global Marine and Polar Programme and World Commission on Protected Areas, Cambridge, MA, USA.
| | - Harriet Harden-Davies
- Australian National Centre for Ocean Resources and Security (ANCORS), University of Wollongong, NSW, Australia
| | | | | | | | - Angela R McLean
- All Souls College, Oxford University, Oxford OX1 4AL, UK. .,Oxford Martin Programme on Collective Responsibility for Infectious Disease, Oxford University, Oxford OX1 3BD, UK
| | | |
Collapse
|
21
|
Krockow EM, Colman AM, Chattoe-Brown E, Jenkins DR, Perera N, Mehtar S, Tarrant C. Balancing the risks to individual and society: a systematic review and synthesis of qualitative research on antibiotic prescribing behaviour in hospitals. J Hosp Infect 2018; 101:428-439. [PMID: 30099092 DOI: 10.1016/j.jhin.2018.08.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/03/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Antimicrobial resistance is a global health threat, partly driven by inappropriate antibiotic prescriptions for acute medical patients in hospitals. AIM To provide a systematic review of qualitative research on antibiotic prescribing decisions in hospitals worldwide, including broad-spectrum antibiotic use. METHODS A systematic search of qualitative research on antibiotic prescribing for adult hospital patients published between 2007 and 2017 was conducted. Drawing on the Health Belief Model, a framework synthesis was conducted to assess threat perceptions associated with antimicrobial resistance, and perceived benefits and barriers associated with antibiotic stewardship. FINDINGS The risk of antimicrobial resistance was generally perceived to be serious, but the abstract and long-term nature of its consequences led physicians to doubt personal susceptibility. While prescribers believed in the benefits of optimizing prescribing, the direct link between over-prescribing and antimicrobial resistance was questioned, and prescribers' behaviour change was frequently considered futile when fighting the complex problem of antimicrobial resistance. The salience of individual patient risks was a key barrier to more conservative prescribing. Physicians perceived broad-spectrum antibiotics to be effective and low risk; prescribing broad-spectrum antibiotics involved low cognitive demand and enabled physicians to manage patient expectations. Antibiotic prescribing decisions in low-income countries were shaped by a context of heightened uncertainty and risk due to poor microbiology and infection control services. CONCLUSIONS When tackling antimicrobial resistance, the tensions between immediate individual risks and long-term collective risks need to be taken into account. Efforts to reduce diagnostic uncertainty and to change risk perceptions will be critical in shifting practice.
Collapse
Affiliation(s)
- E M Krockow
- Department of Health Sciences, University of Leicester, Leicester, UK.
| | - A M Colman
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK
| | - E Chattoe-Brown
- School of Media, Communication and Sociology, University of Leicester, Leicester, UK
| | - D R Jenkins
- Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - N Perera
- Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - S Mehtar
- Tygerberg Academic Hospital and Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - C Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| |
Collapse
|
22
|
Kamenshchikova A, Wolffs PFG, Hoebe CJ, Penders J, Horstman K. Complex narratives of health, stigma and control: Antimicrobial resistance screening among non-hospitalized refugees. Soc Sci Med 2018; 212:43-49. [PMID: 30005223 DOI: 10.1016/j.socscimed.2018.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 06/27/2018] [Accepted: 07/06/2018] [Indexed: 01/23/2023]
Abstract
Antimicrobial resistance (AMR) is often presented as a major public health problem globally. Screening for AMR usually takes place in clinical settings. Recent developments in microbiology stimulated a series of studies focusing on AMR in communities, and particularly in travelers (any mobile individual), which was argued to be important for identifying potential public health risks. Against this background, microbiologists have become interested in non-hospitalized refugees as one of the traveler groups. However, this attention to refugees has provoked some professional debates on potential stigmatization of refugees as dangerous "others". To contribute to these debates, and to explore the idea of AMR screening of non-hospitalized refugees from different perspectives, we conducted a qualitative study among four groups of stakeholders who were chosen because of their associations with potential microbiological screening: microbiologists, public health physicians, public health nurses, and refugees. The study took place in a Dutch city from June to August 2016 and had 17 participants: five microbiologists, two public health nurses, four public health physicians, and six refugees. While microbiologists and public health physicians demonstrated a de-contextualized biomedical narrative in arguing that AMR screening among non-hospitalized refugees could be important for scientific research as well as for AMR prevention in communities, public health nurses displayed a more contextualized narrative bringing the benefits for individuals at the center and indicating that screening exclusively among refugees may provoke fear and stigmatization. Refugees were rather positive about AMR screening but stressed that it should particularly contribute to their individual health. We conclude that to design AMR prevention strategies, it is important to consider the complex meanings of AMR screening, and to design these strategies as a process of co-production by diverse stakeholders, including the target populations.
Collapse
Affiliation(s)
- A Kamenshchikova
- Department of Health, Ethics and Society, School of Public Health and Primary Care (CAPHRI), Maastricht University, Postbus 616, 6200, MD, Maastricht, the Netherlands; Research Centre for Policy Analysis and Studies of Technologies (PAST-Centre), National Research Tomsk State University, Tomsk, Russian Federation.
| | - P F G Wolffs
- Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - C J Hoebe
- Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands; Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service (GGD South Limburg), Heerlen, the Netherlands
| | - J Penders
- Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands; Department of Medical Microbiology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - K Horstman
- Department of Health, Ethics and Society, School of Public Health and Primary Care (CAPHRI), Maastricht University, Postbus 616, 6200, MD, Maastricht, the Netherlands
| |
Collapse
|
23
|
Almagor J, Temkin E, Benenson I, Fallach N, Carmeli Y. The impact of antibiotic use on transmission of resistant bacteria in hospitals: Insights from an agent-based model. PLoS One 2018; 13:e0197111. [PMID: 29758063 PMCID: PMC5951570 DOI: 10.1371/journal.pone.0197111] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/26/2018] [Indexed: 12/15/2022] Open
Abstract
Extensive antibiotic use over the years has led to the emergence and spread of antibiotic resistant bacteria (ARB). Antibiotic resistance poses a major threat to public health since for many infections antibiotic treatment is no longer effective. Hospitals are focal points for ARB spread. Antibiotic use in hospitals exerts selective pressure, accelerating the spread of ARB. We used an agent-based model to explore the impact of antibiotics on the transmission dynamics and to examine the potential of stewardship interventions in limiting ARB spread in a hospital. Agents in the model consist of patients and health care workers (HCW). The transmission of ARB occurs through contacts between patients and HCW and between adjacent patients. In the model, antibiotic use affects the risk of transmission by increasing the vulnerability of susceptible patients and the contagiousness of colonized patients who are treated with antibiotics. The model shows that increasing the proportion of patients receiving antibiotics increases the rate of acquisition non-linearly. The effect of antibiotics on the spread of resistance depends on characteristics of the antibiotic agent and the density of antibiotic use. Antibiotic's impact on the spread increases when the bacterial strain is more transmissible, and decreases as resistance prevalence rises. The individual risk for acquiring ARB increases in parallel with antibiotic density both for patients treated and not treated with antibiotics. Antibiotic treatment in the hospital setting plays an important role in determining the spread of resistance. Interventions to limit antibiotic use have the potential to reduce the spread of resistance, mainly by choosing an agent with a favorable profile in terms of its impact on patient's vulnerability and contagiousness. Methods to measure these impacts of antibiotics should be developed, standardized, and incorporated into drug development programs and approval packages.
Collapse
Affiliation(s)
- Jonatan Almagor
- Laboratory of Geosimulation and Spatial Analysis, Department of Geography and Human Environment, Tel Aviv University, Tel Aviv, Israel
- Department of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- * E-mail:
| | - Elizabeth Temkin
- Department of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Itzhak Benenson
- Laboratory of Geosimulation and Spatial Analysis, Department of Geography and Human Environment, Tel Aviv University, Tel Aviv, Israel
| | - Noga Fallach
- Department of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yehuda Carmeli
- Department of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | |
Collapse
|
24
|
Suppressive drug combinations and their potential to combat antibiotic resistance. J Antibiot (Tokyo) 2017; 70:1033-1042. [PMID: 28874848 DOI: 10.1038/ja.2017.102] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/26/2017] [Accepted: 07/28/2017] [Indexed: 12/25/2022]
Abstract
Antibiotic effectiveness often changes when two or more such drugs are administered simultaneously and unearthing antibiotic combinations with enhanced efficacy (synergy) has been a longstanding clinical goal. However, antibiotic resistance, which undermines individual drugs, threatens such combined treatments. Remarkably, it has emerged that antibiotic combinations whose combined effect is lower than that of at least one of the individual drugs can slow or even reverse the evolution of resistance. We synthesize and review studies of such so-called 'suppressive interactions' in the literature. We examine why these interactions have been largely disregarded in the past, the strategies used to identify them, their mechanistic basis, demonstrations of their potential to reverse the evolution of resistance and arguments for and against using them in clinical treatment. We suggest future directions for research on these interactions, aiming to expand the basic body of knowledge on suppression and to determine the applicability of suppressive interactions in the clinic.
Collapse
|
25
|
Beardmore RE, Peña-Miller R, Gori F, Iredell J. Antibiotic Cycling and Antibiotic Mixing: Which One Best Mitigates Antibiotic Resistance? Mol Biol Evol 2017; 34:802-817. [PMID: 28096304 PMCID: PMC5400377 DOI: 10.1093/molbev/msw292] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Can we exploit our burgeoning understanding of molecular evolution to slow the progress of drug resistance? One role of an infection clinician is exactly that: to foresee trajectories to resistance during antibiotic treatment and to hinder that evolutionary course. But can this be done at a hospital-wide scale? Clinicians and theoreticians tried to when they proposed two conflicting behavioral strategies that are expected to curb resistance evolution in the clinic, these are known as “antibiotic cycling” and “antibiotic mixing.” However, the accumulated data from clinical trials, now approaching 4 million patient days of treatment, is too variable for cycling or mixing to be deemed successful. The former implements the restriction and prioritization of different antibiotics at different times in hospitals in a manner said to “cycle” between them. In antibiotic mixing, appropriate antibiotics are allocated to patients but randomly. Mixing results in no correlation, in time or across patients, in the drugs used for treatment which is why theorists saw this as an optimal behavioral strategy. So while cycling and mixing were proposed as ways of controlling evolution, we show there is good reason why clinical datasets cannot choose between them: by re-examining the theoretical literature we show prior support for the theoretical optimality of mixing was misplaced. Our analysis is consistent with a pattern emerging in data: neither cycling or mixing is a priori better than the other at mitigating selection for antibiotic resistance in the clinic. Key words: antibiotic cycling, antibiotic mixing, optimal control, stochastic models.
Collapse
Affiliation(s)
| | - Rafael Peña-Miller
- Center for Genomic Sciences, Universidad Nacional Autonóma de México, Cuernavaca, Mexico
| | - Fabio Gori
- Biosciences University of Exeter, Devon, United Kingdom
| | - Jonathan Iredell
- Westmead Clinical School, Westmead Hospital, The University of Sydney, Australia
| |
Collapse
|
26
|
Singer AC, Shaw H, Rhodes V, Hart A. Review of Antimicrobial Resistance in the Environment and Its Relevance to Environmental Regulators. Front Microbiol 2016; 7:1728. [PMID: 27847505 PMCID: PMC5088501 DOI: 10.3389/fmicb.2016.01728] [Citation(s) in RCA: 375] [Impact Index Per Article: 46.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/17/2016] [Indexed: 01/25/2023] Open
Abstract
The environment is increasingly being recognized for the role it might play in the global spread of clinically relevant antibiotic resistance. Environmental regulators monitor and control many of the pathways responsible for the release of resistance-driving chemicals into the environment (e.g., antimicrobials, metals, and biocides). Hence, environmental regulators should be contributing significantly to the development of global and national antimicrobial resistance (AMR) action plans. It is argued that the lack of environment-facing mitigation actions included in existing AMR action plans is likely a function of our poor fundamental understanding of many of the key issues. Here, we aim to present the problem with AMR in the environment through the lens of an environmental regulator, using the Environment Agency (England’s regulator) as an example from which parallels can be drawn globally. The issues that are pertinent to environmental regulators are drawn out to answer: What are the drivers and pathways of AMR? How do these relate to the normal work, powers and duties of environmental regulators? What are the knowledge gaps that hinder the delivery of environmental protection from AMR? We offer several thought experiments for how different mitigation strategies might proceed. We conclude that: (1) AMR Action Plans do not tackle all the potentially relevant pathways and drivers of AMR in the environment; and (2) AMR Action Plans are deficient partly because the science to inform policy is lacking and this needs to be addressed.
Collapse
Affiliation(s)
| | - Helen Shaw
- Department for Environment, Food and Rural Affairs London, UK
| | | | | |
Collapse
|
27
|
How Metabolic Diseases Impact the Use of Antimicrobials: A Formal Demonstration in the Field of Veterinary Medicine. PLoS One 2016; 11:e0164200. [PMID: 27716805 PMCID: PMC5055344 DOI: 10.1371/journal.pone.0164200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 09/21/2016] [Indexed: 11/19/2022] Open
Abstract
Decreasing the use of antimicrobials has become a primary objective for both human and veterinary medicine in many countries. Medical prevention and good nutrition are seen as key parameters for reducing antimicrobial use. However, little consideration has been given to how metabolic diseases may influence the use of antimicrobials in humans and animals through limiting the prevalence and severity of infectious diseases. To quantify this relationship using the example of a common metabolic disease in dairy cows (subclinical ketosis, SCK), we constructed a stochastic model reporting the total quantity of curative antimicrobials for a given population with the prevalence of cows at risk for SCK. We considered the prevalence of SCK, the relative risk of the disease in cases of SCK compared to no SCK and the use of antimicrobials to treat SCK-induced infectious diseases. Reducing the percentage of cows at risk for SCK from 80% to 10% was associated with an average decrease in the use of antimicrobials of 11% (prevalence of SCK from 34% to 17%, respectively) or 25% (prevalence of SCK from 68% to 22%, respectively), depending on the relative risk to contract SCK if risk was present. For a large percentage of the cows at risk for SCK, using a preventive bolus of monensin reduced the use of curative antimicrobials to the same level that was observed when the percentage of cows at risk for SCK was low. The present work suggests similar approaches for obesity and diabetes.
Collapse
|
28
|
Dyar OJ, Obua C, Chandy S, Xiao Y, Stålsby Lundborg C, Pulcini C. Using antibiotics responsibly: are we there yet? Future Microbiol 2016; 11:1057-71. [PMID: 27501941 DOI: 10.2217/fmb-2016-0041] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Problems of antibiotic access and excess coexist in the world today and are compounded by rising rates of antibiotic resistance. We introduce two dimensions of responsibility to this context: responsible individual practices and a broad societal obligation centered on sustainability. Acting on these responsibilities requires recognizing the potential tensions between an individual optimum for antibiotic use and the societal optimum. We relate the tragedy of the commons metaphor to this situation to illustrate the complexity involved, and we draw on real-world experiences in Uganda, India, China and France. We conclude that we must form a global stewardship of antibiotics that can link access, innovation and conservation efforts across countries to ensure sustainable access to effective antibiotics for all who need them.
Collapse
Affiliation(s)
- Oliver James Dyar
- Global Health - Health Systems & Policy (HSP): Improving the Use of Medicines, Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden.,Mbarara University of Science & Technology, PO Box 1410, Mbarara, Uganda.,Department of Pharmacology, Pushpagiri Institute of Medical Sciences & Research Centre, Tiruvalla, Kerala, India.,State Key Laboratory for Diagnosis & Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China.,Service de maladies infectieuses et tropicales, Université de Lorraine, EA 4360 APEMAC & CHU de Nancy, Nancy, France
| | - Celestino Obua
- Global Health - Health Systems & Policy (HSP): Improving the Use of Medicines, Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden.,Mbarara University of Science & Technology, PO Box 1410, Mbarara, Uganda.,Department of Pharmacology, Pushpagiri Institute of Medical Sciences & Research Centre, Tiruvalla, Kerala, India.,State Key Laboratory for Diagnosis & Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China.,Service de maladies infectieuses et tropicales, Université de Lorraine, EA 4360 APEMAC & CHU de Nancy, Nancy, France
| | - Sujith Chandy
- Global Health - Health Systems & Policy (HSP): Improving the Use of Medicines, Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden.,Mbarara University of Science & Technology, PO Box 1410, Mbarara, Uganda.,Department of Pharmacology, Pushpagiri Institute of Medical Sciences & Research Centre, Tiruvalla, Kerala, India.,State Key Laboratory for Diagnosis & Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China.,Service de maladies infectieuses et tropicales, Université de Lorraine, EA 4360 APEMAC & CHU de Nancy, Nancy, France
| | - Yonghong Xiao
- Global Health - Health Systems & Policy (HSP): Improving the Use of Medicines, Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden.,Mbarara University of Science & Technology, PO Box 1410, Mbarara, Uganda.,Department of Pharmacology, Pushpagiri Institute of Medical Sciences & Research Centre, Tiruvalla, Kerala, India.,State Key Laboratory for Diagnosis & Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China.,Service de maladies infectieuses et tropicales, Université de Lorraine, EA 4360 APEMAC & CHU de Nancy, Nancy, France
| | - Cecilia Stålsby Lundborg
- Global Health - Health Systems & Policy (HSP): Improving the Use of Medicines, Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden.,Mbarara University of Science & Technology, PO Box 1410, Mbarara, Uganda.,Department of Pharmacology, Pushpagiri Institute of Medical Sciences & Research Centre, Tiruvalla, Kerala, India.,State Key Laboratory for Diagnosis & Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China.,Service de maladies infectieuses et tropicales, Université de Lorraine, EA 4360 APEMAC & CHU de Nancy, Nancy, France
| | - Céline Pulcini
- Global Health - Health Systems & Policy (HSP): Improving the Use of Medicines, Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden.,Mbarara University of Science & Technology, PO Box 1410, Mbarara, Uganda.,Department of Pharmacology, Pushpagiri Institute of Medical Sciences & Research Centre, Tiruvalla, Kerala, India.,State Key Laboratory for Diagnosis & Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China.,Service de maladies infectieuses et tropicales, Université de Lorraine, EA 4360 APEMAC & CHU de Nancy, Nancy, France
| |
Collapse
|
29
|
Littmann J, Buyx A, Cars O. Antibiotic resistance: An ethical challenge. Int J Antimicrob Agents 2015; 46:359-61. [DOI: 10.1016/j.ijantimicag.2015.06.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/10/2015] [Indexed: 11/16/2022]
|
30
|
Givens E, Bencharit S, Byrd WC, Phillips C, Hosseini B, Tyndall D. Immediate Placement and Provisionalization of Implants Into Sites With Periradicular Infection With and Without Antibiotics: An Exploratory Study. J ORAL IMPLANTOL 2015; 41:299-305. [DOI: 10.1563/aaid-joi-d-13-00002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This study explored the necessity of perioperative antibiotics on survival rates of implants immediately placed and provisionalized into sites with infection. Subjects were randomly assigned into antibiotic or placebo groups. Extraction, immediate placement, and provisionalization of an implant were performed. Eight subjects received placebo and five subjects received both a pre- and post-operative antibiotic regimen. One implant from each group failed. Perioperative antibiotic therapy may not be needed in selected immediate implant therapy.
Collapse
Affiliation(s)
- Edward Givens
- Department of Prosthodontics, School of Dentistry, University of North Carolina, Chapel Hill, NC
| | - Sompop Bencharit
- Department of Prosthodontics, School of Dentistry, University of North Carolina, Chapel Hill, NC
- Department of Pharmacology, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Warren C. Byrd
- School of Dentistry, University of North Carolina, Chapel Hill, NC
| | - Ceib Phillips
- Department of Orthodontics, School of Dentistry, University of North Carolina, Chapel Hill, NC
| | - Bashir Hosseini
- Department of Endodontics, School of Dentistry, University of North Carolina, Chapel Hill, NC
| | - Donald Tyndall
- Department of Diagnostic Sciences, School of Dentistry, University of North Carolina, Chapel Hill, NC
| |
Collapse
|
31
|
Campbell EM, Chao L. A population model evaluating the consequences of the evolution of double-resistance and tradeoffs on the benefits of two-drug antibiotic treatments. PLoS One 2014; 9:e86971. [PMID: 24498003 PMCID: PMC3909004 DOI: 10.1371/journal.pone.0086971] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 12/18/2013] [Indexed: 11/18/2022] Open
Abstract
The evolution of antibiotic resistance in microbes poses one of the greatest challenges to the management of human health. Because addressing the problem experimentally has been difficult, research on strategies to slow the evolution of resistance through the rational use of antibiotics has resorted to mathematical and computational models. However, despite many advances, several questions remain unsettled. Here we present a population model for rational antibiotic usage by adding three key features that have been overlooked: 1) the maximization of the frequency of uninfected patients in the human population rather than the minimization of antibiotic resistance in the bacterial population, 2) the use of cocktails containing antibiotic pairs, and 3) the imposition of tradeoff constraints on bacterial resistance to multiple drugs. Because of tradeoffs, bacterial resistance does not evolve directionally and the system reaches an equilibrium state. When considering the equilibrium frequency of uninfected patients, both cycling and mixing improve upon single-drug treatment strategies. Mixing outperforms optimal cycling regimens. Cocktails further improve upon aforementioned strategies. Moreover, conditions that increase the population frequency of uninfected patients also increase the recovery rate of infected individual patients. Thus, a rational strategy does not necessarily result in a tragedy of the commons because benefits to the individual patient and general public are not in conflict. Our identification of cocktails as the best strategy when tradeoffs between multiple-resistance are operating could also be extended to other host-pathogen systems. Cocktails or other multiple-drug treatments are additionally attractive because they allow re-using antibiotics whose utility has been negated by the evolution of single resistance.
Collapse
Affiliation(s)
- Ellsworth M. Campbell
- Section of Ecology, Behavior and Evolution, Division of Biological Sciences, University of California San Diego, La Jolla, California, United States of America
| | - Lin Chao
- Section of Ecology, Behavior and Evolution, Division of Biological Sciences, University of California San Diego, La Jolla, California, United States of America
| |
Collapse
|
32
|
Antibiotic use as a tragedy of the commons: a cross-sectional survey. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2014; 2014:837929. [PMID: 24587818 PMCID: PMC3920666 DOI: 10.1155/2014/837929] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Revised: 10/10/2013] [Accepted: 10/31/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Many believe antibiotic use results in a tragedy of the commons, since overuse may lead to antibiotic resistance and limiting use would benefit society. In contrast, mass antibiotic treatment programs are thought to result in community-wide benefits. A survey was conducted to learn the views of infectious disease experts on the individual- and societal-level consequences of antibiotic use. METHODS The survey instrument was designed to elicit opinions on antibiotic use and resistance. It was sent via SurveyMonkey to infectious disease professionals identified through literature searches. Descriptive statistics were used to analyze the data. RESULTS A total of 1,530 responses were received for a response rate of 9.9%. Nearly all participants believed antibiotic use could result in a tragedy of the commons, at least in certain circumstances (96.0%). Most participants did not believe mass antibiotic treatment programs could produce societal benefits in an antibiotic-free society (91.4%) or in the United States (94.2%), though more believed such programs would benefit antibiotic-free societies compared to the United States (P < 0.001). CONCLUSIONS The experts surveyed believe that antibiotic use can result in a tragedy of the commons and do not believe that mass treatment programs benefit individuals or society.
Collapse
|
33
|
Porco TC, Gao D, Scott JC, Shim E, Enanoria WT, Galvani AP, Lietman TM. When does overuse of antibiotics become a tragedy of the commons? PLoS One 2012; 7:e46505. [PMID: 23236344 PMCID: PMC3517551 DOI: 10.1371/journal.pone.0046505] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 08/31/2012] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Over-prescribing of antibiotics is considered to result in increased morbidity and mortality from drug-resistant organisms. A resulting common wisdom is that it would be better for society if physicians would restrain their prescription of antibiotics. In this view, self-interest and societal interest are at odds, making antibiotic use a classic "tragedy of the commons". METHODS AND FINDINGS We developed two mathematical models of transmission of antibiotic resistance, featuring de novo development of resistance and transmission of resistant organisms. We analyzed the decision to prescribe antibiotics as a mathematical game, by analyzing individual incentives and community outcomes. CONCLUSIONS A conflict of interest may indeed result, though not in all cases. Increased use of antibiotics by individuals benefits society under certain circumstances, despite the amplification of drug-resistant strains or organisms. In situations where increased use of antibiotics leads to less favorable outcomes for society, antibiotics may be harmful for the individual as well. For other scenarios, where a conflict between self-interest and society exists, restricting antibody use would benefit society. Thus, a case-by-case assessment of appropriate use of antibiotics may be warranted.
Collapse
Affiliation(s)
- Travis C. Porco
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
- Center for Infectious Disease and Emergency Readiness, University of California, Berkeley, California, United States of America
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, United States of America
| | - Daozhou Gao
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California San Francisco, San Francisco, California, United States of America
| | - James C. Scott
- Department of Mathematics and Statistics, Colby College, Waterville, Maine, United States of America
| | - Eunha Shim
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Wayne T. Enanoria
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California San Francisco, San Francisco, California, United States of America
- Center for Infectious Disease and Emergency Readiness, University of California, Berkeley, California, United States of America
| | - Alison P. Galvani
- School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Thomas M. Lietman
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California San Francisco, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, United States of America
- Institute for Global Health, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| |
Collapse
|
34
|
Raut GN, Chakraborty K, Verma P, Gokhale RS, Srinivasa Reddy D. Synthesis of isomeric corniculatolides. Tetrahedron Lett 2012. [DOI: 10.1016/j.tetlet.2012.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
35
|
Ding XC, Ubben D, Wells TNC. A framework for assessing the risk of resistance for anti-malarials in development. Malar J 2012; 11:292. [PMID: 22913649 PMCID: PMC3478971 DOI: 10.1186/1475-2875-11-292] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Accepted: 08/01/2012] [Indexed: 11/10/2022] Open
Abstract
Resistance is a constant challenge for anti-infective drug development. Since they kill sensitive organisms, anti-infective agents are bound to exert an evolutionary pressure toward the emergence and spread of resistance mechanisms, if such resistance can arise by stochastic mutation events. New classes of medicines under development must be designed or selected to stay ahead in this vicious circle of resistance control. This involves both circumventing existing resistance mechanisms and selecting molecules which are resilient against the development and spread of resistance. Cell-based screening methods have led to a renaissance of new classes of anti-malarial medicines, offering us the potential to select and modify molecules based on their resistance potential. To that end, a standardized in vitro methodology to assess quantitatively these characteristics in Plasmodium falciparum during the early phases of the drug development process has been developed and is presented here. It allows the identification of anti-malarial compounds with overt resistance risks and the prioritization of the most robust ones. The integration of this strategy in later stages of development, registration, and deployment is also discussed.
Collapse
Affiliation(s)
- Xavier C Ding
- Medicines for Malaria Venture, 20 rte de Pré Bois, Geneva CH 1215, Switzerland.
| | | | | |
Collapse
|
36
|
Skrlin J, Bacic Vrca V, Marusic S, Ciric-Crncec M, Mayer L. Impact of ceftriaxone de-restriction on the occurrence of ESBL-positive bacterial strains and antibiotic consumption. J Chemother 2012; 23:341-4. [PMID: 22233817 DOI: 10.1179/joc.2011.23.6.341] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
As a cost-saving measure, the Drug and Therapeutics Committee (DTC) removed ceftriaxone from the list of restricted antibiotics in May, 2008, which permitted its use as a first-line antibiotic. To evaluate the impact of this change, the occurrence of extended-spectrum beta-lactamase (ESBL)-positive bacterial strains and antibiotic consumption were monitored for 2 years before and after the intervention. In the post-intervention period, ceftriaxone utilization increased, while total antibiotic utilization did not change significantly. The utilization of all restricted antibiotics decreased (p <0.05) in the post-intervention period. Utilization of carbapenems increased (p <0.05), while utilization of quinolones increased nonsignificantly. The density of resistant ESBLs increased (p = 0.001) from 0.99 to 1.34 per 1000 bed-days from the pre- to the postintervention period. Ceftriaxone use was significantly correlated with ESBL occurrence (p <0.005). It can be concluded that ceftriaxone de-restriction increased the occurrence of ESBLs and the utilization of carbapemens.
Collapse
Affiliation(s)
- J Skrlin
- Department of Clinical Microbiology and Hospital Infections, University Hospital Dubrava, Zagreb, Croatia
| | | | | | | | | |
Collapse
|
37
|
Segura Benedicto A. La dimensión social y cultural de la prevención. Aten Primaria 2012; 44:248-9. [DOI: 10.1016/j.aprim.2012.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 01/30/2012] [Accepted: 01/30/2012] [Indexed: 11/29/2022] Open
|
38
|
Siva Swaroop P, Raut GN, Gonnade RG, Verma P, Gokhale RS, Srinivasa Reddy D. Antituberculosis agent diaportheone B: synthesis, absolute configuration assignment, and anti-TB activity of its analogues. Org Biomol Chem 2012; 10:5385-94. [DOI: 10.1039/c2ob25831e] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
39
|
Leibovici L, Paul M, Ezra O. Ethical dilemmas in antibiotic treatment. J Antimicrob Chemother 2011; 67:12-6. [DOI: 10.1093/jac/dkr425] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
40
|
Baquero F, Coque TM, de la Cruz F. Ecology and evolution as targets: the need for novel eco-evo drugs and strategies to fight antibiotic resistance. Antimicrob Agents Chemother 2011; 55:3649-60. [PMID: 21576439 PMCID: PMC3147629 DOI: 10.1128/aac.00013-11] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In recent years, the explosive spread of antibiotic resistance determinants among pathogenic, commensal, and environmental bacteria has reached a global dimension. Classical measures trying to contain or slow locally the progress of antibiotic resistance in patients on the basis of better antibiotic prescribing policies have clearly become insufficient at the global level. Urgent measures are needed to directly confront the processes influencing antibiotic resistance pollution in the microbiosphere. Recent interdisciplinary research indicates that new eco-evo drugs and strategies, which take ecology and evolution into account, have a promising role in resistance prevention, decontamination, and the eventual restoration of antibiotic susceptibility. This minireview summarizes what is known and what should be further investigated to find drugs and strategies aiming to counteract the "four P's," penetration, promiscuity, plasticity, and persistence of rapidly spreading bacterial clones, mobile genetic elements, or resistance genes. The term "drug" is used in this eco-evo perspective as a tool to fight resistance that is able to prevent, cure, or decrease potential damage caused by antibiotic resistance, not necessarily only at the individual level (the patient) but also at the ecological and evolutionary levels. This view offers a wealth of research opportunities for science and technology and also represents a large adaptive challenge for regulatory agencies and public health officers. Eco-evo drugs and interventions constitute a new avenue for research that might influence not only antibiotic resistance but the maintenance of a healthy interaction between humans and microbial systems in a rapidly changing biosphere.
Collapse
Affiliation(s)
- Fernando Baquero
- Department of Microbiology, Institute Ramón and Cajal for Health Research (IRYCIS), CIBER Research Network in Epidemiology and Public Health (CIBERESP), Ramón y Cajal University Hospital, Madrid, Spain.
| | | | | |
Collapse
|
41
|
The evolution of drug resistance and the curious orthodoxy of aggressive chemotherapy. Proc Natl Acad Sci U S A 2011; 108 Suppl 2:10871-7. [PMID: 21690376 DOI: 10.1073/pnas.1100299108] [Citation(s) in RCA: 183] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The evolution of drug-resistant pathogens is a major challenge for 21st century medicine. Drug use practices vigorously advocated as resistance management tools by professional bodies, public health agencies, and medical schools represent some of humankind's largest attempts to manage evolution. It is our contention that these practices have poor theoretical and empirical justification for a broad spectrum of diseases. For instance, rapid elimination of pathogens can reduce the probability that de novo resistance mutations occur. This idea often motivates the medical orthodoxy that patients should complete drug courses even when they no longer feel sick. Yet "radical pathogen cure" maximizes the evolutionary advantage of any resistant pathogens that are present. It could promote the very evolution it is intended to retard. The guiding principle should be to impose no more selection than is absolutely necessary. We illustrate these arguments in the context of malaria; they likely apply to a wide range of infections as well as cancer and public health insecticides. Intuition is unreliable even in simple evolutionary contexts; in a social milieu where in-host competition can radically alter the fitness costs and benefits of resistance, expert opinion will be insufficient. An evidence-based approach to resistance management is required.
Collapse
|
42
|
Mateus A, Brodbelt D, Stärk K. Evidence‐based use of antimicrobials in veterinary practice. IN PRACTICE 2011. [DOI: 10.1136/inp.d2873] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
43
|
Bioactive metabolites of Diaporthe sp. P133, an endophytic fungus isolated from Pandanus amaryllifolius. J Nat Med 2011; 65:606-9. [DOI: 10.1007/s11418-011-0518-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 02/03/2011] [Indexed: 11/26/2022]
|
44
|
Smith DL, Klein EY, McKenzie FE, Laxminarayan R. Prospective strategies to delay the evolution of anti-malarial drug resistance: weighing the uncertainty. Malar J 2010; 9:217. [PMID: 20653960 PMCID: PMC2916917 DOI: 10.1186/1475-2875-9-217] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 07/23/2010] [Indexed: 11/10/2022] Open
Abstract
Background The evolution of drug resistance in malaria parasites highlights a need to identify and evaluate strategies that could extend the useful therapeutic life of anti-malarial drugs. Such strategies are deployed to best effect before resistance has emerged, under conditions of great uncertainty. Methods Here, the emergence and spread of resistance was modelled using a hybrid framework to evaluate prospective strategies, estimate the time to drug failure, and weigh uncertainty. The waiting time to appearance was estimated as the product of low mutation rates, drug pressure, and parasite population sizes during treatment. Stochastic persistence and the waiting time to establishment were simulated as an evolving branching process. The subsequent spread of resistance was simulated in simple epidemiological models. Results Using this framework, the waiting time to the failure of artemisinin combination therapy (ACT) for malaria was estimated, and a policy of multiple first-line therapies (MFTs) was evaluated. The models quantify the effects of reducing drug pressure in delaying appearance, reducing the chances of establishment, and slowing spread. By using two first-line therapies in a population, it is possible to reduce drug pressure while still treating the full complement of cases. Conclusions At a global scale, because of uncertainty about the time to the emergence of ACT resistance, there was a strong case for MFTs to guard against early failure. Our study recommends developing operationally feasible strategies for implementing MFTs, such as distributing different ACTs at the clinic and for home-based care, or formulating different ACTs for children and adults.
Collapse
Affiliation(s)
- David L Smith
- Emerging Pathogens Institute and Department of Biology, University of Florida, Gainesville, 32611, USA.
| | | | | | | |
Collapse
|
45
|
Meyer E, Schwab F, Schroeren-Boersch B, Gastmeier P. Dramatic increase of third-generation cephalosporin-resistant E. coli in German intensive care units: secular trends in antibiotic drug use and bacterial resistance, 2001 to 2008. Crit Care 2010; 14:R113. [PMID: 20546564 PMCID: PMC2911759 DOI: 10.1186/cc9062] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Revised: 12/10/2009] [Accepted: 06/14/2010] [Indexed: 12/02/2022] Open
Abstract
Introduction The objective of the present study was to analyse secular trends in antibiotic consumption and resistance data from a network of 53 intensive care units (ICUs). Methods The study involved prospective unit and laboratory-based surveillance in 53 German ICUs from 2001 through 2008. Data were calculated on the basis of proportions of nonduplicate resistant isolates, resistance densities (that is, the number of resistant isolates of a species per 1,000 patient-days) and an antimicrobial usage density (AD) expressed as daily defined doses (DDD) and normalised per 1,000 patient-days. Results Total mean antibiotic use remained stable over time and amounted to 1,172 DDD/1,000 patient-days (range 531 to 2,471). Carbapenem use almost doubled to an AD of 151 in 2008. Significant increases were also calculated for quinolone (AD of 163 in 2008) and third-generation and fourth-generation cephalosporin use (AD of 117 in 2008). Aminoglycoside consumption decreased substantially (AD of 86 in 2001 and 24 in 2008). Resistance proportions were as follows in 2001 and 2008, respectively: methicillin-resistant Staphylococcus aureus (MRSA) 26% and 20% (P = 0.006; trend test showed a significant decrease), vancomycin-resistant enterococcus (VRE) faecium 2.3% and 8.2% (P = 0.008), third-generation cephalosporin (3GC)-resistant Escherichia. coli 1.2% and 19.7% (P < 0.001), 3GC-resistant Klebsiella pneumoniae 3.8% and 25.5% (P < 0.001), imipenem-resistant Acinetobacter baumannii 1.1% and 4.5% (P = 0.002), and imipenem-resistant K. pneumoniae 0.4% and 1.1%. The resistance densities did not change for MRSA but increased significantly for VRE faecium and 3GC-resistant E. coli and K. pneumoniae. In 2008, the resistance density for MRSA was 3.73, 0.48 for VRE, 1.39 for 3GC-resistant E. coli and 0.82 for K. pneumoniae. Conclusions Although total antibiotic use did not change over time in German ICUs, carbapenem use doubled. This is probably due to the rise in 3GC-resistant E. coli and K. pneumoniae. Increased carbapenem consumption was associated with carbapenem-resistant K. pneumoniae carbapenemase-producing bacteria and imipenem-resistant A. baumannii.
Collapse
Affiliation(s)
- Elisabeth Meyer
- Institute of Hygiene and Environmental Medicine, Charité-University Medicine Berlin, Hindenburgdamm 27, 12203 Berlin, Germany.
| | | | | | | |
Collapse
|
46
|
Antibiotic dose impact on resistance selection in the community: a mathematical model of beta-lactams and Streptococcus pneumoniae dynamics. Antimicrob Agents Chemother 2010; 54:2330-7. [PMID: 20231396 DOI: 10.1128/aac.00331-09] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Streptococcus pneumoniae is a major pathogen in the community and presents high rates of resistance to the available antibiotics. To prevent antibiotic treatment failure caused by highly resistant bacteria, increasing the prescribed antibiotic dose has recently been suggested. The aim of the present study was to assess the influence of beta-lactam prescribed doses on the emergence of resistance and selection in the community. A mathematical model was constructed by combining S. pneumoniae pharmacodynamic and population-dynamic approaches. The received-dose heterogeneity in the population was specifically modeled. Simulations over a 50-year period were run to test the effects of dose distribution and antibiotic exposure frequency changes on community resistance patterns, as well as the accuracy of the defined daily dose as a predictor of resistance. When the frequency of antibiotic exposure per year was kept constant, dose levels had a strong impact on the levels of resistance after a 50-year simulation. The lowest doses resulted in a high prevalence of nonsusceptible strains (> or =70%) with MICs that were still low (1 mg/liter), whereas high doses resulted in a lower prevalence of nonsusceptible strains (<40%) and higher MICs (2 mg/liter). Furthermore, by keeping the volume of antibiotics constant in the population, different patterns of use (low antibiotic dose and high antibiotic exposure frequency versus high dose and low frequency) could lead to markedly different rates of resistance distribution and prevalence (from 10 to 100%). Our results suggest that pneumococcal resistance patterns in the community are strongly related to the individual beta-lactam doses received: limiting beta-lactam use while increasing the doses could help reduce the prevalence of resistance, although it should select for higher levels of resistance. Surveillance networks are therefore encouraged to collect both daily antibiotic exposure frequencies and individual prescribed doses.
Collapse
|
47
|
Evolution in health and medicine Sackler colloquium: a public choice framework for controlling transmissible and evolving diseases. Proc Natl Acad Sci U S A 2009; 107 Suppl 1:1696-701. [PMID: 20018681 DOI: 10.1073/pnas.0906078107] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Control measures used to limit the spread of infectious disease often generate externalities. Vaccination for transmissible diseases can reduce the incidence of disease even among the unvaccinated, whereas antimicrobial chemotherapy can lead to the evolution of antimicrobial resistance and thereby limit its own effectiveness over time. We integrate the economic theory of public choice with mathematical models of infectious disease to provide a quantitative framework for making allocation decisions in the presence of these externalities. To illustrate, we present a series of examples: vaccination for tetanus, vaccination for measles, antibiotic treatment of otitis media, and antiviral treatment of pandemic influenza.
Collapse
|
48
|
Meyer E, Schwab F, Pollitt A, Bettolo W, Schroeren-Boersch B, Trautmann M. Impact of a change in antibiotic prophylaxis on total antibiotic use in a surgical intensive care unit. Infection 2009; 38:19-24. [PMID: 19904488 DOI: 10.1007/s15010-009-9115-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 08/24/2009] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the impact of reducing the length of antibiotic prophylaxis for cerebro spinal shunts on total antibiotic use and key resistant pathogens. METHODS In January 2004, the use of antibiotic prophylaxis was reduced to a single shot dose with cefuroxime in an intensive care unit (ICU). Prior to this intervention, prophylaxis with second-generation cephalosporins was administered during the entire period of external cerebro spinal fluid (CSF) drainage. The effect on the antibiotic use density (AD: DDD [defined daily doses] per 1,000 patient-days[pd]) was calculated prior to (January 2002-December 2003) and following implementation of the intervention(January 2004-December 2006) by segmented regression analysis of an interrupted time series. Resistance proportions(RP) and resistance densities (RD), defined as resistant pathogen/1,000 pd of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus faecalis or E. faecium, third-generation-resistant (3GC) Escherichia coli and Klebsiella pneumoniae, and imipenem-resistant Pseudomonus aeruginosa, were compared by the Fisher's exact test before and after the intervention. RESULTS Total antibiotic use by 147 DDD/1,000 pd decreased after the intervention when pre-operative prophylaxis was changed into single shot prophylaxis, from an estimated mean of 1,036 DDD/1,000 pd before the intervention to 887DDD/1,000 pd post-intervention. This decrease was primarily due to a significant reduction in the amount of cefuroxime used for prophylaxis. The reduction in total antibiotic consumption was sustainable, and it did not increase again during the next 36 months. The RR and RD of third-generation cephalosporin-resistant E. coli increased after January 2004, whereas the percentage of MRSA significantly decreased. CONCLUSION Change to single shot prophylaxis along with an ongoing antibiotic stewardship program resulted in a cut-back in total antibiotic use amounting to as much as 15%. It would therefore appear that targeting interventions aimed at reducing antibiotic prophylaxis in surgical ICUs may be very worthwhile.
Collapse
Affiliation(s)
- E Meyer
- Institute of Hygiene and Environmental Medicine, Charité UniversityMedicine, Berlin, Germany.
| | | | | | | | | | | |
Collapse
|
49
|
Benenson S, Cohen MJ, Block C, Stern S, Weiss Y, Moses AE. Vancomycin-resistant enterococci in long-term care facilities. Infect Control Hosp Epidemiol 2009; 30:786-9. [PMID: 19591581 DOI: 10.1086/598345] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Knowledge of the prevalence rates and associated risk markers of vancomycin-resistant enterococci (VRE) colonization among long-term care facility (LTCF) residents could be used to improve screening policies among newly admitted hospital inpatients. In a cross-sectional survey among 1,215 residents of LTCFs in Jerusalem, the VRE carriage rate was 9.6%. Previous hospitalization and antibiotic treatment were associated with elevated VRE colonization rate. In contrast, moderate and severe levels of dependency and prolonged stay in an LTCF were associated with a decrease in the VRE colonization rate.
Collapse
Affiliation(s)
- Shmuel Benenson
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | | | | | | | | | | | | |
Collapse
|
50
|
Benatar SR, Upshur REG. Dual loyalty of physicians in the military and in civilian life. Am J Public Health 2008; 98:2161-7. [PMID: 18923128 DOI: 10.2105/ajph.2007.124644] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The concept of the dual loyalty physicians may have to both a patient and a third party is important in elucidating the obligations of physicians. The extent to which loyalty may be deflected from a patient to a third party (e.g., an insurance company or a prison commander) is greatly underestimated and has not attracted significant scholarly analysis. We examined dual loyalty in civilian and military contexts and used the principles of public health ethics to construct a framework for determining the legitimacy of physicians' obligations. We illustrate the application of these principles to problems physicians encounter regarding communicable diseases, elder abuse, and driving fitness. In the complex military context, independent ethics tribunals should be created to adjudicate loyalty conflicts.
Collapse
Affiliation(s)
- Solomon R Benatar
- Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada
| | | |
Collapse
|