Antimicrobial stewardship in Spain: Programs for Optimizing the use of Antibiotics (PROA) in Spanish hospitals

The need for evolution in the management of febrile neutropenia in pediatric cancer: TRIIO KIDS update

New treatments have increased the life expectancy of pediatric patients diagnosed with malignant hematological diseases, often at the cost of protracting their immunocompromised state in the form of prolonged neutropenia. This neutropenic state favors the development of bacterial and fungal infections. Moreover, recent years have seen a series of changes in the epidemiology of fungal and Clostridium infections. These changes necessitate adaptations to the management of pediatric patients with febrile neutropenia, who are at risk of further increases in already high rates of morbidity and mortality. This article discusses the current bases for the management of febrile neutropenia and associated emerging fungal infections, as well as the epidemiology, diagnosis, and treatment of Clostridioides difficile in pediatric patients diagnosed with malignant hematological diseases.

Factors influencing antimicrobial prescription attitudes in bloodstream infections: susceptibility results and beyond. An exploratory survey

BACKGROUND

Novel rapid antimicrobial susceptibility testing (RAST) methods promise quicker de-escalation of broad-spectrum antibiotics. However, other behavioural and situational factors influencing antimicrobial prescription are not well known.

AIM

To explore factors associated with optimal antimicrobial prescription in patients with Gram-negative bloodstream infection and to propose specific scenarios in which a rapid antimicrobial susceptibility result may help to optimize prescribing.

METHODS

Exploratory survey (April-August 2018) in the UK and Spain using clinical case-related questions. Seniority, specialty and country of practice were recorded. Cases described patients with Gram-negative bloodstream infections, their empirical treatment and clinical course and the hypothetical RAST result. Respondents chose one of several options regarding antibiotic treatment management. Microbiologically optimal antibiotic choice (MOAC) was agreed by expert consensus beforehand. Responses were categorized as MOAC, request for support or sub-optimal choice. The relationship between the RAST result and the clinical course was defined as concordant (susceptible organism-clinical improvement; resistant organism-clinical deterioration) or as discordant otherwise.

FINDINGS

A total of 426 respondents (UK: 332; Spain: 94) and 1494 answers were analysed. Multivariate analysis identified that requests for support were 87% less likely in Spain; that antimicrobial resistance and clinical deterioration were associated with both increased request for support (odds ratio (OR) 7.66 and OR 4.26, respectively) and MOAC (OR 2.08 and OR 2.06, respectively). A discordant clinical course was associated with 82% lower odds for MOAC. Out-of-hours results, seniority and specialty did not have an effect.

CONCLUSION

Antimicrobial choice is influenced by each country's type of practice, clinical course and susceptibility results. Antimicrobial resistance was associated with increased optimal treatment, suggesting RAST may be less useful for step-down decisions in settings with low baseline resistance rates.

New insights on the combined removal of antibiotics and ARGs in urban wastewater through the use of two configurations of vertical subsurface flow constructed wetlands

The occurrence and removal of 49 antibiotics and 11 selected antibiotic resistance genes (ARGs) were investigated in 2 vertical subsurface flow (VF) constructed wetlands (1.5 m² each): an unsaturated (UVF) unit and a partially saturated (SVF) unit (0.35 m saturated out of 0.8 m) operating in parallel and treating urban wastewater. Thirteen antibiotics were detected in influent wastewater, 6 of which were present in all samples. The SVF showed statistical significance on the removal of 4 compounds (namely ciprofloxacin, ofloxacin, pipemidic acid and azithromycin), suggesting that the wider range of pH and/or redox conditions of this configuration might promote the microbial degradation of some antibiotics. In contrast, the concentration of the latter (except pipemidic acid) and also clindamycin was higher in the effluent than in the influent of the UVF. Five ARGs were detected in influent wastewater, sul1 and sul2, bla_TEM, ermB and qnrS. All of them were detected also in the biofilm of both wetlands, except qnrS. Average removal rates of ARGs showed no statistical differences between both wetland units, and ranged between 46 and 97% for sul1, 33 and 97% for sul2, 9 and 99% for ermB, 18 and 97% for qnrS and 11 and 98% for bla_TEM.

Antimicrobial stewardship in hospitals in Latin America and the Caribbean: a scoping review

OBJECTIVES

To examine published antimicrobial stewardship (AMS) initiatives in hospitals in Latin America and the Caribbean (LAC) in order to characterize AMS terminology usage, geotemporality, and elements of structure (human resources), process (interventions), and outcomes, and to set priority areas for improving AMS reporting.

METHODS

This was a scoping review that searched PubMed, LILACS, EMBASE, and 12 other databases, along with a manual search for academic and grey literature to identify documents on AMS initiatives in hospitals in 33 countries of LAC, up to August 2019. Keywords included 'antibiotic' or 'antimicrobial' AND 'stewardship, policy, strategies, management, control, rational use, appropriate use, surveillance, or interventions' and 33 country names.

RESULTS

Selected articles totalled 147 studies published in 1985 - 2019; of those, 22% used 'antimicrobial stewardship' in the title. Eighteen countries published AMS hospital initiatives, one-half of which were implemented in capital cities. Brazil, Argentina, Colombia, Cuba, Mexico, and Chile, in descending frequency, made up > 59% of published initiatives. Educational interventions were the most frequently reported, followed by persuasive and restrictive strategies. Antimicrobial consumption was the most common outcome measure reported. About one-third of the studies (35%) referred to baseline measures-only in preparation for AMS interventions. Fifty-nine studies from 6 countries reported AMS comprehensively, using structure, process, and outcome (SPO) elements.

CONCLUSIONS

Published hospital AMS initiatives have increased over time and have expanded across LAC. However, more programs need to be developed. Complete reporting of SPO elements is imperative to evaluating and replicating AMS actions.