Antimicrobial resistance and the COVID-19 pandemic

Improving antibiotic prescribing - Recommendations for funding and pricing policies to enhance use of point-of-care tests

Introduction

Diagnostics can contribute to the improved quality of antibiotic prescribing. However, there is potential to enhance the use of point-of-care tests (POCTs) in general practice. This paper presents fit-for-purpose policy recommendations related to funding and pricing for POCTs applied for community-acquired acute respiratory tract infections (CA-ARTIs).

Methods

The development of the recommendations was informed by an analysis of the current status of funding and pricing policy frameworks for CA-ARTI POCTs in European countries, and an identification of barriers and facilitators for their uptake. Draft recommendations were developed and subsequently revised based on written and verbal feedback from meetings with experts.

Results

The proposal includes four recommendations for policy interventions related to funding and three recommendations regarding pricing policies. Two of the funding policy-related recommendations concern physicians' remuneration, and two relate to product-specific reimbursement (public coverage) of the CA-ARTI POCTs. The pricing-related recommendations include a proposal to explore the introduction of price regulation, to pilot subscription-fee procurement models and to enhance more strategic approaches in public procurement of CA-ARTI POCTs.

Conclusions

Optimised pricing and funding policies could make a difference in enhancing uptake of CA-ARTI POCTs. It is crucial for the successful implementation of policies to consider country settings. Additionally, supportive policy action is recommended, including the systematic use of health technology assessment, stakeholder communication, and monitoring and evaluation.

Environmental drivers impact the accumulation and diversity of antibiotic resistance in green stormwater infrastructure

Antibiotic resistance poses an urgent public health concern, with the environment playing a crucial role in the development and dissemination of resistant bacteria. There is a growing body of research indicating that stormwater is a significant source and transport vector of resistance elements. This research sought to characterize the role of green stormwater infrastructure (GSI), designed for stormwater infiltration, in accumulating and propagating antibiotic resistance in the urban water cycle. Sampling included 24 full-scale GSI systems representing three distinct types of GSI - bioswales, bioretention cells, and constructed wetlands. The results indicated that GSI soils accumulate antibiotic resistance genes (ARGs) at elevated concentrations compared to nonengineered soils. Bioretention cells specifically harbored higher abundances of ARGs, suggesting that the type of GSI influences ARG accumulation. Interestingly, ARG diversity in GSI soils was not impacted by the type of GSI design or the diversity of the microbial community and mobile genetic elements. Instead, environmental factors (catchment imperviousness, metals, nutrients, and salts) were identified as significant drivers of ARG diversity. These findings highlight how environmental selective pressures in GSI promote ARG persistence and proliferation independently of the microbial community. Therefore, GSI systems have the potential to be a substantial contributor of abundant and diverse ARGs to the urban water cycle.

Bacterial co-infections, secondary infections and antimicrobial use among hospitalized COVID-19 patients in the sixth wave in Pakistan: findings and implications

INTRODUCTION

Previous studies in Pakistan have shown considerable over prescribing of antibiotics in patients hospitalized with COVID-19 despite very low prevalence of bacterial infections. Irrational use of antibiotics will worsen antimicrobial resistance (AMR).

METHODS

Retrospective analysis of medical records of patients in the COVID-19 wards of three tertiary care hospitals to assess antibiotic use during the sixth COVID-19 wave.

RESULTS

A total of 284 patients were included, most were male (66.9%), aged 30-50 years (50.7%) with diabetes mellitus the most common comorbidity. The most common symptoms at presentation were cough (47.9%) and arthralgia-myalgia (41.5%). Around 3% were asymptomatic, 34.9% had mild, 30.3% moderate, and 23.6% had severe disease, with 8.1% critical. Chest X-ray abnormalities were seen in 43.3% of patients and 37% had elevated white cell counts, with 35.2% having elevated C-reactive protein levels. Around 91% COVID-19 patients were prescribed antibiotics during their hospital stay, with only a few with proven bacterial co-infections or secondary bacterial infections. Most antibiotics were from the 'Watch' category (90.8%) followed by the 'Reserve' category (4.8%), similar to previous COVID-19 waves.

CONCLUSION

There continued to be excessive antibiotics use among hospitalized COVID-19 patients in Pakistan. Urgent measures are needed to address inappropriate prescribing including greater prescribing of Access antibiotics where pertinent.

Outpatient antibiotic prescribing during the first two years of the COVID-19 pandemic: A nationwide register-based time series analysis

The COVID-19 pandemic has imposed an enormous burden on health care systems around the world. Simultaneously, many countries have reported a decrease in the incidence of other infectious diseases, such as acute respiratory infections, leading to a decline in outpatient antibiotic use. The aim of this study is to assess the impact of the COVID-19 pandemic on outpatient antibiotic prescribing in Finland during the first 2 years of the pandemic. We used nationwide register data, applied descriptive methods, and conducted an interrupted time series analysis (ITSA) using ARIMA modelling. Results from the ARIMA modelling showed that at the baseline, before the pandemic, the level of monthly number of antibiotic prescriptions was 248,560 (95% CI: 224,261 to 272,856; p<0.001) and there was a decreasing trend of 1,202 in monthly number of prescriptions (95% CI: -2,107 to -262; p<0.01). After the COVID-19 pandemic began, there was a statistically significant decline of 48,470 (95% CI: -76,404 to -20,535, p<0.001) prescriptions (-19.5% from the baseline level). The greatest decrease in antibiotic prescribing was observed among children aged 0-17 years. While antibiotic prescribing declined in all antibiotic groups associated with respiratory tract infections, the decrease from 2019 to 2020 was the largest with azithromycin (52.6%), amoxicillin (44.8%), and doxycycline (43.8%). Future studies should continue exploring antibiotic prescribing trends during the COVID-19 pandemic and beyond.

Prevalence of pharmaceuticals and personal care products, microplastics and co-infecting microbes in the post-COVID-19 era and its implications on antimicrobial resistance and potential endocrine disruptive effects

The COVID-19 (coronavirus disease 2019) pandemic's steady condition coupled with predominance of emerging contaminants in the environment and its synergistic implications in recent times has stoked interest in combating medical emergencies in this dynamic environment. In this context, high concentrations of pharmaceutical and personal care products (PPCPs), microplastics (MPs), antimicrobial resistance (AMR), and soaring coinfecting microbes, tied with potential endocrine disruptive (ED) are critical environmental concerns that requires a detailed documentation and analysis. During the pandemic, the identification, enumeration, and assessment of potential hazards of PPCPs and MPs and (used as anti-COVID-19 agents/applications) in aquatic habitats have been attempted globally. Albeit receding threats in the magnitude of COVID-19 infections, both these pollutants have still posed serious consequences to aquatic ecosystems and the very health and hygiene of the population in the vicinity. The surge in the contaminants post-COVID also renders them to be potent vectors to harbor and amplify AMR. Pertinently, the present work attempts to critically review such instances to understand the underlying mechanism, interactions swaying the current health of our environment during this post-COVID-19 era. During this juncture, although prevention of diseases, patient care, and self-hygiene have taken precedence, nevertheless antimicrobial stewardship (AMS) efforts have been overlooked. Unnecessary usage of PPCPs and plastics during the pandemic has resulted in increased emerging contaminants (i.e., active pharmaceutical ingredients and MPs) in various environmental matrices. It was also noticed that among COVID-19 patients, while the bacterial co-infection prevalence was 0.2-51%, the fungi, viral, protozoan and helminth were 0.3-49, 1-22, 2-15, 0.4-15% respectively, rendering them resistant to residual PPCPs. There are inevitable chances of ED effects from PPCPs and MPs applied previously, that could pose far-reaching health concerns. Furthermore, clinical and other experimental evidence for many newer compounds is very scarce and demands further research. Pro-active measures targeting effective waste management, evolved environmental policies aiding strict regulatory measures, and scientific research would be crucial in minimizing the impact and creating better preparedness towards such events among the masses fostering sustainability.

Antibiotic prescribing practices and perceptions on antimicrobial resistance among healthcare practitioners in Russia

OBJECTIVES

Antimicrobial resistance (AMR) is a growing global health threat. The misuse of antibiotics is the main factor contributing to the development of AMR. Healthcare practitioners (HCPs) play a crucial role in the use of antibiotics. There are limited data available on antibiotic prescribing patterns among physicians in Russia. The aim of this study was to explore antibiotic prescribing practices and perceptions of AMR among HCPs in the Russian Federation.

STUDY DESIGN

A cross-sectional, multi-centre study was used.

METHODS

A survey using an online questionnaire was conducted among HCPs. A qualitative study was conducted before the questionnaire was developed. The online questionnaire was distributed via email addresses obtained from the Consilium Medicum database, a specialised educational resource for healthcare professionals in Russia.

RESULTS

In total, 746 HCPs from 74 regions of the Russian Federation were included in the study. Physicians who participated in this study did not frequently prescribe antibiotic drugs: 40.6% of participants recommended antibiotics less than five times per week. Gynaecologists, paediatricians, family doctors, and surgeons were the least likely study participants to prescribe antibiotics, whereas clinical pharmacologists, otolaryngologists, urologists, and infectious disease specialists prescribed antibiotics more often. Amoxicillin and amoxicillin/clavulanic acid were the most frequently prescribed antimicrobials. The majority of HCPs in Russia who took part in this survey reported relying on national guidelines for information on antibiotic prescribing. Only 67.8% of study participants perceived AMR as a challenge for their practice.

CONCLUSIONS

Health authorities should regularly provide up-to-date reliable information on AMR in the region. Antimicrobial stewardship programmes are important for specialised medical professionals, such as urologists, gynaecologists, and otolaryngologists, since they are responsible for prescribing second-line antibiotics, which carries with it a greater responsibility.

Response to antimicrobial resistance in South-East Asia Region

Antimicrobial resistance (AMR) inflicts significant mortality, morbidity and economic loss in the 11 countries in the WHO South-East Asia Region (SEAR). With technical assistance and advocacy from WHO, all countries have developed their respective National Action Plans on AMR that are aligned with the Global Action Plan. Historically, the WHO Regional Office has been proactive in advocacy at the highest political level. The past decade has seen an enhancement of the country's capacity to combat AMR through national efforts catalyzed and supported through several WHO initiatives at all levels-global, regional and country levels. Several countries including Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand have observed a worrying trend of increasing drug resistance, despite heightened awareness and actions. Recent AMR data generated by the countries are indicative of fragmented progress. Lack of technical capacity, financial resources, weak regulatory apparatus, slow behavioural changes at all levels of the antimicrobial stewardship landscape and the COVID-19 pandemic have prevented the effective application of several interventions to minimize the impact of AMR.

Recent Progress in Stimuli-Responsive Antimicrobial Electrospun Nanofibers

Electrospun nanofibrous membranes have garnered significant attention in antimicrobial applications, owing to their intricate three-dimensional network that confers an interconnected porous structure, high specific surface area, and tunable physicochemical properties, as well as their notable capacity for loading and sustained release of antimicrobial agents. Tailoring polymer or hybrid-based nanofibrous membranes with stimuli-responsive characteristics further enhances their versatility, enabling them to exhibit broad-spectrum or specific activity against diverse microorganisms. In this review, we elucidate the pivotal advancements achieved in the realm of stimuli-responsive antimicrobial electrospun nanofibers operating by light, temperature, pH, humidity, and electric field, among others. We provide a concise introduction to the strategies employed to design smart electrospun nanofibers with antimicrobial properties. The core section of our review spotlights recent progress in electrospun nanofiber-based systems triggered by single- and multi-stimuli. Within each stimulus category, we explore recent examples of nanofibers based on different polymers and antimicrobial agents. Finally, we delve into the constraints and future directions of stimuli-responsive nanofibrous materials, paving the way for their wider application spectrum and catalyzing progress toward industrial utilization.

Knowledge, Attitudes, and Practices Regarding Antibiotic Use and Resistance: A Cross-Sectional Study among Students in Israel

Antibiotic resistance is one of the biggest threats to human health, food security, and development. This study aimed to examine the level of knowledge and awareness regarding antibiotic resistance while comparing students from health sciences to students in other disciplines. A cross-sectional study was conducted based on the "antibiotic resistance" questionnaire developed by the World Health Organization. A total of 371 students participated in the study. All respondents had taken antibiotics in the past. A tenth had taken them on their own without a prescription, and 14% had not received an explanation regarding the use of antibiotics. The average for the knowledge questions was 15.49 ± 5.35 (out of 27). Many students mistakenly associated antibiotics with viral diseases. Despite these misconceptions, there was a high level of awareness and understanding regarding the ways to treat antibiotic resistance. Still, the awareness of the severity of antibiotic resistance was not high. Differences were found between the disciplines in general knowledge and the level of awareness and understanding about the ways to treat antibiotic resistance, where health science students had the highest scores, followed by social science students and finally, computer and management students. No differences were found in the perception of the severity of the phenomenon. This information is essential to developing educational interventions to improve knowledge, attitudes, and practices regarding antibiotic use among students, especially those unrelated to the health sciences.

Flare of the silent pandemic in the era of the COVID-19 pandemic: Obstacles and opportunities

A noteworthy public health problem, antimicrobial resistance (AMR) has been impeded in many ways by the coronavirus disease 2019 (COVID-19) pandemic. This narrative review discusses the two-sided impact of COVID-19 on the magnitude of AMR. The pandemic has put tremendous strain on healthcare systems, diverting resources, personnel, and attention away from AMR diagnosis and management toward COVID-19 diagnosis and contact tracking and tracing. AMR research has been severely hampered, and surveillance and antimicrobial stewardship (AMS) programs have been de-emphasized, delayed, or halted. Antibiotics, particularly broad-spectrum, were prescribed more frequently without diagnostic confirmation of bacterial infection than before the pandemic. Nonetheless, the COVID-19 pandemic has highlighted the vulnerability of healthcare systems in controlling infectious disease threats and raised awareness of the importance of infection prevention and control. Yet, the pandemic has created opportunities to capitalize on positive effects on AMR management. The review concludes that it is now more important than ever to focus on AMR and strengthen AMS programs to ensure appropriate antibiotic use and other AMR prevention measures in healthcare. We must ensure that one of the COVID-19 legacies is increased support for AMR research, diagnostic implementation, appropriate diagnostic stewardship, and the strengthening of our health systems. The COVID-19 pandemic has demonstrated that prevention is better than cure. Countries will need to step up their efforts to combat AMR as a multidisciplinary community. We must prepare our public health systems to combat multiple threats at the same time.

A cross-sectional study of hospital antimicrobial stewardship programmes in the COVID-19 era

Background

Antimicrobial resistance (AMR) continues to be a global public health issue amid the COVID-19 pandemic; however, unprecedented demands on hospital antimicrobial stewardship programmes (ASPs) potentially altered their core activities.

Objective

We sought to understand how ASPs have been involved in and impacted by the pandemic.

Methods

The 2021 Ontario ASP Landscape Survey was developed based on previous provincial questionnaires and emerging literature on the impact of COVID-19 on hospital ASPs. After pre-testing and piloting, the online questionnaire was distributed to hospital antimicrobial stewardship practitioners in the fall of 2021. Descriptive statistics and inductive thematic analysis were performed.

Results

The response rate was 78% (98/125 organizations); 96% (94/98) of organizations had or were in the process of formalizing an ASP and 53% (50/94) reported designated funding/resources. Despite 82% reporting no change in dedicated full-time equivalents during the pandemic, ASPs were frequently involved in developing treatment guidelines/clinical pathways (51%), anticipating/managing drug shortages (46%) and obtaining investigational use drugs (32%). While many core ASP activities continued, prospective audit and feedback and prescriber education were modified or suspended by 43% and 40% of programmes, respectively. Decreased frequency, adaptation of activities (i.e. virtual or other technology) and challenges with staffing/resources were commonly reported themes. Knowledge translation (KT) activities and 'collaboration and coordination' also emerged as salient themes.

Conclusions

Hospital antimicrobial stewardship practitioners in Ontario have made significant contributions to the pandemic response while continuing to deliver adapted ASP services, despite resource constraints. Moving forward, ASPs will need to continue building capacity while leveraging broader networks to advance the antimicrobial stewardship agenda.

The impact of COVID-19 on multidrug-resistant organisms causing healthcare-associated infections: a narrative review

Coronavirus disease 2019 (COVID-19) changed healthcare across the world. With this change came an increase in healthcare-associated infections (HAIs) and a concerning concurrent proliferation of MDR organisms (MDROs). In this narrative review, we describe the impact of COVID-19 on HAIs and MDROs, describe potential causes of these changes, and discuss future directions to combat the observed rise in rates of HAIs and MDRO infections.

Clinical carbapenem-resistant Klebsiella pneumoniae isolates simultaneously harboring blaNDM-1, blaOXA types and qnrS genes from the Kingdom of Bahrain: Resistance profile and genetic environment

The prevalence of Carbapenem-resistant Klebsiella pneumoniae (CRKP) is currently increasing worldwide, prompting WHO to classify it as an urgent public health threat. CRKP is considered a difficult to treat organism owing to limited therapeutic options. In this study, a total of 24 CRKP clinical isolates were randomly collected from Salmaniya Medical Complex, Bahrain. Bacterial identification and antibiotic susceptibility testing were performed, on MALDI-TOF and VITEK-2 compact, respectively. The isolates were screened for carbapenem resistance markers (bla_NDM,bla_OXA-23,bla_OXA-48 and bla_OXA-51) and plasmid-mediated quinolone resistance genes (qnrA, qnrB, and qnrS) by monoplex PCR. On the other hand, only colistin-resistant isolates (n=12) were screened for MCR-1, MCR-2 and MCR-3 genes by monoplex PCR. Moreover, the Genetic environment of bla_NDM, integrons analysis, and molecular characterization of plasmids was also performed. Antibiotic susceptibility revealed that all the isolates (100%) were resistant to ceftolozane/tazobactam, piperacillin/tazobactam, 96% resistant to ceftazidime, trimethoprim/sulfamethoxazole, 92% resistant to meropenem, gentamicin and cefepime, 88% resistant to ciprofloxacin, imipenem, and 37% resistant to amikacin. Ceftazidime/avibactam showed the least resistance (12%). 75% (n=12/16) were resistant to colistin and 44% (n=7/16) showed intermediate susceptibility to tigecycline. The detection of resistant determinants showed that the majority (95.8%) of CRKP harbored bla_NDM-1, followed by bla_OXA-48 (91.6%) bla_OXA-51 (45.8%), and bla_OXA-23 (41.6%). Sequencing of the bla_NDM amplicons revealed the presence of bla_NDM-1. Alarmingly, 100% of isolates showed the presence of qnrS. These predominant genes were distributed in various combinations wherein the majority were bla_NDM-1 + bla_OXA-51+ qnrS + bla_OXA-48 (n =10, 41.7%), bla_NDM-1 + bla_OXA-23+ qnrS + bla_OXA-48 (n=8, 33.3%), among others. In conclusion, the resistance rate to most antibiotics is very high in our region, including colistin and tigecycline, and the genetic environment of CRKP is complex with the carriage of multiple resistance markers. Resistance to ceftazidime/avibactam is uncommon and hence can be used as a valuable option for empirical therapy. Molecular data on resistance markers and the genetic environment of CRKP is lacking from this geographical region; this would be the first report addressing the subject matter. Surveillance and strict infection control strategies should be reinforced in clinical settings to curb the emergence and spread of such isolates.