Antibiotic Resistance in Pediatric Infections: Global Emerging Threats, Predicting the Near Future

The Etiology of Bloodstream Infections at an Italian Pediatric Tertiary Care Hospital: A 17-Year-Long Series

Knowledge of epidemiology is essential for guiding correct antibiotic prescription, reducing bacteremia-associated mortality, and implementing targeted infection control programs. However, only a few studies have reported on the epidemiology of bloodstream infections (BSIs) in pediatrics. We performed a retrospective analysis of all BSIs (excluding those caused by common skin contaminants) diagnosed from 2006 to 2022 in patients younger than 18 years who were treated at an Italian pediatric tertiary care hospital. Overall, 2395 BSIs were recorded, including 2207 (92.15%) due to bacteria and 188 (7.85%) due to fungi. The incidence rate (BSIs/10,000 hospital discharges, IR) of bacterial BSIs significantly increased during the study period. In particular, BSIs caused by S. aureus (including MRSA), Enterobacterales (including ESBL and AmpC producers), Enterococcus spp., and P. aeruginosa became more common. The frequency of carbapenem-resistant strains was <1% and stable over time. Conversely, there was a significant reduction in the incidence of BSIs due to S. pneumoniae. The BSIs were stratified by patient age, and S. aureus was the most frequent cause of BSIs in all age groups, while E. coli was the most frequent in the Enterobacterales family. S. agalactiae was the third most frequent cause of neonatal early-onset BSIs. The prevalence of Enterococcus spp. increased in the subgroups from 8 days to 5 years of age, while P. aeruginosa became more prevalent in children over 5 years of age. S. aureus was also the most frequent isolate in both community- and hospital-onset BSIs, followed by E. coli. The prevalence of multidrug-resistant (MDR) pathogens was very low. It was <5% for both Gram-positive (i.e., MRSA and VRE) and Gram-negative (ESBL, AmpC, and carbapenem-resistant) pathogens, and MDR pathogens were almost exclusively detected in hospital-onset BSIs. Fungi accounted for just under 8% of BSIs. C. albicans was the most frequently isolated strain, followed by C. parapsilosis. Notably, the IR of fungemia did not change significantly during the study period, in spite of an increase in the absolute number of events. The continuous monitoring of local epidemiology is essential to identify changes in the IRs of pathogens and antibiotic susceptibility and to guide antibiotic treatments, especially in the phase when antibiograms are not yet available.

Paediatric Escherichia coli urinary tract infection: susceptibility trends and clinical management-a retrospective analysis of a 10-year period

BACKGROUND

Escherichia coli is the predominant urinary pathogen in children. Irish and international studies have demonstrated increasing antimicrobial resistance (AMR) to antibiotics such as co-amoxiclav.

AIMS

We aimed to (1) examine the AMR patterns of paediatric urinary E. coli isolates, from both hospital and community sources, over a 10-year period; (2) assess the effectiveness of Children's Health Ireland (CHI) antimicrobial guidance given local susceptibility data; and (3) review the clinical management of an admitted patient sub-set over a 6-year period.

METHODS

Pure growth of urinary E. coli from patients aged ≤ 14 from 2012 to 2021 were analysed for AMR. Differences in susceptibility rates were assessed. A retrospective chart review conducted on inpatients aged ≥ 2 months to ≤ 14 years, 2016-2021.

RESULTS

E. coli accounted for 70.8% of likely significant positive pure growth cultures (9314 isolates). Susceptibility to co-amoxiclav significantly increased over time, from 66.7% to 80.4% (2016-2021, p < 0.001). Nitrofurantoin and cefalexin had significantly higher susceptibility rates than trimethoprim (< 70% annually). 85.1% of isolates were susceptible to the combination of co-amoxiclav and gentamicin, recommended for those > 2months and systemically unwell. The additional gain in empiric susceptibility provided by gentamicin above that provided by co-amoxiclav alone has fallen from 16.4% to 6.7% (2016-2021). The 222 clinical cases reviewed showed improved antimicrobial guideline compliance over time.

CONCLUSIONS

This study provides important regional AMR data. Co-amoxiclav susceptibility increased significantly over time, contrasting with previous studies. This was temporally associated with stewardship measures reducing co-amoxiclav prescribing. Decreasing utility of gentamicin supports recent CHI guideline updates reducing gentamicin use.

Assessment of antimicrobial stewardship programmes and antibiotic use among children admitted to two hospitals in Sierra Leone: a cross-sectional study

INTRODUCTION

Antimicrobial resistance (AMR) is a global public health concern and irrational use of antibiotics in hospitals is a key driver of AMR. Even though it is not preventable, antimicrobial stewardship (AMS) programmes will reduce or slow it down. Research evidence from Sierra Leone has demonstrated the high use of antibiotics in hospitals, but no study has assessed hospital AMS programmes and antibiotic use specifically among children. We conducted the first-ever study to assess the AMS programmes and antibiotics use in two tertiary hospitals in Sierra Leone.

METHODS

This was a hospital-based cross-sectional survey using the World Health Organization (WHO) point prevalence survey (PPS) methodology. Data was collected from the medical records of eligible patients at the Ola During Children's Hospital (ODCH) and Makeni Regional Hospital (MRH) using the WHO PPS hospital questionnaire; and required data collection forms. The prescribed antibiotics were classified according to the WHO Access, Watch, and Reserve (AWaRe) classification. Ethics approval was obtained from the Sierra Leone Ethics and Scientific Review Committee. Statistical analysis was conducted using the SPSS version 22.

RESULTS

Both ODCH and MRH did not have the required AMS infrastructure; policy and practice; and monitoring and feedback mechanisms to ensure rational antibiotic prescribing. Of the 150 patients included in the survey, 116 (77.3%) were admitted at ODCH and 34 (22.7%) to MRH, 77 (51.3%) were males and 73 (48.7%) were females. The mean age was 2 years (SD=3.5). The overall prevalence of antibiotic use was 84.7% (95% CI: 77.9% - 90.0%) and 77 (83.8%) of the children aged less than one year received an antibiotic. The proportion of males that received antibiotics was higher than that of females. Most (58, 47.2 %) of the patients received at least two antibiotics. The top five antibiotics prescribed were gentamycin (100, 27.4%), ceftriaxone (76, 20.3%), ampicillin (71, 19.5%), metronidazole (44, 12.1%), and cefotaxime (31, 8.5%). Community-acquired infections were the primary diagnoses for antibiotic prescription.

CONCLUSION

The non-existence of AMS programmes might have contributed to the high use of antibiotics at ODCH and MRH. This has the potential to increase antibiotic selection pressure and in turn the AMR burden in the country. There is need to establish hospital AMS teams and train health workers on the rational use of antibiotics.

Fruit Extract and Phenolic Compounds of Phyllanthus emblica Fruits as Bioactivity Enhancer of Chloramphenicol Against Bacterial Species

Phyllanthus emblica L. (syn. Emblica officinalis) fruits have been traditionally exploited to enhance the immune system and provide protection against bacterial and fungal diseases. The present study aimed to evaluate the synergistic interactions between chloramphenicol and several phenolic compounds found in P. emblica fruits against bacterial strains. The combination of P. emblica fruit extracts and its phenolic compounds demonstrated synergistic antibacterial activity when used in conjunction with chloramphenicol against both Gram-positive and Gram-negative bacteria. The combination of MICGA with ½MICChl exhibited a significant increase in bioactivity, with a 333.33-fold enhancement against B. subtilis. Similarly, the combination of MICGA with 2MICChl displayed a bioactivity enhancement of 16.02 folds against S. aureus. The co-administration of ½MICQ and ½MICChl resulted in a significant 35.71-fold increase in bioactivity against P. aeruginosa. Similarly, the combination of MIC GA and ½MICChl exhibited a remarkable 166.66-fold enhancement in bioactivity against E. coli. The combinations of 2MICFPE and ½MICChloramphenicol, as well as ½MICGA and ½MICChl demonstrated the highest bioactivity enhancement of 17.85 folds for K. pneumoniae. This study claimed that the fruit extracts of P. emblica and its phenolic compounds could be utilized to augment the effectiveness of conventional antibiotics, which have acquired resistance to bacterial infections.

Antibiotics for Pediatric Patients With Laryngotracheobronchitis in Korea: A Nationwide Study Based on Administrative Data

BACKGROUND

Antimicrobial resistance (AMR) is an important global public health concern in adults and children. Laryngotracheobronchitis (croup) is a common acute respiratory infection (ARI) among children, most often caused by a virus, and should not be treated with antibiotics. Reducing the usage of unnecessary antibiotics in ARI using an antimicrobial stewardship program (ASP) is an effective measure against AMR in children. This study investigates the antibiotic prescription pattern in pediatric patients with laryngotracheobronchitis in Korea. Our results will be useful to improve the ASP.

METHODS

The data were obtained from the government agency Health Insurance Review and Assessment Service. We analyzed outpatient prescriptions issued to children ≤ 5 years of age with a first-listed diagnosis code for laryngotracheobronchitis, i.e., International Classification of Disease, 10th Revision, code J050 (croup), J040 (laryngitis), or J041 (tracheitis), during 2017-2020. For each prescription, demographic information and information about medical facilities visited (type of hospital, specialty of physician, location of hospital) were extracted. The overall antibiotic prescription rate was subsequently estimated, and multivariable analysis was conducted to determine the associated factors of antibiotic prescription. Prescribed antibiotics were described and classified into extended-spectrum penicillins, cephalosporin, and macrolides.

RESULTS

Of 2,358,194 prescriptions reviewed, 829,172 (35.2%) contained antibiotics. In the multivariable analysis, management in a hospital was the strongest factor associated with antibiotic prescription (adjusted odds ratio [aOR], 22.33; 95% confidence interval [CI], 20.87-23.89; P < 0.001), followed by management in a clinic (aOR, 12.66; 95% CI, 11.83-13.54; P < 0.001) and management in a general hospital (aOR, 8.96; 95% CI, 8.37-9.59; P < 0.001). Antibiotic prescription was also significantly associated with patients who were ≤ 2 years of age, managed by a pediatric specialist, and treated at a hospital located in a non-metropolitan region. Overall, extended-spectrum penicillins were the most frequently prescribed (18.6%) antibiotics, followed by cephalosporins (9.4%) and macrolides (8.5%).

CONCLUSION

The results of our study suggest that ASPs need to focus on physicians in hospitals, clinics, general hospitals, and pediatric specialties. Providing education programs to these groups to increase awareness of AMR and appropriate antibiotics use could be effective ASP policy and may help to reduce unnecessary prescriptions of antibiotics for laryngotracheobronchitis among pediatric patients and therefore potentially AMR in children in Korea.

Understanding the outcome and management of children aged 2-59 months with chest indrawing pneumonia: a study protocol for an observational study in Ethiopia, India, Nigeria, Pakistan, Uganda and Zambia

INTRODUCTION

Childhood pneumonia is a leading cause of morbidity and mortality among children aged 2-59 months, particularly in low-income and middle-income countries (LMICs), where healthcare providers face significant challenges in diagnosing and treating childhood pneumonia. Many LMICs have taken steps to address this issue by revising their national policies and aligning them with WHO's revised guidelines for pneumonia management. These revised guidelines aim to facilitate the outpatient management of children aged 2-59 months chest indrawing pneumonia. Despite these efforts, there is limited empirical evidence regarding the management and outcomes of these children in primary-level healthcare settings. This study aims to assess the survival status of children aged 2-59 months with chest indrawing pneumonia presenting at primary healthcare facilities.

METHODS AND ANALYSIS

A prospective, observational cohort study will be conducted in Ethiopia, Nigeria, Uganda, Zambia, India and Pakistan on children aged 2-59 months presenting at selected primary-level healthcare facilities with chest indrawing pneumonia. Eligible participants will be enrolled and managed by facility healthcare providers who are trained in Integrated Management of Childhood Illness and will be followed up on day 15 to record the treatment-related information and vital status, including conducting verbal autopsies in case of child death. The sample size for each site will be 310. The analysis will involve exploring site-specific trends before conducting a pooled analysis of de-identified data from all sites. The first data collection started at the Ethiopian site in September 2022, followed by other sites. The data collection will continue until June 2025.

ETHICS AND DISSEMINATION

The study protocol, enrolment forms and consent forms will undergo ethical review by the Institutional Review Boards of the University of Gondar, Gondar, Ethiopia; the INCLEN Trust International Independent Ethics Committee, New Delhi, India; Ethical Review Committee of the University of Ibadan, Ethical Review Committees of Lagos State and Ethical Review Committee of University College London, UK; Institutional Review Board, International Research Force, Islamabad, Pakistan; Institutional Review Board, People's Primary Healthcare Initiative-Sindh, Karachi and National Bioethics Committee, Islamabad, Pakistan; Makerere University School of Biomedical Sciences Research Ethical Committee, Kampala, Uganda; University of Zambia Biomedical Research Ethics committee, Lusaka, Zambia and Ethical Review Committee of WHO, Geneva, Switzerland. Ethical procedures include WHO and local review board evaluations, parental consent in the local/national language, permits enrolment, follow-up, and, if required, clinical video recording for children with chest indrawing pneumonia, ensuring their eligibility. Adherence to local regulations encompasses precollection ethical approvals, risk management strategies and secure, de-identified data storage. Findings will be disseminated through seminars, publications and meetings, engaging diverse stakeholders to foster collaborations.

TRIAL REGISTRATION NUMBER

ISRCTN12687253.

Antibiotic prophylaxis in pediatric dog bite injuries: Infection rates and prescribing practices

Objective

Pediatric dog bite injuries are a major public health concern and antibiotic prophylaxis is often prescribed due to concern about the development of infection. The Infectious Diseases Society of America recommends 3‒5 days of antibiotic prophylaxis for high-risk dog bites. The purpose of our study was to compare infection rates among patients receiving antibiotic prophylaxis and those who did not receive antibiotic prophylaxis.

Methods

We conducted a retrospective cohort study of children aged 3 months to 17 years enrolled in the healthcare systems' affiliated accountable care organization (ACO). Eligible children with a dog bite injury presented at an urgent care center or emergency department between 2016 and 2019. We excluded children who were immunosuppressed or had bites that required closure by a surgeon. An electronic health record review was completed and ACO claims data were used to determine if a prescription was filled. Patients with an International Classification of Diseases (ICD)-10 code concerning for infection within 7 days of injury were recorded as having a bite infection.

Results

A total of 2653 non-immunosuppressed children presented for care of dog bite injuries and 672 children met eligibility criteria. Thirty-five children developed an infection of their injury. Of the 539 children who received antibiotic prophylaxis, 5.8% developed an infection and 3.0% of the 133 children who did not receive antibiotic prophylaxis developed an infection (p = 0.28).

Conclusion

The overall infection rate for pediatric dog bite injuries was 5.2%. In our single-center study, no difference in infection rates was found between those receiving and not receiving antibiotic prophylaxis.

Carbapenem-Resistant and Extended-Spectrum β-Lactamase-Producing Enterobacterales in Children, United States, 2016-2020

2019–2020 at 6 US sites. Among 159 CRE cases in children (median age 5 years), CRE was isolated from urine for 131 (82.4%) and blood from 20 (12.6%). Annual CRE incidence rate (cases/100,000 population) was 0.47–0.87. Among 207 ESBL-E cases in children (median age 6 years), ESBL-E was isolated from urine of 196 (94.7%) and blood of 8 (3.9%). Annual ESBL-E incidence rate was 26.5 in 2019 and 19.63 in 2020. CRE and ESBL-E rates were >2-fold higher among infants than other age groups. Most CRE and ESBL-E cases were healthcare-associated community-onset (68 [43.0%] for CRE vs. 40 [23.7%] for ESBL-E) or community-associated (43 [27.2%] for CRE vs. 109 [64.5%] for ESBL-E). Programs to detect, prevent, and treat multidrug-resistant infections must include pediatric populations (particularly the youngest) and outpatient settings.

Factors associated with severe respiratory syncytial virus infection among hospitalized children in Thammasat University Hospital

Background

Respiratory syncytial virus (RSV) is one of the most significant respiratory pathogens that causes acute lower respiratory tract infections (LRTI) early in life. Most children have a history of RSV infection within 24 months of age, and recurrent infections are common throughout life.

Methods

Children under five years of age were identified through a review of medical records with a diagnosis of RSV-LRTI between 2016 and 2020. Severe RSV-LRTI was defined as a prolonged length of stay (> 7 days), admission to the intensive care unit, need for mechanical ventilation, non-invasive positive pressure ventilation, or in-hospital mortality. Factors associated with severe RSV-LRTI were investigated using univariate and multivariate analyses.

Results

During the study period, 620 patients were diagnosed with RSV-LRTI and 249 (40.16%) patients had severe RSV-LRTI. In the multivariable logistic regression analysis, the factors for severe RSV-LRTI were being under 3 months (aOR 2.18 CI 1.39-3.43, p0.001), cardiovascular disease (aOR 3.55 CI 1.56-8.06, p0.002), gastrointestinal disease (aOR 5.91 CI 1.90-18.46, p0.002), genetic disease (aOR 7.33 CI 1.43-37.54, p0.017), and pulmonary disease (aOR 9.50, CI 4.56-19.80, p<0.001). Additionally, the presence of ≥ 2 co-morbidities (aOR 6.23 CI 2.81-14.81, p<0.016), experiencing illness for more than 5 days (aOR 3.33 CI 2.19-5.06, p<0.001), co-detection of influenza (aOR 8.62 CI 1.49-38.21, p0.015), and nosocomial RSV infection (aOR 9.13 CI 1.98-41.30, p0.012), markedly increased the risk of severe RSV-LTRI. The severe RSV-LRTI group demonstrated higher hospitalization expenses (median, US $720.77 vs $278.00, respectively; p<0.001), and three infants died in-hospital.

Conclusion

Children at high risk for RSV-LRTI due to underlying genetic and gastrointestinal diseases are at an increased risk for severe RSV-LRTI. Further studies to determine the cost-effectiveness of RSV immunization in these potential co-morbidities should be initiated to prioritize RSV immunization, especially in resource-constrained regions with limited availability of nirsevimab.

High prevalence of multidrug-resistant Enterobacterales carrying extended-spectrum beta-lactamase and AmpC genes isolated from neonatal sepsis in Ahvaz, Iran

OBJECTIVES

In the recent years, multidrug resistant (MDR) neonatal septicemia-causing Enterobacterales has been dramatically increased due to the extended-spectrum beta-lactamases (ESBLs) and AmpC enzymes. This study aimed to assess the antibiotic resistance pattern, prevalence of ESBLs/AmpC beta-lactamase genes, and Enterobacterial Repetitive Intergenic Consensus Polymerase Chain Reaction (ERIC-PCR) fingerprints in Enterobacterales isolated from neonatal sepsis.

RESULTS

In total, 59 Enterobacterales isolates including 41 (69.5%) Enterobacter species, 15 (25.4%) Klebsiella pneumoniae and 3 (5.1%) Escherichia coli were isolated respectively. Resistance to ceftazidime and cefotaxime was seen in all of isolates. Furthermore, all of them were multidrug-resistant (resistant to three different antibiotic categories). The phenotypic tests showed that 100% of isolates were ESBL-positive. Moreover, AmpC production was observed in 84.7% (n = 50/59) of isolates. Among 59 ESBL-positive isolates, the highest percentage belonged to blaCTX-M-15 gene (66.1%) followed by blaCTX-M (45.8%), blaCTX-M-14 (30.5%), blaSHV (28.8%), and blaTEM (13.6%). The frequency of blaDHA, blaEBC, blaMOX and blaCIT genes were 24%, 24%, 4%, and 2% respectively. ERIC-PCR analysis revealed that Enterobacterales isolates were genetically diverse. The remarkable prevalence of MDR Enterobacterales isolates carrying ESBL and AmpC beta-lactamase genes emphasizes that efficient surveillance measures are essential to avoid the more expansion of drug resistance amongst isolates.

Phenotypic and molecular characterization of β-lactamase-producing Klebsiella species among children discharged from hospital in Western Kenya

BACKGROUND

The emergence and spread of β-lactamase-producing Klebsiella spp. has been associated with a substantial healthcare burden resulting in therapeutic failures. We sought to describe the proportion of phenotypic resistance to commonly used antibiotics, characterize β-lactamase genes among isolates with antimicrobial resistance (AMR), and assess the correlates of phenotypic AMR in Klebsiella spp. isolated from stool or rectal swab samples collected from children being discharged from hospital.

METHODS

We conducted a cross-sectional study involving 245 children aged 1-59 months who were being discharged from hospitals in western Kenya between June 2016 and November 2019. Whole stool or rectal swab samples were collected and Klebsiella spp. isolated by standard microbiological culture. β-lactamase genes were detected by PCR whilst phenotypic antimicrobial susceptibility was determined using the disc diffusion technique following standard microbiology protocols. Descriptive analyses were used to characterize phenotypic AMR and carriage of β-lactamase-producing genes. The modified Poisson regression models were used to assess correlates of phenotypic beta-lactam resistance.

RESULTS

The prevalence of β-lactamase carriage among Klebsiella spp. isolates at hospital discharge was 62.9% (154/245). Antibiotic use during hospitalization (adjusted prevalence ratio [aPR] = 4.51; 95%CI: 1.79-11.4, p < 0.001), longer duration of hospitalization (aPR = 1.42; 95%CI: 1.14-1.77, p < 0.002), and access to treated water (aPR = 1.38; 95%CI: 1.12-1.71, p < 0.003), were significant predictors of phenotypically determined β-lactamase. All the 154 β-lactamase-producing Klebsiella spp. isolates had at least one genetic marker of β-lactam/third-generation cephalosporin resistance. The most prevalent genes were blaCTX-M 142/154 (92.2%,) and blaSHV 142/154 (92.2%,) followed by blaTEM 88/154 (57.1%,) and blaOXA 48/154 (31.2%,) respectively.

CONCLUSION

Carriage of β-lactamase producing Klebsiella spp. in stool is common among children discharged from hospital in western Kenya and is associated with longer duration of hospitalization, antibiotic use, and access to treated water. The findings emphasize the need for continued monitoring of antimicrobial susceptibility patterns to inform the development and implementation of appropriate treatment guidelines. In addition, we recommend measures beyond antimicrobial stewardship and infection control within hospitals, improved sanitation, and access to safe drinking water to mitigate the spread of β-lactamase-producing Klebsiella pathogens in these and similar settings.

Applications of peptides in nanosystems for diagnosing and managing bacterial sepsis

Sepsis represents a critical medical condition stemming from an imbalanced host immune response to infections, which is linked to a significant burden of disease. Despite substantial efforts in laboratory and clinical research, sepsis remains a prominent contributor to mortality worldwide. Nanotechnology presents innovative opportunities for the advancement of sepsis diagnosis and treatment. Due to their unique properties, including diversity, ease of synthesis, biocompatibility, high specificity, and excellent pharmacological efficacy, peptides hold great potential as part of nanotechnology approaches against sepsis. Herein, we present a comprehensive and up-to-date review of the applications of peptides in nanosystems for combating sepsis, with the potential to expedite diagnosis and enhance management outcomes. Firstly, sepsis pathophysiology, antisepsis drug targets, current modalities in management and diagnosis with their limitations, and the potential of peptides to advance the diagnosis and management of sepsis have been adequately addressed. The applications have been organized into diagnostic or managing applications, with the last one being further sub-organized into nano-delivered bioactive peptides with antimicrobial or anti-inflammatory activity, peptides as targeting moieties on the surface of nanosystems against sepsis, and peptides as nanocarriers for antisepsis agents. The studies have been grouped thematically and discussed, emphasizing the constructed nanosystem, physicochemical properties, and peptide-imparted enhancement in diagnostic and therapeutic efficacy. The strengths, limitations, and research gaps in each section have been elaborated. Finally, current challenges and potential future paths to enhance the use of peptides in nanosystems for combating sepsis have been deliberately spotlighted. This review reaffirms peptides' potential as promising biomaterials within nanotechnology strategies aimed at improving sepsis diagnosis and management.

Evaluating drug use patterns among paediatric outpatients in Burundi

Background

Rational prescribing is key to optimising therapeutic outcomes and avoiding risks associated with irrational use of medicines. Using WHO drug use indicators, this study evaluated drug use patterns among paediatric outpatient encounters at Primary Healthcare Centers (PHCs) in Bujumbura Mairie, Republic of Burundi.

Methods

Descriptive cross-sectional research assessed paediatric medicine use in 20 PHCs. From 8 February to 7 April 2023, 800 randomly selected paediatric encounters' 2022-year data were retrospectively collected. Data for specific facility indicators were prospectively collected. SPSS 23 was used to analyse data.

Results

800 outpatient child encounters were analysed, 48.4% female and 51.6% male. The mean number of medicines per encounter was 2.4(±0.99). The injection rate was 9.9%. Overall, 78.8% of generics and 85.2% of essential medicines were prescribed. Results show drug prescribing differences between private and government PHCs (p < 0.001). All PHCs studied had no standard treatment guidelines (STGs), while 50% had an essential medicine list (EML) and 85% of key medicines were available.

Conclusion

Poor prescribing practices were found indicating the need for interventions to promote good drug use practices. A large study at a national scale is required to provide a more comprehensive understanding of the overall drug use practices.

Prevalence of phenotypic multi-drug resistant Klebsiella species recovered from different human specimens in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Multidrug-resistant (MDR) Klebsiella species are among public health important bacteria that cause infections difficult to treat with available antimicrobial agents. Infections with Klebsiella lead to high morbidity and mortality in developing countries particularly in patients admitted to the intensive care unit. This systematic review and meta-analysis aimed to determine the pooled prevalence of MDR Klebsiella species from different human specimens using studies conducted in Ethiopia from 2018-2022.

METHODS

We have systematically searched online databases such as PubMed/Medline, Google Scholar, Hinari, African journals online, Web of Science, Cochrane, and grey literature (Addis Ababa University and Hawassa University) to identify studies reporting the proportion of MDR Klebsiella species in Ethiopia. Published articles were selected based on the Preferred Reporting Item of Systematic Review and Meta-analysis (PRISMA). R-Studio version 4.2.3 was used to conduct pooled prevalence, heterogeneity test, and publication bias. A binary random effect model was used to determine the pooled prevalence. Heterogeneity was checked with the inconsistency index (I2). Publication bias was checked with a funnel plot and Egger test. Sensitivity analysis was conducted with leave-one-out analysis. Joanna Briggs Institute's critical appraisal tool for prevalence studies was used to check the quality of each article.

RESULTS

In this systematic review and meta-analysis, 40 articles were included in which 12,239 human specimens were examined. Out of the total specimens examined, 721 Klebsiella species were isolated and 545 isolates were reported to be MDR Klebsiella species. The prevalence of MDR Klebsiella species ranged from 7.3%-100% whereas the pooled prevalence of MDR Klebsiella species was 72% (95% CI: 63 - 82%, I2 = 95%). Sub-group analysis based on region revealed the highest prevalence of MDR from Addis Ababa (97%) and the least from the Somali region (33%); whereas sub-group analysis based on the specimen type indicated the highest prevalence was from blood culture specimens 96% and the least was from other specimens (ear and vaginal discharge, and stool) (51%).

CONCLUSION

Our finding indicated a high prevalence of MDR Klebsiella species found in different human specimens. The prevalence of MDR Klebsiella varies across regions in Ethiopia, age, the type of specimens, source and site of infection. Therefore, integrated action should be taken to reduce the prevalence of MDR Klebsiella species in regional states and focus on clinical features. Effective infection and prevention control should be applied to reduce the transmission within and outside health care settings.

Trends in Antibiotic Use in a Large Children's Hospital in London (United Kingdom): 5 Years of Point Prevalence Surveys

Background: Antibiotics are commonly prescribed in paediatrics. As their excessive use contributes to adverse drug events, increased healthcare costs, and antimicrobial resistance, antimicrobial stewardship initiatives are essential to optimising medical care. These single-centre point prevalence surveys aimed to provide insights into antibiotic prescribing trends and identify targets for paediatric AMS activities. Methods: 14 point prevalence surveys were conducted from March 2016-April 2021, collecting data on antibiotic prescriptions, indication, adherence to guidelines, and route of administration. The UK adapted the World Health Organisation's AWaRe classification-guided antibiotic categorization. Results: 32.5% of all inpatients were on at least one antimicrobial; this remained stable during all surveys (range: 20-44%, p = 0.448). Of all prescriptions, 67.2% had an end- or review-date, and the majority was for agents in the Watch category (46.8-70.5%). Amoxicillin and clavulanate were the most frequently prescribed antibiotics (20.8%), followed by gentamicin (15.3%). Approximately 28.8% of all prescriptions were for prophylactic indications, while 7.6% of the prescriptions were not adherent to the hospital guidelines. Conclusions: This study highlights the importance of ongoing monitoring and robust AMS initiatives to ensure prudent antibiotic prescribing in paediatric healthcare. It underscores the need for tailored guidelines, educational efforts, and targeted interventions to enhance the quality of antibiotic usage, ultimately benefiting both individual patients and public health.

Insight into Private General Physicians' Practices: an Exploratory Qualitative Study in a Rural District of Pakistan

OBJECTIVE

The study aimed to assess private general physicians'(GPs) healthcare practices, identifying perceived malpractices, the support they receive, and barriers they experience in providing healthcare services.

DESIGN

Qualitative exploratory study.

SETTING

Rural district, Thatta in Province of Sindh, Pakistan.

PARTICIPANTS

15 GPs.

RESULTS

Our results include increased motivation among GPs for continued professional development, the high influence of pharmaceutical companies on providers' prescribing practices, perceived malpractices by GPs, and the prevalence of quackery and ineffective regulatory mechanisms for private GPs in a rural district.

CONCLUSION

Our findings have implications for the capacity building of GPs by academic institutions, enforcement of regulatory measures by the authorities, and the introduction of measures to curb practices by unqualified practitioners. Finally, more research will be needed to further understand the perceptions of GPs, their needs and the service delivery interventions that will enhance the quality of care they provide.

Extended Infusion of Beta-Lactams and Glycopeptides: A New Era in Pediatric Care? A Systematic Review and Meta-Analysis

Optimizing antibiotic therapy is imperative with rising bacterial resistance and high infection mortality. Extended infusion defined as a continuous infusion (COI) or prolonged infusion (PI) of beta-lactams and glycopeptides might improve efficacy and safety compared to their intermittent administration (IA). This study aimed to evaluate the efficacy and safety of extended infusion in pediatric patients. Adhering to Cochrane standards, we conducted a systematic review with meta-analysis investigating the efficacy and safety of COI (24 h/d) and PI (>1 h/dose) compared to IA (≤1 h/dose) of beta-lactams and glycopeptides in pediatrics. Primary outcomes included mortality, clinical success, and microbiological eradication. Five studies could be included for the outcome mortality, investigating meropenem, piperacillin/tazobactam, cefepime, or combinations of these. The pooled relative risk estimate was 0.48 (95% CI 0.26-0.89, p = 0.02). No significant differences between the administration modes were found for the outcomes of clinical success, microbiological eradication (beta-lactams; glycopeptides), and mortality (glycopeptides). No study reported additional safety issues, e.g., adverse drug reactions when using COI/PI vs. IA. Our findings suggest that the administration of beta-lactams by extended infusion leads to a reduction in mortality for pediatric patients.

Role of vertical and horizontal microbial transmission of antimicrobial resistance genes in early life: insights from maternal-infant dyads

Early life represents a critical window for metabolic, cognitive and immune system development, which is influenced by the maternal microbiome as well as the infant gut microbiome. Antibiotic exposure, mode of delivery and breastfeeding practices modulate the gut microbiome and the reservoir of antibiotic resistance genes (ARGs). Vertical and horizontal microbial gene transfer during early life and the mechanisms behind these transfers are being uncovered. In this review, we aim to provide an overview of the current knowledge on the transfer of antibiotic resistance in the mother-infant dyad through vertical and horizontal transmission and to highlight the main gaps and challenges in this area.

Antibiotic action and resistance: updated review of mechanisms, spread, influencing factors, and alternative approaches for combating resistance

Antibiotics represent a frequently employed therapeutic modality for the management of bacterial infections across diverse domains, including human health, agriculture, livestock breeding, and fish farming. The efficacy of antibiotics relies on four distinct mechanisms of action, which are discussed in detail in this review, along with accompanying diagrammatic illustrations. Despite their effectiveness, antibiotic resistance has emerged as a significant challenge to treating bacterial infections. Bacteria have developed defense mechanisms against antibiotics, rendering them ineffective. This review delves into the specific mechanisms that bacteria have developed to resist antibiotics, with the help of diagrammatic illustrations. Antibiotic resistance can spread among bacteria through various routes, resulting in previously susceptible bacteria becoming antibiotic-resistant. Multiple factors contribute to the worsening crisis of antibiotic resistance, including human misuse of antibiotics. This review also emphasizes alternative solutions proposed to mitigate the exacerbation of antibiotic resistance.

The impact of anthropogenic climate change on pediatric viral diseases

The adverse effects of climate change on human health are unfolding in real time. Environmental fragmentation is amplifying spillover of viruses from wildlife to humans. Increasing temperatures are expanding mosquito and tick habitats, introducing vector-borne viruses into immunologically susceptible populations. More frequent flooding is spreading water-borne viral pathogens, while prolonged droughts reduce regional capacity to prevent and respond to disease outbreaks with adequate water, sanitation, and hygiene resources. Worsening air quality and altered transmission seasons due to an increasingly volatile climate may exacerbate the impacts of respiratory viruses. Furthermore, both extreme weather events and long-term climate variation are causing the destruction of health systems and large-scale migrations, reshaping health care delivery in the face of an evolving global burden of viral disease. Because of their immunological immaturity, differences in physiology (e.g., size), dependence on caregivers, and behavioral traits, children are particularly vulnerable to climate change. This investigation into the unique pediatric viral threats posed by an increasingly inhospitable world elucidates potential avenues of targeted programming and uncovers future research questions to effect equitable, actionable change. IMPACT: A review of the effects of climate change on viral threats to pediatric health, including zoonotic, vector-borne, water-borne, and respiratory viruses, as well as distal threats related to climate-induced migration and health systems. A unique focus on viruses offers a more in-depth look at the effect of climate change on vector competence, viral particle survival, co-morbidities, and host behavior. An examination of children as a particularly vulnerable population provokes programming tailored to their unique set of vulnerabilities and encourages reflection on equitable climate adaptation frameworks.

Pharmacokinetics and safety of a single dose of telavancin in pediatric subjects 2-17 years of age

Antimicrobial resistance increases infection morbidity in both adults and children, necessitating the development of new therapeutic options. Telavancin, an antibiotic approved in the United States for certain bacterial infections in adults, has not been examined in pediatric patients. The objectives of this study were to evaluate the short-term safety and pharmacokinetics (PK) of a single intravenous infusion of telavancin in pediatric patients. Single-dose safety and PK of 10 mg/kg telavancin was investigated in pediatric subjects >12 months to ≤17 years of age with known or suspected bacterial infection. Plasma was collected up to 24-h post-infusion and analyzed for concentrations of telavancin and its metabolite for noncompartmental PK analysis. Safety was monitored by physical exams, vital signs, laboratory values, and adverse events following telavancin administration. Twenty-two subjects were enrolled: 14 subjects in Cohort 1 (12-17 years), 7 subjects in Cohort 2 (6-11 years), and 1 subject in Cohort 3 (2-5 years). A single dose of telavancin was well-tolerated in all pediatric age cohorts without clinically significant effects. All age groups exhibited increased clearance of telavancin and reduced exposure to telavancin compared to adults, with mean peak plasma concentrations of 58.3 µg/mL (Cohort 1), 60.1 µg/mL (Cohort 2), and 53.1 µg/mL (Cohort 3). A 10 mg/kg dose of telavancin was well tolerated in pediatric subjects. Telavancin exposure was lower in pediatric subjects compared to adult subjects. Further studies are needed to determine the dose required in phase 3 clinical trials in pediatrics.

Prophylactic Antibiotics to Prevent Cholangitis in Children with Biliary Atresia After Kasai Portoenterostomy: A Meta-Analysis

OBJECTIVES

A connection between the bowel and bile ducts after the Kasai hepatoportoenterostomy (HPE) procedure poses a risk of ascending cholangitis. There were only a few evidence-based consensuses on the benefits of prophylactic antibiotics. This study aims to assess the value of prophylactic antibiotics in reducing the risk of cholangitis following the Kasai HPE procedure.

METHODS

Meta-analysis is performed using random-effects model from the search result of 5 online databases (PubMed, Google Scholar, EBSCO MEDLINE, ClinicalTrials.gov , and EuropePMC) from inception to October 27, 2021. The keywords used were "antibiotic," "antimicrobial," "Kasai," "portoenterostomy," "biliary atresia," and "bile duct atresia." Cochrane Risk of Bias tool and Newcastle-Ottawa Scale is used to assess the risk of bias. The outcomes are incidence of cholangitis and native liver survival.

RESULTS

Six studies consisting of 4 cohorts and 2 cross-sectional studies were extracted. A total of 714 patients reported different cholangitis incidence after prophylactic antibiotics administration post-Kasai HPE. The incidence of cholangitis following Kasai HPE was not statistically significant among participants. There is conflicting evidence on the efficacy of antibiotics in prolonging native liver survival.

CONCLUSIONS

The existing evidence does not support the administration of prophylactic antibiotics in preventing cholangitis after Kasai HPE among biliary atresia patients. Additionally, their roles in native liver survival are still inconclusive. The fact that there were heterogeneous method and antibiotic usage between existing studies must also be highlighted for better design in future studies.

Challenges and opportunities for incentivising antibiotic research and development in Europe

Antimicrobial, and particularly antibiotic resistance are one of the world's biggest challenges today, and urgent action is needed to reinvigorate the antibiotic development pipeline. To inform policy discussions during and after the 2023 Swedish Presidency of the Council of the European Union, we critically appraise incentive options recently proposed by the European Commission, and member states, and consider what has been achieved over the last two decades in relation to antibiotic research and development. While several new antibiotics have achieved regulatory approval in recent years, almost none have innovative characteristics such as new chemical classes or novel mechanisms of action. We consider four incentive options to incentivise research and development of new antibiotics, including subscription payments, market entry rewards, transferable exclusivity extensions, and milestone payments. While each option has advantages and drawbacks, a combination of incentives may be required and continued investment is needed by the EU in push incentives, such as direct funding and grants, to incentivise drug discovery and preclinical stages of development. The EU must also coordinate with international initiatives and support access to new and pre-existing antibiotics in LMICs through platforms such as the WHO, and G7 and G20 group of countries.

Changes in the Prescription of Antibiotics and Phytopharmaceuticals in Children Treated for Acute Upper and Lower Respiratory Tract Infections in Pediatric Practices in Germany in 2013, 2018, and 2022

Background: Little is known about the recent trends in antibiotic and phytopharmaceutical prescribing for acute upper (URIs) and lower respiratory tract infections (LRIs) in children and adolescents. Therefore, this study investigated changes in the prescription of antibiotics and phytopharmaceuticals in children diagnosed with acute URIs and LRIs in pediatric practices in Germany in 2013, 2018, and 2022. Methods: The present retrospective study included children aged 2-12 years diagnosed with acute URIs or LRIs in one of 180 pediatric practices in 2013, 2018, and 2022. The URIs included nasopharyngitis, sinusitis, pharyngitis, tonsillitis, laryngitis and tracheitis, and upper respiratory infections of multiple and unspecified sites, while the LRIs corresponded to bronchitis. The primary outcomes were the proportion of children being prescribed antibiotics and the proportion of those being prescribed phytopharmaceuticals. Results: A total of 120,894 children were diagnosed with acute URIs or LRIs in 2013 compared to 116,844 in 2018 and 127,821 in 2022. The prevalence of antibiotic prescription decreased for all diagnoses between 2013 and 2022. This decrease was statistically significant for both 2013-2018 and 2018-2022 for nasopharyngitis, pharyngitis, and bronchitis. Meanwhile, there was a significant increase in the use of phytopharmaceuticals for all diagnoses between 2013 and 2018. The prevalence of phytopharmaceutical prescription decreased slightly between 2018 and 2022, but this decrease was generally not statistically significant. Conclusions: The prescription of antibiotics has decreased and that of phytopharmaceuticals has increased in children diagnosed with acute URIs and LRIs in Germany over the last decade. More data are needed to corroborate these findings in other settings.

Genomic characterisation of multi-drug resistant Escherichia coli and Klebsiella pneumoniae co-harbouring mcr-1 and mcr-3 genes on a single plasmid from paediatric clinical cases

OBJECTIVES

Emergence of the plasmid-born mobile colistin resistance (mcr) gene is a growing concern in healthcare. Therefore, this study aimed to genomically characterise multidrug-resistant Escherichia coli and Klebsiella pneumoniae co-harbouring the mcr-1 and mcr-3 genes in young children.

METHODS

E. coli (n = 3) and K. pneumoniae (n = 2) were collected from abdominal secretions and blood, respectively. The isolates were screened using tryptone soy broth with 4 µL/mL polymyxin-B. Growing bacteria were identified using the VITEK-2 system, matrix-assisted laser desorption/ionisation time-of-flight, and 16s RNA sequencing, followed by antibiotic susceptibility testing. Metallo-β-lactamase (MBL) and extended-spectrum β-lactamase (ESBL) production was also detected. Afterwards, strains were subjected to molecular screening targeting mcr variants and ESBL/MBL-encoding genes. Conjugation, pulsed-field gel electrophoresis, Southern hybridisation, multilocus sequence typing, and phylogenic group detection were performed, along with plasmid-genome sequencing and bioinformatics analysis.

RESULTS

E. coli isolates (EC-19-322, 323, and 331) and K. pneumoniae isolates (KP-19-225 and 226) harboured both mcr-1 and mcr-3 genes. These strains were also found to be resistant to more than three classes of antibiotics. The conjugation experiment revealed the presence of mcr-1 and mcr-3 on a single plasmid, and the transmission frequency was 10-2 to 10-3. Both strains were found to be able to produce ESBLs and MBL. E. coli EC-19-322 and 323 were identified as ST131(O25a:H41); SP-19-331, as ST1577 (O16:H30); and K. pneumoniae, as ST231 (K2). All E. coli strains belonged to phylogenetic group B2, and the results of pulsed-field gel electrophoresis supported the multilocus sequence typing findings.

CONCLUSION

This study reported the co-occurrence of mcr-1 and mcr-3 genes on a single plasmid in pathogenic ESBL/MBL-producing E. coli and K. pneumoniae isolated from young children.

Comparison of TiO2 and ZnO for Heterogeneous Photocatalytic Activation of the Peroxydisulfate Ion in Trimethoprim Degradation

The persulfate-based advanced oxidation process is a promising method for degrading organic pollutants. Herein, TiO2 and ZnO photocatalysts were combined with the peroxydisulfate ion (PDS) to enhance the efficiency. ZnO was significantly more efficient in PDS conversion and SO4•- generation than TiO2. For ZnO, the PDS increased the transformation rate of the trimethoprim antibiotic from 1.58 × 10-7 M s-1 to 6.83 × 10-7 M s-1. However, in the case of TiO2, the moderated positive effect was manifested mainly in O2-free suspensions. The impact of dissolved O2 and trimethoprim on PDS transformation was also studied. The results reflected that the interaction of O2, PDS, and TRIM with the surface of the photocatalyst and their competition for photogenerated charges must be considered. The effect of radical scavengers confirmed that in addition to SO4•-, •OH plays an essential role even in O2-free suspensions, and the contribution of SO4•- to the transformation is much more significant for ZnO than for TiO2. The negative impact of biologically treated domestic wastewater as a matrix was manifested, most probably because of the radical scavenging capacity of Cl- and HCO3-. Nevertheless, in the case of ZnO, the positive effect of PDS successfully overcompensates that, due to the efficient SO4•- generation. Reusability tests were performed in Milli-Q water and biologically treated domestic wastewater, and only a slight decrease in the reactivity of ZnO photocatalysts was observed.

The Silent Threat: Antimicrobial-Resistant Pathogens in Food-Producing Animals and Their Impact on Public Health

The emergence of antimicrobial resistance (AMR) is a global health problem without geographic boundaries. This increases the risk of complications and, thus, makes it harder to treat infections, which can result in higher healthcare costs and a greater number of deaths. Antimicrobials are often used to treat infections from pathogens in food-producing animals, making them a potential source of AMR. Overuse and misuse of these drugs in animal agriculture can lead to the development of AMR bacteria, which can then be transmitted to humans through contaminated food or direct contact. It is therefore essential to take multifaceted, comprehensive, and integrated measures, following the One Health approach. To address this issue, many countries have implemented regulations to limit antimicrobial use. To our knowledge, there are previous studies based on AMR in food-producing animals; however, this paper adds novelty related to the AMR pathogens in livestock, as we include the recent publications of this field worldwide. In this work, we aim to describe the most critical and high-risk AMR pathogens among food-producing animals, as a worldwide health problem. We also focus on the dissemination of AMR genes in livestock, as well as its consequences in animals and humans, and future strategies to tackle this threat.

Antimicrobial resistance landscape and COVID-19 impact in Egypt, Iraq, Jordan, and Lebanon: A survey-based study and expert opinion

OBJECTIVES

The objective of this study was to assess the antimicrobial resistance (AMR) landscape and the impact of COVID-19 on AMR in Egypt, Iraq, Jordan, and Lebanon, and to gather expert opinions on the barriers to the implementation of antimicrobial stewardship (AMS) initiatives in the region.

METHODS

A cross-sectional questionnaire survey was used to assess the current AMR landscape, existing AMS initiatives, barriers to implementing AMS initiatives, and the impact of COVID-19 on AMR in the four countries.

RESULTS

The survey was completed by 204 physicians from Egypt (n = 82), Lebanon (n = 49), Iraq (n = 43), and Jordan (n = 30). Previous antibiotic use and previous bacterial colonization were perceived as the most common risk factors for an increase in AMR. According to the survey, multidrug-resistant (MDR) gram-negative bacteria were most common in lower respiratory tract infections, and Klebsiella pneumoniae and Escherichia coli were the most commonly identified gram-negative bacteria in hospital-acquired infections. Only 14.8% of pediatric physicians and 28.6% of adult physicians reported that target pathogen genotyping and phenotyping were done in hospitals, and the most commonly reported reasons for the lack of testing were technological and resource constraints. These constraints, coupled with the scarcity and high cost of newer antibiotics, have been identified as the most significant barriers to the successful management of MDR gram-negative bacterial infections in the region. It was reported that the spectrum of activity and safety of the antibiotic, the site of infection, the presence of comorbidities, and published guidelines and local antibiograms determined the choice of empirical antibiotic therapy for patients in the region. The four countries experienced a significant rise in AMR due to several factors during the COVID-19 pandemic, including an increase in hospital occupancy, a shift in priorities away from AMR surveillance, and changes in AMR epidemiology. Additionally, the large volumes of unnecessary and unsubstantiated antibiotic prescriptions during the COVID-19 pandemic has led to subsequent antibiotic shortages and significant increases in AMR in the region. Physicians also noted that the majority of COVID-19 patients were already on antibiotics before visiting the healthcare facility. MDR gram-negative bacteria were found in the majority of COVID-19 patients admitted to the intensive care unit. Despite the fact that various AMS initiatives have been implemented, they are not standardized across the region. Some of the main barriers to AMS implementation in the region are a lack of adequately trained AMS staff, lack of AMS knowledge and training among healthcare professionals, financial constraints, and the lack of AMR surveillance systems.

CONCLUSION

These survey results provide valuable insights into the existing AMR and AMS landscape in the region, as well as the barriers that impede efficient AMS and AMR management. Based on these findings, the authors developed a call to action that suggests ways for each country in the region to address these challenges.

Antimicrobial Resistance Studies Using Raman Spectroscopy on Clinically Relevant Bacterial Strains

There has been a steep rise in the emergence of antibiotic-resistant bacteria in the past few years. A timely diagnosis can help in initiating appropriate antibiotic therapy. However, conventional techniques for diagnosing antibiotic resistance are time-consuming and labor-intensive. Therefore, we investigated the potential of Raman spectroscopy as a rapid surveillance technology for tracking the emergence of antibiotic resistance. In this study, we used Raman spectroscopy to differentiate clinical isolates of antibiotic-resistant and -sensitive bacteria of Escherichia coli, Acinetobacter baumannii, and Enterobacter species. The spectra were collected with or without exposure to various antibiotics (ciprofloxacin, gentamicin, meropenem, and nitrofurantoin), each having a distinct mechanism of action. Ciprofloxacin- and meropenem-treated sensitive strains showed a decrease in the intensity of Raman bands associated with DNA (667, 724, 785, 1378, 1480, and 1575 cm^-1) and proteins (640 and 1662 cm^-1), coupled with an increase in the intensity of lipid bands (891, 960, and 1445 cm^-1). Gentamicin- and nitrofurantoin-treated sensitive strains showed an increase in the intensity of nucleic acid bands (668, 724, 780, 810, 1378, 1480, and 1575 cm^-1) while a decrease in the intensity of protein bands (640, 1003, 1606, and 1662 cm^-1) and the lipid band (1445 cm^-1). The Raman spectral changes observed in the antibiotic-resistant strains were opposite to that of antibiotic-sensitive strains. The Raman spectral data correlated well with the antimicrobial susceptibility test results. The Raman spectral dataset was used for partial least-squares (PLS) analysis to validate the biomarkers obtained from the univariate analysis. Overall, this study showcases the potential of Raman spectroscopy for detecting antibiotic-resistant and -sensitive bacteria.

Antimicrobial Resistance Genes (ARGs), the Gut Microbiome, and Infant Nutrition

The spread of antimicrobial resistance genes (ARGs) is a major public health crisis, with the ongoing spread of ARGs leading to reduced efficacy of antibiotic treatments. The gut microbiome is a key reservoir for ARGs, and because diet shapes the gut microbiome, diet also has the potential to shape the resistome. This diet-gut microbiome-resistome relationship may also be important in infants and young children. This narrative review examines what is known about the interaction between the infant gut microbiome, the infant resistome, and infant nutrition, including exploring the potential of diet to mitigate infant ARG carriage. While more research is needed, diet has the potential to reduce infant and toddler carriage of ARGs, an important goal as part of maintaining the efficacy of available antibiotics and preserving infant and toddler health.

Duration of antibiotic therapy among paediatricians: A national survey of current clinical practice in Spain

OBJECTIVES

Appropriate duration of antibiotic treatment is a key principle to reduce the emergence of bacterial resistance and antibiotic harm. The aim of this study was to document current clinical practice among Spanish paediatricians in terms of the duration of antibiotic therapy in both inpatient and outpatient settings, mapping the difference between practice and guidelines, and thus identifying opportunities to improve practice.

METHODS

A national exploratory work survey was distributed in 2020 as a questionnaire about seven main infectious syndromes in children: genitourinary; skin and soft tissue; osteoarticular; ear, nose and throat; pneumonia; central nervous system; and bacteraemia. The answers were contrasted with current recommendations regarding the duration of antibiotic therapy. Demographic analysis was also performed.

RESULTS

The survey was completed by 992 paediatricians in Spain, representing 9.5% of paediatricians working in the Spanish national health system. Hospital care clinicians accounted for 42.7% (6662/15590) of responses. The antibiotic duration used in practice was longer than recommended in 40.8% (6359/15590) of responses, and shorter than recommended in 16% (1705/10654) of responses. Only 25% (249/992) and 23% (229/992) of respondents indicated that they would prescribe antibiotics for the recommended treatment duration for lower urinary tract infection and community-acquired pneumonia (AI evidence). Among severe hospital-managed infections, a tendency towards longer courses of antibiotics was found for non-complicated meningococcal infections and non-complicated pneumococcal, Gram-negative and S. aureus bacteraemia.

CONCLUSIONS

A noteworthy tendency towards prescribing antibiotics for longer than recommended among paediatricians was evidenced in this nationwide study, highlighting a wide range of opportunities for potential improvement.

Infection control measures against multidrug-resistant Gram-negative bacteria in children and neonates

The increase in infections caused by multidrug-resistant (MDR) Gram-negative bacteria in neonatal and pediatric intensive care units over recent years is alarming. MDR Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii have constituted the main causes of the MDR Gram-negative bacteria problem. The implementation of infection control measures such as hand hygiene, cohorting of patients, contact precautions, active surveillance and environmental cleaning could diminish their spread. Recently, water safety has been identified as a major component of infection control policies. The aim of the current review is to highlight the effectiveness of these infection control measures in managing outbreaks caused by MDR Gram-negative bacteria in neonatal and pediatric intensive care units and highlight future perspectives on the topic.

Individualised versus standard duration of antibiotic therapy in children with acute uncomplicated febrile urinary tract infection: a study protocol and statistical analysis plan for a multicentre randomised clinical trial

INTRODUCTION

Febrile urinary tract infection is one of the most common bacterial infections in children. Currently, recommended antibiotic duration is 10 days. However, recent evidence suggests that 90%-95% of children with febrile urinary tract infections are afebrile and clinically improved 48-72 hours after treatment initiation. Accordingly, individualised duration of antibiotic therapy, according to the recovery time, might be more beneficial than current recommendations, but no evidence exists.

METHODS AND ANALYSIS

An open-label randomised clinical trial equally randomising children aged 3 months to 12 years from eight Danish paediatric departments with uncomplicated febrile (≥38°C) urinary tract infection to either individualised or standard duration of antibiotic therapy. Children allocated to individualised duration of antibiotic therapy will terminate antibiotic therapy 3 days after clinical improvement with no fever, flank pain or dysuria. Children allocated to standard duration will receive 10 days of antibiotic therapy. Co-primary outcomes are non-inferiority for recurrent urinary tract infection or death within 28 days after the end of treatment (non-inferiority margin 7.5 percentage points) and superiority for the number of days with antibiotic therapy within 28 days after treatment initiation. Seven other outcomes will also be assessed. A total of 408 participants are needed to detect non-inferiority (one-sided alpha 2.5%; beta 80%).

ETHICS AND DISSEMINATION

This trial has been approved by the Ethics Committee (H-21057310) and the Data Protection Agency (P-2022-68) in Denmark. Regardless of the trial's findings (whether positive, negative or inconclusive), the results will be compiled into one or more manuscripts for publication in international peer-reviewed scientific journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT05301023.

Short-term antibiotic therapy for the most common bacterial respiratory infections in infants and children

Overuse and misuse of antibiotics have strongly accelerated the progressive increase in bacterial antimicrobial resistance (AMR). The evidence that antimicrobial selective pressure was greater the longer the antibiotic therapy was continued has led some experts to reconsider duration of antibiotic therapy testing the use of short-term drug administration. If as effective as long-term therapy, short-term therapy could have been an easy measure to limit AMR emergence. In the present narrative review, whether present knowledge on short-term therapy of acute streptococcal pharyngitis (ASF), acute otitis media (AOM) and mild to moderate community-acquired pneumonia (CAP) allows systematic use of short-term therapy in infants and children with these diseases is discussed. Literature analysis showed that reducing the duration of antibiotic therapy for some of the most common pediatric respiratory infections could be a valid measure to contain the antibiotic abuse and the consequent impact on the emergence of AMR. Several data seem to indicate that this type of intervention is possible, as short-term therapy has been found as effective as the traditionally recommended long-term therapy in some cases of ASF, AOM and mild to moderate CAP. However, further studies are needed to better characterize infants and children who can have benefit with short-term antibiotic therapy in common bacterial respiratory infections.

Bacterial Species and Antibiotic Resistance-A Retrospective Analysis of Bacterial Cultures in a Pediatric Hospital

Antimicrobial resistance (AMR) has become a major healthcare concern having a rising incidence, especially in pediatric patients who are more susceptible to infections. The aim of our study was to analyze the bacterial species isolated from patients admitted to our tertiary hospital and their AMR profiles. We conducted a retrospective observational study by examining the bacterial cultures collected from pediatric patients admitted to our hospital over a period of one year. We identified the most common bacterial species from 1445 clinical isolates and their AMR patterns using standard microbiological techniques. Our analysis revealed that the most frequently isolated bacterial species were Escherichia coli (23.73%), Staphylococcus aureus (15.64%), Klebsiella species (12.04%), and Pseudomonas species (9.96%). Additionally, these species exhibited varying levels of resistance to commonly used antibiotics. Notably, we observed high rates of resistance among Gram-negative bacteria, including extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella species. Among Gram-positive bacteria, we observed a high level of methicillin-resistant Staphylococcus aureus. Our findings highlight the urgent need for effective antibiotic management programs and infection control measures to address the rising incidence of AMR in pediatric hospitals. Further research is needed to identify the mechanisms of resistance in these bacterial species and to develop new strategies for preventing and treating infections caused by antibiotic-resistant bacteria in pediatric patients.

Off-label use of antimicrobials among hospitalized children: a retrospective study of 3,406 patients

Introduction

Off-label drug use is a global problem for which many countries and regions have issued legal provisions or reached an expert consensus. Off-label use is sometimes a necessity, especially since antibacterial drugs have become one of the most widely used drugs in pediatric settings and the issue of causing antimicrobial resistance has increasingly become unavoidable. It also poses additional risks, such as adverse drug reactions.

Methods

Our study analyzed the antimicrobial prescriptions of pediatric inpatients in a large Chinese hospital in the first half of 2021. This retrospective investigation included 6,829 prescriptions, including 2,294 off-label prescriptions. We performed descriptive analyses of prescription antimicrobial agents among pediatric populations and reported the percentages and frequencies.

Results

It was found that off-label use of antibiotics was present in many children (n = 1,665, 48.9%) and was most common in newborns (n  = 328, 82.8%). Among the commonly used antibiotics in pediatric patients, cephalosporins (n  = 2,778, 40.7%) accounted for a relatively low proportion of offlabel use (n  = 360, 15.7%), while macrolides (n  = 628, 27.4%) and penicillins (n  = 610, 26.6%) accounted for a higher proportion. The off-label type mainly referred to the appropriate population (46.5%) and dosage (dose, 10.0%; frequency of administration, 48.3%).

Discussion

Off-label use was due to imperfect labels, improper medications, or medication errors. Only a few consensuses could apply to pediatric patients. More clinical trials are required to update the consensus, and drug labels must be continuously improved. The prescription behavior of doctors is also needed to be regulated. Rational use of drugs, especially antimicrobials, is the responsibility of all people, including the states, medical institutions, and individuals.

Implementation research for promoting access and rational use of antibiotics for children: lessons learnt from Tanzania

Implementation research (IR) has proved to be a potential catalyst in facilitating the uptake of evidence-based innovations into routine practices and thereby maximizing public health outcomes. IR not only focuses on the effectiveness of the innovations but also identifies and addresses the barriers and facilitators to maximize their uptake into routine practices. This article describes the processes undertaken to implement a research project aimed at promoting access and rational use of antibiotics for children (PARAC). It also provides an overview of the lessons learnt during its implementation in Tanzanian hospital and community settings.

The Characterization and Beta-Lactam Resistance of Staphylococcal Community Recovered from Raw Bovine Milk

Staphylococci is an opportunistic bacterial population that is permanent in the normal flora of milk and poses a serious threat to animal and human health with some virulence factors and antibiotic-resistance genes. This study was aimed at identifying staphylococcal species isolated from raw milk and to determine hemolysis, biofilm, coagulase activities, and beta-lactam resistance. The raw milk samples were collected from the Düzce (Türkiye) region, and the study data represent a first for this region. The characterization of the bacteria was performed with MALDI-TOF MS and 16S rRNA sequence analysis. The presence of coa, icaB, blaZ, and mecA was investigated with PCR. A nitrocefin chromogenic assay was used for beta-lactamase screening. In this context, 84 staphylococci were isolated from 10 different species, and the dominant species was determined as S. aureus (32.14%). Although 32.14% of all staphylococci were positive for beta hemolysis, the icaB gene was found in 57.14%, coa in 46.42%, mecA in 15.47%, and blaZ in 8.33%. As a result, Staphylococcus spp. strains that were isolated from raw milk in this study contained some virulence factors at a high level, but also contained a relatively low level of beta-lactam resistance genes. However, considering the animal–environment–human interaction, it is considered that the current situation must be monitored constantly in terms of resistance concerns. It must not be forgotten that the development of resistance is in constant change among bacteria.

Prevalence and Predictors of Using Antibiotics without a Prescription in a Pediatric Population in the United States

Non-prescription antibiotic use (using antibiotics without clinical guidance) increases the risk of the development of antibiotic resistance, adverse drug reactions, and other potential patient harm. Few studies have explored non-prescription use in children in the U.S. From January 2021 to April 2022, a diverse sample of caregivers of children under 18 years were surveyed in English and Spanish at two safety net clinics in Texas. We assessed the prevalence of antibiotic use in children in the previous 12 months, storage of antimicrobials, and intended use of non-prescription antibiotics (professed intention for future non-prescription antibiotic use). We also measured sociodemographic factors, types of antibiotics used, and symptoms that trigger non-prescription use. The response rate was 82%, and 17% were surveyed in Spanish. Of 322 participants surveyed, three Spanish-speaking caregivers reported giving non-prescription antibiotics to their child in the previous 12 months. Approximately 21% (n = 69) reported storing antimicrobials at home, specifically amoxicillin (n = 52), clindamycin (n = 10), cephalexin (n = 5), penicillin (n = 3), and trimethoprim/sulfamethoxazole (n = 3). Nearly 15% (n = 46) reported intention to give non-prescription antibiotics to their children. Younger caregiver age was associated with storage and intended use of non-prescription antibiotics. Our findings will guide the development of an educational intervention to decrease non-prescription antibiotic use.

Antibiotic-resistant bacteria in bovine milk in India

Antibiotic resistance (ABR) is a global issue that draws the attention of all healthcare experts in the veterinary and medical fields. Of various factors, indiscriminate and unregulated antibiotic usage in the animals reared for food production, especially in cows and buffaloes suffering from mastitis, contribute significantly to the rising incidence of resistant bacteria. A literature survey reveals the spread of resistant strains of mastitis-causing bacteria, like Staphylococcus aureus and Escherichia coli, to humans. In addition, antibiotic residues detected in milk samples against all major groups of antibiotics are likely to enter the human body through the food chain and aggravate the condition. The cumulative effects of ABR have emerged as a silent killer. The benefits of systematic surveillance on ABR in India are yet to be available. Here is an attempt to understand the ABR burden in India associated with bovine milk and its mitigation strategies.

Bloodstream Infection Due to a VIM-Metallo-β-Lactamase-Producing Klebsiella pneumoniae Treated with Cefiderocol in a Preterm Newborn

BACKGROUND

The prevalence of certain multidrug-resistant organisms (MDROs), especially Gram-negative bacteria, is dramatically increasing in patient care settings, including pediatric and neonatal units. However, most of the new drugs available for the treatment of MDROs have not yet been studied in children and newborns.

CASE REPORT

We report the clinical case of a preterm neonate, born at 31 weeks gestation + 1 day of age by emergency Cesarean Section (CS), with a bloodstream infection (BSI) due to a Verona integron-borne metallo-β-lactamase (VIM)-producing Klebsiella pneumoniae. We successfully treated the infection with cefiderocol in an off-label regimen at the following dose: loading dose 60 mg/kg and then 40 mg/kg every 8 h in extended infusion for 9 days. The baby showed a quick clinical and biochemical improvement and tolerated well the treatment. Follow-up blood cultures at 48 h after the start of cefiderocol were negative.

CONCLUSIONS

Antimicrobial-resistant pathogens are of increasing concern in neonatal settings. More studies in this unique population are necessary to better describe the pharmacokinetic and pharmacodynamic profile of the new drugs against MDROs, such as cefiderocol, and to define a proper effective dose.

Antioxidant and Antimicrobial Evaluations of Moringa oleifera Lam Leaves Extract and Isolated Compounds

Moringa oleifera, native to India, grows in tropical and subtropical regions around the world and has valuable pharmacological properties such as anti-asthmatic, anti-diabetic, anti-inflammatory, anti-infertility, anti-cancer, anti-microbial, antioxidant, and many more. The purpose of this study was to assess the free radical scavenging ability of two extracts and two pure compounds of M. oleifera Lam (hexane, ethanol, compound E3, and compound Ra) against reactive oxygen species, as well as their reducing power and antimicrobial activities. Bioautography antioxidant assay, 2,2-diphenyl-1-picrylhydrazyl (DPPH), hydrogen peroxide (H₂O₂) free radical scavenging, and iron (iii) (Fe³⁺ to Fe²⁺) chloride reducing power assays were used to assess the extracts' qualitative and quantitative free radical scavenging activities. Furthermore, the extract and the compounds were tested against both Gram-positive and Gram-negative bacterial strains suspended in Mueller-Hinton Broth. The extracts and pure compounds showed noteworthy antioxidant potential, with positive compound bands in the Rf range of 0.05-0.89. DPPH), H₂O₂, and Fe³⁺ to Fe²⁺ reduction assays revealed that ethanol extract has a high antioxidant potential, followed by compound E3, compound Ra, and finally hexane extract. Using regression analysis, the half maximal inhibitory concentration (IC₅₀) values for test and control samples were calculated. Compound Ra and ethanol exhibited high antioxidant activity at concentrations as low as ≈0.28 mg/mL in comparison with n-hexane extract, compound E3, ascorbic acid, and butylated hydroxytoluene standards. The radical scavenging activity of almost all M. oleifera plant extracts against DPPH was observed at 0.28 mg/mL; however, the highest activity was observed at the same concentration for ascorbic acid and butylated hydroxytoluene (BHT) with a low IC₅₀ value of 0.08 mg/mL and compound Ra and ethanol with a low IC₅₀ of 0.4 mg/mL, respectively. The extracts and pure compounds of M. oleifera have little to no antibacterial potential. M. oleifera extracts contain antioxidant agents efficient to alleviate degenerative conditions such as cancer and cardiovascular disease but have little activity against infectious diseases.

Advancing evidence-based treatment of infectious diseases in children with real-world data: Opportunities and challenges

There is an increased interest in utilizing real-world data (RWD) for pharmaceutical research and regulatory decision-making. The development and use of pediatric medicines could benefit greatly from real-world data studies given nearly half of drugs prescribed to children are "off-label", meaning there is a lack of pediatric-specific evidence from controlled trials, while there is an abundance of data from routine clinical practice. Currently, the use of real-world data, such as data from electronic health records, is lacking in pediatric research, especially within infectious diseases. Here, we discuss opportunities and challenges for real-world data to generate evidence on the optimal treatment and management of infectious diseases in children.

Nurses’ knowledge regarding children antibiotic use and resistance in Jordan: A cross-sectional study

<b>Purpose: </b>This study aimed at examining nurses’ knowledge, attitudes, and practices related to antibiotics use and resistance. A second objective was to identify Jordanian nurses’ sources of information about antibiotics.<br /> <b>Method: </b>A cross-sectional design was used for this study. Nurses (n=594) completed an online survey using Google Forms. Google Forms web link was distributed on Facebook, LinkedIn, Twitter, and other social media applications. The study included Jordanian nurses who worked in hospitals<b> </b>and healthcare institutions. the European Center for Diseases Control and Prevention survey was used that took about 15 minutes to complete.<br /> <b>Results: </b>According to the study, 48.2% of nurses prescribed antibiotics to patients daily or multiple times per day in the previous week; 13.3% of nurses offered support for daily or more frequent antibacterial drug use or infection control; and 42.3% of nurses mentioned they did not give antibiotics advice because they did not have a leaflet about their use and because the patients did not receive one.<br /> <b>Conclusion: </b>The study found that<b> </b>the most reported source for antibiotics information was Facebook and Instagram. Nurses need further education on proper use of antibiotics. Antimicrobial stewardship can benefit from the study findings, which can help develop interventions to improve antibiotics proper use.

Evaluation of changes in antimicrobial susceptibility in bacteria infecting children and their mothers in pediatric, neonatal-intensive care unit, and gynecology/obstetrics wards of a quaternary referral hospital during the COVID-19 pandemic

The World Health Organization released a statement warning of increased risk for the incidence of multidrug resistant microorganisms and the absence of new drugs to control such infections soon. Since the beginning of the COVID-19 pandemic, the prescription of antimicrobial agents has increased and may have accelerated the emergence of multidrug resistant (MDR) bacteria. This study aimed to evaluate maternal and pediatric infections within a hospital from January 2019 to December 2021. An observational retrospective cohort study was performed at a quaternary referral hospital in a metropolitan area of Niteroi city, Rio de Janeiro state, Brazil. A total of 196 patients' medical records were analyzed. The data from 90 (45.9%) patients were collected before the SARS-CoV-2 pandemic, 29 (14.8%) from the 2020 pandemic period, and 77 (39.3%) from the 2021 pandemic period. A total of 256 microorganisms were identified during this period. Out of those, 101 (39.5%) were isolated in 2019, 51 (19.9%) in 2020, and 104 (40.6%) in 2021. Antimicrobial susceptibility tests were performed on 196 (76.6%) clinical isolates. The exact binomial test showed that the distribution of Gram-negative bacteria was predominant. The most common microorganism was Escherichia coli (23%; n = 45), followed by Staphylococcus aureus (17.9%, n = 35), Klebsiella pneumoniae (12.8%, n = 25), Enterococcus faecalis (7.7%, n = 15), Staphylococcus epidermidis (6.6%, n = 13) and Pseudomonas aeruginosa (5.6%, n = 11). Staphylococcus aureus was the predominant species among resistant bacteria. Among the antimicrobial agents tested, the following were resistant, presented on a descending scale: penicillin (72.7%, p = 0.001, Binomial test), oxacillin (68.3%, p = 0.006, Binomial test), ampicillin (64.3%, p = 0.003, Binomial test), and ampicillin/sulbactam (54.9%, p = 0.57, Binomial test). Infections with S. aureus were 3.1 times greater in pediatrics and maternal units than in other hospital wards. Despite the global reduction in the incidence of MRSA, we observed an increase in MDR S. aureus in this study. No changes were observed in the frequency of resistance profiles of the clinical isolates after the establishment of the global SARS-CoV-2 pandemic. More comprehensive studies are needed to understand the impact of the global SARS-CoV-2 pandemic on the resistance levels of bacteria associated with neonate and pediatric patients.

Evaluation of Community Pharmacists' Competences in Identifying and Resolve Drug-Related Problems in a Pediatric Prescription Using the Simulated Patient Method

Background: Drug-related problems (DRPs) are a global issue that impacts the efficacy and safety of the therapy, and pediatric patients are considered to be more vulnerable to DRPs, thus requiring more attention. Community pharmacists (CPs) are in a position that allow them to identify and alleviate these DRPs. Objectives: This study evaluated the ability of CPs in identifying and resolving DRPs in a pediatric prescription. Methods: A cross-sectional study was carried out in 235 community pharmacies to evaluate the ability of CPs working in the Khartoum locality to identify DRPs in a pediatric prescription and how they intervene to resolve these problems. Fifth-final year B. Pharm. Students were selected and trained to act as simulated patients (SPs) for this study. The visits were performed by using a simulated prescription that contains three different types of DRPs. The information obtained from the visits was documented immediately by the SPs after leaving the pharmacy in a data collection form. Results: All planned SPs visits were completed. Of the 235 community pharmacies, only 50 (21.3%) CPs were able to identify at least one of the DRPs. The most common type of DRP identified was the wrong duration of the treatment 19%, followed by the wrong dose 4%. The interventions made by CPs to mitigate the identified DRPs included recalculation and correction of the dose according to weight, which was made by 10 CPs, and correction of the duration, which was done by 45 CPs. None of the CPs who identified the presented DRPs communicated with the physician or referred the SP to the prescriber. The average dispensing time of the CPs was 68.18 ± 36.1 s. Conclusions: The majority of the CPs in the Khartoum locality were unable to identify DRPs in a pediatric prescription. Correction of the dose and duration of treatment were from the attempts of CPs to resolve DRPs. However, no collaboration was observed between CPs and physicians. In general, the practice of CPs in Khartoum locality in this area requires substantial improvement.

Implementation of antibiotic stewardship programmes in paediatric patients in regional referral hospitals in Tanzania: experience from prescribers and dispensers

Background

In 2017, Tanzania launched the National Action Plan for Antimicrobial Resistance (NAPAR), 2017-2022 and implementation of antibiotic stewardship programmes (ASPs) was one of the agendas. Since the launch of the National Action Plan, no study has been done to assess its implementation.

Objectives

To explore the experiences of prescribers and dispensers on implementing ASPs among paediatric patients attending Regional Referral Hospitals (RRHs) in Tanzania.

Methods

An exploratory qualitative study was conducted among key informants, in 14 RRHs in Tanzania between July and August 2020. A total of 28 key informants, 14 dispensers in charge of pharmacies and 14 medical doctors in charge of paediatric departments (prescribers), were interviewed. A hybrid thematic analysis was conducted on the gathered information.

Results

Most of the study participants were not conversant with the term 'antibiotic stewardship'. Some had heard about the programmes but were not aware of the activities involved in the programme. Those who were knowledgeable on ASPs mentioned the lack of existence of such programmes in their settings. They further added that absence or limited knowledge of the stewardship concepts may have influenced the current poor practices. Barriers to the implementation of ASPs mentioned were lack of laboratory facilities to support culture and susceptibility tests, lack of materials and reagents, management pressure to prevent loss or to generate income, patients' influence and limited training opportunities.

Conclusions

Despite launching the NAPAR in 2017, we found limited implementation of ASPs in the management of paediatric patients. This study highlighted some barriers and identified possible intervention points.

Naturopathic patient care during different life stages: an international observational study of naturopathic practitioners and their patients

BACKGROUND

An individual's health status varies with age, with most health problems increasing through different life stages. Yet, a key feature of the majority of conditions contributing burden to society globally, irrespective of life stage, is the predominance of chronic, non-communicable diseases (NCDs). An important response to this growing burden is the increasing recognition of addressing NCD prevention through a life-course perspective through primary care and public health. Naturopathy is a traditional medicine system originating from Europe, and its practitioners commonly provide primary care and focus on prevention and wellness. However, little is known about naturopathic practitioners (NPs) contribution to health care across different life stages.

METHODS

This secondary analysis of a cross-sectional study aimed to describe the approach to the care of NPs based on the life stage of their patients. The primary study recruited NPs from 14 regions or countries, who were invited to complete a short survey about 20 consecutive patients. The multilingual survey included the following domains: patient demographics, reason for visit, prescribed or recommended treatments, and naturopathic interpretation of the health conditions. Descriptive statistics were tabulated as frequencies and percentages and chi square tests were used to test associations and compare groups. Effect size was determined by Cramer's V.

RESULTS

Participant NPs (n = 56) provided consultation details for 854 patients encounters. There were differences in the patient's primary reason for visiting, the additional physiological systems the NP considered important in the management of the patient's health, and the treatments prescribed across all life stages. However, diet (45.1-70.0%) and lifestyle (14.3-60.0%) prescription were the most common categories of treatments across all patient groups.

CONCLUSION

NPs provide care to patients across all life stages, and diverse conditions pertinent to those life stages while also demonstrating a holistic approach that considers broader health concerns and long term treatment practices. While there may be emerging evidence supporting and informing NP clinical outcomes, the breadth and diversity of health conditions, populations and treatments within the scope of naturopathic practice underscores a need for urgent and widescale research investigating naturopathic care across the life course.