Implications of Overprescription of Antibiotics: A Cross-Sectional Study

Uses of a real-time automatic nosocomial infection surveillance system to support prevention and control of hospital-acquired infections in the ICU

Introduction

The intensive care unit (ICU) caters to patients with severe illnesses or injuries who require constant medical attention. These patients are susceptible to infections due to their weak immune systems and prolonged hospital stays. This makes the ICU the specialty with the highest hospital-acquired infection (HAI) cases. The core dimension of infection prevention and control for ICUs is infection surveillance, which analyses the risk factors of HAI and implements comprehensive interventions for HAI prevention and control. Hence, this study aimed to investigate the potential risk factors for developing HAI in the ICU using real-time automatic nosocomial infection surveillance systems (RT-NISS) to surveil, and analyze the effectiveness of RT-NISS coupled with comprehensive interventions on HAI prevention and control in the ICU.

Methods

A retrospective analysis was conducted using data from an RT-NISS for all inpatients in the ICU from January 2021 to December 2022. Univariate and multivariate logistic regression analyses were performed to analyse potential risk factors for HAI in the ICU. Surveillance of the prevalence proportion of HAI, the prevalence proportion of site-specific HAI, the proportion of ICU patients receiving antibiotics, the proportion of ICU patients receiving key antimicrobial combination, the proportion of HAI patients with pathogen detection, the proportion of patients with pathogen detection before antimicrobial treatment and the proportion of patients before receiving key antimicrobial combination, the utilization rate of devices and the rate of device-associated HAIs were monitored monthly by the RT-NISS. Comprehensive interventions were implemented in 2022, and we compared the results of HAIs between 2021 and 2022 to evaluate the effect of the RT-NISS application combined with comprehensive interventions on HAI prevention and control.

Results

The relative risk factors, observed as being a significantly higher risk of developing HAI, were hospitalization over 2 weeks, chronic lung diseases, chronic heart diseases, chronic renal diseases, current malignancy, hypohepatia, stroke, cerebrovascular accident, severe trauma, tracheal intubation and tracheostomy and urinary catheter. By implementing comprehensive interventions depending on infection surveillance by the RT-NISS in 2022, the prevalence proportion of HAI was reduced from 12.67% in 2021 to 9.05% in 2022 (χ2 = 15.465, p < 0.001). The prevalence proportion of hospital-acquired multidrug-resistant organisms was reduced from 5.78% in 2021 to 3.21% in 2022 (χ2 = 19.085, p < 0.001). The prevalence proportion of HAI in four sites, including respiratory tract infection, gastrointestinal tract infection, surgical site infection, and bloodstream infection, was also significantly reduced from 2021 to 2022 (both p < 0.05). The incidence of ventilator-associated pneumonia in 2022 was lower than that in 2021 (15.02% vs. 9.19%, χ2 = 17.627, p < 0.001).

Conclusion

The adoption of an RT-NISS can adequately and accurately collect HAI case information to analyse the relative high-risk factors for developing HAIs in the ICU. Furthermore, implementing comprehensive interventions derived from real-time automation surveillance of the RT-NISS will reduce the risk and prevalence proportions of HAIs in the ICU.

Extensively and multidrug-resistant bacterial strains: case studies of antibiotics resistance

The development of antibiotic resistance compromises the effectiveness of our most effective defenses against bacterial infections, presenting a threat to global health. To date, a large number of research articles exist in the literature describing the case reports associated with extensively drug-resistant (XDR) and multidrug-resistant (MDR) bacterial strains. However, these findings are scattered, making it time-consuming for researchers to locate promising results and there remains a need for a comparative study to compile these case reports from various geographical regions including the Kingdom of Saudi Arabia. Additionally, no study has yet been published that compares the genetic variations and case reports of MDR and XDR strains identified from Saudi Arabia, the Middle East, Central Europe, and Asian countries. This study attempts to provide a comparative analysis of several MDR and XDR case reports from Saudi Arabia alongside other countries. Furthermore, the purpose of this work is to demonstrate the genetic variations in the genes underlying the resistance mechanisms seen in MDR and XDR bacterial strains that have been reported in Saudi Arabia and other countries. To cover the gap, this comprehensive review explores the complex trends in antibiotic resistance and the growing risk posed by superbugs. We provide context on the concerning spread of drug-resistant bacteria by analyzing the fundamental mechanisms of antibiotic resistance and looking into individual case reports. In this article, we compiled various cases and stories associated with XDR and MDR strains from Saudi Arabia and various other countries including China, Egypt, India, Poland, Pakistan, and Taiwan. This review will serve as basis for highlighting the growing threat of MDR, XDR bacterial strains in Saudi Arabia, and poses the urgent need for national action plans, stewardship programs, preventive measures, and novel antibiotics research in the Kingdom.

Prevalence and predictors of antibiotic prescription among patients hospitalized with viral lower respiratory tract infections in Southern Province, Sri Lanka

BACKGROUND

Antimicrobial overprescription is common for lower respiratory tract infections (LRTI), as viral and bacterial infections generally present with similar clinical features. Overprescription is associated with downstream antimicrobial resistance. This study aims to identify the prevalence and predictors of antibiotic prescription among patients hospitalized with viral LRTI.

METHODS

A prospective cohort study was conducted among patients aged ≥1 year hospitalized with viral LRTI in a tertiary care hospital in Southern Province, Sri Lanka from 2018-2021. Demographic, clinical, and laboratory data were recorded. Nasopharyngeal and blood samples were collected for multiplex polymerase chain reaction testing for 21 respiratory pathogens and procalcitonin (PCT) detection, respectively. Demographic and clinical features associated with antibiotic prescription were identified using Chi Square and t-tests; significant variables (p<0.05) were further included in multivariable logistic regression models. The potential impact of biomarker testing on antibiotic prescription was simulated using standard c-reactive protein (CRP) and PCT cut-offs.

RESULTS

Of 1217 patients enrolled, 438 (36.0%) had ≥1 respiratory virus detected, with 48.4% of these patients being male and 30.8% children. Influenza A (39.3%) and human rhinovirus/ enterovirus (28.3%) were most commonly detected. A total of 114 (84.4%) children and 266 (87.8%) adults with respiratory viruses were treated with antibiotics. Among children, neutrophil percentage (median 63.6% vs 47.6%, p = 0.04) was positively associated with antibiotic prescription. Among adults, headache (60.6% vs 35.1%, p = 0.003), crepitations/crackles (55.3% vs 21.6%, p<0.001), rhonchi/wheezing (42.9% vs 18.9%, p = 0.005), and chest x-ray opacities (27.4% vs 8.1%, p = 0.01) were associated with antibiotic prescription. Access to CRP and procalcitonin test results could have potentially decreased inappropriate antibiotic prescription in this study by 89.5% and 83.3%, respectively.

CONCLUSIONS

High proportions of viral detection and antibiotic prescription were observed among a large inpatient cohort with LRTI. Increased access to point-of-care biomarker testing may improve antimicrobial prescription.

Evaluation of metagenomic assembly methods for the detection and characterization of antimicrobial resistance determinants and associated mobilizable elements

Antimicrobial resistance genes (ARGs) can be transferred between members of a bacterial population by mobile genetic elements (MGE). Understanding the risk of these transfer events is important in monitoring and predicting antimicrobial resistance (AMR), especially in the context of a One Health Continuum. However, there is no universally accepted method for detection of ARGs and MGEs, and especially for determining their linkages. This study used publicly available shotgun metagenomic DNA short-read (Illumina, 100 bp paired-end) sequence data from samples across the One Health Continuum (including beef cattle composite feces from feedlots, catch basin water at feedlots, agricultural soil from feedlot manured surrounding fields, and urban/municipal sewage influent from two municipal wastewater treatment plants) to develop a workflow to identify and associate ARGs and MGEs. ARG- and MGE-based targeted-assemblies with available short-read data were unable to meet this analysis goal. In contrast, de novo assembly of contigs provided enough sequence context to associate ARGs and MGEs, without compromising discovery rate. However, to estimate the relative abundance of these elements, unassembled sequence data must still be used.

Rothia nasimurium as a Cause of Disease: First Isolation from Farmed Chickens

Rothia nasimurium is a facultative anaerobic Gram-positive coccus belonging to the Rothia genus of the Micrococcaceae family. While Rothia nasimurium is considered an opportunistic pathogen, to date few studies have investigated its pathogenicity and drug resistance. In January 2022, chickens at a poultry farm in China's Xinjiang Uygur Autonomous Region became ill and died. Treatment with commonly used Chinese medicines and antibiotics was ineffective, causing economic losses to the poultry farm. In order to determine the cause of the disease in these poultry farm chickens, the isolation and identification of the pathogens in the livers and other internal organs of the sick and dead chickens were performed. Further, animal pathogenicity tests, antibiotic susceptibility tests, and the detection of antibiotic resistance genes were carried out to analyze the pathogenicity and drug resistance of the identified pathogens. A Gram-positive coccus was isolated from the livers of the diseased chickens. The isolate was resistant to 17 antibiotics, including ciprofloxacin, chloramphenicol, and florfenicol, and was only sensitive to penicillin, amikacin, and tigecycline, to varying degrees. The results of the drug resistance gene testing indicated that the isolated bacterium carried 13 kinds of resistance genes. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, morphological observations, biochemical tests, and 16S rRNA gene sequence analysis were performed on the isolated bacterium, and it was determined that the isolated bacterial strain was Rothia nasimurium. The animal pathogenicity tests showed that the isolate caused feather loss and death in chicks; the clinical symptoms and necropsy lesions of the test chicks were consistent with those observed in the farmed chickens. A review of the literature revealed that, to date, there are no reports of infection with Rothia nasimurium in chickens. Thus, in this study, Rothia nasimurium was isolated from chickens for the first time and an investigation of the biological characteristics of the bacterium was carried out in order to provide a reference for the clinical treatment, prevention, and control of Rothia nasimurium infection.

Anti- and Pro-Oxidant Properties of Essential Oils against Antimicrobial Resistance

The rapid evolution of antimicrobial resistance (AMR) has remained a major public health issue, reducing the efficacy of antibiotics and increasing the difficulty of treating infections. The discovery of novel antimicrobial agents is urgently needed to overcome the challenges created by AMR. Natural products such as plant extracts and essential oils (EOs) have been viewed as potential candidates to combat AMR due to their complex chemistry that carries inherent pro-oxidant and antioxidant properties. EOs and their constituents that hold pro-oxidant properties can induce oxidative stress by producing reactive oxygen species (ROS), leading to biological damage in target cells. In contrast, the antioxidant properties scavenge free radicals through offsetting ROS. Both pro-oxidant and antioxidant activities in EOs represent a promising strategy to tackle AMR. Thus, this review aimed to discuss how pro-oxidants and antioxidants in EOs may contribute to the mitigation of AMR and provided a detailed description of the challenges and limitations of utilizing them as a means to combat AMR.

Investigating forthcoming strategies to tackle deadly superbugs: current status and future vision

INTRODUCTION

Superbugs are microorganisms that cause disease and have increased resistance to the treatments typically used against infections. Recently, antibiotic resistance development has been more rapid than the pace at which antibiotics are manufactured, leading to refractory infections of pathogenic bacteria. Scientists are concerned that a particularly virulent and lethal "superbug" will one day join the ranks of existing bacteria that cause incurable diseases, resulting in a global health disaster on the scale of the Black Death.

AREAS COVERED

Therefore, this study highlights the current developments in the management of antibiotic-resistant bacteria and recommends strategies for further regulating antibiotic-resistant microorganisms associated with the healthcare system. This review also addresses the origins, prevalence, and pathogenicity of superbugs, and the design of antibacterial against these growing multidrug-resistant organisms from a medical perspective.

EXPERT OPINION

It is recommended that antimicrobial resistance (AMR) should be addressed by limiting human-to-human transmission of resistant strains, lowering the use of broad-spectrum antibiotics, and developing novel antimicrobials. Using the risk-factor domains framework from this study would assure that not only clinical but also community and hospital-specific factors are covered, lowering the chance of confounders. Extensive subjective research is necessary to fully understand the underlying factors and uncover previously unexplored areas.

We can't mitigate what we don't monitor: using informatics to measure and improve healthcare systems' climate impact and environmental footprint

Climate change, human health, and healthcare systems are inextricably linked. As the climate warms due to greenhouse gas (GHG) emissions, extreme weather events, such as floods, fires, and heatwaves, will drive up demand for healthcare. Delivering healthcare also contributes to climate change, accounting for ∼5% of the global carbon emissions. To rein in healthcare's carbon footprint, clinicians and health policy makers must be able to measure the GHG contributions of healthcare systems and clinical practices. Herein, we scope potential informatics solutions to monitor the carbon footprint of healthcare systems and to support climate-change decision-making for clinicians, and healthcare policy makers. We discuss the importance of methods and tools that can link environmental, economic, and healthcare data, and outline challenges to the sustainability of monitoring efforts. A greater understanding of these connections will only be possible through further development and usage of models and tools that integrate diverse data sources.

Rothia nasimurium as a Cause of Disease: First Isolation from Farmed Geese

Rothia nasimurium was known previously as an opportunistic pathogen of animals. However, there are few reports regarding the pathogenicity of Rothia nasimurium. In September 2020, geese contracted a disease of unknown cause which brought economic losses to a farm in Jiangsu Province, China, prompting a series of investigations. The bacterium was isolated, cultured, and purified, and then identified using Gram staining, biochemical tests, matrix-assisted laser desorption/ionization time of flight mass spectrometry, and 16S rRNA sequence analysis. After determining the obtained bacteria species, antibiotic susceptibility tests and animal regression experiments were carried out. A strain of bacterium was successfully isolated from the livers of the diseased geese, which was identified as a strain of the Gram-positive bacterium Rothia nasimurium according to the 16S rRNA sequencing results. By indexing references, no goose was reported to have been infected with Rothia nasimurium. The antibiotic susceptibility testing showed that only four antibiotics (amikacin, cefazolin, fosfomycin, and ampicillin/sulbactam) could effectively inhibit the growth of the Rothia nasimurium strain. The animal regression experiments showed that the novel isolated strain could infect goslings, and it also causes serious depilation of goslings. The results of the manuscript expanded the range of pathogenic microorganisms in geese, which is helpful to develop methods for avian endemic control.

Antibiotic misuse and improper practices in India: Identifying the scope to improve through a narrative review

BACKGROUND

In India, antibiotic resistance is high and by 2050, two million people will be affected.

OBJECTIVE

To review antibiotic practices in India and the variables that impact them.

METHODS

For this narrative review, research articles on antibiotic awareness, perception and practices were retrieved from PubMed and Google Scholar using search terms such as 'India AND antibiotic use AND cross sectional AND awareness'. A total of 1730 results were found on 30 June 2020, of which 35 articles were eligible for summarizing the common antibiotic practices.

RESULTS

We found that there are deficiencies in the implementation of existing policies in India. Several issues such as overprescribing of antibiotics, use without prescription and non-adherence to treatment regimens are contributing to irrational antibiotic practices in the country.

CONCLUSION

There is a need for policies at the institute level to help curb the problem of antibiotic resistance.

Leveraging Marine Natural Products as a Platform to Tackle Bacterial Resistance and Persistence

Antimicrobial resistance to existing antibiotics represents one of the greatest threats to human health and is growing at an alarming rate. To further complicate treatment of bacterial infections, many chronic infections are the result of bacterial biofilms that are tolerant to treatment with antibiotics because of the presence of metabolically dormant persister cell populations. Together these threats are creating an increasing burden on the healthcare system, and a "preantibiotic" age is on the horizon if significant action is not taken by the scientific and medical communities. While the golden era of antibiotic discovery (1940s-1960s) produced most of the antibiotic classes in clinical use today, followed by several decades of limited development, there has been a resurgence in antibiotic drug discovery in recent years fueled by the academic and biotech sectors. Historically, great success has been achieved by developing next-generation variants of existing classes of antibiotics, but there remains a dire need for the identification of novel scaffolds and/or antimicrobial targets to drive future efforts to overcome resistance and tolerance. In this regard, there has been no more valuable source for the identification of antibiotics than natural products, with 69-77% of approved antibiotics either being such compounds or being derived from them.Our group has developed a program centered on the chemical synthesis and chemical microbiology of marine natural products with unusual structures and promising levels of activity against multidrug-resistant (MDR) bacterial pathogens. As we are motivated by preparing and studying the biological effects of these molecules, we are not initially pursuing a biological question but instead are allowing the observed phenotypes and activities to guide the ultimate project direction. In this Account, our recent efforts on the synoxazolidinone, lipoxazolidinone, and batzelladine natural products will be discussed and placed in the context of the field's greatest challenges and opportunities. Specifically, the synoxazolidinone family of 4-oxazolidinone-containing natural products has led to the development of several chemical methods to prepare antimicrobial scaffolds and has revealed compounds with potent activity as adjuvants to treat bacterial biofilms. Bearing the same 4-oxazolidinone core, the lipoxazolidinones have proven to be potent single-agent antibiotics. Finally, our synthetic efforts toward the batzelladines revealed analogues with activity against a number of MDR pathogens, highlighted by non-natural stereochemical isomers with superior activity and simplified synthetic access. Taken together, these studies provide several distinct platforms for the development of novel therapeutics that can add to our arsenal of scaffolds for preclinical development and can provide insight into the biochemical processes and pathways that can be targeted by small molecules in the fight against antimicrobial-resistant and -tolerant infections. We hope that this work will serve as inspiration for increased efforts by the scientific community to leverage synthetic chemistry and chemical microbiology toward novel antibiotics that can combat the growing crisis of MDR and tolerant bacterial infections.

Antibiotic abuse during endodontic treatment: A contributing factor to antibiotic resistance

Antibiotic resistance is one of our most serious global health threats. The adverse effects of overusing and misusing antibiotics are highly publicized in the health professional literature. Antibiotic abuse occurs during routine endodontic treatment and there are deficiencies in knowledge regarding prescribing antibiotic and appropriate prophylactic antibiotic use. Multidisciplinary coordination and cooperation among dentists, pharmacists, and patients is needed to curb antibiotic abuse. As endodontists, we can become part of the solution to the antibiotic resistance crisis and deal with it conclusively. This review article discusses antibiotic resistance resulting from antibiotic abuse during endodontic treatment, various factors contributing to it, and measures required for stopping antibiotic abuse in endodontic treatment. A web-based research on MedLine was performed with terms Review Articles published in the last 10 year's dental journals in English for literature researching, extracting, and synthesizing data. Relevant articles were shortlisted. Important cross-reference articles were also reviewed.