Interprofessional education in antimicrobial stewardship, a collaborative effort

Introduction

Antimicrobial stewardship (AMS) education and interprofessional collaboration are integral to the success of a stewardship programme. An interactive interprofessional AMS workshop, designed to encourage workplace interprofessional collaboration was piloted in a tertiary hospital.

Objectives

To obtain feedback to determine the suitability and sustainability of the AMS workshop.

Methods

Feedback was elicited through a predesigned questionnaire containing both open-ended and closed questions on the content and structure of the workshop.

Results

The survey had a 70% (n = 16) overall response rate. All participants agreed that the goals of the workshop were met and that the knowledge and skills gained from the workshop would help them in their AMS roles. All participants indicated that the workshop content, and the level at which it was pitched, met their expectations and that it had improved their knowledge and skills. All agreed that they found it advantageous and enjoyed learning as an interprofessional group. Open feedback showed that the workshop was found to be useful and would potentially result in improved patient care, dissemination of knowledge, improved teamwork and organizational culture.

Conclusions

The positive feedback and changes made following the workshop demonstrated that a targeted AMS educational workshop adds value to an antimicrobial stewardship programme.

Antimicrobial resistance and antimicrobial stewardship in South Africa: a survey of healthcare workers in academic and nonacademic hospitals

Objective

Antimicrobial stewardship programmes (ASPs) facilitate appropriate antimicrobial use and require contextualization for optimal functioning. We aimed to investigate perceptions of and antimicrobial resistance (AMR) and ASPs among healthcare workers in academic and nonacademic hospitals.

Design

Cross-sectional survey.

Setting

Three academic (Charlotte Maxeke Johannesburg Academic, Inkosi Albert Luthuli, Tygerberg) and three nonacademic hospitals (Leratong, Prince Mshiyeni Memorial, and Paarl) in South Africa from January to June 2022.

Participants

Doctors, nurses, and pharmacists.

Methods

Voluntary questionnaire using Google Forms, encompassing AMR, ASPs, and selected discipline-specific components.

Results

Participants comprised 79 doctors (50 academic), 178 nurses (169 academic), and 21 pharmacists (18 academic) and were female predominant. AMR was a problem in academic hospitals (74.7% vs 51.2%, p 0.004); 73.5% overall reported inappropriate antimicrobial use as a major contributor. Adequate education on antimicrobials occurred in only 36.4% overall. Microbiological testing guided therapy more often in nonacademic settings (80.0% vs 50.2%, p <0.001). In both settings, antimicrobial availability drove selection in 48.2%. Overall, ASPs improved patient care (89.8%) and reduced antimicrobial use (86.9%), although felt to override prescriber autonomy in academic settings (29.4% vs 7.5%, p 0.007), mainly among nurses. Only 50.2% reported successful local ASPs. A minority of pharmacists (20.0%) reported sufficient hospital support for ASPs. Education, involvement of infection control staff, and inclusion of nurses in ASPs were most impactful on AMR.

Conclusion

Selected healthcare worker perspectives differ by category and setting and can be targeted to improve ASPs. Further studies should target a higher number of clinical staff in both settings.

Evaluating systematic targeted universal testing for tuberculosis in primary care clinics of South Africa: A cluster-randomized trial (The TUTT Trial)

BACKGROUND

The World Health Organization (WHO) recommends systematic symptom screening for tuberculosis (TB). However, TB prevalence surveys suggest that this strategy does not identify millions of TB patients, globally. Undiagnosed or delayed diagnosis of TB contribute to TB transmission and exacerbate morbidity and mortality. We conducted a cluster-randomized trial of large urban and rural primary healthcare clinics in 3 provinces of South Africa to evaluate whether a novel intervention of targeted universal testing for TB (TUTT) in high-risk groups diagnosed more patients with TB per month compared to current standard of care (SoC) symptom-directed TB testing.

METHODS AND FINDINGS

Sixty-two clinics were randomized; with initiation of the intervention clinics over 6 months from March 2019. The study was prematurely stopped in March 2020 due to clinics restricting access to patients, and then a week later due to the Coronavirus Disease 2019 (COVID-19) national lockdown; by then, we had accrued a similar number of TB diagnoses to that of the power estimates and permanently stopped the trial. In intervention clinics, attendees living with HIV, those self-reporting a recent close contact with TB, or a prior episode of TB were all offered a sputum test for TB, irrespective of whether they reported symptoms of TB. We analyzed data abstracted from the national public sector laboratory database using Poisson regression models and compared the mean number of TB patients diagnosed per clinic per month between the study arms. Intervention clinics diagnosed 6,777 patients with TB, 20.7 patients with TB per clinic month (95% CI 16.7, 24.8) versus 6,750, 18.8 patients with TB per clinic month (95% CI 15.3, 22.2) in control clinics during study months. A direct comparison, adjusting for province and clinic TB case volume strata, did not show a significant difference in the number of TB cases between the 2 arms, incidence rate ratio (IRR) 1.14 (95% CI 0.94, 1.38, p = 0.46). However, prespecified difference-in-differences analyses showed that while the rate of TB diagnoses in control clinics decreased over time, intervention clinics had a 17% relative increase in TB patients diagnosed per month compared to the prior year, interaction IRR 1.17 (95% CI 1.14, 1.19, p < 0.001). Trial limitations were the premature stop due to COVID-19 lockdowns and the absence of between-arm comparisons of initiation and outcomes of TB treatment in those diagnosed with TB.

CONCLUSIONS

Our trial suggests that the implementation of TUTT in these 3 groups at extreme risk of TB identified more TB patients than SoC and could assist in reducing undiagnosed TB patients in settings of high TB prevalence.

TRIAL REGISTRATION

South African National Clinical Trials Registry DOH-27-092021-4901.

Antimicrobial susceptibility of bacterial uropathogens in a South African regional hospital

Background

Urinary tract infections are common bacterial infections affecting millions worldwide. Although treatment options for urinary tract infections are well established, with ciprofloxacin long considered one of the antibiotics of choice, increasing antibiotic resistance may delay the initiation of appropriate therapy. While this increase in antimicrobial resistance has been demonstrated in multiple studies around the world, there is a dearth of information from developing countries.

Objective

This study aimed to describe the antimicrobial susceptibility patterns of commonly isolated bacterial uropathogens in a South African hospital.

Methods

Antimicrobial susceptibility data of isolates obtained from urine specimens at the RK Khan Hospital, a regional hospital in KwaZulu-Natal, South Africa, between January 2018 and December 2020 were retrieved from the hospital's laboratory information system and analysed to determine the differences in resistance rates between the most frequently isolated bacterial uropathogens.

Results

Of the 3048 bacterial urinary pathogens isolated between 2018 and 2020, Escherichia coli (1603; 53%) was the most common, followed by Klebsiella spp. (437; 14%). Both E. coli and Klebsiella spp. showed high rates of resistance to amoxicillin/clavulanic acid (29.8% and 42.3%) and ciprofloxacin (37.7% and 30.4%). Nitrofurantoin resistance was low among E. coli (6.2%) but high among Klebsiella spp. (61.3%).

Conclusion

E. coli and Klebsiella spp. in this study were highly resistant to amoxicillin/clavulanic acid and ciprofloxacin, two of the frequently prescribed oral treatment options.

What this study adds

This study highlights the importance of regular local antimicrobial resistance surveillance to inform appropriate empiric therapy.

Postpasteurization Testing of Human Milk Sterility at Human Milk Banks in Resource-Limited Settings: An Alternative to Standard Microbiological Quality Testing

Introduction: Pasteurized donor human milk provides nutrition and bioactive factors for infant growth and health when a mother's own milk is not available. Bacteriological testing is recommended for each pasteurized batch of donor milk before distribution to ensure that the milk is safe for use. Charm Peel Plates (CPPs) are a simplified, easy-to-use culture method for detecting microorganisms in milk and milk products. This study investigates the feasibility of using CPPs as an alternative test for current standard postpasteurization screening by human milk banks (HMBs), particularly those in resource-limited settings. Aim: The aim of this study was to evaluate the feasibility of using the CPP versus the 5% horse blood agar (HBA) plate (standard South African National Health Laboratory Service method) for detecting bacterial growth in pasteurized human milk samples. Methods: For each of the 50 pasteurized donor milk samples, 100-μL aliquots were cultured on routine HBA and 1 mL on CPPs for the total bacterial colony count. Any positive growth was identified using VITEK^® 2 (bioMérieux). To demonstrate the ability of CPPs to support bacterial growth, four spiked samples were tested. Results: Concurrent negative test results were reported for 49/50 (98%) samples with only one positive test with HBA. Conclusions and Recommendations: The CPP is equivalent to HBA for detection of bacterial growth. Additional advantages of CPPs are ease of use and cost-effectiveness. The CPP is therefore recommended as a point-of-care, bacteriological screening method for donor human milk by HMBs, particularly those in resource-limited settings.

Consequences of rpoB mutations missed by the GenoType MTBDRplus assay in a programmatic setting in South Africa

Background

Rifampicin resistance missed by commercial rapid molecular assays but detected by phenotypic assays may lead to discordant susceptibility results and affect patient management.

Objective

This study was conducted to evaluate the causes of rifampicin resistance missed by the GenoType MTBDRplus and its impact on the programmatic management of tuberculosis in KwaZulu-Natal, South Africa.

Methods

We analysed routine tuberculosis programme data from January 2014 to December 2014 on isolates showing rifampicin susceptibility on the GenoType MTBDRplus assay but resistance on the phenotypic agar proportion method. Whole-genome sequencing was performed on a subset of these isolates.

Results

Out of 505 patients with isoniazid mono-resistant tuberculosis on the MTBDRplus, 145 (28.7%) isolates showed both isoniazid and rifampicin resistance on the phenotypic assay. The mean time from MTBDRplus results to initiation of drug-resistant tuberculosis therapy was 93.7 days. 65.7% of the patients had received previous tuberculosis treatment. The most common mutations detected in the 36 sequenced isolates were I491F (16; 44.4%) and L452P (12; 33.3%). Among the 36 isolates, resistance to other anti-tuberculosis drugs was 69.4% for pyrazinamide, 83.3% for ethambutol, 69.4% for streptomycin, and 50% for ethionamide.

Conclusion

Missed rifampicin resistance was mostly due to the I491F mutation located outside the MTBDRplus detection area and the L452P mutation, which was not included in the initial version 2 of the MTBDRplus. This led to substantial delays in the initiation of appropriate therapy. The previous tuberculosis treatment history and the high level of resistance to other anti-tuberculosis drugs suggest an accumulation of resistance.

Low prevalence of macrolide resistance in Mycoplasma genitalium infections in a cohort of pregnant women living with human immunodeficiency virus

OBJECTIVE

Macrolide resistance in Mycoplasma genitalium (M. genitalium) is increasing as a result of the widespread use of azithromycin in the treatment of sexually transmitted infections (STIs). To date, there are few published studies on macrolide resistance patterns in South African pregnant women. This study now contributes to the growing body of knowledge.

METHODS

This study included 385 pregnant women living with HIV. Vaginal swabs were collected from consenting pregnant women and used for the detection of M. genitalium using the TaqMan assay. Macrolide resistance-associated mutations in the 23S rRNA gene were determined for all samples that tested positive for M. genitalium using the Allplex^TM MG & AziR assay (Seegene) which allows for the simultaneous detection and identification of M. genitalium and six mutations (A2058C, A2058G, A2058T, A2059C, A2059G and A2059T) responsible for azithromycin resistance. The correlation between the TaqMan assay and Allplex^TM MG & AziR assay (Seegene) for the detection of M. genitalium was also performed in a subset of 121 samples.

RESULTS

Of the 385 samples tested in this study, 14 samples were positive for M. genitalium estimating a prevalence of 3.6%. The same 14 samples also tested positive on the Allplex^TM assay indicating a good correlation between the TaqMan Assay and the Allplex^TM. Of the 14 positive samples, one sample carried a mutation at position A2059G denoting macrolide resistance in this pathogen. Mutations in the other regions of the 23S rRNA were not detected. All assay controls used in the mutation scanning produced the desired results showing the validity of the assay.

CONCLUSION

In this study, macrolide resistance in M. genitalium was detected. Despite the low prevalence of resistance determinants ongoing antimicrobial resistance surveillance is vital considering that azithromycin is used in the syndromic management for the treatment of vaginal discharge syndrome.

Pyrazinamide resistance in rifampicin discordant tuberculosis

Introduction

Mycobacterium tuberculosis strains with phenotypically susceptible rpoB mutations (rifampicin discordant) have emerged following implementation of rapid molecular drug resistance testing for tuberculosis. Whilst rifampicin resistance is known to be associated with resistance to other rifamycins (rifapentine and rifabutin) as well as isoniazid and pyrazinamide, rifampicin discordant strains have shown high rates of susceptibility to isoniazid and rifabutin. However, pyrazinamide susceptibly testing results have not been reported.

Materials and methods

We evaluated pyrazinamide resistance in 80 rifampicin discordant and 25 rifampicin and isoniazid susceptible isolates from KwaZulu-Natal in South Africa using Mycobacteria Growth Indicator Tube method and sequencing of the pncA. We also compared susceptibility of pyrazinamide with that of isoniazid.

Results

Pyrazinamide resistance was found in 6/80 (7.5%) rifampicin discordant isolates. All pyrazinamide resistant isolates were also resistant to isoniazid and pyrazinamide resistance was found to be associated with isoniazid resistance. No pyrazinamide resistance was found among the isoniazid susceptible isolates.

Conclusion

Given the low prevalence of pyrazinamide resistance in rifampicin discordant TB, this anti-TB drug still has a significant role in the treatment of these patients. Performing pyrazinamide susceptibility testing remains a challenge, our findings show that isoniazid susceptible isolates are unlikely to be resistant to pyrazinamide among the discordant TB isolates.

Neonatal sepsis in a tertiary unit in South Africa

BACKGROUND

Antimicrobial resistance (AMR) has emerged as a global threat to healthcare resulting in an increase in morbidity and mortality. Neonatal sepsis is ranked as the third highest cause of neonatal demise globally, in which AMR accounted for 31.0% of deaths. AMR in neonates has been poorly characterised in Durban, South Africa. Thus, the resultant effect of AMR on empiric regimens for neonatal sepsis is uncertain in this setting. Therefore, this study analysed the aetiology and antimicrobial susceptibility patterns of bloodstream infections within the neonatal intensive care unit at a tertiary hospital in Durban, with the aim of establishing an effective empiric regimen for the unit.

METHODS

A retrospective data review on positive blood cultures from the neonatal intensive care unit at Inkosi Albert Luthuli Central Hospital was conducted. Three time periods were analysed: 2014, 2016 and 2018. Culture data from neonates aged 0-30 days were included and repeat cultures were de-duplicated. The frequency of common organisms and their antimicrobial susceptibilities were analysed. Fischer's exact test was used for subgroup analysis. Poisson and logistic regressions were used to assess significant trends in organisms and antimicrobial susceptibilities over time.

RESULTS

Late-onset sepsis (86.8%) predominated over early-onset sepsis (13.2%). A preponderance of gram-positive organisms (68.7%) over gram-negatives (26.8%) and fungi (4.5%) was detected. Common pathogens included coagulase-negative staphylococci (53.5%), Klebsiella pneumoniae (11.6%), enterococci (9.3%), and Acinetobacter baumannii (7.7%). Despite the small contribution of fungi to the microbial profile, fluconazole-resistant Candida parapsilosis predominated within that group. High rates of resistance to first- and second-line antibiotics were also noted among gram-positive and gram-negative organisms. Multidrug resistant organisms included extended-spectrum beta-lactamase (ESBL) K. pneumoniae (7.6%) and extensively-drug resistant A. baumannii (7.0%). However, a statistically significant decrease in ESBL-producing organisms was documented during the entire study period (p = 0.005).

CONCLUSIONS

It was determined that first-line antimicrobials, advocated by the World Health Organization for treatment of neonatal sepsis, proved ineffective in this unit due to high levels of AMR. Therefore, this study advises that meropenem with or without vancomycin provides optimal empiric cover. Amphotericin B is advocated for empiric antifungal therapy. Ongoing surveillance is necessary.

Antimicrobial stewardship approach: Prevalence of antimicrobial resistant bacteria at a regional hospital in South Africa

Introduction: Antimicrobial stewardship practices are crucial for the regular surveillance to change the antimicrobial policy. This study was conducted to decide the prevalence of common bacteria and their antibiogram regarding antimicrobial stewardship program within one year, at the regional and district, Stanger hospital in South Africa. Methodology: It was based the study on clinical data and laboratory records of the patients. It reviewed the clinical and laboratory data. The prevalence/proportion rate was calculated and correlated with the majority of microorganism vs empirical therapy. Results: The prevalence of MRSA, MRSE, VRSA, ESBL+ K. pneumoniae; E. coli cultured from the blood was 25%, 49%, 2%, 62% and 27% respectively. Similarly, we analysed for other targeted MDROs organisms (Acinetobacter species and P. aeruginosa, CRE, CPE) isolated from blood culture and endotracheal aspirate. The prevalence of MDR Acinetobacter species exceeded 61%, 33% from the blood and ETA respectively. The prevalence of MDR P. aeruginosa was 10% from ETA. The MRSA, MRSE, VRSA, VRE were observed in blood specimen. The majority of the microorganisms cultured from the CSF was Cryptococcus neoformans and followed by bacteria: Streptococcus pneumonia, Streptococcus group B and Haemorphilus influenza. Conclusion: The selection of empirical antimicrobial therapy relates not only the institutions or unit-specific antibiogram but also the site of infection. We can further suggest continuing to do surveillance of antibiogram and prevalence of MDR organisms for infection control as well as for empirical therapy, part of the antimicrobial  stewardship program based on yearly records to change the local hospital antibiotic policy.

Association of Staphylococcus nasal colonization and HIV in end-stage renal failure patients undergoing peritoneal dialysis

INTRODUCTION

Staphylococcal infections can cause significant morbidity in patients undergoing dialysis. This study evaluated the effects of HIV infection on nasal carriage of Staphylococcus aureus, staphylococcal peritonitis, and catheter infection rates in patients with end-stage renal failure managed with continuous ambulatory peritoneal dialysis (CAPD).

METHODS

Sixty HIV-positive and 59 HIV-negative CAPD patients were enrolled and followed up for up to 18 months. S. aureus nasal carriage (detected by nasal swab culture), Staphylococcal peritonitis (diagnosed by clinical presentation, and CAPD effluent Staphylococcal culture and white blood cell count ≥100 cells/µL), and catheter infections (including exit site and tunnel infections) were assessed monthly.

RESULTS

At 18 months, S. aureus nasal carriage rates were 43.3% and 30.5% (p = 0.147) and the methicillin-resistant S. aureus (MRSA) nasal carriage rates were 31.7% and 13.6% (p = 0.018) for the HIV-positive and HIV-negative cohorts, respectively. The HIV-positive cohort was associated with increased hazards for staphylococcal peritonitis, (adjusted hazard ratio [AHR] 2.85, 95% confidence interval [CI] 1.19-6.84, p = 0.019) due to increased coagulase-negative staphylococcal (CNS) peritonitis rate in the HIV-positive cohort compared with the HIV-negative cohort (0.435 vs. 0.089 episodes/person-years; AHR 7.64, CI 2.18-26.82, p = 0.001). On multivariable analysis, CD4+ cell count <200 cells/µL, diabetes, and S. aureus nasal carriage were found to be independent predictors of S. aureus peritonitis.

CONCLUSIONS

These findings suggest that HIV infection may be a risk factor for MRSA nasal colonization and may increase the risks of CNS peritonitis, while a CD4+ cell count <200 cells/µL and S. aureus nasal carriage may be important predictors of S. aureus peritonitis.

Horizontal transfer of OXA-23-carbapenemase-producing Acinetobacter species in intensive care units at an academic complex hospital, Durban, KwaZulu-Natal, South Africa

Introduction: Carbapenemase production is an important mechanism of carbapenem resistance in Acinetobacter species. This study investigated the presence of the carbapenem-hydrolysing class D β–lactamase- encoding genes, blaOXA-23 and blaOXA-58, and their association with the spread of multidrug-resistant (MDR) Acinetobacter species in intensive care units at an academic hospital. Method: Forty-four MDR Acinetobacter species were confirmed using VITEK®2 and Epsilometer tests. The blaOXA-23 and blaOXA-58 genes were detected by polymerase chain reaction (PCR) in twenty-four selected isolates. The blaOXA-23 amplicons were sequenced and compared to the GenBank database. Genotypic relatedness of isolates was determined by pulsed field gel electrophoresis (PFGE). Clinical and laboratory data were analysed. Results: Among the twenty-four isolates, eighteen were carbapenem resistant and six were sensitive. The blaOXA-23 gene, but not blaOXA-58, was detected in the eighteen resistant strains. The blaOXA-23 amplicons showed 100% identity with the GenBank database of blaOXA-23. The MICs of carbapenems against Acinetobacter species carrying the blaOXA-23 gene were 8 to 16 μg/ml. Genetic relatedness was evident among isolates of seven pairs from fourteen patients. Of these patients, twelve were in the same ICUs and two were adjacent to another ICU during the same hospitalisation period. Conclusion: The selected MDR Acinetobacter species carried the blaOXA-23 gene responsible for resistance to carbapenems, while molecular and clinical data analysis suggested horizontal transmission in ICUs. In addition, the PFGE typing of a diverse collection of MDR Acinetobacter species clones showed that isolates were related to no more than two patients, suggesting that no outbreak had occurred.

Analysis of clinical and microbiological data on Acinetobacter baumannii strains assist the preauthorization of antibiotics at the patient level for an effective antibiotic stewardship program

Drug resistant Acinetobacter baumannii (A. baumannii) poses serious treatment challenges and is on the rise worldwide. The Infectious Diseases Society of America/Society for Healthcare Epidemiology of America recommends preauthorization of antibiotics to ensure successful antibiotic stewardship programs (ASWPs). This study estimates and analyzes the microbiological and clinical characteristics of A. baumanii strains with differentiating criteria for sepsis versus colonization, in order to support preauthorization and assist ASWPs at the patient level. A retrospective observational study was performed from 2008 to 2014. The clinical and microbiological characteristics of A. baumannii strains were correlated to assess pathogenic status and antibiotic resistance patterns. A flow chart was produced to differentiate between sepsis and colonization amongst patient groups. A. baumannii was cultured in 2656 cases, with a prevalence of 0.9-2.4% during 7 years study periods. There was a statistically significant difference between the sepsis and colonization groups (P=0.02). Sepsis accounted for 37-51% of A. baumanii isolates and colonisation for 49-63% (P=<0.01). Multidrug resistant (MDR), extensive drug resistant (XDR) and pandrug resistant (PDR) A. baumannii was detected in 53-60%, 1-19% and 1% of cultures in the sepsis group, and 75%, 8-23% and 1% in the colonized group. There was a high percentage of polymicrobial infection in the sepsis group and pure growth was not always significant for sepsis. Cases of MDR and XDR A. baumannii increased over the seven-year study, while PDR strains emerged. For a successful ASWP, both clinical and microbiological information should be interpreted when establishing preauthorization/decision to treat.