Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review

Background

Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally.

Methods

MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data.

Results

Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides.

Conclusions

Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.

Antibiotic prescriptions in acute otitis media and pharyngitis in Italian pediatric outpatients

Background

Acute otitis media (AOM) and pharyngitis are very common infections in children and adolescents. Italy is one of the European countries with the highest rate of antibiotic prescriptions. The aim of this study is to describe first-line treatment approaches for AOM and pharyngitis in primary care settings in Italy over six years, including the prevalence of ‘wait and see’ for AOM, where prescription of antibiotics is delayed 48 h from presentation, and differences in prescribing for pharyngitis when diagnostic tests are used.

Methods

The study is a secondary data analysis using Pedianet, a database including data at outpatient level from children aged 0–14 in Italy. Prescriptions per antibiotic group, per age group and per calendar year were described as percentages. “Wait and see” approach rate was described for AOM and pharyngitis prescriptions were further grouped according to the diagnostic test performed and test results.

Results

We identified 120,338 children followed by 125 family pediatricians between January 2010 and December 2015 for a total of 923,780 person-years of follow-up. Among them 30,394 (mean age 44 months) had at least one AOM diagnosis (n = 54,943) and 52,341 (mean age 5 years) had at least one pharyngitis diagnosis (n = 126,098). 82.5% of AOM diagnoses were treated with an antibiotic within 48 h (mainly amoxicillin and amoxicillin/clavulanate) and the “wait and see” approach was adopted only in 17.5% of cases. The trend over time shows an increase in broad spectrum antibiotic prescriptions in the last year (2015). 79,620 (63%) cases of pharyngitis were treated and among GABHS pharyngitis confirmed by rapid test 56% were treated with amoxicillin. The ones not test confirmed were treated mainly with broad spectrum antibiotics.

Conclusions

Despite guidance to use the ‘wait and see’ approach in the age group analyzed, this strategy is not often used for AOM, as previously noted in other studies in hospital settings. Broad-spectrum antibiotic prescription was more frequent when pharyngitis was not confirmed by rapid test, in keeping with evidence from other studies that diagnostic uncertainty leads to overuse of antibiotics.

Electronic supplementary material

The online version of this article (10.1186/s13052-019-0696-9) contains supplementary material, which is available to authorized users.

Factors Determining Survival and Retention among HIV-Infected Children and Adolescents in a Community Home-Based Care and a Facility-Based Family-Centred Approach in Kampala, Uganda: A Cohort Study

We describe factors determining retention and survival among HIV-infected children and adolescents engaged in two health care delivery models in Kampala, Uganda: one is a community home-based care (CHBC) and the other is a facility-based family-centred approach (FBFCA). This retrospective cohort study reviewed records from children aged from 0 to 18 years engaged in the two models from 2003 to 2010 focussing on retention/loss to follow-up, mortality, use of antiretroviral therapy (ART), and clinical characteristics. Kaplan Meier survival curves with log rank tests were used to describe and compare retention and survival. Overall, 1,623 children were included, 90.0% (1460/1623) from the CHBC. Children completed an average of 4.2 years of follow-up (maximum 7.7 years). Median age was 53 (IQR: 11-109) months at enrolment. In the CHBC, retention differed significantly between patients on ART and those not (log-rank test, adjusted, P < 0.001). Comparing ART patients in both models, there was no significant difference in long-term survival (log-rank test, P = 0.308, adjusted, P = 0.489), while retention was higher in the CHBC: 94.8% versus 84.7% in the FBFCA (log-rank test, P < 0.001, adjusted P = 0.006). Irrespective of model of care, children receiving ART had better retention in care and survival.

Plasma Acceleration Above Martian Magnetic Anomalies

Auroras are caused by accelerated charged particles precipitating along magnetic field lines into a planetary atmosphere, the auroral brightness being roughly proportional to the precipitating particle energy flux. The Analyzer of Space Plasma and Energetic Atoms experiment on the Mars Express spacecraft has made a detailed study of acceleration processes on the nightside of Mars. We observed accelerated electrons and ions in the deep nightside high-altitude region of Mars that map geographically to interface/cleft regions associated with martian crustal magnetization regions. By integrating electron and ion acceleration energy down to the upper atmosphere, we saw energy fluxes in the range of 1 to 50 milliwatts per square meter per second. These conditions are similar to those producing bright discrete auroras above Earth. Discrete auroras at Mars are therefore expected to be associated with plasma acceleration in diverging magnetic flux tubes above crustal magnetization regions, the auroras being distributed geographically in a complex pattern by the many multipole magnetic field lines extending into space.

Solar Wind-Induced Atmospheric Erosion at Mars: First Results from ASPERA-3 on Mars Express

The Analyzer of Space Plasma and Energetic Atoms (ASPERA) on board the Mars Express spacecraft found that solar wind plasma and accelerated ionospheric ions may be observed all the way down to the Mars Express pericenter of 270 kilometers above the dayside planetary surface. This is very deep in the ionosphere, implying direct exposure of the martian topside atmosphere to solar wind plasma forcing. The low-altitude penetration of solar wind plasma and the energization of ionospheric plasma may be due to solar wind irregularities or perturbations, to magnetic anomalies at Mars, or both.

Alkylaminopropenones and alkylamino-propenoates as efficient and versatile synthons in microwave-assisted combinatorial synthesis

A simple and fast one-pot method using microwave irradiation for the synthesis of a number of small libraries of diverse heterocycles is described in this paper. The two-step one-pot method includes the formation of alkylaminopropenones or alkylaminopropenoates in 5 min at 180 degrees C and a subsequent treatment with dinucleophiles for 3 to 5 min at 150 degrees C to 180 degrees C to form a variety of biologically interesting heterocycles in a cascade-type reaction. The combination of combinatorial chemistry and microwave-assisted synthesis was found to be very efficient.

Familiarity with and social distance from people who have serious mental illness

OBJECTIVES

This study examined the effects of familiarity with and social distance from persons who have serious mental illness on stigmatizing attitudes about mental illness.

METHODS

A total of 208 community college students completed three written measures about familiarity, perception of dangerousness, fear, and social distance. Path analysis with manifest-variable structural modeling techniques was used to test a version of a model in which familiarity influences the perception of dangerousness, which in turn influences fear, which influences social distance from persons with serious mental illness.

RESULTS

Most of the participants reported experience with mental illness. Scores on the three written measures largely supported the path model. Correlations between the perception of dangerousness and fear as well as between fear and social distance were particularly strong.

CONCLUSIONS

Approaches to social change that increase the public's familiarity with serious mental illness will decrease stigma. Further studies are warranted that focus on how contact between members of the general public and persons who have serious mental illness may be facilitated.

Identification of benzethonium chloride in commercial grapefruit seed extracts

Commercial grapefruit seed extracts (GSE) were extracted with chloroform. The solvent was evaporated, and the resulting solid was subsequently analyzed by high-performance liquid chromatography, electrospray ionization mass spectrometry, nuclear magnetic resonance (NMR) spectroscopy, and elemental analysis (by proton-induced X-ray emission [PIXE] analysis). The main constituent was identified as benzethonium chloride, a synthetic antimicrobial agent commonly used in cosmetics and other topical applications. This compound comprised 8.03% (n = 2) of the liquid GSE sample. Higher amounts of benzethonium chloride were found in powder GSE samples.

Rural health and IT&T in Australia--the results of qualitative and quantitative surveys of the needs, perceptions and expectations of rural and remote health professionals

This paper reports an initial overview of the findings of qualitative and quantitative surveys of rural and remote health professionals in Australia to determine their present use of information technology and telecommunications (IT&T), barriers to the use of IT&T, and expected future uses. The survey research commissioned for this project supports the degree of importance rural and remote health professionals attach to the introduction and use of IT&T to reduce their sense of professional isolation and to support their service provision.

Nuclear magnetic resonance studies of the C-terminal human growth hormone fragment I179-C182-[SS]-C189-P191 and the related trisulfide peptide I179-C182-[SSS]-C189-P191

The synthetic C-terminal hGH fragment I179-C182-[SS]-C189-P191 and the related trisulfide peptide I179-C182-[SSS]-C189-P191 have been studied using homonuclear 1H-NMR methods and distance geometry calculations. The 1H-NMR spectra of both the disulfide (diS) and the trisulfide (triS) were completely assigned. Amide proton exchange rates, NOEs and the temperature dependence of the NH chemical shifts indicate a hydrogen bond in triS between Val185 and Ser188 stabilizing a turn in this region. 3JH,H coupling constants and NOEs were measured and used as input for distance geometry calculations. For triS two families of structures with averaged pairwise backbone root mean square deviations for Cys182-Cys189 of 1.3-1.5 A were found, only one of which is compatible with experimental data. For diS only one family of structures was found, but with such a low structural definition (back bone rmsd > 2 A) that no interpretation into a consensus structure is useful. The generated structures were compared to the crystal structure of the terminal loop in hGH, complexed to its binding proteins. The resemblance was low between the solution structures of the tridecapeptides and the terminal hGH loop.

Isolation and characterization of a trisulfide variant of recombinant human growth hormone formed during expression in Escherichia coli

A new variant of human growth hormone was recently found [Pavlu, B. & Gellerfors, P. (1993) Bioseparation 3, 257-265]. We report here the identification and the structural determination of this variant. The variant, which is formed during the expression of human growth hormone in Escherichia coli, was found to be more hydrophobic than rhGH as judged by its prolonged elution time by hydrophobic interaction chromatography. The rhGH hydrophobic variant (rhGH-HV) was isolated and subjected to trypsin digestion and RP-HPLC analysis, resulting in an altered retention time of one single tryptic peptide as compared to the corresponding fragment of rhGH. This tryptic peptide constitutes the C-terminus (aa 179-191) of hGH and contains one of the two disulfide bridges in hGH, viz. Cys182-Cys189. Amino acid sequences and composition analyses of the tryptic peptide from rhGH-HV (Tv18-19) and the corresponding tryptic peptide from rhGH (T18+19) were identical. Electrospray mass spectrometry (ES MS) of Tv18+19 isolated from rhGH-HV revealed a monoisotopic mass increase of 32.7, as compared to T18+19 from rhGH. A synthetic Tv18+19 peptide having a trisulfide bridge between Cys182 and Cys189 showed identical fragment in ES/MS compared to Tv18+19 isolated from rhGH-HV, i.e. m/z 617.7 and 682.9. These fragments are formed through a unique cleavage in the trisulfide (Cys182-SSS-Cys189) bridge not found in the corresponding T18+19 disulfide peptide. Furthermore, the synthetic Tv18+19 co-eluted in RP-HPLC with Tv18+19 isolated from rhGH-HV. Two-dimensional NMR spectroscopy of the synthetic T18+19 and Tv18+19 peptides were performed. Using these data all protons were assigned. The major chemical shift changes (delta delta > 0.05 ppm) observed were for the beta-protons of Cys182 and Cys189 in Tv18+19 as compared to T18+19. CD spectroscopy data were also in agreement with the above results. Based on these physico-chemical data rhGH-HV has been structurally defined as a trisulfide variant of rhGH. The receptor binding properties of rhGH-HV was studied by a biosensor device, BIAcore. The binding capacity of rhGH-HV was similar to rhGH with a binding stoichiometry to the rhGHBP of 1:1.6 and 1:1.5, respectively, indicating that the trisulfide modification did not affect its receptor binding properties.

Evaluation of volume selection methods in in vivo MRS. Design of a new test phantom

In vivo MR spectroscopy (MRS) requires some kind of volume selection method to be able to measure the signal from a selected part of the body. To be able to interpret the spectra correctly, the quality of the volume selection must be investigated for each new MRS application using phantom measurements. A new phantom, especially suitable for precision measurements of the volume selection performance, is presented. It contains a small, remotely controlled signal source placed inside a larger vessel. This principle can be applied to various body regions, coil types and nuclei. The measurement conditions are close to the clinical situation. The phantom does not have to be repositioned during a signal profile measurement and the signal contribution from each point along the profile is determined regarding sign and amplitude.

Dispersion flattening in a W fiber

An exhaustive and simple method for dispersion flattening in double-clad single-mode fibers is presented. The idea is to generate all such fibers with a certain cutoff wavelength and then find, by one-dimensional minimization and direct inspection, fibers yielding minimum dispersion. As examples, the root mean square chromatic dispersion over the wavelength range (1.25, 1.60 µm) is minimized for a W fiber and also for a triangular-index fiber with a depressed inner cladding. The material dispersion is included through a Sellmeier refractive-index formula. The full vector solution of Maxwell's equations is used. It is found, as is well known, that the W fiber is capable of dispersion flattening. The validity of the numerical results presented depends on the validity of the approximate refractive-index model used.

Minimization of the chromatic dispersion over a broad wavelength range in a single-mode optical fiber

The effective refractive index as a function of vacuum wavelength is approximated by Lagrange interpolation polynomials. The rms value of the chromatic dispersion is then calculated analytically. Itis demonstrated that use of fourth-degree polynomials is far more efficient than the use of second-degree polynomials. The rms value of the chromatic dispersion over the wavelength range (1.25 µm, 1.60 µm) is calculated and minimized for step-index fibers, triangular index fibers, and α-power fibers. The full vector solution of Maxwell's equations is used. The error induced by the approximate refractive-indexmodel is found to be negligible at the point of minimum dispersion.

Evaluation of treatment provided patients hospitalized with orofacial odontogenic infections: a retrospective study

The purpose of this study was to evaluate the treatment that patients receive when they are hospitalized for orofacial infections. Results indicated that dental consultations were not always obtained by medical personnel prior to the diagnosis and treatment of patients and that the antibiotic therapy employed did not always involve the recognized drug of choice.