Impact of coronavirus disease 2019 (COVID-19) on antimicrobial resistance among major pathogens causing healthcare-associated infection

BACKGROUND

Coronavirus disease 2019 (COVID-19) has caused great impact on healthcare systems, including antibiotic usage and multi-drug resistant (MDR) bacterial infections at hospitals. We aim to investigate the trends of antimicrobial resistance among the major pathogens causing healthcare-associated infection (HAI) at intensive care units (ICU).

MATERIAL AND METHODS

The demographic characteristics of hospitalization, usage of antimicrobial agents, counted by half-an-year DID (defined daily dose per 1000 patient-days), and HAI density of five major MDR bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), carbapenem-resistant Acinetobacter baumannii (CRAB), carbapenem-resistant Klebsiella pneumoniae (CRKP), and carbapenem-resistant Pseudomonas aeruginosa (CRPA), of ICU patients at a medical center in Taiwan during January 2017 to December 2021 were collected and analyzed.

RESULTS

The total antibiotic usage, counted by DID, had a significant increasing trend, before COVID-19 occurrence in 2017-2019, but no further increase during the pandemic period in 2020-2021. However, comparing the two time periods, antibiotics consumption was significantly increased during pandemic period. There was no significant change of HAI density in MRSA, VRE, CRAB, CRKP, and CRPA, comparing the pandemic to the pre-pandemic period. Although, CRKP and CRPA infection rates were increasing during the pre-pandemic period, there was no further increase of CRKP and CRPA HAI rates during the pandemic period.

CONCLUSION

During COVID-19 pandemic, there was no significant increase in HAI density of five major MDR bacteria at ICU in Taiwan, despite increased antibiotic usage. Strict infection prevention measures for COVID-19 precautions and sustained antimicrobial stewardship probably bring these effects.

Antibiotics usage practices in aquaculture in Bangladesh and their associated factors

Background

Irrational and inappropriate use of antibiotics in aquaculture can contribute to the development of antibiotic resistance.

Objectives

In this study, we aimed to assess antibiotic usage in inland and coastal fish farms in Bangladesh and identify factors associated with this practice.

Methods

We conducted a cross-sectional study to collect antibiotic usage information from 672 fish farmers in Bangladesh. The frequency of use, the types of antibiotics, the purpose of usage, and antibiotic prescribing practices were estimated. Adjusted odds ratios (aOR) were calculated to measure the association between antibiotic usage and factors related to the characteristics of the farms and farmers using multivariable logistic regression models.

Results

Twenty-two farms reported using antibiotics in the last 24 h preceding the interview (3%, 95% CI: 2-5%); 36 farms (5%, 95% CI: 4-7%) in the last 72 h, 141 farms (21%, 95% CI: 18-24%) in the last 14 days, and 478 farms (71%, 68-75%) reported antibiotic usage at least once since the start of their production cycle. Antibiotics usage in the last 14 days preceding the interviews was higher in freshwater fish farms (98%) than in brackish water farms (2%). Oxytetracycline, ciprofloxacin, and amoxicillin were the most frequently used antibiotics. Most of the antibiotics were reported to be used for both therapeutic and prophylactic purposes (71%, 95% CI: 63-78%). Antibiotics used within the last 14 days were mainly advised by feed dealers or drug sellers (51%, 95% CI: 43-60%), followed by farmers themselves (31%, 95% CI: 23-38%) and local service providers (18%, 95% CI, 12-25%). Fish farms having history of antibiotic use within the last 14 days preceding interviews was significantly associated with illness in fish (aOR 1.98, 95% CI:1.21-3.29) compared to farms with healthy fish and fishes cultured in ponds (aOR 9.34, 95% CI: 3.69-23.62) compared to enclosure cultures.

Conclusions

Improvement of fish health through better farming practices and changes in feed dealers' and farmers' attitudes towards self-prescription of antibiotic without veterinarian diagnostics may help to reduce the levels of antibiotic usage and thus contribute to mitigating antimicrobial resistance.

Myths and Misconceptions around Antibiotic Resistance: Time to Get Rid of Them

The antibiotic resistance arena is fraught with myths and misconceptions, leading to wrong strategies to combat it. It is crucial to identify them, discuss them in light of current evidence, and dispel those that are unequivocally wrong. This article proposes some concepts that may qualify as misconceptions around antibiotic resistance: the susceptible-resistant dichotomy; that incomplete antibiotic courses cause resistance; that resistance "emerges" in patients and hospitals; that antibiotics are mostly abused clinically; that resistance is higher in countries that use more antibiotics; that reducing antibiotic usage would reduce resistance; that financial incentives would "jumpstart" research and development of antibiotics; that generic and "original" antibiotics are the same; and that new anti-infective therapies are just around the corner. While some of these issues are still controversial, it is important to recognize their controversial status, instead of repeating them in specialized literature and lectures and, especially, in the planning of strategies to cope with resistance.

Effects of monthly evaluations on the rates of irrational antimicrobial prescription in the outpatient and emergency departments at Ningbo No. 6 Hospital, Ningbo, China

BACKGROUND

Antibiotic resistance is a major global public health problem. The primary cause of antibiotic resistance is inappropriate antibiotic use. In this study, we aimed to verify whether the monthly evaluation of antibiotic prescription improves clinical antibiotic use in outpatient and emergency departments.

METHODS

A minimum of 25% of the prescriptions for antibacterial drugs were randomly selected at the outpatient and emergency departments to enter the monthly evaluation system from July 2016 to June 2019. We analysed the rate of irrational prescription of antibiotics, proportion of the use of antibiotics, and consistency between the evaluation and expert groups after implementing the monthly assessment to validate the role of monthly evaluations.

RESULTS

After 3 years of monthly evaluations of antibiotic prescriptions, the utilisation rate of single antibiotics in the outpatient and emergency departments was found to increase each year. Each year, a decreasing trend was observed for the irrational use of antibiotics, whereas the proportion of antibiotics to the total drugs prescribed gradually decreased in the same period. In addition, the consistency of prescription evaluation results between the evaluation and expert groups increased continuously.

CONCLUSIONS

Monthly evaluation of antibiotic prescriptions is an effective management tool for the rational use of antibiotics in clinical practice. This practice could help reduce the combinative use of antibiotics, rate of irrational antibiotic prescription, and antibiotic use ratio, and play an important role in safe clinical drug use.

Knowledge, attitudes and practices of parents towards antibiotic use in rural communities in Peru: a cross-sectional multicentre study

Background

The inappropriate use of antibiotics significantly contributes to the development of antibiotic resistance. There is limited information about the use of antibiotics among parents from rural areas in Peru. This study aimed to describe the knowledge, attitudes and practices towards antibiotics among parents of children < 5 years of age from rural communities in Peru; to explore the association between knowledge and attitudes towards antibiotics and to explore determinants of low knowledge and self-medicating his/her child with antibiotics.

Methods

Cross-sectional study in six rural primary health centres in Peru using a self-administered survey. Crude and adjusted Prevalence Ratios (PR), and 95% Confidence Intervals (95% CI) were calculated to explore determinants of low knowledge and of having self-medicated his/her child with antibiotics. Linear regression was used to explore the association between knowledge and attitudes.

Results

A total of 231 parents were included. The largest gap in knowledge was among 183 parents (79%) who did not know that antibiotics cannot cure viral infections. The largest gap in attitudes was among 185 participants (80%) that did not disagree with “If I want my child to receive antibiotics, I would not be satisfied if the doctor refuses to prescribe them”. More than half of parents (n = 120, 52%) reported having self-medicated his/her child with antibiotics. A positive correlation was found between knowledge and attitudes (Coefficient 0.53, 95% CI 0.38–0.68) after adjusting for the age and the education of the parent. Parents who were < 20 years old were more likely to have low knowledge about antibiotics (crude PR 2.39, 95% CI 1.32–4.34) compared to those aged > 40 years.

Parents who had self-medicated his/her child with antibiotics (n = 120, 52%) were more likely to have purchased antibiotics without prescription (aPR 2.70, 95% CI 1.74–4.19) and to have received antibiotics after the recommendation of a pharmacist (aPR 1.79, 95% CI 1.13–2.82).

Conclusions

Knowledge about antibiotics among parents from rural settings in Peru is limited and highlights the need for educational interventions. Public health policies to limit the acquisition of antibiotics without prescription should be implemented.

Marked reduction in antibiotic usage following intensive malaria control in a cohort of Ugandan children

BACKGROUND

Intensive malaria control may have additional benefits beyond reducing the incidence of symptomatic malaria. We compared antibiotic treatment of children before and after the implementation of highly effective malaria control interventions in Tororo, a historically high transmission area of Uganda.

METHODS

Two successive cohorts of children, aged 0.5 to 10 years, were followed from September 2011 to October 2019 in a dedicated study clinic. Universal distribution of long-lasting insecticidal nets was conducted in 2013 and 2017. Sustained indoor residual spraying of insecticide (IRS) was initiated in December 2014. Generalized linear mixed-effects models were used to compare the incidence of antimalarial and antibiotic treatments before and after vector control measures were implemented.

RESULTS

Comparing the period prior to the implementation of IRS to the period after IRS had been sustained for 4-5 years, the adjusted incidence of malaria treatments decreased from 2.68 to 0.05 per person-year (incidence rate ratio [IRR] = 0.02, 95% CI 0.01-0.03, p < 0.001), and the adjusted incidence of antibiotic treatments decreased from 4.14 to 1.26 per person-year (IRR = 0.30, 95% CI 0.27-0.34, p < 0.001). The reduction in antibiotic usage was primarily associated with fewer episodes of symptomatic malaria and fewer episodes of fever with sub-microscopic parasitemia, both of which were frequently treated with antibiotics.

CONCLUSIONS

In a historically high transmission setting, the implementation of highly effective vector control interventions was followed by a marked reduction in antibiotic treatment of children. This added benefit of malaria control could have important implications for antibiotic prescribing practices, efforts to curtail antimicrobial resistance, and health system costs.

Impact of mass and systematic antibiotic administration on antibiotic resistance in low- and middle-income countries? A systematic review

Antibiotic consumption is a key driver of antimicrobial resistance (AR), particularly in low- and middle-income countries (LMICs) where risk factors for AR emergence and spread are prevalent. However, the potential contribution of mass drug administration (MDA) and systematic drug administration (SDA) of antibiotics to AR spread is unknown. We conducted a systematic review to provide an overview of MDA/SDA in LMICs, including indications, antibiotics used and, if investigated, levels of AR over time. This systematic review is reported in accordance with the PRISMA statement. Of 2438 identified articles, 63 were reviewed: indications for MDA/SDA were various, and targeted populations were particularly vulnerable, including pregnant women, children, human immunodeficiency virus (HIV)-infected populations, and communities in outbreak settings. Available data suggest that MDA/SDA may lead to a significant increase in AR, especially following azithromycin administration. However, only 40% of studies evaluated AR. Integrative approaches that evaluate AR in addition to clinical outcomes are needed to understand the consequences of MDA/SDA implementation, combined with standardised AR surveillance for timely detection of AR emergence.

Antimicrobial resistance in commensal Escherichia coli and Enterococcus spp. is influenced by production system, antimicrobial use, and biosecurity measures on Spanish pig farms

Background

Antimicrobial resistance (AMR) is a global public health threat consequence of antimicrobial use (AMU) in human and animal medicine. In food-producing animals factors such as management, husbandry or biosecurity may impact AMU. Organic and extensive Iberian swine productions are based on a more sustainable and eco-friendly management system, providing an excellent opportunity to evaluate how sustained differences in AMU impact the AMR in indicator bacteria. Here, we evaluate the usefulness of commensal Escherichia coli and Enterococcus spp. isolates as AMR bioindicators when comparing 37 Spanish pig farms from both intensive and organic-extensive production systems, considering the effect of AMU and biosecurity measures, the last only on intensive farms.

Results

The production system was the main factor contributing to explain the AMR differences in E. coli and Enterococcus spp. In both bacteria, the pansusceptible phenotype was more common (p < 0.001) on organic-extensive farms when compared to intensive herds. The microbiological resistance in commensal E. coli was, for most of the antimicrobials evaluated, significantly higher (p < 0.05) on intensive farms. In enterococci, the lincosamides usage revealed the association between AMR and AMU, with an increase in the AMR for erythromycin (p < 0.01), quinupristin-dalfopristin (p < 0.01) and the multidrug-resistant (MDR) phenotype (p < 0.05). The biosecurity measures implemented on intensive farms influenced the AMR of these bioindicators, with a slightly lower resistance to sulfamethoxazole (p < 0.01) and the MDR phenotype (p < 0.05) in E. coli isolated from farms with better cleaning and disinfection protocols. On these intensive farms, we also observed that larger herds had a higher biosecurity when compared to smaller farms (p < 0.01), with no significant associations between AMU and the biosecurity scores.

Conclusions

Overall, this study evidences that the production system and, to a lesser extent, the biosecurity measures, contribute to the AMR development in commensal E. coli and Enterococcus spp., with antimicrobial usage as the main differential factor, and demonstrates the potential value of these bacteria as bioindicators on pig farms in AMR surveillance programs.

Increased antimicrobial resistance during the COVID-19 pandemic

In addition to SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection itself, an increase in the incidence of antimicrobial resistance poses collateral damage to the current status of the COVID-19 (coronavirus disease 2019) pandemic. There has been a rapid increase in multidrug-resistant organisms (MDROs), including extended-spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae, carbapenem-resistant New Delhi metallo-β-lactamase (NDM)-producing Enterobacterales, Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus (MRSA), pan-echinocandin-resistant Candida glabrata and multi-triazole-resistant Aspergillus fumigatus. The cause is multifactorial and is particularly related to high rates of antimicrobial agent utilisation in COVID-19 patients with a relatively low rate of co- or secondary infection. Appropriate prescription and optimised use of antimicrobials according to the principles of antimicrobial stewardship as well as quality diagnosis and aggressive infection control measures may help prevent the occurrence of MDROs during this pandemic.

Poor compliance with an antibiotic directive-A call for intensified monitoring

BACKGROUND

In April 2017, the Central Denmark Region Antibiotic Stewardship Committee issued a directive to reduce the general use of piperacillin-tazobactam and prescribe narrow-spectrum antibiotics for mild and moderate pneumonia. The directive was distributed to all regional hospital clinicians.

METHODS

Electronic medical records were used to obtain de-identified details of all antibiotics administered (together with diagnosis codes) to all in-hospital patients (pre-directive and post-directive) in the nine regional hospitals. Average moving range statistical process control charts were used to analyze pre-directive and post-directive variation in antibiotic usage patterns.

RESULTS

Upon the distribution of the directive, a period of decline of the overall usage of piperacillin-tazobactam ensued. Rather than benzylpenicillin, as recommended for pneumonia, the initial decline in piperacillin/tazobactam usage was accompanied by increased use of cefuroxime.

CONCLUSIONS

A steward-directed reduction in piperacillin-tazobactam usage was accompanied by less desirable usage of a broad-spectrum alternative. Future antibiotic stewardship initiatives will hopefully benefit from close monitoring and timely feedback to clinicians. A dialogue with clinicians based on near real-time data is predicted to improve antibiotic stewardship actions.

A population-base survey on knowledge, attitude and awareness of the general public on antibiotic use and resistance

Objectives

This study was designed to assess the awareness and knowledge of antibiotic usage and antibiotic resistance among the general public in the Cape Coast metropolis of Ghana. It also tries to decipher whether the level of education and the professional status of an individual has a positive association with the level of knowledge on antibiotic resistance.

Methods

A population-base survey involving members of the public was conducted from August to November 2019. A structured questionnaire was developed to collect data from 632 respondents. Data were analyzed through SPSS v.21 using Chi square statistics and multivariate regression. Differences in knowledge were evaluated using ANOVA and the assumption of equal variance was tested with Levene statistics.

Results

The response rate was 74.3%. Lower educational status group had a greater knowledge level (39.7%) on antibiotic resistance. Despite the high score, the lowest educational status group, (M = 1.82, SD = 0.769), middle educational status group (M = 1.98, SD = 0.748), and the high educational status group (M = 1.88, SD = 0.773) were not significantly different from each other with regard to their general knowledge level on antibiotic resistance (P < 0.05). The study revealed that, working in the healthcare sector is a major contributor to the level of knowledge on antibiotic resistance.

Conclusion

Given the scale of the issue on antibiotic resistance and the fact that attempts to resolve it will involve efforts on the part of all, it is important that the public is aware of the importance of the issue of antibiotic resistance, its implications and what they can do to address it. The level of knowledge among respondents with lower educational status should be enough evidence to introduce more educational campaigns on antibiotic resistance.

Evidence-Based Strategies in Using Persuasive Interventions to Optimize Antimicrobial Use in Healthcare: a Narrative Review

A rise in antimicrobial resistance, seen especially since 2000, is in part caused by indiscriminate antimicrobial use. Varied types of persuasive interventions aimed to optimize antimicrobial use have been tried with varying success. Our review seeks to identify and assess factors associated with the successful implementation of persuasive interventions. We searched five databases (MEDLINE, EMBASE, The Cochrane Library, PsycINFO, and ERIC) to identify critical studies published between 2000 and December 2018 of interventions employing audit and feedback, education through meetings, academic detailing, reminders, and patient, family, or public education. Outcome measures of interest were any means to measure antimicrobial use. We included 26 articles in our analysis. Seventeen examined multimodal interventions and the most common was audit and feedback and meeting (four studies). Nine examined single interventions and the most common was audit and feedback (five studies). Our findings inform four evidence-based strategies to enable healthcare administrators, clinicians, and researchers to make informed choices when planning and designing an antimicrobial stewardship program: (1) implement a combination of persuasive interventions from both groups: audit and feedback, academic detailing, or patient, family, or provider education; and meeting or reminders, (2) design interventions that last one year or longer; post-intervention, assess the intervention's long-term effects for at least another one year, (3) conduct quality improvement projects examining persuasive interventions if the prescribing database provides adequate diagnosis information, and most importantly, (4) make patient, family, or provider education an integral component of multimodal intervention.

Metronidazole versus lactic acid for treating bacterial vaginosis (VITA): protocol for a randomised controlled trial to assess the clinical and cost effectiveness of topical lactic acid gel for treating second and subsequent episodes of bacterial vaginosis

Background

Bacterial vaginosis (BV) affects 30–50% of women at some time in their lives and is an embarrassing and distressing condition which can be associated with potentially serious comorbidities. Current antibiotic treatments such as metronidazole are effective but can result in side effects, and recurrence is common. This trial aims to investigate whether lactic acid gel is clinically effective and cost effective in the treatment of recurrent BV compared with metronidazole.

Methods

VITA is an open-label, multicentre, parallel group randomised controlled trial for women with a clinical diagnosis of BV and at least one previous BV episode in the past 2 years. Participants will be randomised 1:1 to intravaginal lactic acid gel 5 ml once daily for 7 days or oral metronidazole tablets 400 mg twice daily for 7 days. All participants will be followed up for 6 months to assess health status and healthcare costs. A subgroup will be interviewed to further explore adherence, tolerability and acceptability of treatment. The estimated sample size is 1900 participants to detect a 6% absolute increase in response rate to 86% in those receiving lactic acid gel. The primary outcome is participant-reported resolution of BV at Week 2.

Discussion

Results from this trial will help inform UK treatment guidelines for BV and may provide an alternative effective treatment for recurrent episodes of this condition which avoids repeated exposure to antibiotics.

Trial registration

ISRCTN, ISRCTN14161293. Registered on 8 September 2017.

Sepsis calculator for neonatal early onset sepsis - a systematic review and meta-analysis

BACKGROUND

Over investigation and overuse of empirical antibiotics is a concern in management of neonatal early onset sepsis (EOS) using the Centers for Disease Control and Prevention guidelines. "Sepsis calculator" is a risk-based prediction model for managing neonates at risk of EOS.

OBJECTIVE

To compare outcomes of neonatal EOS using of sepsis calculator versus conventional approach.

METHODS

A systematic review of randomized controlled trials (RCT) and non-RCTs reporting on outcomes after implementation of sepsis calculator for EOS for neonates >34-week gestation was conducted using the Cochrane methodology. Databases PubMed, CINAHL, Embase, Cochrane Central library and Google Scholar were searched in May 2019. Primary outcomes were antibiotics usage and laboratory tests for managing EOS. Secondary outcomes included hospital admissions and readmissions, blood culture positive EOS and mortality. The level of evidence (LOE) was summarized using the GRADE guidelines.

RESULTS

A total of 387 articles were retrieved after initial search. Six high quality non-RCTs fulfilled inclusion criteria. Meta-analysis (random effects model) showed that implementation of sepsis calculator was associated with reduced antibiotic usage [N = 172,385; OR = 0.22 (0.14-0.36); p < .00001; heterogeneity (I²) = 97%, Number needed to treat (NNT): 22], laboratory tests [N = 168,432; OR = 0.14 (0.08-0.27); p < .00001; I² = 99%, NNT = 8], and admissions to neonatal unit [N = 16,628; OR = 0.24 (0.11-0.51); p = .0002; I² = 98%, NNT = 7]; LOE: moderate. There was no difference in mortality, culture positive EOS, and readmissions.

CONCLUSION

Moderate quality evidence indicates that the implementation of a sepsis calculator was associated with reduced usage of antibiotics, laboratory tests and admission to neonatal unit with no increase in mortality and readmissions.

Adaptation and implementation of the ARK (Antibiotic Review Kit) intervention to safely and substantially reduce antibiotic use in hospitals: a feasibility study

BACKGROUND

Antimicrobial stewardship initiatives in secondary care depend on clinicians undertaking antibiotic prescription reviews but decisions to limit antibiotic treatment at review are complex.

AIM

To assess the feasibility and acceptability of implementing ARK (Antibiotic Review Kit), a behaviour change intervention made up of four components (brief online tool, prescribing decision aid, regular data collection and feedback process, and patient leaflet) to support stopping antibiotic treatment when it is safe to do so among hospitalized patients; before definitive evaluation through a stepped-wedge cluster-randomized controlled trial.

METHODS

Acceptability of the different intervention elements was assessed for a period of 12 weeks by uptake of the online tool, adoption of the decision aid into prescribing practice, and rates of decisions to stop antibiotics at review (assessed through repeated point-prevalence surveys). Patient perceptions of the information leaflet were assessed through a brief questionnaire.

FINDINGS

All elements of the intervention were successfully introduced into practice. A total of 132 staff encompassing a broad range of prescribers and non-prescribers completed the online tool (19.4 per 100 acute beds), including 97% (32/33) of the pre-specified essential clinical staff. Among 588 prescription charts evaluated in seven point-prevalence surveys over the 12-week implementation period, 82% overall (76-90% at each survey) used the decision aid. The median antibiotic stop rate post implementation was 36% (range: 29-40% at each survey) compared with 9% pre implementation (P < 0.001).

CONCLUSION

ARK provides a feasible and acceptable mechanism to support stopping antibiotics safely at post-prescription reviews in an acute hospital setting.

Efficiency of using a vaginal drain after hysterectomy: A systematic review

Objective Hysterectomy is the second most frequently performed surgical procedure for women of reproductive age topped only by caesarean section. Hysterectomies may be associated with a significant risk of ultrasonographically detected vault haematomas in up to 59% with consequent postoperative morbidity. The aim of this systematic review was to compare women who had a vaginal drain placed intraoperatively after a hysterectomy and the impact on peri and postoperative outcomes related to vault haematomas. Study Design Electronic searches of AMED, BNI, CINAHL, EMBASE, HBE, HMIC, Medline, PsycINFO and PubMed, Cochrane register of controlled trials (CCTR), Cochrane database of systematic reviews (CDSR) CINAHL and Google scholar were performed. A systematic review and meta-analysis of studies comparing women with and without a vaginal drain after a hysterectomy and the impact on different outcomes was carried out. Results Ten studies involving 1778 women, 811 with a vaginal drain and 967 without a drain, were included in the meta-analysis. This suggests that the use of a vaginal drain after hysterectomy may significantly reduce the incidence of vault haematoma (OR 0.22, 95% CI 0.08 - 0.57) and febrile morbidity (OR 0.54, 95% CI 0.40 to 0.73), non- significantly reduce the rate of usage of antibiotics (OR 0.80, 95% CI 0.46-1.42) and makes no difference to the length of hospital stay (MD 0.12, 95% CI -0.14 to 0.38). Conclusion The use of a vaginal drain after hysterectomy could reduce the incidence of vault haematoma and febrile morbidity.

Knowledge, attitude and practice of antibiotic use among university students: a cross sectional study in UAE

BACKGROUND

Antibiotic resistance became a marker of irrational and overuse of these medicines in many countries. This study aims to evaluate the knowledge, attitude and practice (KAP) of medical students (MS) and non-medical students (NS) towards antibiotic use in the United Arabs Emirates (UAE).

METHOD

A descriptive cross-sectional study was conducted amongst 1200 MS and NS from Ajman University in UAE. A self-administered questionnaire was used to assess the knowledge, attitude and practice of antibiotic use. The later was composed into knowledge, attitude and practice of antibiotic use. Descriptive analysis was used to analyse the qualitative variables while quantitative variables were summarised using mean ± Standard Deviation (±SD). A Chi-square test was used to compare differences in the proportions of qualitative variables. Unpaired student's t-test was used to test the average differences in quantitative variables across medical and non-medical students. A p < 0.05 was considered statistically significant.

RESULTS

One thousand two hundred students (MS: 600 and NS: 600) were considered valid for analysis. On average, participants scored higher in attitude score followed by knowledge and practice scores. The average attitude score was 76% (95% CI: [75, 78%]) compared to 59% for knowledge (95% CI: [58, 60%]) and 45% (95% CI: [44, 47%]) for practice. The results suggest that overall, medical students scored remarkably better than non-medical students on KAP of antibiotic use, respectively (p = 0.0001), (p = 0.000) and (p = 0.002).

CONCLUSION

The students' knowledge, attitude and practice regarding antibiotic use, which drive the practice of self-medication, reflect a gap in medical curricula in UAE institutes and medical colleges.

Removing prophylactic antibiotics from pig feed: how does it affect their performance and health?

BACKGROUND

Antibiotics (AB) are an important tool to tackle infectious disease in pig farms; however some research indicates that their frequent mis/over-use may contribute to the development of antibiotic resistance and the WHO has declared that this issue should be addressed. Little is known about the long term consequences of withdrawing prophylactic AB from pig feed; hence we aimed to assess its effects on performance and health of pigs from weaning to slaughter. Six batches of 140 pigs each were monitored on a commercial farm through the weaner and finisher stages to slaughter. In-feed antibiotics were not added to the feed for half of the pigs (NOI) and were added in the other half (ABI) within each batch for the whole weaner stage. Individual pigs in both treatments were treated with parenteral administrations if and when detected as ill or lame. Productive performance, parenteral treatments and mortality were recorded on farm and the presence of respiratory disease was recorded at slaughter. Pen was considered the experimental unit.

RESULTS

ABI pigs showed higher growth (P = 0.018) and feed intake (P = 0.048) than NOI pigs in the first weaner stage but feed efficiency was not affected (NOI = 1.48 vs. ABI = 1.52). Despite an initial reduction in performance, NOI pigs had similar performance in finisher stage (ADG: NOI = 865.4 vs. ABI = 882.2) and minimal effects on health compared to ABI pigs. No difference between treatments was found at the abattoir for the percentage of pigs affected by pneumonia, pleurisy, pleuropneumonia and abscesses (P > 0.05). Mortality rate was not affected by treatment during the weaner stage (P = 0.806) although it tended to be slightly higher in NOI than ABI pigs during the finisher stage (P = 0.099). Parenteral treatments were more frequent in NOI pigs during the weaner stage (P <  0.001) while no difference was recorded during the finisher stage (P = 0.406).

CONCLUSIONS

These data suggest that the removal of prophylactic in-feed antibiotics is possible with only minor reductions in productive performance and health which can be addressed by improved husbandry and use of parenteral antibiotics.

Consecutive antibiotic use in the outpatient setting: an extensive, longitudinal descriptive analysis of antibiotic dispensing data in the Netherlands

Introduction

Taking consecutive antibiotic use into account is of importance to obtain insight in treatment within disease episodes, use of 2nd- and 3rd-choice antibiotics, therapy failure and/or side effects. Nevertheless, studies dealing with consecutive antibiotic use are scarce. We aimed at evaluating switch patterns in antibiotic use in the outpatient setting in the Netherlands.

Methods

Outpatient antibiotic dispensing data was processed to antibiotic treatment episodes consisting of single prescriptions or consecutive prescriptions (2006 to 2014). Consecutive prescriptions were categorised into prolongations and switches. Switches were further analysed to obtain antibiotic switch percentages and trends over time. Outcomes were compared with recommendations of Dutch guidelines.

Results

A total of 43,179,867 antibiotic prescriptions were included in the analysis, consisting of single prescriptions (95%), prolongations (2%) and switches (3%). The highest switch percentages were found for trimethoprim (7.6%) and nitrofurantoin (5.4%). For fosfomycin, ciprofloxacin, flucloxacillin and trimethoprim we found the highest yearly increase in switching. Amoxicillin/clavulanic acid was most often used as second antibiotic in a switch. A surprisingly high number of 2nd- and 3rd-choice antibiotics are prescribed as first antibiotic in a treatment.

Conclusions

Although the actual reason for a switch is unknown, switch patterns can reveal problems concerning treatment failure and guideline adherence. In general, switch percentages of antibiotics in the Netherlands are low. The data contributes to the knowledge regarding antibiotic switch patterns in the outpatient setting.

Antimicrobial defined daily dose adjusted by weight: a proposal for antibiotic consumption measurement in children

INTRODUCTION

Antimicrobial defined daily dose (DDD), has limitations for antimicrobial consumption measurement in paediatrics. An alternative DDD design applicable for children is proposed.

METHODS

Children (<16 years-old) from 10 Spanish hospitals during a 12-months period were included. Weight for age (50th percentile) was calculated for the median age of the cohort using standardized World Health Organization tables. DDD (g) for each antimicrobial was calculated by multiplying the obtained weight times the recommended dose (mg/kg) of the antimicrobial for the most common infectious indication.

RESULTS

A total of 40,575 children were included. Median age was 4.17 (IQR: 1.36-8.98) and 4.81 (IQR: 1.42-9.60) years for boys and girls, respectively. Mean weight for this age was 17.08kg. Standardized DDD for representative antimicrobials were calculated.

CONCLUSIONS

A useful method for antimicrobial DDD measurement in paediatrics has been proposed and should be validated in future studies for its use in paediatric antimicrobial stewardship programmes.

Correlation between antibiotic consumption and resistance of bloodstream bacteria in a University Hospital in North Eastern Italy, 2008-2014

PURPOSE

The spread of multidrug-resistant bacteria is a worrisome problem worldwide. This study investigated the correlation between antibiotic consumption and antimicrobial resistance trends of the most important bacteria causing bacteremia at the University hospital of Trieste, Italy, from 2008 to 2014.

METHODS

Antibiotic consumption (Defined Daily Dose-DDD-per 100 patient/days) and antibiotic resistance (percentage of antibiotic intermediate o resistant isolates) were analyzed independently with linear correlation by year. Potential correlations between antibiotic consumption and bacteria resistance rates were investigated through the Pearson's correlation.

RESULTS

The overall consumption of antibiotic grew from 80 to 97 DDD 100 patient/days (p = 0.005) during the study period. The increased consumption of amoxicillin/clavulanate and piperacillin/tazobactam was associated with the reduction of MRSA rate from 48.5 to 25.9% (p = 0.007 and p = 0.04, respectively). The increased consumption of piperacillin/tazobactam was associated with the reduction of ESBL-positive Enterobacteriaceae rate from 28.9 to 20.9% (p = 0.01). The increased consumption of carbapenems was associated with the increased rate of carbapenem-resistant Acinetobacter baumannii from 0 to 96.4% (p = 0.03). No carbapenem-resistant Enterobacteriaceae isolates were reported. The consumption of vancomycin grew significantly (p = 0.005). A dramatic spread of vancomycin-resistant Enterococcus faecium occurred in 2014. The consumption of fluoroquinolones and extended-spectrum cephalosporins remained stable.

CONCLUSIONS

An antibiotic stewardship program targeted to limit the consumption of extended-spectrum cephalosporins and fluoroquinolones in favor of amoxicillin/clavulanate and piperacillin/tazobactam correlates with a decreasing rate of MRSA and ESBL-positive Enterobacteriaceae. The analysis of correlations between antibiotic consumption and bacterial resistance rates is a useful tool to orient antimicrobial stewardship policies at local level.

Misuse of antibiotics reserved for hospital settings in outpatients: a prospective clinical audit in a university hospital in Southern France

Some antibiotics are reserved essentially for hospital settings owing to cost effectiveness and in order to fight the emerging antibiotic resistance crisis. In some cases, antibiotics reserved exclusively for use in hospitals may be prescribed in outpatients for serious infections or in the absence of a therapeutic alternative. A 30-day prospective audit of outpatient prescriptions of antibiotics reserved exclusively for use in hospitals was performed. The objective of this study was to evaluate the relevance of outpatient antibiotic prescriptions by measuring appropriateness according to guidelines. During the study period, 53 prescriptions were included, only 40% of which were appropriate. Among the 32 inappropriate prescriptions, 4 cases lacked microbial arguments, 1 case was not adequate for the infection type, 1 case involved an incorrect antibiotic dosage, 1 case involved an incorrect interval of dose administration, 3 cases had a therapeutic alternative and 22 cases were not recommended. Of the 53 prescriptions, 66% were started in hospital and 34% in outpatients. Only 25% of cases were prescribed with infectious diseases specialist (IDS) advice, 64% were based on microbiological documentation and 13% had a negative bacterial culture. Inappropriate prescriptions were usually observed in antibiotic lock therapy, skin infections, Clostridium difficile colitis, intra-abdominal infections and intravascular catheter-related infections. Outpatient prescriptions of antimicrobial drugs reserved exclusively for use in hospitals are frequently inappropriate. We recommend a real-time analysis algorithm with the involvement of an IDS for monitoring prescriptions to improve the quality of these prescriptions and possibly to prevent antibiotic resistance.

Antibiotic Prescribing Pattern in a Tertiary Level Neonatal Intensive Care Unit

INTRODUCTION

Neonatal sepsis is a major cause of morbidity and mortality worldwide especially in developing countries, which justifies early diagnosis and prompt treatment with antibiotics. Antibiotics are the most frequently used medicines in Neonatal Intensive care units. Data regarding rational antibiotic use in neonates is very limited. Hence, it is essential that the antibiotic prescribing patterns be evaluated periodically for its rational use. Therefore, the present study been carried out to identify the prescribing patterns of antibiotics in neonatal intensive care unit of a tertiary care hospital, Western Maharashtra, India.

MATERIALS AND METHODS

A prospective observational study was carried out for 6 months between April to September 2014. The data regarding patient demographics and antibiotic use was collected daily in a structured proforma. Collected data was subjected to statistical analysis.

RESULTS

Out of total 528 neonates with male preponderance (62%), 370 received antibiotics. Mean gestational age and birth weight were 35±3.2 weeks and 2±0.7 kg respectively. Mean length of hospital stay was 14.26±15.36 days (range 1 to 136 days). A total of 1123 antibiotics were prescribed to 370 neonates. The majority of neonates (55.9%) received between 1-2 antibiotics, 37.3% had 3 to 5 antibiotics prescribed, while 6.7% neonates were prescribed more than 5 antibiotics. Number of antibiotics used had statistically significant inverse relationship with gestational age. Among antibiotics; Amikacin, Cefotaxime and Levofloxacin were the drugs most often prescribed. Amikacin and Cefotaxime were given more to term infants whereas other antibiotics like Levofloxacin, Pipercillin- tazobactam and Meropenem were prescribed more to preterm and outborn neonates.

CONCLUSION

The use of a high number of antibiotics is a common practice. Although the indications for use of most antibiotics could be justified, the increased frequency of anbiotics use in some neonates was of concern. Guidelines for the use of antibiotics in neonates are required and larger studies are needed on this issue.

Carbapenem use in French hospitals: A nationwide survey at the patient level

The objective of this study was to evaluate the characteristics of carbapenem use in French healthcare settings in order to guide future actions. Healthcare facilities voluntarily participated in a nationwide cross-sectional survey in 2011. Medical data and reasons for carbapenem treatment (CPR) and discontinuation were recorded for all patients treated with carbapenems. A total of 2338 patients were recorded by 207 facilities. The median duration of CPR was 8 days, and 31.4% of patients received CPR for >10 days. An antibiotic consultant was involved in the initial choice of CPR in 36.8% of cases. CPR was chosen on an empirical (EP) basis for 1229 patients (52.6%), mainly because of severe sepsis (48.6%) or a perceived risk of bacterial resistance (33.7%). Among EP patients, de-escalation was more frequent in the case of intervention of an antibiotic consultant (35.1%) than without intervention (22.9%) (P<0.01). Among the 1109 patients receiving CPR initially based on bacteriological results, 607 (54.7%) had ESBL-producing Enterobacteriaceae and 397 (35.8%) had Gram-negative bacilli susceptible to at least one β-lactam other than carbapenems or to fluoroquinolones. Among the latter, de-escalation was performed in 59 cases (14.9%). The intervention of an antibiotic consultant did not favour de-escalation in this group. In conclusion, carbapenems are frequently used for treating suspected or confirmed multidrug-resistant bacteria, and overall CPR duration is long. De-escalation is frequently not implemented despite isolates being susceptible to other drugs. More frequent antibiotic consultant intervention may help to decrease carbapenem use in the case of EP treatment.

Pattern of Use of Antibiotics Following Snake Bite in a Tertiary Care Hospital

INTRODUCTION

There are several conflicting recommendations on the use of antibiotics in snakebite victims. This study aimed to identify the pattern of antibiotics used following snake envenomation in a tertiary care hospital of Kerala.

MATERIALS AND METHODS

Retrospective review of case records from January to August 2011 was done and all the cases filed as snakebite were reviewed and details entered in a structured performa. Data was analysed using SPSS 16 and results were expressed mainly using descriptive statistics.

RESULTS

Three hundred and thirteen cases were evaluated with mean age 37.58± 14.54 year and 51.1% were males. Out of total, 94.6% received antibiotics of which 88.85% were oral, 8.1% parenteral and 3.04% both. There were total 454 prescriptions of antibiotics. In all seven different types of antibiotics were prescribed alone or in combination of which Ampicillin (205) was the commonest followed by Cloxacillin (194). The mean antibiotic usage was 1.46±0.716 per patient and the mean duration of antibiotic use was 3.16±1.446 days. In patients with no envenomation the mainly prescribed antibiotic was Cloxacillin (126). Intravenous antibiotics like Piperacillin plus Tazobactam were given only in patients with either local or systemic envenomation.

CONCLUSION

The main pattern of use of antibiotics following snakebite envenomation is Ampicillin alone or in combination empirically, Cloxacillin prophylatically and Piperacillin with Tazobactam for severe established infections. The choice of antibiotics is based on the clinician's discretion. Since the study setting is in a developing country the prophylactic use of antibiotics may be justified weighing the concerns of secondary infections.

Point prevalence surveys of healthcare-associated infections and use of indwelling devices and antimicrobials over three years in a tertiary care hospital in India

Few hospitals in India perform regular surveillance for healthcare-associated infections (HAIs) and use of indwelling devices and antimicrobials. The aim of this study was to conduct two one-day point prevalence surveys of HAIs and use of indwelling devices and antimicrobials in a large 1800-bed tertiary care hospital in India. The overall prevalence of HAIs was 7%, and surgical site infections were the most common (33%). Indwelling devices were present in 497 (27%) patients, and 915 (50%) patients were receiving antimicrobials. This study helped to generate robust baseline data on the prevalence of HAIs and use of indwelling devices and antimicrobials in the study hospital.

Global impact of an educational antimicrobial stewardship programme on prescribing practice in a tertiary hospital centre

The misuse of antibiotics has been related to increased morbidity, mortality and bacterial resistance. The development of antimicrobial stewardship programmes (ASPs) has been encouraged by scientific societies as an essential measure. An educational, institutionally supported ASP was developed in our tertiary-care centre. Local guidelines on the management of infectious syndromes were created. Antimicrobial prescriptions were chosen arbitrarily weekly and counselling interviews by expert clinicians were carried out, using a paedagogic, non-restrictive methodology. Satisfaction with the interview was assessed using anonymous questionnaires. The appropriateness of antimicrobial prescriptions as well as consumption was assessed prospectively throughout the year. Feedback regarding the correct use of treatments was communicated to each participating department periodically. The improvement in antimicrobial prescription was included among the annual objectives linked to economic incentives in every department. A total of 1206 counselling interviews were carried out during the first year. Fifty-three per cent of antimicrobial prescriptions (176/332) were inappropriate when the programme started. The rate of inappropriate prescriptions continuously declined to 26.4% (107/405) in the fourth trimester (p <0.001; RR = 0.38; 95% CI, 0.23-0.43). Antimicrobial consumption decreased from 1150 defined daily doses (DDDs) per 1000 occupied bed-days in the first trimester to 852 DDDs in the fourth, reflecting a reduction in antimicrobial expenditures of 42%. A total of 352 satisfaction questionnaires were received and 98% described the advice as positive. In conclusion, the implementation of an education-based ASP achieved a significant improvement in all antimicrobial prescriptions in the centre and a reduction in antimicrobial consumption, even when no restrictive measures were implemented. The programme was highly accepted by all prescribers.

Antimicrobial resistance among nosocomial isolates in a teaching hospital in goa

Background:

Emergence of polyantimicrobial resistant strains of hospital pathogens has presented a challenge in the provision of good quality in-patient care. Inappropriate use of antibiotics in the hospital is largely responsible for this catastrophe. Bacteriological surveillance of the cases of nosocomial infections is crucial for framing an evidence-based antimicrobial policy for a hospital.

Materials and Methods:

A prospective study was undertaken among 498 patients from medicine and surgery wards in a tertiary teaching hospital in Goa. The patients were followed up clinico-bacteriologically for the occurrence of nosocomial infections (NI). Antibiotic susceptibility testing was done using Kirby-Bauer disc diffusion method.

Results:

The overall infection rate was 33.93 ± 4.16 infections per 100 patients. Urinary tract infection was the most common NI (26.63%), followed by surgical site infection (23.67%), wound infection (23%) and nosocomial pneumonia (18.34%). Ninety-seven percent of the isolates were bacterial, while the others were fungal. More than 80% of the NIs were caused by Gram-negative bacteria, predominantly Pseudomonas aeruginosa, Escherichia coli and Aceinetobacter baumanii. Almost 70% of the isolates were resistant to all the antibiotics for which susceptibility was tested; the rest were sensitive to amikacin, cefoperazone-sulbactam and other antibiotics including methicillin, co-trimoxazole, teicoplenin, vancomycin and rifampicin, either singly or in combination. The proportion of MRSA was 71.4%. Resistance to a particular antibiotic was found to be directly proportional to the antibiotic usage in the study setting.

Conclusion:

Surveillance of nosocomial infections with emphasis on the microbiologic surveillance and frequent antimicrobial audit are critical towards curbing the evil of polyantimicrobial resistant nosocomial infections in a hospital.