Antibiotic usage in 14 equine practices over a 10-year period (2012-2021)

BACKGROUND

Monitoring antibiotic usage is an important part of tackling antimicrobial resistance. The use of computerised records for monitoring has been previously described in the equine sector but there is currently no consensus on metrics used to report usage.

OBJECTIVES

To document antibiotic use in equine practices in the United Kingdom over a 10-year period using commercially available practice management software.

STUDY DESIGN

Retrospective survey.

METHODS

A custom antibiotic usage report was created using Eclipse® practice management software. Participating practices were given instructions on how to generate the usage report. Annual reports were requested for a 10-year period (2012-2021 inclusive). Each report provided sales of each class of antibiotic in total mg and in mg/kg, based on the number of equids treated (for any transaction) and their average weight. The defined daily dose for animals (DDDvet) and the DDD/1000 (used in people) were also calculated to correct for variation in dosage rates between antibiotics.

RESULTS

Fourteen practices submitted data for an annual maximum of 107 977 horses. Overall, median annual antibiotic usage was 54.25 mg/kg (range 45.34-60.27 mg/kg), 1.52 defined daily doses/animal/year (range 1.39-1.70) and 4.17 defined daily dose/1000 animals (range 3.82-4.66). Overall median highest priority critically important antimicrobial usage was 0.67 mg/kg (range 0.56-1.71), 0.12 defined daily doses/animal/year (range 0.10-0.14) and 0.33 defined daily dose/1000 animals (range 0.29-0.39).

MAIN LIMITATIONS

The software relied on the accurate identification of antibiotic preparations. The calculation of DDDvet was complicated by the varying dose rates of antimicrobials used in equine practice.

CONCLUSIONS

A reliable technique to measure antibiotic usage is presented. Defined daily dosage calculations may be more helpful in equine practice due to the preponderance of potentiated sulphonamides usage. These data and methods may provide the basis for future clinical audits aiming to enhance antimicrobial stewardship.

Examining the Perspectives and Attitudes Towards Antibiotic Use and Resistance Among the General Public in Muzaffarpur in Bihar, India

Objective This study aimed to examine the current understanding and perspectives about the use of antibiotics among the general public living in the city of Muzaffarpur, Bihar, and the surrounding areas. Methodology A cross-sectional study was carried out from March 2023 to August 2023 in Muzaffarpur. Data was obtained through interviews based on a standardized questionnaire derived from a prior study. The findings were summarized using descriptive statistics, frequencies, and percentages, and then presented in tabular form. Results This study recruited 384 participants in total; the majority of them (n=200, 52.1%) were females, while the remaining 184 (47.9%) participants were males. Our findings revealed that 368 (96%) participants agreed on the necessity of prescribing distinct antibiotics for the treatment of various ailments. Nevertheless, the participants held divergent perspectives regarding the efficacy of antibiotics in treating coughs and colds, as well as their effectiveness against viruses and bacteria. Overall, 354 (92.1%) participants agreed with the importance of finishing the prescribed antibiotic regimen, and 335 (87.2%) agreed that people should refrain from retaining drugs for future use. Of note, 90% of the participants (n=346) stated that they did not think it was advisable to get antibiotics from friends and family without first consulting a doctor. Conclusion The current study documented a prevalent utilization of antibiotics among the study participants, with a significant proportion of these medications being obtained without a prescription. The respondents demonstrated a general lack of understanding, particularly concerning the significance of antibiotics in treating mild viral illnesses.

PRRSV-1 Stabilization Programs in French Farrow-to-Finish Farms: A Way to Reduce Antibiotic Usage

Infection with the porcine reproductive and respiratory syndrome virus type 1 (PRRSV-1) has serious economic consequences for the pig industry. Swine practitioners and other agricultural advisors often describe an increase in antibiotic use when PRRSV-1 is circulating. Our objective was to assess the impact of PRRSV-1 stabilization programs on reducing antibiotic use in 19 French farrow-to-finish farms that successfully implemented such a protocol between 2007 and 2019. For each farm, we compared the global antibiotic consumption, including all physiological stages (expressed in mg/PCU and ALEA) one year before (P1) and one year after (P2) the implementation of the protocol, and the change between P1 and P2 was calculated in percentages. The data were also analyzed by level of consumption. We showed that antibiotic use decreased significantly between P1 and P2 if expressed in mg/PCU and showed a decreased tendency in terms of exposure (ALEA) after PRRSV-1 stabilization. Concerning the change from P1 to P2, depending on the level of consumption in P1, our results showed that the higher the consumption levels were in P1, the greater the antibiotic reduction in P2. This study highlights the ability of a stabilization protocol against PRRSV-1 to reduce antibiotic use, especially on farms that have high consumption rates. These hopeful results show that further investigations about the relationship between PRRSV-1 and antibiotic usage could be beneficial.

Awareness and Knowledge of Antimicrobial Resistance, Antimicrobial Stewardship and Barriers to Implementing Antimicrobial Susceptibility Testing among Medical Laboratory Scientists in Nigeria: A Cross-Sectional Study

Background: Antimicrobial resistance (AMR) is now considered one of the greatest global health threats. This is further compounded by a lack of new antibiotics in development. Antimicrobial stewardship programmes can improve and optimize the use of antibiotics, thereby increasing the cure rates of antibiotic treatment and decreasing the problem of AMR. In addition, diagnostic and antimicrobial stewardships in the pathology laboratories are useful tools to guide clinicians on patient treatment and to stop the inappropriate use of antibiotics in empirical treatment or narrow antibiotics. Medical Laboratory Scientists are at the forefront of performing antibiotics susceptibility testing in pathology laboratories, thereby helping clinicians to select the appropriate antibiotics for patients suffering from bacterial infections. Methods: This cross-sectional study surveyed personal antimicrobial usage, the knowledge and awareness on AMR, and antimicrobial stewardship, as well as barriers to antimicrobial susceptibility testing among medical laboratory scientists in Nigeria using pre-tested and validated questionnaires administered online. The raw data were summarized and exported in Microsoft Excel and further analyzed using IBM SPSS version 26. Results: Most of the respondents were males (72%) and 25-35 years old (60%). In addition, the BMLS degree was the highest education qualification most of the respondents (70%) achieved. Of the 59.2% of the respondents involved in antibiotics susceptibility testing, the disc diffusion method was the most commonly used (67.2%), followed by PCR/Genome-based detection (5.2%). Only a small percentage of respondents used the E-test (3.4%). The high cost of testing, inadequate laboratory infrastructure, and a lack of skilled personnel are the major barriers to performing antibiotics susceptibility testing. A higher proportion of a good AMR knowledge level was observed in male respondents (75%) than females (42.9%). The knowledge level was associated with the respondent's gender (p = 0.048), while respondents with a master's degree were more likely to possess a good knowledge level of AMR (OR: 1.69; 95% CI: 0.33, 8.61). Conclusion: The findings of this study indicate that Nigerian medical laboratory scientists had moderate awareness of AMR and antibiotic stewardship. It is necessary to increase investments in laboratory infrastructure and manpower training, as well as set up an antimicrobial stewardship programme to ensure widespread antibiotics susceptibility testing in hospitals, thereby decreasing empirical treatment and the misuse of antibiotics.

Prescribing Antibiotics in Public Primary Care Clinics in Singapore: A Retrospective Cohort Study

BACKGROUND

Antibiotic prescription practices in primary care in Singapore have received little scholarly attention. In this study, we ascertained prescription prevalence and identified care gaps and predisposing factors.

METHODS

A retrospective study was conducted on adults (>21 years old) at six public primary care clinics in Singapore. Prescriptions >14 days were excluded. Descriptive statistics were used to showcase the prevalence data. We used chi-square and logistic regression analyses to identify the factors affecting care gaps.

RESULTS

A total of 141,944 (4.33%) oral and 108,357 (3.31%) topical antibiotics were prescribed for 3,278,562 visits from 2018 to 2021. There was a significant reduction in prescriptions (p < 0.01) before and after the pandemic, which was attributed to the 84% reduction in prescriptions for respiratory conditions. In 2020 to 2021, oral antibiotics were most prescribed for skin (37.7%), genitourinary (20.2%), and respiratory conditions (10.8%). Antibiotic use in the "Access" group (WHO AWaRe classification) improved from 85.6% (2018) to 92.1% (2021). Areas of improvement included a lack of documentation of reasons for antibiotic use, as well as inappropriate antibiotic prescription for skin conditions.

CONCLUSION

There was a marked reduction in antibiotic prescriptions associated with the onset of the COVID-19 pandemic. Further studies could address the gaps identified here and evaluate private-sector primary care to inform antibiotic guidelines and the local development of stewardship programs.

Field Study on Antibiotic Use and Associated Risks Among Saudi Arabian Community Members

<b>Background and Objective:</b> Antibiotic resistance is a problem that needs to be solved, according to the World Health Organization (WHO). The main objective of this study was to uncover knowledge, attitudes and practices related to the use of antibiotics and the associated risks. <b>Materials and Methods:</b> A descriptive survey method was used to collect data from a purposive sample of Saudi citizens. A total of 2067 participants completed the study questionnaire in the period of March, 2023 to June, 2023. Questionnaire included a number of 14 questions related to the demographic characteristics of the study sample and about knowledge, attitudes and practices related to the use of antibiotics. The IBM SPSS was used to statistically evaluate the survey findings and the data were reported as frequencies and percentages. <b>Results:</b> There is a high level of awareness about what antibiotics are, their medical efficacy and how to use them among respondents, as a large percentage of respondents are convinced of the importance of taking antibiotics to treat diseases related to bacterial infection under the supervision of a specialized doctor and not based on the recommendations of their acquaintances or relatives. People with low levels of education should be among the categories specifically targeted for educational intervention regarding proper antibiotic usage. <b>Conclusion:</b> The participants who were knowledgeable about the use of antibiotics exhibited a favorable attitude towards them. While people with low levels of education needs a proper education regarding antibiotics and their uses.

Characterization of the Composition Variation of Healthy Human Gut Microbiome in Correlation with Antibiotic Usage and Yogurt Consumption

Antibiotic usage and yogurt consumption are the major interventions for gut microbiota, yet their shared characteristics and disparities in healthy human gut microbiome remain unclear. This study aimed to decipher the composition changes among healthy humans, comparing antibiotic usage and yogurt consumption. The relative bacterial abundances of 1113 fecal samples were collected from an ongoing, population-based longitudinal cohort study in China that covered lifestyle, diet, disease status and physical measurements, and biological indicators of participants were obtained by the sequencing of 16S rRNA. The samples were divided into three groups, which were antibiotic users (122), yogurt consumers (497) and controls (494), where data visualization, alpha diversity, beta diversity and LEfSe analysis were conducted. At the family level, the relative abundances of Streptococcaceae, Enterobacteriaceae and Enterococcaceae families in antibiotic users increased almost 50%, 70% and 200%, respectively, while yogurt consumption also increased relative abundances of Streptococcaceae and Enterococcaceae, but not Enterobacteriaceae. Alpha diversity analyses suggested that the microbiome of the antibiotic usage and yogurt consumption groups exhibited an alpha diversity lower than that of the control. LEfSe analysis showed that, at the family level, the number of biomarkers in the yogurt consumption and antibiotic usage group were respectively 5 and 7, lower than that of the control (13). This study demonstrated the importance in considering the potential assistance of yogurt consumption on ARG gene transfer from commensal bacteria to pathogens in the human gut, which may pose a risk for human health. Antibiotic usage and yogurt consumption share more identical changes on healthy human gut flora than disparities. Therefore, in order to understand the potential risks of antibiotic usage and yogurt consumption on antibiotic resistance transmission in human gut microbiota, further research needs to be undertaken.

A Tumor Treated With Antibiotics: A Rare Case

Pott's puffy tumor, a rare condition, is an osteomyelitis involving the frontal bone with accompanying subperiosteal abscess. Patients typically present with swelling of the scalp and forehead, headache, fever, tenderness of the frontal sinus, and nasal discharge. MRI is the modality of choice for diagnosis and assessment. The standard of care is incision and drainage with long-course antibiotics. The prognosis is excellent; however, complications from a hematogenous spread can lead to meningitis or epidural spaces if not treated properly.

Survey on antimicrobial resistance knowledge and perceptions in university students reveals concerning trends on antibiotic use and procurement

BACKGROUND

The World Health Organization (WHO) has declared that antimicrobial resistance is one of the top ten global public health threats humanity is facing. To tackle this problem, it is necessary to not only address it in the hospital setting, but even more so in the community. In this context, understanding people's knowledge, attitudes, and practices towards antimicrobial resistance is of utmost importance. Accordingly, we investigated whether students from the Université de Montréal (Quebec, Canada) had perceptions and behaviours that could foster bacterial resistance.

METHODS

We conducted an observational, cross-sectional, prospective, and descriptive study from November 30 to December 11, 2020. We applied an online questionnaire (Google Forms) adapted from the WHO survey entitled 'Antibiotic resistance: Multi-country public awareness survey.'

RESULTS

Overall, 106 participants were included in this study. Most of them demonstrated reasonable understanding and behaviours related to antimicrobial resistance. Erroneous response proportions ranged from 0.9% to 25.5%, except for the statement 'Antibiotic resistance occurs when your body becomes resistant to antibiotics, and they no longer work,' where 63.2% of participants answered that it was true, even though it is false. Regarding antibiotic use, 28.3% of participants said they already had used antibiotics without a doctor's prescription. Of these, 55.2% were Canadian students.

CONCLUSIONS

This study indicates a possible misuse of antimicrobials in an area where antibiotics should not be easily accessible without a prescription. It is necessary to investigate why these medications are being used without being prescribed. Furthermore, we demonstrate a need to increase public awareness to better understand antimicrobial resistance's theoretical basis.

Antibiotic usage in surgical sperm retrievals among IVF centers

Surgical sperm retrieval (SSR) is currently one of the most common procedures in in vitro fertilization (IVF). However, a gap between the guidelines and routine clinical practice regarding antibiotic use in SSR, which might lead to antibiotic resistance, is a challenging problem worldwide. A cross-sectional survey was conducted from May 1, 2021, to July 15, 2021, to investigate antibiotic usage by medical professionals when performing SSR in IVF centers in Vietnam. The confidential questionnaire comprised 12 items, including characteristics of the study population, awareness of antimicrobial resistance, attitude toward prescribing antibiotics, and current practice of prescribing antibiotics when performing SSR. Surveys were completed by 30 of 45 registered IVF centers (66.7%). Among 67 physicians working at those centers, the age and work-experience years (mean ± standard deviation [s.d.]) were 38.6 ± 6.6 years and 11.2 ± 7.0 years, respectively. Over 60% of them held a degree in Obstetrics and Gynecology, and over four-fifths were men. Most respondents "often/very often/always" raised awareness of antimicrobial resistance to their patients (83.3%), but only half of them "often/occasionally" prescribed antibiotics to patients with SSR in cases where the prescription would be optional. About one-tenth of respondents followed the recommendation from the American Urological Association using "prophylaxis only" for SSR patients. For more invasive SSR, physicians tended to prescribe more complicated and sometimes inappropriate regimens. In conclusion, antibiotic usage in SSR was not always appropriate among IVF centers. Further studies may define specific recommendations for regimens, intervention strategies, and programs to promote appropriate antibiotic use for SSR patients among IVF specialists.

Factors influencing the detection of antibacterial-resistant Escherichia coli in faecal samples from individual cattle

AIMS

To investigate whether on-farm antibacterial usage (ABU), environmental antibacterial-resistant (ABR) Escherichia coli prevalence, sampling and sample handling methodologies are associated with ABR E. coli positivity in individual faecal samples from dairy heifers.

METHODS AND RESULTS

Three hundred and sixty-four heifers from 37 farms were sampled via rectal or faecal pat sampling. Samples were stored at -80°C for variable periods before microbiological analysis. Data analysis was done through a multilevel, multivariable logistic regression approach. Individual rectal samples had increased odds of positivity for amoxicillin-, cefalexin- and tetracycline-resistant E. coli. Sample storage for 6-12 months was associated with decreased odds of finding amoxicillin- and tetracycline-resistant E. coli. On-farm ABU had little influence, and environmental ABR E. coli prevalence had no significant influence on the odds of sample-level positivity for ABR E. coli.

CONCLUSIONS

Sampling methodology and sample handling have a greater association than on-farm factors with the detection of ABR E. coli in individual faecal samples from dairy heifers.

SIGNIFICANCE AND IMPACT OF THE STUDY

Sampling and storage methodologies should be considered carefully at the point of designing ABR surveillance studies in livestock and their environments and, where possible, these methodologies should be standardized between and within future studies.

Impact of an antibiotic stewardship programme in a surgical setting

Background

Antibiotics are miracles of science and critical for many surgical procedures. However, the emergence of multidrug resistant pathogens resulting from inappropriate antibiotic use is a threat to modern medicine. This study aimed to determine the appropriateness of antibiotic use, cost, consumption and impact of an antibiotic stewardship intervention round in a surgical ward setting.

Methods

Baseline antibiotic utilisation was determined with a retrospective cross-sectional study in two surgical wards in a tertiary academic hospital in South Africa where medical records of 264 patients who received antibiotics were reviewed. In the second stage of the study, records of 212 patients who received antibiotics were reviewed during a weekly antibiotic stewardship intervention round. The volume of antibiotics consumed was determined using defined daily doses (DDDs)/1000 patients' days, and the appropriateness of the antibiotic prescription for treatment was also determined using a quality-of-use algorithm.

Results

There was a reduction in the volume of antibiotic consumption from a total 739.30 DDDs/1000 to 564.93 DDDs/1000 patient days, with reduction in inappropriate antibiotic use from 35% to 26% from baseline to antibiotic stewardship programme stages, respectively. There was an overall increase in culture targeted therapy in both wards in the antibiotic stewardship programme stage.

Conclusion

The implementation of an antibiotic stewardship programme led to a reduction in antibiotic consumption and improvement in appropriate use of antibiotics.

"If It Works in People, Why Not Animals?": A Qualitative Investigation of Antibiotic Use in Smallholder Livestock Settings in Rural West Bengal, India

Smallholder farms are the predominant livestock system in India. Animals are often kept in close contact with household members, and access to veterinary services is limited. However, limited research exists on how antibiotics are used in smallholder livestock in India. We investigated antibiotic supply, usage, and their drivers in smallholder livestock production systems, including crossover-use of human and veterinary antibiotics in two rural sites in West Bengal. Qualitative interviews were conducted with key informants (n = 9), livestock keepers (n = 37), and formal and informal antibiotic providers from veterinary and human health sectors (n = 26). Data were analysed thematically and interpreted following a One Health approach. Livestock keepers and providers used antibiotics predominantly for treating individual animals, and for disease prevention in poultry but not for growth promotion. All providers used (highest priority) critically important antimicrobials for human health and engaged in crossover-use of human antibiotic formulations in livestock. Inadequate access to veterinary drugs and services, and a perceived efficacy and ease of dosing of human antibiotics in animals drove crossover-use. Veterinary antibiotics were not used for human health due to their perceived adverse effects. Given the extent of usage of protected antibiotics and crossover-use, interventions at the community level should adopt a One Health approach that considers all antibiotic providers and livestock keepers and prioritizes the development of evidence-based guidelines to promote responsible use of antibiotics in animals.

Occurrence of the Colistin Resistance Gene mcr-1 and Additional Antibiotic Resistance Genes in ESBL/AmpC-Producing Escherichia coli from Poultry in Lebanon: A Nationwide Survey

The objective of the present study was to determine genomic characteristics of expanded-spectrum cephalosporin (ESC)-resistant Escherichia coli spreading in healthy broilers in Lebanon in 2018. Rectal swabs (n = 280) from 56 farms were screened for the presence of ESC-resistant E. coli isolates. Antimicrobial susceptibility and extended-spectrum β-lactamase (ESBL)/AmpC production were determined by the disk diffusion method. Whole-genome sequencing (WGS) of 102 representative isolates of E. coli was performed to determine their phylogenetic diversity, serotypes, sequence types (ST), acquired resistance genes, and virulence-associated genes. Fifty-two out of 56 farms housed broilers carrying ESC-resistant E. coli isolates. These farms had large and recurrent antimicrobial practices, using, for some of them, critically important antibiotics for prophylactic and therapeutic purposes. Among the 102 sequenced multidrug-resistant (MDR) E. coli isolates, the proportion of ESBL, plasmid-mediated AmpC β-lactamase (pAmpC) producers, and ESBL/pAmpC coproducers was 60%, 27.6%, and 12.4%, respectively. The most prevalent ESBL/pAmpC genes were bla_CMY-2, bla_CTX-M-3, bla_CTX-M-15, bla_CTX-M-27, and bla_CTX-M-14b (n = 42, n = 31, n =15, n = 9, and n = 7, respectively). These ESBL/pAmpC producers were distributed in different STs, most being well-known avian-associated and sometimes pathogenic STs (ST-10, ST-48, ST-93, ST-115, ST-117, and ST-457). Phylogenetic single nucleotide polymorphism (SNP) analysis confirmed their genetic diversity and wide dispersion across the Lebanese territory. Most isolates were also resistant to ciprofloxacin (101/102 with 3 QRDR mutations), and 19/102 isolates from 11 unrelated STs also carried the mobile resistance gene mcr-1. This survey illustrates the alarming prevalence of MDR E. coli resistant to medically important antibiotics in broilers in Lebanon. This advocates the need for surveillance programs of antimicrobial resistance in Lebanon and the reduction of excessive use of antibiotics to limit the spread of MDR E. coli in food-producing animals.

IMPORTANCE Poultry production is a main contributor of the global trend of antimicrobial resistance arising from food-producing animals worldwide. In Lebanon, inappropriate use of antibiotics is frequent in chickens for prophylactic reasons and to improve productivity, resulting in an alarming prevalence of extended-spectrum β-lactamase (ESBL)/AmpC-producing Escherichia coli, also resistant to other medically important antibiotics (i.e., colistin and ciprofloxacin). Their complex genomic epidemiology highlighted by an important genetic diversity suggests that these resistance determinants are largely spreading in enteric bacteria in Lebanese poultry. Further molecular surveillance is needed to understand the country-specific epidemiology of ESBL/AmpC and mcr-1 genes in Lebanese poultry production. In addition, decisive interventions are urgently needed in order to ban the use of critically important antibiotics for human medicine in food-producing animals and limit the spread of antibiotic resistance in Lebanon.

Clostridium Difficile and COVID-19: General Data, Ribotype, Clinical Form, Treatment-Our Experience from the Largest Infectious Diseases Hospital in Western Romania

Background and Objectives: In Coronavirus Disease 2019 (COVID-19), which is caused by the infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the clinical manifestations are primarily related to the pulmonary system. Under 10% of cases also develop gastrointestinal events such as diarrhea, nausea, vomiting and abdominal pain. Materials and Methods: We conducted an observational, retrospective study in the Infectious Diseases Clinic of "Victor Babes" Hospital, Timis County, in order to assess the incidence, outcome and risk factors for clostridium difficile infection (CDI) in COVID-19 patients. Results: Out of 2065 COVID-19 cases, hospitalized between 1st September 2020 and 30th April 2021, 40 cases of CDI were identified with 32 cases of hospital-onset of CDI and eight cases of community-onset and healthcare-associated CDI. By randomization, polymerase chain reaction ribotyping of Clostridium Difficile was performed in six cases. All the randomized cases tested positive for ribotype 027. The percentage of cases recovered with complications at discharge was higher among COVID-19 patients and CDI (p = 0.001). The in-hospital stay, 36 days versus 28 days, was longer among COVID-19 patients and CDI (p = 0.01). The presence of previous hospitalization (p = 0.004) and administration of antibiotics during the hospital stay, increased the risk of CDI among COVID-19 patients. The mean adjusted CCI at admission was lower among controls (p = 0.01). In two cases, exitus was strictly CDI-related, with one case positive for 027 ribotype. Conclusions: CDI has complicated the outcome of COVID-19 patients, especially for those with comorbidities or previously exposed to the healthcare system. In the face of the COVID-19 pandemic and the widespread, extensive use of antibiotics, clinicians should remain vigilant for possible CDI and SARS-CoV-2 co-infection.

Understanding Antibiotic Usage on Small-Scale Dairy Farms in the Indian States of Assam and Haryana Using a Mixed-Methods Approach-Outcomes and Challenges

The use and misuse of antibiotics in both humans and animals contributes to the global emergence of antimicrobial resistant (AMR) bacteria, a threat to public health and infection control. Currently, India is the world’s leading milk producer but antibiotic usage within the dairy sector is poorly regulated. Little data exists reflecting how antibiotics are used on dairy farms, especially on small-scale dairy farms in India. To address this lack of data, a study was carried out on 491 small-scale dairy farms in two Indian states, Assam and Haryana, using a mixed method approach where farmers were interviewed, farms inspected for the presence of antibiotics and milk samples taken to determine antibiotic usage. Usage of antibiotics on farms appeared low only 10% (95% CI 8–13%) of farmers surveyed confirmed using antibiotics in their dairy herds during the last 12 months. Of the farms surveyed, only 8% (6–11%) had milk samples positive for antibiotic residues, namely from the novobiocin, macrolides, and sulphonamide classes of antibiotics. Of the farmers surveyed, only 2% (0.8–3%) had heard of the term “withdrawal period” and 53% (40–65%) failed to describe the term “antibiotic”. While this study clearly highlights a lack of understanding of antibiotics among small-scale dairy farmers, a potential factor in the emergence of AMR bacteria, it also shows that antibiotic usage on these farms is low and that the possible role these farmers play in AMR emergence may be overestimated.

Secrets of the Hospital Underbelly: Patterns of Abundance of Antimicrobial Resistance Genes in Hospital Wastewater Vary by Specific Antimicrobial and Bacterial Family

Background: Hospital wastewater is a major source of antimicrobial resistance (AMR) outflow into the environment. This study uses metagenomics to study how hospital clinical activity impacts antimicrobial resistance genes (ARGs) abundances in hospital wastewater. Methods: Sewage was collected over a 24-h period from multiple wastewater collection points (CPs) representing different specialties within a tertiary hospital site and simultaneously from community sewage works. High throughput shotgun sequencing was performed using Illumina HiSeq4000. ARG abundances were correlated to hospital antimicrobial usage (AMU), data on clinical activity and resistance prevalence in clinical isolates. Results: Microbiota and ARG composition varied between CPs and overall ARG abundance was higher in hospital wastewater than in community influent. ARG and microbiota compositions were correlated (Procrustes analysis, p=0.014). Total antimicrobial usage was not associated with higher ARG abundance in wastewater. However, there was a small positive association between resistance genes and antimicrobial usage matched to ARG phenotype (IRR 1.11, CI 1.06-1.16, p<0.001). Furthermore, analyzing carbapenem and vancomycin resistance separately indicated that counts of ARGs to these antimicrobials were positively associated with their increased usage [carbapenem rate ratio (RR) 1.91, 95% CI 1.01-3.72, p=0.07, and vancomycin RR 10.25, CI 2.32-49.10, p<0.01]. Overall, ARG abundance within hospital wastewater did not reflect resistance patterns in clinical isolates from concurrent hospital inpatients. However, for clinical isolates of the family Enterococcaceae and Staphylococcaceae, there was a positive relationship with wastewater ARG abundance [odds ratio (OR) 1.62, CI 1.33-2.00, p<0.001, and OR 1.65, CI 1.21-2.30, p=0.006 respectively]. Conclusion: We found that the relationship between hospital wastewater ARGs and antimicrobial usage or clinical isolate resistance varies by specific antimicrobial and bacterial family studied. One explanation, we consider is that relationships observed from multiple departments within a single hospital site will be detectable only for ARGs against parenteral antimicrobials uniquely used in the hospital setting. Our work highlights that using metagenomics to identify the full range of ARGs in hospital wastewater is a useful surveillance tool to monitor hospital ARG carriage and outflow and guide environmental policy on AMR.

Antibiotic Usage and Resistance in Food Animal Production: What Have We Learned from Bangladesh?

Irrational and inappropriate use of antibiotics in commercial chicken and aquaculture industries can accelerate the antibiotic resistance process in humans and animals. In Bangladesh, the growing commercial chicken and aquaculture industries are playing significantly important roles in the food value chain. It is necessary to know the antibiotic usage practices and antibiotic resistance in food animal production to design rational policies, guidelines, and interventions. We conducted a narrative review to understand the level of antibiotic usage and resistance in food animal production in Bangladesh. Information about antibiotic usage in different food animal production systems, including commercial chickens and aquaculture in Bangladesh is inadequate. Only a few small-scale studies reported that the majority (up to 100%) of the broiler and layer chicken farms used antibiotics for treating and preventing diseases. However, numerous studies reported antibiotic-resistant bacteria of public health importance in commercial chicken, fish, livestock, and animal origin food. The isolates from different pathogenic bacteria were found resistant against multiple antibiotics, including quinolones, the third or fourth generation of cephalosporins, and polymyxins. Veterinary practitioners empirically treat animals with antibiotics based on presumptive diagnosis due to inadequate microbial diagnostic facilities in Bangladesh. Intensive training is helpful to raise awareness among farmers, feed dealers, and drug sellers on good farming practices, standard biosecurity practices, personal hygiene, and the prudent use of antibiotics. Urgently, the Government of Bangladesh should develop and implement necessary guidelines to mitigate irrational use of antibiotics in food animals using a multi-sectoral One Health approach.

The Tick Microbiota Dysbiosis Promote Tick-Borne Pathogen Transstadial Transmission in a Babesia microti-Infected Mouse Model

Ticks are obligate hematophagous ectoparasites. They are important vectors for many pathogens, of both medical and veterinary importance. Antibiotic residues in animal food are known, but very little is known about the effects of antibiotic residues in animals on the microbiome diversity of ticks and tick-borne pathogen transmission. We used a Haemaphysalis longicornis–infested mouse model to evaluate the effect of antibiotic usage on tick microbiome. Nymphal ticks were fed on an antibiotic cocktail-treated or water control mice. Adult ticks molted from nymphs fed on the antibiotic cocktail-treated mouse had a dysbiosed microbiota. Nymphal ticks were also fed on a B. microti–infected mice that had been treated with antibiotic cocktail or water. We found that the B. microti infection in adult ticks with a dysbiosed microbiota (44.7%) was increased compared with the control adult ticks (24.2%) by using qPCR targeting 18S rRNA gene. This may increase the risk of tick-borne pathogens (TBPs) transmission from adult ticks to a vertebrate host. These results show that an antibiotic-treated mouse can induce tick microbiota dysbiosis. Antibiotic treatment of B. microti-infected mouse poses the possibility of increasing transstadial transmission of B. microti from the nymph to the adult H. longicornis. These findings suggest that B. microti transmission may be exacerbated in high antibiotic usage areas.

Evaluation of more than one billion outpatient prescriptions and eight-year trend showing a remarkable reduction in antibiotic prescription in Turkey: A success model of governmental interventions at national level

PURPOSE

To present the antibiotic prescription trend between 2011-2018 at primary healthcare in Turkey in order to evaluate the effects of interventions at national level for providing rational prescription of antibiotics.

METHODS

Electronic prescription data of the family physicians collected from January 1, 2011 to December 31, 2018 in 81 provinces of Turkey were recorded through the Prescription Information System and screened for the antimicrobial drugs. The interventions to promote rational antibiotic use during 2011-2018 in Turkey includes reminding the legislation to stop access of antibiotics without prescription, monitoring of antibiotic prescription behaviors of primary healthcare physicians, and education of healthcare workers and the public on the appropriate use of antibiotics.

RESULTS

A total of 1 054 261 396 prescriptions for outpatients of all age groups were recorded during this period. Of the prescriptions written by family physcians, 34.94% were containing at least one antibiotic in 2011, which declined to 24.55% in 2018. Antibiotics constituted 13.99% of all the items in prescriptions in 2011 and 10.47% in 2018. Percentage of total antibiotic expenditure to the total drug expanditure decreased from 14.14% to 4.12% during 2011-2018. The most commonly prescribed antibiotics were amoxicillin and enzyme inhibitor combination, cefdinir, and cefuroxime during 2011-2018, with an increasing trend for prescription of first-line antibiotic, amoxicillin, in recent years.

CONCLUSIONS

Governmental interventions at national level have contributed to reducing antibiotic prescription and increasing preference of first-line antibiotics at primary healthcare level in Turkey over a course of 8 years. Turkey's model of governmental interventions may set an example for other countries with high consumption of antibiotics, and contribute to the actions against antimicrobial resistance worldwide.

A prospective, observational study of fidaxomicin use for Clostridioides difficile infection in France

OBJECTIVE

To describe the characteristics, management and outcomes of hospitalised patients with Clostridioides difficile infection (CDI) treated with and without fidaxomicin.

METHODS

This prospective, multicentre, observational study (DAFNE) enrolled hospitalised patients with CDI, including 294 patients treated with fidaxomicin (outcomes recorded over a 3-month period) and 150 patients treated with other CDI therapies during three 1-month periods. The primary endpoint was baseline and CDI characteristics of fidaxomicin-treated patients.

RESULTS

At baseline, the fidaxomicin-treated population included immunocompromised patients (39.1%) and patients with severe (59.2%) and recurrent (36.4%) CDI. Fidaxomicin was associated with a high rate of clinical cure (92.2%) and low CDI recurrence (16.3% within 3 months). Clinical cure rates were ≥90% in patients aged ≥65 years, those receiving concomitant antibiotics and those with prior or severe CDI. There were 121/296 (40.9%) patients with adverse events (AEs), 5.4% with fidaxomicin-related AEs and 1.0% with serious fidaxomicin-related AEs. No fidaxomicin-related deaths were reported.

CONCLUSIONS

Fidaxomicin is an effective and well-tolerated CDI treatment in a real-world setting in France, which included patients at high risk of adverse outcomes.Trial registration: Description of the use of fidaxomicin in hospitalised patients with documented Clostridium difficile infection and the management of these patients (DAFNE), NCT02214771, www.ClinicalTrials.gov.

Antibiotic usage and resistance in Mexico: an update after a decade of change

Ten years ago, a review on the status of resistance in Mexico was bleak: with antibiotics freely sold over the counter and poor regulation of generic drugs, among other conditions, resistance among relevant pathogens often ranked top, either among Latin American countries, or even worldwide. Since then, there have been some regulatory changes, along a decline in antibiotics usage: antibiotics are (supposedly) no longer sold without prescription, generic drugs (supposedly) have to demonstrate bioequivalence, and antibiotic usage has drop, from about 13 defined daily doses per 1,000 inhabitants per day, to 7. While these changes may sound encouraging, an analysis show that regulatory changes are incomplete at best, and usage decline may be the consequence of factors such as growing poverty. The assessment of resistance continues to be haphazard, without an organized network of laboratories providing a coherent picture. However, judging from a few nationwide reports, it appears that resistance among some nosocomial pathogens (MRSA, enterococci, Pseudomonas aeruginosa) is declining, as it is among pneumococci and enteropathogens; but it is rising among community-acquired, uropathogenic Escherichia coli. Resistance to colistin is slowly increasing; and worrisome resistance determinants, such as blaNDM-1 and mcr-1, appeared in Mexico shortly after their first report elsewhere. After four years from the United Nations General Assembly high-level meeting on antibiotic resistance, Mexico is yet to deploy the basic measures to assess and control antibiotic resistance. As such, and despite the regulatory changes, the 2010-2020 period looks like a "lost decade".

Veterinary Interventions to Improve Neonatal Survival on British Beef and Sheep Farms: A Qualitative Study

Neonatal lamb and calf deaths are a major issue in UK agriculture. Consistent mortality rates over several decades, despite scientific advances, indicate that socioeconomic factors must also be understood and addressed for effective veterinary service delivery to improve lamb and calf survival. This qualitative study utilised semi-structured interviews with vets and farmers to explore the on-farm mechanisms and social context, with a particular focus on the role of the vet, to manage and reduce neonatal losses in beef calves and lambs on British farms. Data were analysed using a realist evaluation framework to assess how the mechanisms and context for veterinary service delivery influence survival as the outcome of interest. A lack of a clear outcome definition of neonatal mortality, and the financial, social and emotional impact of losses on both vets and farmers, are barriers to recording of losses and standardisation of acceptable mortality levels at a population level. Despite this, there appears to be an individual threshold on each farm at which losses become perceived as problematic, and veterinary involvement shifts from preventive to reactive mechanisms for service delivery. The veterinarian-farmer relationship is central to efforts to maximise survival, but the social and economic capital available to farmers influences the quality of this relationship. Health inequalities are well-recognised as an issue in human healthcare and the findings indicate that similar inequalities exist in livestock health systems.

Practice of antimicrobial stewardship in a government hospital of India and its impact on extended point prevalence of antibiotic usage

BACKGROUND

Antimicrobial resistance (AMR) is a global concern requiring immediate attention. Among many proven measures of decreasing AMR, practice of antimicrobial stewardship is the lowest hanging which can be adapted with negligible financial implications.

METHODS

This is a case record based extended cross-sectional type of observational operation research study conducted at an institute of national importance established by Government of India. Point prevalence of antibiotic usage among the patients admitted in the hospital, on four different days in four different quarters of a year was done to study the impact of antimicrobial stewardship program (AMSP).

RESULTS

A cumulative 711 patients were exposed on antibiotics among 1396 study participants. There was a significant decrease in antibiotic consumption across the 1st and 4th quarter. The average antibiotic usage was 50.9% (61.75, 60%, 48.4%, and 39% respectively in the 1st to 4th quarter). Among the total number of patients, intravenous antibiotic usage was 47.9% (60.71%, 58.4%, 44.9%, and 34.2% respectively in 1st to 4th quarter). Among the newly admitted patients, the consumption of antibiotic usage decreased from 45.9% to 25.7%. Among the intravenous antibiotics, the top 10 consumed antibiotics were 3rd generation cephalosporin (39.8%), aminoglycoside (14.8%), amoxicillin/amoxy-clav (12.5%), piperacillin-tazobactum (8.5%), carbapenams (6.6%), cefuroxime (6.4%), quinolones (4.3%), vancomycin/linezolid (4.1%), colistin (0.8%), and others (0.8%).

CONCLUSION

Government run hospitals can run low budget antimicrobial stewardship program with sustainable impact on antibiotic consumption. For a successful AMSP, it requires change in attitude, commitment, and administrative support rather than a huge financial support.

Quillaja saponaria (Molina) Extracts Inhibits In Vitro Piscirickettsia salmonis Infections

P. salmonis infections are the cause of major bacterial disease in salmonids in Chile, and the reason for using more antibiotics compared to other salmon-producing countries. Vaccination and antibiotics have not been efficient and new approaches are needed. The safety of Quillaja saponaria extracts was measured by cytotoxicity using flow cytometry of cytopathic and death of fish cell cultures and efficacy was assessed using in vitro infection models with pathogenic P. salmonis. Cytotoxicity was low and control of in vitro infections was achieved with all products, with protection of over 90%. Minimum inhibitory concentrations were much higher than those in the infection using cell cultures. These results suggest a dual mechanism of action where less purified extracts with a combination of saponin and non-saponin components simultaneously decrease P. salmonis infection while protecting cell lines, rather than exerting a direct antimicrobial effect. Quillaja saponins controlled in vitro infections with P. salmonis and could be considered good candidates for a new, safe and sustainable method of controlling fish bacterial infectious diseases.

Risk Perceptions of Antibiotic Usage and Resistance: A Cross-Sectional Survey of Poultry Farmers in Kwara State, Nigeria

Overwhelming empirical evidence has highlighted the contribution of indiscriminate antibiotic usage (ABU) in food animals to the overall burden of antibiotic resistance (ABR) in humans, thus making antibiotic use the main selective pressure driving antibiotic resistance. The social and behavioral perspective on antibiotic use and resistance in poultry is limited. Our study therefore aimed at obtaining information on antibiotic usage, awareness of ABR, and the attitude and perceptions towards prudent antibiotic usage and ABR. A cross-sectional survey using a structured questionnaire was conducted in 125 poultry farms in Kwara state in December 2019. Most farmers (69.6%, n = 87/125) were aware of ABR and had satisfactory knowledge about ABR with a mean knowledge score of 3.2 ± 1.5. Age (older farmers; OR: 1.1, 95% CI: 1.0, 1.2) and gender (male respondents, OR: 8.5, 95% CI: 3.0, 23.9; p < 0.01) were more likely to have satisfactory knowledge of ABR. Tertiary education was significantly associated with ABR awareness (OR: 4.7; 95% CI: 0.1, 0.7; p = 0.007) and the ABR knowledge level (OR: 7.8; 95% CI: 3.3, 18.7; p < 0.01). Higher flock size was significantly associated with a satisfactory knowledge of ABR (OR: 9.5; 95% CI: 3.8, 23.6; p < 0.01). Most of the poultry farmers (68%) had positive attitudes towards prudent antibiotic use with a mean score of 2.7 ± 0.9. On the contrary, only 32.8% of poultry farmers had a desirable perception of ABR with a mean perception score of 4.9 ± 1.1. The ABR knowledge level was significantly associated with the perceptions of farmers (p < 0.05) but not their attitudes toward ABU and ABR (p = 0.083). There was evidence of unprescribed use of antibiotics in poultry and a failure to observe antibiotic withdrawal periods. These constitute a risk of exposure to unacceptable levels of drug residues from poultry products and an increased risk of ABR. Improving education and communication on antibiotic stewardship programs are crucial to prevent the looming antibiotic threat.

Toward Antibiotic Stewardship: Route of Antibiotic Administration Impacts the Microbiota and Resistance Gene Diversity in Swine Feces

Oral antibiotics are a critical tool for fighting bacterial infections, yet their use can have negative consequences, such as the disturbance of healthy gut bacterial communities and the dissemination of antibiotic residues in feces. Altering antibiotic administration route may limit negative impacts on intestinal microbiota and reduce selective pressure for antimicrobial resistance genes (ARG) persistence and mobility. Thus, a study was performed in pigs to evaluate route of therapeutic oxytetracycline (oxytet) administration, an antibiotic commonly used in the U.S. swine industry, on intestinal microbial diversity and ARG abundance. Given that oral antibiotics would be in direct contact with intestinal bacteria, we hypothesized that oral administration would cause a major shift in intestinal bacterial community structure when compared to injected antibiotic. We further postulated that the impact would extend to the diversity and abundance of ARG in swine feces. At approximately 3 weeks-of-age, piglets were separated into three groups (n = 21–22 per group) with two groups receiving oxytet (one via injection and the second via feed) and a third non-medicated group. Oxytet levels in the plasma indicated injected antibiotic resulted in a spike 1 day after administration, which decreased over time, though oxytet was still detected in plasma 14 days after injection. Conversely, in-feed oxytet delivery resulted in lower but less variable oxytet levels in circulation and high concentrations in feces. Similar trends were observed in microbial community changes regardless of route of oxytet administration; however, the impact on the microbial community was more pronounced at all time points and in all samples with in-feed administration. Fecal ARG abundance was increased with in-feed administration over injected, with genes for tetracycline and aminoglycoside resistance enriched specifically in the feces of the in-feed group. Sequencing of plasmid-enriched samples revealed multiple genetic contexts for the resistance genes detected and highlighted the potential role of small plasmids in the movement of antibiotic resistance genes. The findings are informative for disease management in food animals, but also manure management and antibiotic therapy in human medicine for improved antibiotic stewardship.

Assignment of Canadian Defined Daily Doses and Canadian Defined Course Doses for Quantification of Antimicrobial Usage in Cattle

Standardized units are essential to allow quantification and comparison of antimicrobial usage (AMU) between species and regions. In Canada, defined daily and course doses have not yet been harmonized for cattle. Our objective was to assign defined daily and course doses (named DDDbovCA and DCDbovCA, respectively) for cattle in Canada, by antimicrobial agent (AM) and by route of administration, based on the label of all products containing at least one AM, marketed and authorized in Canada for use in cattle. In April and December 2019, a systematic search was performed from the online Drug Product Database (DPD) of Health Canada to identify veterinary products containing at least one AM, marketed in Canada for use in cattle. Products were divided by route of administration (intramammary, intrauterine, injectable, oral, and topical). The monograph was retrieved for each product from the DPD, or from the Canadian Edition of the Compendium of Veterinary Products (CVP), and read completely to extract recommended dosages in cattle. Standard weights were applied to compute doses if required. DDDbovCA and DCDbovCA were assigned by calculating an average of daily and course doses, respectively, by AM and route of administration. Two products were excluded from calculations because of their claim as growth promotion or feed efficiency (no longer authorized in Canada for certain categories of AM). Overall, 39 injectable, 75 oral (including 23 medicated premixes), 8 intramammary (4 for lactating cows and 4 for dry cows), 5 intrauterine, and 4 topical products were used for calculations. DDDbovCA and DCDbovCA values were assigned successfully for each AM identified, by route of administration. These metrics will allow harmonized and transparent quantification of AMU in cattle in Canada.

Assessing farmers' perspective on antibiotic usage and management practices in small-scale layer farms of Mymensingh district, Bangladesh

Background and Aim

Indiscriminate and injudicious use of antibiotics in layer farms is a common practice of Bangladesh for the compensation of Poor management practices and ignorance. Despite this scenario, there is no published documentation on antibiotic usage pattern and farm management practices in layer farms. This study was undertaken to understand the farmers' perspective in small-scale layer farms regarding antibiotics usage and farm management.

Materials and Methods

A questionnaire survey was conducted in 120 small-scale layer farms of Mymensingh district during January-February 2017. We only considered farms in production. Data were analyzed on antibiotic usage, purpose, egg management, understanding of antibiotic residue, withdrawal period, and other issues.

Results

Among 120 farmers, about 94.16% of farmers are using antibiotics without respecting the withdrawal period. Only 39.1% of farmers possess knowledge of residues. In our surveyed farms, 91.83% of farmers are not practicing egg washing before supplying to the market and 52.67% of farmers are unaware of cleaning and disinfection of egg tray. Ten different types of antibiotics of seven classes have found in the survey. Most antibiotics are in the Watch (49%) and Reserve (8%) groups according to the WHO AWaRe categorization and 73% antibiotics are critically important for human medicine and are considered as last resort.

Conclusion

This study found that due to the lack of knowledge and poor management, farmers consider using antibiotics as the most effective practices to control disease and enhancement of egg production. These indiscriminate uses of antibiotics are responsible for antibiotic residual and resistance problem. Here, we also provide some suggestion and guidelines to improve management practices to minimize the emerging problems of antimicrobial resistance through small-scale layer farms.

University students' knowledge, attitudes, and practice regarding antibiotic use and associated factors: a cross-sectional study in the United Arab Emirates

Purpose: Antibiotic resistance is one of the world’s most fatal health crises. Medical students are the antibiotic prescribers of tomorrow, so better understanding of their knowledge, attitudes, and practice (KAP) pertaining to antibiotic use is crucial.

Objectives: This study aimed to assess the KAP of antibiotics and associated factors among university students in the United Arab Emirates (UAE).

Methods: This was a descriptive cross-sectional study conducted among a random sample of undergraduate students from Ajman University in the UAE. A self-administered pretested questionnaire was used to collect data on students’ demographics and their KAP regarding antibiotic use. Data were analysed using STATA version 14.2. P<0.05 was considered statistically significant.

Results: This study showed that university students have a high rate of antibiotic self-medication. The average KAP score was 56% (95% CI 55%–57%). Statistical modeling showed that major, study year, age, and sex were strong determinants of KAP regarding antibiotic use.

Conclusion: There is a need to develop an effective and comprehensive antibiotic-stewardship program as part of undergraduate education. Moreover, reinforcing antibiotic-use policies, involving pharmacies, drug supply, distribution, and sale, are also urgently needed.

Prevalence of Antibiotic Residues and Antibiotic Resistance in Isolates of Chicken Meat in Korea

The aim of study was to investigate the correlation between the level of 17 antibiotic residues and 6 antibiotic resistances of Escherichia coli isolates in chicken meats. A total of 58 chicken meats were collected from retail grocery stores in five provinces in Korea. The total detection rate of antibiotic residues was 45% (26 out of 58). Ten out of 17 antibiotics were detected in chicken meats. None of the antibiotics exceeded the maximum residue level (MRLs) in chicken established by the Ministry of Food and Drug Safety (MFDS). The most detected antibiotics were amoxicillin (15.5%), followed by enrofloxacin (12.1%) and sulfamethoxazole (10.3%). In a total of 58 chicken meats, 51 E. coli strains were isolated. E. coli isolates showed the highest resistance to ampicillin (75%), followed by tetracycline (69%), ciprofloxacin (65%), trimethoprim/ sulfamethoxazole (41%), ceftiofur (22%), and amoxicillin/clavulanic acid (12%). The results of study showed basic information on relationship between antibiotic residue and resistance for 6 compounds in 13 chicken samples. Further investigation on the antibiotic resistance patterns of various bacteria species is needed to improve food safety.

Antibiotic Utilization and the Role of Suspected and Diagnosed Mosquito-borne Illness Among Adults and Children With Acute Febrile Illness in Pune, India

Background

Antibiotic resistance mechanisms originating in low- and middle- income countries are among the most common worldwide. Reducing unnecessary antibiotic use in India, the world's largest antibiotic consumer, is crucial to control antimicrobial resistance globally. Limited data describing factors influencing Indian clinicians to start or stop antibiotics are available.

Methods

Febrile adults and children admitted to a public tertiary care hospital in Pune, India, were enrolled. Antibiotic usage and clinical history were recorded. Immunoassays for mosquito-borne disease and bacterial cultures were performed by protocol and clinician-directed testing. Clinical factors were assessed for association with empiric antibiotic initiation and discontinuation by day 5 using multivariable logistic regression and propensity score-matched Cox proportional hazard models.

Results

Among 1486 participants, 683 (82%) adults and 614 (94%) children received empiric antibiotics. Participants suspected of having mosquito-borne disease were less likely to receive empiric antibiotics (adjusted odds ratio [AOR], 0.5; 95% confidence interval [CI], .4-.8). Empiric antibiotics were discontinued in 450 (35%) participants by day 5. Dengue or malaria testing performed before day 4 was positive in 162 (12%) participants, and was associated with antibiotic discontinuation (AOR, 1.7; 95% CI, 1.2-2.4). In a propensity score-matched model accounting for admission suspicion of mosquito-borne disease, positive dengue or malaria tests increased hazard of antibiotic discontinuation (hazard ratio, 1.6; 95% CI, 1.2-2.0).

Conclusions

Most patients with acute febrile illness in an Indian public hospital setting receive empiric antibiotics. Mosquito-borne disease identification is associated with reduced empiric antibiotic use and faster antibiotic discontinuation.

Prevailing practices in the use of antibiotics by dairy farmers in Eastern Haryana region of India

AIM

The aim of the study was to assess the antibiotic use in dairy animals and to trace its usage pattern among the small, medium, and large dairy farmers in Eastern Haryana region of India.

MATERIALS AND METHODS

Karnal and Kurukshetra districts from Eastern region of Haryana state were purposively selected, and four villages from each district were selected randomly. From each village, 21 farmers were selected using stratified random sampling by categorizing into small, medium, and large farmers constituting a total of 168 farmers as respondents. An antibiotic usage index (AUI) was developed to assess usage of antibiotics by dairy farmers.

RESULTS

Frequency of veterinary consultancy was high among large dairy farmers, and they mostly preferred veterinarians over para-veterinarians for treatment of dairy animals. Small farmers demanded low-cost antibiotics from veterinarians whereas large farmers rarely went for it. Antibiotics were used maximum for therapeutic purposes by all categories of farmers. Completion of treatment schedules and follow-up were strictly practiced by the majority of large farmers. AUI revealed that large farmers were more consistent on decision-making about prudent use of antibiotics. Routine use of antibiotics after parturition to prevent disease and sale of milk without adhering to withdrawal period was responsible for aggravating the antibiotic resistance. The extent of antibiotic use by small farmers depended on the severity of disease. The large farmers opted for the prophylactic use of antibiotics at the herd level.

CONCLUSION

Antibiotic usage practices were judicious among large dairy farmers, moderately prudent by medium dairy farmers and faulty by small farmers. The frequency of veterinary consultancy promoted better veterinary-client relationship among large farmers.

Knowledge, Attitude, and Practice of Parents Regarding Antibiotic Usage in Treating Children's Upper Respiratory Tract Infection at Primary Health Clinic in Kuala Lumpur, Malaysia: Pilot Study

Objectives:

To assess the knowledge, attitude, and practice of parents regarding antibiotic usage for treating upper respiratory tract infection (URTI) among children.

Methods:

A cross-sectional study was conducted among 320 randomly selected parents attending a primary health clinic using self-administered questionnaires.

Results:

About two-thirds (69.1%) of the parents had poor knowledge level. Only 25.2% and 21.6% of the parents could correctly identify amoxicillin and penicillin as the treatment of children’s URTI. However, about two-thirds (67.5%) of the parents were aware of the antibiotic resistance caused by overuse of antibiotics. A significant association was noted between the father’s and mother’s educational level and family income with the knowledge level. Only mother’s educational level depicted a significant association with the attitude.

Conclusion:

The knowledge of parents regarding antibiotic usage for URTI was poor. More numbers of health promotions and educational campaigns are required to help parents understand about antibiotic usage.

Impact of antimicrobial drug restrictions on doctors' behaviors

BACKGROUND/AIM

Broad-spectrum antibiotics have become available for use only with the approval of infectious disease specialists (IDSs) since 2003 in Turkey. This study aimed to analyze the tendencies of doctors who are not disease specialists (non-IDSs) towards the restriction of antibiotics.

MATERIALS AND METHODS

A questionnaire form was prepared, which included a total of 22 questions about the impact of antibiotic restriction (AR) policy, the role of IDSs in the restriction, and the perception of this change in antibiotic consumption. The questionnaire was completed by each participating physician.

RESULTS

A total of 1906 specialists from 20 cities in Turkey participated in the study. Of those who participated, 1271 (67.5%) had ≤5 years of occupational experience (junior specialists = JSs) and 942 (49.4%) of them were physicians. Specialists having >5 years of occupational experience in their branch expressed that they followed the antibiotic guidelines more strictly than the JSs (P < 0.05) and 755 of physicians (88%) and 720 of surgeons (84.6%) thought that the AR policy was necessary and useful (P < 0.05).

CONCLUSION

This study indicated that the AR policy was supported by most of the specialists. Physicians supported this restriction policy more so than surgeons did.

A systematic review of the management of acute pyogenic flexor tenosynovitis

Pyogenic flexor tenosynovitis (PFT) is an aggressive closed-space infection that can result in severe morbidity. Although surgical treatment of pyogenic flexor tenosynovitis has been widely described, the role of antibiotic therapy is inadequately understood. We conducted a literature review of studies reporting on acute pyogenic flexor tenosynovitis management. A total of 28 case series articles were obtained, all of which used surgical intervention with varied use of antibiotics. Inconsistencies among the studies limited summative statistical analysis. Our results showed that use of antibiotics as a component of therapy resulted in improved range of motion outcomes (54% excellent vs. 14% excellent), as did using catheter irrigation rather than open washout (71% excellent vs. 26% excellent). These studies showed benefits of early treatment of pyogenic flexor tenosynovitis and of systemic antibiotic use. As broad-spectrum antibiotics have changed the management of other infectious conditions, we must more closely evaluate consistent antibiotic use in pyogenic flexor tenosynovitis management.

LEVEL OF EVIDENCE

Therapeutic, Level III.

Antibiotic and shared decision-making preferences among adolescents in Malaysia

BACKGROUND

The purpose of this study was to establish baseline information on the current level of knowledge about, attitude toward, and experience with antibiotic usage, and preferences for shared decision making among adolescents in Malaysia.

METHODS

A cross-sectional survey, involving 1,105 respondents who were aged between 13 and 17 years and who lived in Malaysia, was conducted using a validated questionnaire. The survey assessed knowledge, attitude, and experience with regard to antibiotic usage, and adolescents' preferences for the style of shared decision-making process.

RESULTS

The majority (n=786 [71.13%]) of the respondents had a low level of knowledge, 296 (26.79%) had a moderate level of knowledge, and 23 (2.08%) had a high level of knowledge. Further, they demonstrated a slightly negative attitude mean score of 3.30±0.05 (range: 0-8 points) but a positive experience mean score of 2.90±0.029 (range: 0-4 points). There was a positive correlation between knowledge and attitude scores, with a higher knowledge level associated with a more positive attitude toward antibiotic usage (r=0.257, P<0.001). Higher knowledge scores were associated with a more negative experience with antibiotic usage (r=-0.83, P=0.006). When assessing preference in shared decision making, more adolescents preferred an active role (n=408 [37%]) compared with collaborative (n=360 [32.6%]) or passive (n=337 [30.5%]) (P=0.028) roles.

CONCLUSION

Current health care settings should involve adolescents in the decision-making process. Education packages can be introduced to improve adolescents' knowledge of and practice of taking antibiotics, as well as to encourage their participation in decision making, in an attempt to reduce misuse of antibiotics.

Determinants of antibiotic dispensing without a medical prescription: a cross-sectional study in the north of Spain

Objectives

Antibiotic resistance is a major public health concern and is greatly exacerbated by inappropriate antibiotic use at a community level. The aim of this study was to ascertain which attitudes of community pharmacists were related to inappropriate antibiotic dispensing.

Methods

We conducted a cross-sectional study of community pharmacists in a region situated in northern Spain (n = 393). Personal interviews were conducted using a self-administered questionnaire. The degree of agreement with each item of knowledge and attitude was measured using an unnumbered, horizontal visual analogue scale, with replies being scored from 0 (total disagreement) to 10 (total agreement). The data were analysed using logistic regression.

Results

Of the total of 286 pharmacists (72.8%) who completed the questionnaire, 185 (64.7%) acknowledged having undertaken dispensing of antibiotics without a medical prescription (DAwMP). Attitudes such as patient complacency, external responsibility, indifference and insufficient knowledge were shown to be related to DAwMP. In contrast, no association was found with any of the pharmacists' personal or professional traits.

Conclusions

This study confirms that, albeit unlawful, DAwMP is a common practice in Spanish pharmacies. DAwMP was seen to be usually associated with some of the attitudes evaluated.

Antibiotic usage in 2013 on a dairy CAFO in NY State, USA

Antimicrobial resistance is threatening humans and animals worldwide. Biosecurity and 1-year usage of antibiotics on a dairy concentrated animal feeding operation (CAFO) in NY State, USA, were mapped: how much antibiotics were used, for what purpose, and whether any decrease could be warranted. Approximately 493 kg antibiotics was used, of which 376 kg was ionophores (monensin and lasalocides), 79 kg penicillin, 16.5 kg lincosamides, 8.0 kg aminoglycosides, 7.7 kg sulfamides, 3.4 kg cephalosporin, 2 kg macrolides, 0.7 kg amphenicols, and 0.1 kg fluoroquinolones. Usage reduction by 84% was realistic without compromising the animal welfare. Further reduction could be possible by improving the biosecurity and by utilizing antibiotic sensitivity testing.

Can appropriate diagnosis and treatment of childhood asthma reduce excessive antibiotic usage?

INTRODUCTION

This study compared the frequency of antibiotic usage and the number of asthma episodes before and after the diagnosis and treatment of pediatric asthma patients who were followed up by specialists.

SUBJECTS AND METHODS

Included in this study were 334 patients (211 males and 123 females) of 2-16 years of age who were diagnosed with asthma and followed up for at least 1 year in our clinic. The frequency of antibiotic usage and the number of asthma episodes in the year prior to diagnosis and treatment were compared to these same variables after 1 year of follow-up by specialists.

RESULTS

The median age was 84 months (range: 24-192) and 212 (63%) children were at school or in day care centers. Atopy and a family history of asthma were present in 200 (60%) of the patients, and 137 (41%) reported that at least one member of their household smoked. Antibiotics were used a median number of 7 times [interquartile range (IQR) = 6] in the year before the asthma diagnosis, and 2 times (IQR = 3) during the year after treatment (p < 0.001). The mean number of asthma episodes before diagnosis, i.e. 4 (IQR = 8) was reduced to 0 (IQR = 2) in the year after treatment when the patients were followed up by specialists (p < 0.001).

CONCLUSION

This study shows that appropriate diagnosis and treatment of childhood asthma significantly reduce the frequency of antibiotic usage and the number of asthmatic episodes.

Antimicrobial stewardship and Clostridium difficile-associated diarrhea

Antimicrobial stewardship programs are essential to health care institutions to promote the appropriate use of antibiotics not only to decrease antimicrobial resistance but to prevent the spread and infection of Clostridium difficile. Clostridium difficile-associated diarrhea is increasing rapidly in the United States and is now considered a major public health problem that poses an immediate threat to the health of patients prescribed antibiotics, more so than antimicrobial resistance. Clostridium difficile-associated disease is the result of collateral damage to the normal bacterial flora of the human body, which is an inevitable consequence of any antibiotic use. Antimicrobial stewardship programs such as audit with feedback and antibiotic restriction are designed to help limit Clostridium difficile infections and other hospital-associated organisms by optimizing antimicrobial selection, dosing, de-escalation, and duration of therapy. These programs also incorporate implementation of hospital-wide guidelines, staff education, enforcement of infection-control policies, and the use of electronic medical records when possible to help control antibiotic use. This article reviews the literature on how antimicrobial stewardship programs impact Clostridium difficile rates and discusses experiences in designing, implementing, monitoring, and follow-through of such programs.

Antibiotic prescription patterns at admission into a tertiary level intensive care unit in Northern India

Context:

An audit of antibiotic prescribing patterns is an important indicator of the quality and standard of clinical practice.

Aims:

To study the (1) antibiotic prescription and consumption patterns at admission into the intensive care unit (ICU); (2) average costs of antibiotics prescribed; and (3) correlation of antibiotic usage and the costs incurred with age, severity of illness, and diagnosis.

Settings and Design:

A 13-bedded tertiary level ICU. A prospective, observational audit.

Materials and Methods:

Two hundred consecutive prescriptions on patients admitted to the ICU from August to October, 2008, were audited. The total number of drugs and antibiotics, the class, dose, route, and cost of antibiotics were noted and the Defined Daily Dose/100 bed-days (DDD/100 bed-days) of the 10 most frequently prescribed antibiotics were calculated. Statistical analysis used: Univariate analysis was performed using Epi Info software (version 8.0).

Results:

A total of 1246 drugs and 418 antibiotics were prescribed in the 200 patients studied, that is, an average of 6.23 (± SD 2.73) drugs/prescription and 2.09 (± SD 1.27) antibiotics/prescription. Antibiotics were prescribed on 190 patients (95%) at admission. There was a significant correlation between the number of patients prescribed three or more antibiotics and mortality rates (53% nonsurvivors vs. 33.5% survivors (P = 0.015). The average cost of the antibiotics was Rupees 1995.08 (± SD 2099.99) per patient and antibiotics expenditure accounted for 73.2% of the total drug costs.

Conclusions:

Antibiotics are commonly prescribed to most ICU patients at admission and contribute significantly to the total drug costs. Antibiotic restriction policies and a multidisciplinary effort to reduce usage are urgently required.

Antibiotic use in neonatal intensive care units and adherence with Centers for Disease Control and Prevention 12 Step Campaign to Prevent Antimicrobial Resistance

BACKGROUND

The Centers for Disease Control and Prevention (CDC) 12-Step Campaign to Prevent Antimicrobial Resistance was launched to educate clinicians about antimicrobial resistance and provide strategies to improve clinical practice, including antimicrobial utilization.

METHODS

A multicenter retrospective observational study of antibiotic use was performed in 4 tertiary care NICUs to assess adherence to the guidelines defined by the CDC 12-Step Campaign using predetermined criteria. Fifty infants per NICU were identified who received intravenous antibiotics at greater than 72 hours of age. Antibiotic regimens, clinical and microbiologic data, and indications for initiation and continuation of antibiotics (after 72 hours of use) were recorded. Inappropriate utilization was characterized at initiation, continuation, by agent, and by CDC 12-Step.

RESULTS

Two hundred neonates received 323 antibiotic courses totaling 3344 antibiotic-days. Ninety (28%) courses and 806 (24%) days were judged to be nonadherent to a CDC 12-Step. Inappropriate use was more common with continuation of antibiotics (39%) than with initiation (4%) of therapy. Vancomycin was the most commonly used drug (n = 895 antibiotic-days) of which 284 (32%) days were considered inappropriate. Carbapenems were used less frequently (n = 310 antibiotic-days), and 132 (43%) of these days were inappropriate. Common reasons for nonadherence at the time of continuation included failure to narrow antibiotic coverage after microbiologic results were known and prolonged antibiotic prophylaxis after surgery with chest tube placement.

CONCLUSIONS

The CDC 12-Step Campaign can be modified for neonatal populations. Inappropriate antibiotic prescribing was common in the study NICUs. Improvement efforts should target antibiotic use 72 hours after initiation, particularly focusing on narrowing therapy and instituting protocols to limit prophylaxis.