Abstract
BackgroundThe burden of antimicrobial-resistance, specifically carbapenem-resistance in gram-negative bacteria (CRGN), presents a serious public health threat worldwide. In Europe, Southern and Eastern countries (SEC) display a higher CRGN-prevalence as compared to Northern and Western countries (NWC). Since SEC also display lower nurse-density on average, we hypothesized that the occurrence of CRGN might correlate with nurse understaffing and therefore aimed at quantifying a potential independent effect of nurse-density on total CRGN in Europe.MethodsA 30-country cross-sectional study was conducted. Cumulative six-year CRGN-prevalence (2011–2016) in four gram-negative bacterial species was determined based on > 700 k clinical invasive isolates (EARS-net). We performed multivariable log-linear regression to provide estimations of the effect of nurse-density while adjusting to various health-system variables.ResultsMultivariable analysis (adj.-R2 ~ 93%) suggested an average 0.4% [95%-CI 0.2–1.0%] CRGN-increase due to a decrement of one practicing nurse per week of hospital-stay of one population individual. Our modeling provided CRGN-estimations in two non-EARS-net countries (Switzerland and Turkey), which were almost equal to empirically estimated values (CAESAR-Network). Furthermore, a nurse-density-dependent moderation of the inter-species distribution balance was a likely pathway of the observed effect. These observations were specific for CRGN, in contrast to other resistance types in the same species.ConclusionsThis is the first attempt of quantifying potential nurse-density effects on antimicrobial-resistance at national level. Our results suggest an increase in CRGN by decreasing nurse-density. Nurse-density is thus a novel factor that might improve our understanding of the unbalanced CRGN-distribution among sub-European regions. Consequently, integrating nurse-density in future AMR-policies could be beneficial.
Highlights
The burden of antimicrobial-resistance, carbapenem-resistance in gram-negative bacteria (CRGN), presents a serious public health threat worldwide
The proportion of carbapenem-resistance was highest in Acinetobacter spp. (52.0% [95%-CI 51.2–52.7%]) followed by P. aeruginosa (18.5% [18.2–18.9%]), K. pneumoniae (7.1% [6.9–7.2%]) and E. coli (0.08% [0.07–0.09%])
Neither the Fluoroquinolone–resistant gram-negatives (FRGN) (M6.S), nor the Aminoglycoside-resistant gram-negatives (NRGN) (M7.S) model displayed an independent moderation effect of EAPD by nurse-density. These results indicate that the observed effects of nurse-density on the resistance prevalence in gram-negative invasive isolates were specific for CRGN under the applied test conditions (Additional file 1, model Eqs. 4—7)
Summary
The burden of antimicrobial-resistance, carbapenem-resistance in gram-negative bacteria (CRGN), presents a serious public health threat worldwide. As compliance to prescription guidelines within distinct societies might involve a cultural aspect, an “out of the box” thinking approach has been suggested in past years, investigating the influence of cultural determinants on AMR In this context, countries which apply more strict antibiotic stewardship (ABS) measures had lower proportions of methicillin-resistant Staphylococcus aureus (MRSA) compared to other countries, in which the implementation of ABS programs is less stringent [8]. Countries which apply more strict antibiotic stewardship (ABS) measures had lower proportions of methicillin-resistant Staphylococcus aureus (MRSA) compared to other countries, in which the implementation of ABS programs is less stringent [8] Within this frame, pooled AMR proportions of several drugspecies pairs were strongly associated with corruption [9], which can be considered as a cultural determinant of non-compliance to common guidelines. Recent research on the other hand, including our own work, suggested the association between climate (change) and AMR in both Europe and the USA [11,12,13]
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