NEW APPROACHES FOR COMBATING POLYRESISTANT ESKAPE PATHOGENS

The CDC estimates 23% of healthcare-associated infections to be surgical site infections, with alarming prevalence of antibiotic-resistant organisms. While there is consensus regarding preoperative prophylaxis, orthopaedic surgeons' use of prophylactic postoperative oral antibiotics is less defined. We investigated surgeons' use of prophylactic postoperative oral antibiotics after elective outpatient foot or ankle procedures, identifying (1) frequency of use, (2) regimen preferences, (3) personal indications, and (4) associated experience and demographics. Using a cross-sectional survey design, a questionnaire was emailed to all active and candidate members of the American Orthopaedic Foot and Ankle Society. Supplementary questions captured demographic information. We invited 1136 members to participate; 22 addresses produced delivery failure messages, leaving 1114 members as potential participants. After nonresponses and exclusions, 312 (28%) responses were analyzed. Statistical analysis used Pearson's chi-square test, Fisher's exact test, and multivariate regression. The majority (75%) of respondents reported use of prophylactic postoperative oral antibiotics. Most users (69%) prescribed to fewer than 25% of patients, although 16% prescribed for all elective cases. The most frequent regimen was cephalexin 500 mg four times a day (63%) and the most common duration was 5 to 7 days (50%). Surgeons' most common indications were previous infection (71%), medical comorbidities (65%), and previous wound-healing difficulties (56%). Those who do and do not prescribe prophylactic postoperative oral antibiotics showed no difference in surgical site infection rate or any demographic category. Surgeons' reported use of prophylactic postoperative oral antibiotics after elective foot or ankle surgery was common, without demographic association. Commonalities were identified in antibiotic regimen and personal indications for this practice. Comparative clinical studies are warranted to elucidate the efficacy of prophylactic postoperative oral antibiotics and establish evidence-based guidelines for their use.

Antibiotics are substances that are very useful in killing and inhibiting the growth of microorganisms, especially bacteria. Inappropriate use of antibiotics can occur due to lack of information from health workers, especially pharmacists and misuse of antibiotics because they are easy to obtain without a doctor's prescription, sudden discontinuation of treatment, excessive doses, use of residual antibiotics, and use of antibiotics for an inappropriate period of time. The need for education to minimize the occurrence of inappropriate use of antibiotics. This counseling activity aims to provide education to the public, especially Dharma Andalas University education staff on the proper use of antibiotics and to determine the effect of providing education on increasing knowledge about the use of antibiotics. This service method is a participatory community empowerment method, namely a method that emphasizes community involvement in a series of activities, with a pre-test and post-test. Data were analyzed using paired t-test. This community service activities ran smoothly and successfully. Based on the evaluation, there is an increase in knowledge of the proper use of antibiotics. There is a significant difference between before and after education and increasing the knowledge of education staff on the proper and wise use of antibiotics (p <0.05). It is hoped that through this counseling, the community will become aware of the use and handling of drugs, especially antibiotics.

Background: Antibiotics are widely used in dentistry. Dentists often provide antibiotics unnecessarily. Excessive use can induce resistant bacterial strains. There are certain indications for the proper use of antibiotics for pediatric dentistry according to the European and American Pediatric Dentistry (EAPD and AAPD). Very often dentists do not follow these guidelines. Objectives: This study aims to examine the level of knowledge among general dentists (who also treat children) and pediatric dentists on proper use of antibiotics. In addition, we examined whether there is unjustified use of antibiotics, if dentists are aware of the new and conservative approach of administering antibiotics to patients, and whether there is a relationship between years of professional seniority and dentist’s knowledge level of proper use of antibiotics. Methods: One hundred general dentists (GD) who treat children in addition to 100 pediatric dentists (PD) completed the study questionnaires which measured knowledge, practice and attitudes regrading using antibiotics during dental treatment among children. Results: The general average of level of knowledge on proper use of antibiotics among general dentists was relatively low for both GD (60.7%) and PDs (65%). PDs demonstrated a relatively greater knowledge of correct use of antibiotics, especially in cases of endodontics and trauma. PDs also showed higher awareness to latest guidelines for the admission of “prophylactic antibiotics” according to the American Association (AAPD) and/or the European Union (EAPD) compared with GDs (86.2% vs. 66.3%). Conclusion: The level of knowledge of both general dentists and pediatric dentists is poor, with a large percentage of dentists from both groups not knowing whether antibiotics are needed in a specific dental case or not. Compliance with the EAPD/AAPD guidelines is also low and inadequate. The method of prescribing antibiotics given by dentists can be improved by increasing awareness, educational initiatives, and postgraduate courses among dentists regarding the recommended indications.

With the goal of ensuring maximal safety, surgeons tend to apply antibiotic prophylaxis generously to patients undergoing selective operative procedures. However, the indiscriminate or inappropriate use of prophylactic antibiotics i) leads to the selection of resistant microbial organisms and ii) results in an increase in general medical treatment costs. Given this controversy, the clinic of reconstructive surgery implemented in 1999 a set of guidelines for the proper use of antibiotics. Antibiotic prophylaxis was defined as a pre- or perioperative application of antibiotics as a single to maximum triple-shot dose. It was recommended only for operations involving special risk factors or the implantation of alloplastic material. The recommended medication of choice was the widely-accepted standard first-generation cephalosporin product Cefazolin. We have carried out a quality control trial to analyse prospectively our own experience with the implementation of these guidelines and to compare results with a retrospective group of patients. A total of 792 patients (441 in the retrospective group, 351 in the prospective group) were enrolled in the study. About one third of all patients received an antibiotic prophylaxis. Of these, about 3/4 received the antibiotic prophylaxis without having one of the above-mentioned indications. We observed that 35% of all prophylaxis were given for breast surgery, followed by surgery for scar revisions and lipodystrophy. The most commonly used antibiotic was Cefuroxim rather than Cefazolin. There was no significant reduction in the general application of antibiotic prophylaxis yet apparent in the prospective group. However, there was a clear increase in the use of Cefazolin from 0.2% to 13.2%. We conclude that guidelines can be created to reduce the incidence of uninformed and inappropriate decisions, but their implementation requires time, motivation, and thorough and repeated information campaigns.

In the 47(4), August 2021 issue of Journal of Oral Implantology, the editorial asked, “What is the proper antibiotic prophylaxis regimen for dental implant placement?” Considerations were the following:This editorial will examine relevant literature regarding the need for possible additional postoperative antibiotic doses in medically compromised patients. The benefits of administering antibiotic prophylaxis both pre- and postoperatively are often misunderstood and can lead to irrational expectations and unnecessary use. The principles of antibiotic prophylaxis are well-known; however, they are not frequently followed. Pre- and postoperative antibiotic prophylaxis are beneficial only in select clinical scenarios. Proper antibiotic prophylaxis use is beneficial in patients with a compromised immune system, but unnecessary use may cause adverse effects. Implant clinicians must be aware of the indications and contraindications for postoperative antibiotic prophylaxis. Prophylactic antibiotics are indicated to diminish or eliminate surgical site and metastatic bacteremia in high risk patients.2Clinicians take precautionary steps to assure successful implant treatments. However, arbitrary antibiotic use is unacceptable and may not lead to better implant success rates, but rather increase the risk of failure due to the overgrowth of nonsusceptible microorganisms. Binanhmed et al3 found there was no greater efficacy observed with a 7-d postoperative antibiotic therapeutic course vs. a single preoperative dose.Lockhart et al4 performed a systematic literature search addressing antibiotic prophylaxis for invasive dental procedures in patients with 8 controversial medical conditions (or devices) who are traditionally given pre- and postoperative antibiotic prophylactic doses. The conditions and devices were (i) cardiac-native heart valve disease, prosthetic heart valves, and pacemakers; (ii) hip, knee, and shoulder prosthetic joints; (iii) renal dialysis shunts; (iv) cerebral fluid shunts; (v) vascular grafts; (vi) immunosuppression secondary to cancer and chemotherapy; (vii) insulin dependent (type 1) diabetes mellitus; and (viii) systemic lupus erythematosus. The practice of prescribing postoperative antibiotics is driven by long-standing dogma and habit, medicolegal concerns, and the potentially devastating consequences of infection in some patients. The weight of evidence suggests that the practice of routine antibiotic prophylaxis for many of the patients in these groups should be re-evaluated. The focus should be directed towards daily, thorough oral hygiene to purposefully reduce chronic oral bacteremia.4 There is a lack of evidence regarding the benefits of prolonged antibiotic prescribing; however, there is a problem of identifying patients at high risk, and there is no well-defined list of dental procedures that increase the patient's inherent danger. Therefore, prospective, randomized placebo-controlled clinical trials are needed to guide clinicians in making confident antibiotic prescribing recommendations regarding which patients and implant procedures represent a significantly increased risk of distant site infections.4Based on information currently available in the peer-reviewed literature, it would be incorrect to say that all medically compromised patients require postoperative antibiotic coverage for 7–10 d. Understanding the severity of a patient's compromised immune response will guide the need for postoperative antibiotic coverage and thus prevent some distant site infections. It is unreasonable to expect a dental implant clinician to have the ability, skills, or knowledge to evaluate which patients may or may not benefit from postoperative antibiotic coverage. The patient's physician would be the professional most likely able to determine the value in providing additional antibiotics in these cases. Physicians have the responsibility of understanding how to effectively evaluate a patient's immune risk.It would be clinically wrong to provide all medically compromised patients postoperative antibiotic therapy. Overprescribing antibiotics can lead to (i) an increased risk of superinfections, (ii) promotion of antibiotic-resistant microorganisms that could induce damage to hosts and the microbial ecological niche, and (iii) encouragement of careless or inept surgical techniques. When antibiotics are not used prudently, there may be an increased probability of antibiotic-induced allergies and toxic reactions. Remember, if no antibiotic prophylaxis is provided, there are no drug-related adverse effects to be harmful. However, ignoring the use of antibiotics 100% of the time would be negligent and may lead to poor clinical outcomes in some patients due to unnecessary infections.5For the medically compromised patient, a consultation with the patient's physician is necessary to determine whether postoperative antibiotic prophylaxis is required to prevent a systemic infection from the proposed invasive dental implant procedure. The consultation with the physician should begin with the implant clinician explaining what is to be done, how aggressive the intended procedure is, and what the expected procedural or surgical time is. Providing this information is the responsibility of the implantologist. The physician's responsibility is to provide guidance regarding the nature and risks of the patient's medical condition(s), and if the current treatment is optimized. Once the consultation has been completed, a well-informed decision regarding the need for a single preoperative dose or longer postoperative prophylactic antibiotic prescribing can be made.

The working committee for the proper use of antibiotics was organized at Tokushima University Hospital in March 2002, and the institutional guidelines for the selection and use of antibiotics were established. The infection control team (ICT) also started monitoring the use of particular antibiotics, including third-and fourthgeneration cephalosporins, calbapenems and anti-MRSA antibiotics, and reported on their use in August 2002. To assess these activities, we examined the status of antibiotic use for injections and compared our findings with the previous data.The results were as follows : 1) the reports required were presented in 47% of the total antibiotics used; 2) after starting the surveillance, the use of the third-and fourth-generation cephalosporins and calbapenems shifted to the first-and second-generation drugs, while the use of anti-MRSA drugs clearly decreased; 3) these changes resulted in a savings of more than two million yen in medical expenditures in a month. These results suggest that closely monitoring the use of antibiotics may thus be beneficial not only for promoting the proper use of antibiotics but also for reducing overall medical costs.

Self-medication is defined as self treatment and self-diagnose for conditions such as cough, flu, fever, pain, stomach ulcers, worms, diarrhea, rash, and some other minor illnesses. Based on the data from Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI (2013), there were 103.860 of 294.959 households (35,2%) in Indonesia which store medicines for selfmedication (including 35,7% “Obat Keras” or “Gevaarlijk” and 27,8% antibiotics). DKI Jakarta (56,4%) is the highest province with respect to stored medicines. Some studies have found that 40-62% of antibiotics are not used properly. The inappropriate use of antibiotics can lead to antibiotic resistance risk and can be life-threatening for people in every part of the world. To address this problem, this community service was conducted to provide information about selfmedication of influenza and cough illness and to improve people’s knowledge in the proper use of antibiotics. Lecturing was chosen as the method for explaining the rational use of antibiotics and participants were requested to fill out a questionnaire. This activity was attended by 34 participants (and 32 participants filled out the questionnaire). About 13 participants (40,6%) provided correct answers to questions on the proper use of antibiotics. Twenty six participants (81,25%) said they had previously used antibiotics, 14 of them (53,85%) admitted to purchasing antibiotics without a prescription. Antibiotics are taken to treat symptoms such as runny nose, cough, sore throat, fever, and other conditions. A total of 7 participants (26,92%) admitted taking antibiotics with dosage modification and 8 participants (30,77%) switched one type of antibiotics with another type of antibiotics. Based on the results, we concluded that people did not have sufficient knowledge about the rational use of antibiotics. We suggested that counseling about the proper use of antibiotics should be improved.

Objective To analyze the clinical distribution and drug resistance of acinetobacter baumannii in our hospital to provide basis for the proper use of antibiotics in clinic. Method s Various specimens from inpatients in our hospital from January 2014 to December 2018 were retrospectively analyzed. Identification and drug sensitivity test were implemented by the instrument method, analysis on the clinical distribution and drug resistance of acinetobacter baumannii. Result s 408 strains of acinetobacter baumannii were isolated, mainly from sputum specimens (64.7%). The main distribution was ICU, respiratory department, oncology department, neurosurgery department, and general department. Only the drug resistance rate of polymyxin B was less than 50.0% in antibiotics (0.3%), and that of the rest were all more than 50.0%. Conclusion The drug resistance of acinetobacter baumannii in our hospital is very serious. The hospital should actively carry out its drug resistance test, develop a reasonable usage program of antibiotic drugs, strengthen hand hygiene, environmental and object surface management, in order to prevent the spread of multi drug resistant bacteria. Key words: Acinetobacter baumannii; Drug resistance; Antibiotic; Rational administration of drug

Purpose: Many surgeons are reluctant to discontinue prophylactic antibiotics after 24 hours in tissue expander breast reconstruction (TEBR) due to increased risk of surgical site infection (SSI). There is currently no consensus regarding antibiotic prophylaxis duration in TEBR. In addition, there remains a lack of research investigating microorganisms involved in SSI across various perioperative antibiotic protocols. The purpose of this study was to examine how two different prophylactic antibiotic regimens impacted the bacterial profiles of SSI and rate of implant loss after TEBR. Methods: A single institution retrospective review was performed of immediate TEBRs between 2001-2018. Demographics, chemotherapy/radiation, prophylactic antibiotic regimen and SSI cultures were analyzed. SSIs requiring hospitalization before stage 2 were included. Outpatient managed SSIs were excluded. Highly virulent organisms were defined as ESKAPE pathogens (Enterococcus faecium, Staphylococcus Aureus, Klebsiella Pneumoniae, Acinetobacter baumannii, Pseudomonas Aeruginosa, Enterobacter species) based on literature. Implant loss was defined as removal of TE without immediate replacement. Results: Of 660 TEBRs, 85 (12.9%) developed an SSI prior to stage 2. Fifty-six (65.9%) previously received <24 hours perioperative prophylactic IV antibiotics and oral antibiotics after discharge (Group 1) and 29 (34.1%) were given <24 hours prophylactic IV antibiotics only (Group 2). There was no significant difference in demographics (i.e. BMI, age, smoking status, preoperative chemotherapy/radiation) or inpatient treatment of the SSI (Oral/IV antibiotics) between the two groups. In Group 1, 64% (n=36) developed culture positive SSIs, compared to 83% (n=24) in Group 2. Staphylococcus Aureus was the most common bacteria in both groups. Group 2 demonstrated a significantly increased incidence of gram-positive organisms (46.4% vs 72.4%, p=0.022) and Staphylococcus Aureus (21.4% vs 55.2%, p=0.002). However, there was no significant difference in overall highly virulent (p=0.168), gram-negative (p=0.416), or total isolated organisms (p=0.192) between groups. Interestingly, Group 1 demonstrated an increase in Pseudomonas Aeruginosa SSIs, (14.3% vs 3.4%, p=0.124) but this finding did not reach significance. Implant loss between Groups 1 and 2 (62.5% vs. 62.1%, p=0.969) respectively, was nearly identical. Conclusion: Our study demonstrates that despite differences in bacterial profiles between the two antibiotic protocols, prolonged postoperative antibiotic use did not provide additional protection against overall highly virulent infections. In addition, the implant loss rate between the two groups was similar. Antibiotic stewardship guidelines against the overuse of prolonged prophylactic regimens should be considered. Further analysis regarding timing of SSIs and antibiotic treatment is warranted.

Introduction: The preoperative phase is an important period in which to prevent surgical site infections (SSIs). Prophylactic antibiotic use helps to reduce SSI rates, leading to reductions in hospitalization time and cost. In clinical practice, besides effectiveness and safety, the selection of prophylactic antibiotic agents should also consider the evidence with regard to costs and microbiological results. This review assessed the current research related to the use of antibiotics for SSI prophylaxis from an economic perspective and the underlying epidemiology of microbiological findings.Methods: A literature search was carried out through PubMed and Embase databases from 1 January 2006 to 31 August 2017. The relevant studies which reported the use of prophylactic antibiotics, SSI rates, and costs were included for analysis. The causing pathogens for SSIs were categorized by sites of the surgery. The quality of reporting on each included study was assessed with the “Consensus on Health Economic Criteria” (CHEC).Results: We identified 20 eligible full-text studies that met our inclusion criteria, which were subsequently assessed, studies had in a reporting quality scored on the CHEC list averaging 13.03 (8–18.5). Of the included studies, 14 were trial-based studies, and the others were model-based studies. The SSI rates ranged from 0 to 71.1% with costs amounting to US$480-22,130. Twenty-four bacteria were identified as causative agents of SSIs. Gram negatives were the dominant causes of SSIs especially in general surgery, neurosurgery, cardiothoracic surgery, and obstetric cesarean sections.Conclusions: Varying results were reported in the studies reviewed. Yet, information from both trial-based and model-based costing studies could be considered in the clinical implementation of proper and efficient use of prophylactic antibiotics to prevent SSIs and antimicrobial resistance.

Background Antibiotics resistance is a major public health threat worldwide. Super bugs, for example, drug resistant tuberculosis or Staphylococcus aureus, are increasingly common in the communities. Hong Kong is one of the areas which have the highest antibiotics resistant strains prevalence rate in the world. Irrational use of antibiotics is an important contributing factor to the emergence of antibiotics resistance. Physician stewardship in the prescription of antibiotics is pivotal in the prevention of antibiotics resistance emergence. Medical students are going to be practicing doctors after graduation from medical school. But few studies had been conducted to investigate their knowledge and attitude towards antibiotics resistance and use, and relations with anticipated antibiotics prescription behaviour. Method 145 medical students at the University of Hong Kong were recruited in this study to complete a self-administered questionnaire. There were in total 14 questions in this questionnaire, covering 2 major themes 1.Self-report of current and past antibiotic use and behaviour; 2.Anticipated prescription behaviour of antibiotics upon graduation and practice in the future. Chi-square test was used to investigate the association between attitude and knowledge of antibiotics with their anticipated prescription behavior upon graduation and practice. Multivariable logistic regression model was used to adjust for potential confounders. Results 67.6 % of the participants hold the correct knowledge of the proper use of antibiotics. Compare with the participants who hold the wrong knowledge, they were to 0.18 times more likely to inappropriately prescribe antibiotics for non-complicated Upper respiratory tract infections (URTI). (OR: 0.18, 95 % CI: (0.08, 0.43); p <0.001). Respectively 33.6 % and 4.9% of all the participants perceived the severity of antibiotics resistance in Hong Kong as “Severe” and “Very severe “. Those who rated “Severe” or above were 0.37 times more likely to inappropriately prescribe antibiotics for non-complicated URTIs compared with the participants who rated “Neutral” or below. (OR: 0.37, 95 % CI: (0.15, 0.91); p = 0.03). Logistic regression model was employed to test the interaction effect. Result showed that clinical training significantly interacted with antibiotics knowledge (p < 0.01)and perceived severity of antibiotics resistance (p = 0.02) in their relations with inappropriate prescription for non-complicated URTIs. Conclusion For the medical students who have received clinical training, those who were more aware of the severity of antibiotics resistance in Hong Kong were less likely to inappropriately prescribe antibiotics for non-complicated URTI. For the medical students who have not received clinical training, correct knowledge of antibiotic use is associated with less inappropriate antibiotics prescription behaviour. These suggest that knowledge and attitude towards antibiotics resistance and use are important factors that may impact on physician stewardship in antibiotics use in the community.

Background: Improper antibiotic use is a significant community health issue that contributes to antibiotic resistance. Insufficient mothers’ knowledge about the cautious antibiotics use in treating common childhood diseases can end in its misuse. Improving mothers’ awareness about correct antibiotic use is the main aspect. The study is aimed to assess the effect of an educational intervention on mothers' knowledge, practice and attitude about proper antibiotic use. Method: A quasi-experimental design – one group pre-post-test among 130 mothers was carried out in selected family health centers. Baseline knowledge, practice and attitude (pre-intervention) regarding judicious antibiotic use was assessed using structured interview questionnaire developed by researcher which comprised of socio-demographic data of mother and child, source of knowledge, the mothers’ knowledge, subjective practice and their attitude about appropriate antibiotic use. Educational intervention on proper antibiotic use of children was administered after baseline assessment. The effect of this intervention was evaluated using same questionnaire post the intervention and after 3 months. Findings: About 41.5% of the mothers age were from 20 to not more than 35 years. Mothers had poor knowledge about the concept of judicious use of antibiotics, indication of proper antibiotic use, side effect and causes of antibiotic resistance in the pre-test that improved after implementation of the educational session. Health education sessions significantly improved antibiotic-related practice and attitude of the mothers. Conclusion: The health education session about appropriate antibiotic use revealed a major effect in improving the participants’ level of awareness, practice and changing attitude about proper use of antibiotic of their children.

Preoperative Prophylactic Antibiotics in Total Hip and Knee Arthroplasty: What, When, and How

Are we using too many antibiotics during pregnancy?

The definition of late PJI is variable in literature. Majority of the members of the consensus felt that any infection occurring after one year should be considered as late. Coventry defined stages of PJI, where Stage I is an acute infection that occurred within 3 months of the index procedure, Stage II is a delayed infection that occurred between 3 months and 2 years after the index procedure where there was no pain-free interval, and Stage III is a hematogenous infection where there is a pain-free stage [1]. Garvin and Hanssen defined a late chronic PJI as one that occurred 4 weeks after the index procedure with an insidious clinical onset [2]. McPherson et al defined a chronic infection as one that had symptoms for 4 weeks or longer [3]. In Sweden, a late PJI is defined as one that occurs 2 years after the index procedure. Due to the huge variation in time frames, we did not find consensus in defining a timeframe for a late PJI. However, we classified late PJI as late hematogenous PJI, where there was an asymptomatic period followed by clinical and/or radiographical signs of infection. The workgroup feels that late PJI arises as a result of bacteremia at a later stage [4] and should be distinguished with infections arising as a result of intraoperative contamination. Risk factors for late PJI are similar to those described for PJI in Workgroup 1 (Please see Question 1, Workgroup 1).