Antibiotic Stewardship Guidelines Research Articles

Antibiotic Resistance in Staphylococcus aureus from Poultry and Poultry Products in uMgungundlovu District, South Africa, Using the "Farm to Fork" Approach.

Background: This study determined the prevalence and antibiotic susceptibility profiles of Staphylococcus aureus isolated from selected critical control points (farm, transport, abattoir, and retail product) in an intensive poultry production system in the uMgungundlovu District, South Africa, using the "farm to fork" approach. Materials and Methods: Three hundred eighty-four samples from poultry and poultry products were examined across the "farm to fork" continuum for S. aureus using selective media, biochemical tests, and API Staph kit and confirmed by polymerase chain reaction identification of the nuc gene. Antibiotic susceptibility testing of the isolates was determined by the Kirby-Bauer disc diffusion method to 19 antimicrobials and to vancomycin by the broth microdilution technique. Results: The overall prevalence rate of S. aureus was 31.25% (n = 120/384), distributed across the continuum: farm site (40), transport (15), abattoir (30), and retail point (35). The isolates were resistant to tetracycline (61.67%), penicillin G (55.83%), erythromycin (54.17%), clindamycin (43.33%), doxycycline (36.67%), ampicillin (34.17%), moxifloxacin (30.83%), amikacin (30.83%), trimethoprim-sulfamethoxazole (30.00%), and levofloxacin (23.33%). A 100% susceptibility to tigecycline, teicoplanin, vancomycin, nitrofurantoin, chloramphenicol, and linezolid was observed in all isolates. The rate of multidrug resistance and the multiple antibiotic resistance index of the strains were 39.17% and 0.23%, respectively. The isolates showed similar patterns of resistance to commonly used growth promoters and antibiotics in veterinary and human medicine belonging to the same class. Conclusion: It is evident that the different antibiotics and growth promoters used in poultry production are exerting selection pressure for the emergence and co-selection of antibiotic-resistant bacteria in the production system, necessitating efficient antibiotic stewardship guidelines to streamline their use.

Correlation between Empirical Antibiotic Therapy and Bone Culture Results in Patients with Osteomyelitis

To analyze the correlation between empirical antibiotic therapies prescribed in primary care centers by general practitioners and the microbiology results of bone culture in patients with diabetic foot-related osteomyelitis. This observational study involved 80 patients with diabetic foot ulcers and clinically suspected osteomyelitis. The patients were taking antibiotics prescribed by general practitioners to treat diabetic foot infections. Bone samples were taken from every patient for microbiology analysis in a specialized diabetic foot unit. The sensitivity of the bone cultures to antibiotics was compared with the patient's previous antibiotic therapy, and antibiotic and bacterial resistance were analyzed. The bone cultures from only 16 patients (22.3%) showed sensitivity to the antibiotics that the patient had been prescribed. Fifty-six patients (77.8%) displayed bacterial resistance to the antibiotic that they were taking. Awareness and implementation of international antibiotic stewardship guidelines are poor in primary care centers. It is important to establish strategies that foster a better understanding of treatment management standards and ensure the proper implementation of guidelines.

Antimicrobial stewardship: a qualitative study of the development of national guidelines for antibiotic use in hospitals

BackgroundAs effective antibiotics are becoming a scarce resource, governmental regulation is needed to promote responsible use. Implementation of antibiotic stewardship and practice guidelines in health care facilities seems to be crucial to this effort. Empirical studies suggest, however, that guidelines have limited influence on health professionals’ behavior and practice. Barriers and facilitators to guideline implementability are much studied, but little attention has been given to health professionals’ perceptions of normative acceptability of guidelines as a condition for compliance. The aim of the present study was first, to examine if and how aspects potentially promoting acceptability and compliance among clinical target users were addressed during development of Norwegian national guidelines for antibiotic use in hospitals and second, to identify procedural characteristics of the development process that were perceived by target users to yield legitimate guidelines.MethodsQualitative deductive thematic analysis was used. A theoretical framework inspired by the AGREE II Instrument and the Accountability for reasonableness framework assisted data gathering and interpretation. Archival data was collected and used to detail the guideline development process. Semi-structured, in-depth interviews with eight clinicians with extensive knowledge of the guidelines were carried out.ResultsGuideline development was characterized by i) broad agreement about scope and purpose, ii) broad involvement of stakeholders in the development process, iii) use of systematic methods to search for and apply evidence, iv) easily identifiable and specific recommendations, v) provision of tools on how to put recommendations into practice, and vi) editorial independence. Several procedural characteristics were perceived by the interviewees as promoting guideline legitimacy; i) diverse perspectives systematically involved in the process, ii) accessibility and transparency of the rationales for decision making, iii) opportunities for appeals and reconsiderations, and iv) regulative authority.ConclusionsThis study provides insights as to how guidelines that are intended to promote responsible use of antibiotics in hospitals can be carefully developed to facilitate perceptions of relevance, transparency, and authority by health professionals.

Improving Antimicrobial Stewardship in Cancer Patients Through Implementation of Clinical Guidelines

Purpose of review Antimicrobial stewardship programs have consistently demonstrated the ability to reduce excessive antibiotic utilization, improve the management of targeted diseases, improve outcomes, and reduce costs. Implementation of institutional guidelines are effective options to promote appropriate cost-effective antimicrobial utilization and are recommended by the Infectious Diseases Society of America and the U.S. Centers for Disease Control and Prevention. Cancer patients are frequent users of antimicrobials and present unique challenges for antimicrobial stewardship programs, due to high risk for infection and risk for opportunistic infection and infection with multi-drug-resistant pathogens. Thus, this review evaluates the impact of guidelines on antibiotic management and associated clinical outcomes in cancer patients. Recent findings This review demonstrates that antibiotic stewardship guidelines targeting cancer patients can improve suboptimal or delayed antimicrobial prescribing and lead to subsequent reductions in mortality and decreased length of hospitalization. Additionally, guideline implementation can reduce excessive durations of unnecessary antimicrobial therapy without adversely impacting clinical outcomes. Summary Implementation of antibiotic stewardship guidelines could be an effective tool to promote appropriate antibiotic prescribing and reduce unnecessary antibiotic utilization in cancer patients.

Non-antibiotic Isotretinoin Treatment Differentially Controls Propionibacterium acnes on Skin of Acne Patients.

Emergence and potential transfer of antibiotic resistance in skin microorganisms is of current concern in medicine especially in dermatology contexts where long term treatment with antibiotics is common. Remarkably, non-antibiotic therapy in the form of isotretinoin – a non-antimicrobial retinoid is effective at reducing or eradicating the anaerobe Propionibacterium acnes which is causally involved in the complex pathogenesis of Acne vulgaris. This study measured the extent of colonization of P. acnes in patients with primary cystic or severe acne from three defined skin sites in ‘non-lesion’ areas before, during and after treatment with isotretinoin. Patients attending acne clinics were investigated using standardized skin sampling techniques and the recovery of anaerobic P. acnes from 56 patients comprising 24 females and 32 males (mean age 22 years, age range 15–46 years) who were given a standard course of isotretinoin (1 mg/kg/day) are reported. P. acnes cultured from the external cheek surface of patients following treatment showed a significant reduction (1–2 orders of magnitude) compared with their pre-treatment status. Interestingly, other distinct sites (nares and toe web) failed to show this reduction. In addition, high levels of antibiotic-resistant P. acnes were recorded in each patients’ skin microbiota before, during and after treatment. In this study, microbial composition of the skin appears substantially altered by isotretinoin treatment, which clearly has differential antimicrobial effects on each anatomically distinct site. Our study confirmed that orally administered isotretinoin shows good efficacy in the resolution of moderate to severe acne that correlates with reductions in the number of P. acnes on the skin, including resistant isolates potentially acquired from previous treatments with antibiotics. Our study suggests that the role of tetracycline’s and macrolides, which are currently first line treatments in dermatology, might be reserved for severe or life-threatening infections since current antibiotic stewardship guidelines from medical departments no longer prescribe these antibiotics for routine use.

Use of antimicrobial agents for treatment and prevention of travellers' diarrhoea in the face of enhanced risk of transient fecal carriage of multi-drug resistant enterobacteriaceae: setting the stage for consensus recommendations.

The recommendation that antibiotics should be used for routine therapy of travellers' diarrhoea is being reconsidered in view of growing evidence that the therapy may lead to intestinal carriage of multi-drug resistant (MDR) colonic microbiota. This review attempts to put the issues of therapy and MDR acquisition in perspective to help in the establishment of therapeutic recommendations for travellers' diarrhoea. The existing literature showing the risk and consequences of acquisition of MDR microbiota in antibiotic-treated travellers was reviewed. Issues important to the development of firm evidence-based recommendations for antibiotics use for treatment and prevention of travellers' diarrhoea were researched. Six areas of research needed to allow the development of evidence-based recommendations for antibiotic-treatment and -prevention of travellers' diarrhoea were identified. Increasing worldwide occurrence of antibiotic resistance should alert public health officials of the importance of encouraging local antibiotic stewardship guidelines. Six areas to research are identified in this review to allow the development of evidence-based recommendations for use of antibiotics for treatment and selective prevention of travellers' diarrhoea. An interdisciplinary ISTM Consensus group will consider the data available and develop current recommendations for therapy and chemoprevention of travellers' diarrhoea considering groups who would benefit the most from antimicrobials while recognizing the hazards associated with broad use of these drugs. With interim recommendations and ultimately evidence-based recommendations, guidelines can be developed for management of travellers' diarrhoea considering populations and destinations.

Impact of An Electronic “Antibiotic Time Out” on Provider Prescribing Patterns

BackgroundCurrent antibiotic stewardship guidelines suggest the use of an antibiotic time-out (ATO) 48–72 hours after antibiotic initiation to encourage review of empiric regimens once additional diagnostic information is available; however, the recommendation is based on low-quality evidence. Our objective was to retrospectively evaluate the impact of an electronic ATO alert within the EPIC™ electronic health record on provider prescribing patterns after implementation.MethodsThe ATO alerts were instituted in January 2017 and were triggered when an inpatient received Vancomycin (VAN), Piperacillin/Tazobactam (PT), Ceftriaxone (CEF), or a combination of them for >72 hours. We used an EPIC™ benchside report to identify ATO alerts between January and April 2017 and systematically reviewed charts from the last week of each month to identify de-escalation opportunities (DEO). Pediatric, bone marrow transplant, orthopedic, and cystic fibrosis patients were excluded. The primary outcome was de-escalation within 12 hours of the alert, defined as narrowing of spectrum or discontinuation of antibiotics.ResultsWe identified 805 alerts among 209 patients; 87 patients were excluded from analysis. Among 122 included patients, a median of 3 alerts were triggered per patient (470 in total). DEO was identified in 34.7% of alerts; de-escalation events (DEE) occurred in 34.3% of DEO. Table 1 lists alerts, DEO, and DEE by antibiotic. PT was the most frequently de-escalated antibiotic (46.4% [26/56] of DEE). De-escalation occurred more frequently among patients either actively followed (P < 0.01) or receiving new consultations by Infectious Disease (P = 0.04).Table 1.De-escalation opportunities and events by antibioticAntibioticAlerts(n = 470)De-escalation opportunities(n = 163)De-escalation events(n = 56)VAN130 (27.6%)23 (14.1%)8 (14.3%)PT137 (29.1%)66 (40.5%)26 (46.4%)CEF123 (26.2%)9 (5.5%)6 (10.7%)VAN/PT65 (13.8%)62 (38.0%)15 (26.8%)VAN/CEF15 (3.2%)3 (1.8%)1 (1.8%)ConclusionAn electronic ATO alert triggered only on the basis of drug and duration lacked specificity in identifying opportunities for antibiotic de-escalation. De-escalation occurred significantly more frequently with Infectious Disease team involvement. Additional study is required to identify how to best support de-escalation efforts.Disclosures J. S. Lewis II, Merck & Co.: Consultant, Consulting fee. J. C. McGregor, Merck & Co.: Grant Investigator, Research grant.

New antibiotic stewardship guidelines focus on appropriate use

New antibiotic stewardship guidelines focus on appropriate use

Use of antimicrobial agents for treatment and prevention of travellers' diarrhoea in the face of enhanced risk of transient fecal carriage of multi-drug resistant enterobacteriaceae: setting the stage for consensus recommendations.

The recommendation that antibiotics should be used for routine therapy of travellers' diarrhoea is being reconsidered in view of growing evidence that the therapy may lead to intestinal carriage of multi-drug resistant (MDR) colonic microbiota. This review attempts to put the issues of therapy and MDR acquisition in perspective to help in the establishment of therapeutic recommendations for travellers' diarrhoea. The existing literature showing the risk and consequences of acquisition of MDR microbiota in antibiotic-treated travellers was reviewed. Issues important to the development of firm evidence-based recommendations for antibiotics use for treatment and prevention of travellers' diarrhoea were researched. Six areas of research needed to allow the development of evidence-based recommendations for antibiotic-treatment and -prevention of travellers' diarrhoea were identified. Increasing worldwide occurrence of antibiotic resistance should alert public health officials of the importance of encouraging local antibiotic stewardship guidelines. Six areas to research are identified in this review to allow the development of evidence-based recommendations for use of antibiotics for treatment and selective prevention of travellers' diarrhoea. An interdisciplinary ISTM Consensus group will consider the data available and develop current recommendations for therapy and chemoprevention of travellers' diarrhoea considering groups who would benefit the most from antimicrobials while recognizing the hazards associated with broad use of these drugs. With interim recommendations and ultimately evidence-based recommendations, guidelines can be developed for management of travellers' diarrhoea considering populations and destinations.

Aggressive versus conservative initiation of antibiotics – Authors' reply

We appreciate the comments in response to our recent publication. However, before addressing the specific concerns, we wish to place the study in a clinical context. We work in a 15-bed, surgical trauma intensive-care unit (ICU). As we write this letter, 13 of our patients meet at least two of the criteria for systemic inflammatory response syndrome and they all have at least one organ system dysfunction. Five are being treated for a documented infection, and the remaining eight could possibly be infected and are in various stages of assessment. The question is do we need to give antimicrobials to all these patients, who meet criteria for severe sepsis but not septic shock? We don’t think so, yet the misinterpretation of previous retrospective studies implies this is the case. A more conservative approach, based on our data,1 seems to be safe. Our research showed improved mortality in haemodynamically stable, surgical ICU patients after waiting for objective evidence of infection before starting empirical antimicrobials. These findings might be related to our study of traumatised and postsurgical patients in whom persistent inflammation is common, decreasing the specificity of many signs of infection, including hyperthermia and leucocytosis. Additionally, our analysis excluded patients admitted to the ICU with sepsis, which was often the focus of past publications. Since infections in our study were all ICU-acquired, they were secondary events and, therefore, their characteristics might be different from those in which infection is the primary problem. Delay in empirical antibiotic administration (12 h in the aggressive treatment group) might have confounded our study’s results. How ever, these data are similar to the 17 h delay documented by Barie and colleagues2 in a similar ICU. As a pragmatic, protocol implementation trial, these findings are probably typical in patients in whom diagnosis is not clear. Additionally, the timing data were based on time to definitive intervention, not antimicrobial admini stration. Thus, a patient who had blood cultures sent and antimicrobials started 1 h later, but 24 h later underwent drain placement, was considered as having their therapy started 24 h after blood culture, not 1 h. In terms of empirical antibiotics, we used piperacillin/tazobactam and vancomycin according to institutional antibiotic stewardship guidelines. The most common pathogens that were treated inadequately were vancomycin-resistant enterococci (VRE) and yeast (predominantly Candida albicans). Whether substituting linezolid or daptomycin for vancomycin to empirically treat VRE would improve outcomes is unclear. Antifungal drugs were started empirically in patients with a high suspicion of a fungal infection (eg, upper gastrointestinal leak), but antifungal agents are unlikely to benefit all normotensive patients suspected of having a new infection. Finally, prophylactic perioperative antibiotics might have changed culture results. Most infections, however, occurred many days after an operation and this confounder might be of less importance. Ideally, we would have done the study in two equivalent ICUs, where patients in one unit would have been treated under the aggressive protocol throughout the study to control for other changes in therapy, but we only have access to one surgical ICU. Also, we could have incorporated all patients admitted to the ICU into our data analysis, but ultimately chose to focus on those with infections. An expanded, multicentre study has been proposed to collect such variables. Finally, a randomised controlled study would have been an alternative trial design, but would not have answered questions of effectiveness (as opposed to efficacy) and would not have allowed a full understanding of the effect of the different approaches on unit-wide epidemiology. We hope to address these concerns in a multicentre study that will use cluster randomisation.