Antibiotic Switch Research Articles

Intake of antibiotics and fasting during the holy month of Ramadan: A Literature Review

Pharmacology, Toxicology and Biomedical Reports,2019,5,2,65-68.DOI:10.5530/PTB.2019.5.11Published:July 2019Type:Review ArticleAuthors:Yousef Ahmed Alomi, Mohammed Abdulaziz Altuwaijri, Mohsen Huraybie Alshammari, and Nouf Hameed Al-Muallad Author(s) affiliations:Yousef Ahmed Alomi*, General Administration of Pharmaceutical Care, Ministry of Health, Riyadh, SAUDI ARABIA. Mohammed Abdulaziz Altuwaijri, ENT Consultant, King Saud Medical City, Riyadh, SAUDI ARABIA. Mohsen Huraybie Alshammari, Hail Maternaty and Childern Hospital, Ministry of Health, Hail, SAUDI ARABIA. Nouf Hameed Al-Muallad, Ibn Sina College Hospital, Jeddah, SAUDI ARABIA. Abstract:Objectives: To review the intake of antibiotics and fasting during the holy month of Ramadan. Methods: In this study, we performed an extensive search of 50 databases following the Saudi Digital Library search engine. We included meta-analysis, randomized controlled studies and observational studies published in English language with human study only for update May 2017. The search terms included Ramadan, fasting, medication, therapy, type of disease and medication based on therapeutic class. The list of antibiotic medication and switch from regular days to Ramadan days based on literature search revealed comparative safety studies, efficacy studies and cost of type of medication for each disease studies and national or international evidence-based guidelines of switching short half-life to long halflife. All parenteral dosage form of medication were excluded from study. All medications should be listed in the Ministry of Health drug formulary. Results: A total of 710 studies were obtained after an extensive search with specific terms. Of those, 104 studies were duplicate studies and 606 were considered for further evaluation. After evaluation, we obtained 30 studies which discussed about the antibiotics and Ramadan. Of these 30 studies, only 2 studies were found to be appropriate for further revision. Among the two, one study was an observational study regarding the pattern of prescribing antibiotics during the holy month of Ramadan. The second study was about the systemic review on the safety of fasting and several infectious diseases. The suggested draft of list of antibiotic switch from regular days to the holy Ramadan days was explored in this review. Conclusion: The investigations about antibiotics intake during fasting not found. The studies of antibiotic during the holy month of Ramadan is required during legal registrations at all Muslim countries. Antibiotics switch therapy during fasting is highly recommended at all Muslim patients in the world. Keywords:Antibiotics, Fasting, Literature, Ramadan, ReviewView:PDF (190.51 KB) PDF PDF Images Table 1: The antibiotic studies conducted during the holy month of Ramadan.

Early switching of antibiotic therapy from intravenous to oral using a combination of education, pocket-sized cards and switch advice: A practical intervention resulting in reduced length of hospital stay

To assess the effectiveness of a combined intervention on the timing and rate of switching from intravenous (IV) to oral antibiotic therapy. The study used a historically-controlled prospective intervention design. Interventions consisted of educating physicians, handing out pocket-sized cards and providing switch advice in the electronic patient record (EPR). All patients hospitalized at the surgery department who were treated with IV antibiotics for at least 24 h and who fulfilled the switch criteria within 72 h of IV treatment were included. Outcomes before and during the intervention were compared. An early IV to oral switch took place in 35.4% (35/99) of the antibiotic courses in the baseline period and in 67.7% (42/62) of the antibiotic courses in the intervention period (odds ratio [OR] 3.84, 95% confidence interval [CI] 1.96-7.53). Duration of IV therapy was significantly reduced from 5 to 3 days (P<0.01). Length of hospitalization was reduced from 6 to 5 days (P<0.05). The interventions were effective in promoting an early IV to oral antibiotic switch by shortening the length of IV therapy and hospital stay.

Intravenous-to-oral antibiotic switch therapy: a cross-sectional study in critical care units

BackgroundThis study aimed to evaluate the oral switch (OS) stewardship intervention in the intensive care unit (ICU).MethodsThis was a retrospective study with a convenience sample in two Brazilian ICUs from different hospitals in patients with sepsis receiving antibiotic therapy. The stewardship intervention included OS in patients diagnosed with sepsis when clinical stability was achieved. The primary outcome was overall mortality. Other variables evaluated were as follows: cost of antimicrobial treatment, daily costs of intensive care, acute kidney injury, and length of stay.ResultsThere was no difference in mortality between the OS and non-OS groups (p = 0.06). Length of stay in the ICU (p = 0.029) was shorter and acute kidney injury incidence (p = 0.032) and costs of antimicrobial therapy (p < 0.001) were lower in the OS group.ConclusionOS stewardship programs in the ICU may be considered a safe strategy. Switch therapy reduced the cost and shortened the length of stay in ICUs.

Effectiveness of a Bundled Intervention Including Adjunctive Corticosteroids on Outcomes of Hospitalized Patients With Community-Acquired Pneumonia

Community-acquired pneumonia remains a leading cause of hospitalization, mortality, and health care costs worldwide. Randomized clinical trials support the use of adjunctive corticosteroids, early progressive mobilization, antibiotic switching rules, and dietary interventions in improving outcomes. However, it is uncertain whether implementing these interventions will translate into effectiveness under routine health care conditions. To evaluate the effectiveness of a bundle of evidence-supported treatments under conditions of routine care in a representative population hospitalized for community-acquired pneumonia. A double-blind, stepped-wedge, cluster-randomized clinical trial with 90-day follow-up was conducted between August 1, 2016, and October 29, 2017, in the general internal medicine service at 2 tertiary hospitals in Melbourne, Australia, among a consecutive sample of patients with community-acquired pneumonia. The primary analysis and preparation of results took place between May 14 and November 25, 2018. Treating clinical teams were advised to prescribe prednisolone acetate, 50 mg/d, for 7 days (in the absence of any contraindication) and de-escalate from parenteral to oral antibiotics according to standardized criteria. Algorithm-guided early mobilization and malnutrition screening and treatment were also implemented. Hospital length of stay, mortality, readmission, and intervention-associated adverse events (eg, gastrointestinal bleeding and hyperglycemia). A total of 917 patients were screened, and 816 (351 women and 465 men; mean [SD] age, 76 [13] years) were included in the intention-to-treat analysis, with 401 patients receiving the intervention and 415 patients in the control group. An unadjusted geometric mean ratio of 0.95 (95% CI, 0.78-1.16) was observed for the difference in length of stay (days) between the intervention and control groups. Similarly, no significant differences were observed for the secondary outcomes of mortality and readmission, and the results remained unchanged after further adjustment for sex and age. The study reported higher proportions of gastrointestinal bleeding in the intervention group (9 [2.2%]) compared with the controls (3 [0.7%]), with an unadjusted estimated difference in mean proportions of 0.008 (95% CI, 0.005-0.010). This bundled intervention including adjunctive corticosteroids demonstrated no evidence of effectiveness and resulted in a higher incidence of gastrointestinal bleeding. Efficacy of individual interventions demonstrated in clinical trials may not necessarily translate into effectiveness when implemented in combination and may even result in net harm. ClinicalTrials.gov identifier: NCT02835040.

RAIN study: a protocol for a randomised controlled trial evaluating efficacy, safety and cost-effectiveness of intravenous-to-oral antibiotic switch therapy in neonates with a probable bacterial infection

IntroductionHigh morbidity and mortality rates of proven bacterial infection are the main reason for substantial use of intravenous antibiotics in neonates during the first week of life. In older children,...

Oral antibiotics for neonatal infections: a systematic review and meta-analysis.

BackgroundWorldwide many neonates suffer from bacterial infections. Adequate treatment is important but is associated with prolonged hospitalization for intravenous administration. In older children, oral switch therapy has been proven effective and safe for several indications and is now standard care.ObjectivesTo evaluate the currently available evidence on pharmacokinetics, safety and efficacy of oral antibiotics and oral switch therapy in neonates (0–28 days old).MethodsWe performed systematic searches in Medline, Embase.com, Cochrane, Google Scholar and Web of Science. Studies were eligible if they described the use of oral antibiotics in neonates (0–28 days old), including antibiotic switch studies and pharmacological studies.ResultsThirty-one studies met the inclusion criteria. Compared with parenteral administration, oral antibiotics generally reach their maximum concentration later and have a lower bioavailability, but in the majority of cases adequate serum levels for bacterial killing are reached. Furthermore, studies on efficacy of oral antibiotics showed equal relapse rates (OR 0.95; 95% CI 0.79–1.16; I2 0%) or mortality (OR 1.11; 95% CI 0.72–1.72; I2 0%). Moreover, a reduction in hospital stay was observed.ConclusionsOral antibiotics administered to neonates are absorbed and result in adequate serum levels, judged by MICs of relevant pathogens, over time. Efficacy studies are promising but robust evidence is lacking, most importantly because in many cases clinical efficacy and safety are not properly addressed. Early oral antibiotic switch therapy in neonates could be beneficial for both families and healthcare systems. There is a need for additional well-designed trials in different settings.

Piriformis pyomyositis, a cause of piriformis syndrome-a systematic search and review.

Piriformis pyomyositis is a rare form of purulent skeletal myositis. As previous studies concerning piriformis pyomyositis had lower level of evidence and no systematic review has been published yet, we performed a systematic search to review and describe causes, symptoms, red flags, and available treatment options for piriformis pyomyositis. Using PubMed and PubMed Central databases, we found 21 articles describing 23 cases of piriformis pyomyositis. Based on the retrieved information, alongside acute sciatica like buttock and/or hip pain, high-grade fever, aggressive deep seated gluteal pain, neurological deficit of sciatic nerve distribution, positive straight leg raising test, and raised inflammatory biomarkers (erythrocyte sedimentation rate, ESR, C-reactive protein, CRP) provide clues for diagnosis of piriformis pyomyositis. Some cases were very ill but no death was documented. Staphylococcus aureus was the most common pathogen, but Group A as well as Group β Streptococcus, Salmonella typhi, Proteus mirabilis, Brucella melitensis, and Escherichia coli were also involved in the disorder. To treat the piriformis pyomyositis, broad-spectrum antibiotics were found to be useful; however, sometimes, antibiotic switching was warranted based on blood and tissue aspirate reports. Drainage and/or surgical exploration of the affected piriformis muscle were required in cases where antibiotics appeared ineffective. Piriformis pyomyositis is a rara avis and performing of prospective studies will hardly be feasible.

Early switch/early discharge opportunities for hospitalized patients with methicillin-resistant Staphylococcus aureus complicated skin and soft tissue infections in Brazil

BackgroundEarly antibiotic switch and early discharge protocols have not been widely studied in Latin America. Our objective was to describe real-world treatment patterns, resource use, and estimate opportunities for early switch from intravenous to oral antibiotics and early discharge for patients hospitalized with methicillin-resistant Staphylococcus aureus complicated skin and soft-tissue infections. Materials/methodsThis retrospective medical chart review recruited 72 physicians from Brazil to collect data from patients hospitalized with documented methicillin-resistant Staphylococcus aureus complicated skin and soft tissue infections between May 2013 and May 2015, and discharged alive by June 2015. Data collected included clinical characteristics and outcomes, hospital length of stay, methicillin-resistant Staphylococcus aureus-targeted intravenous and oral antibiotic use, and early switch and early discharge eligibility using literature-based and expert-validated criteria. ResultsA total of 199 patient charts were reviewed, of which 196 (98.5%) were prescribed methicillin-resistant Staphylococcus aureus -active therapy. Only four patients were switched from intravenous to oral antibiotics while hospitalized. The mean length of methicillin-resistant Staphylococcus aureus-active treatment was 14.7 (standard deviation, 10.1) days, with 14.6 (standard deviation, 10.1) total days of intravenous therapy. The mean length of hospital stay was 22.2 (standard deviation, 23.0) days. The most frequent initial methicillin-resistant Staphylococcus aureus-active therapies were intravenous vancomycin (58.2%), intravenous clindamycin (19.9%), and intravenous daptomycin (6.6%). Thirty-one patients (15.6%) were discharged with methicillin-resistant Staphylococcus aureus -active antibiotics of which 80.6% received oral antibiotics. Sixty-two patients (31.2%) met early switch criteria and potentially could have discontinued intravenous therapy 6.8 (standard deviation, 7.8) days sooner, and 65 patients (32.7%) met early discharge criteria and potentially could have been discharged 5.3 (standard deviation, 7.0) days sooner. ConclusionsOnly 2% of patients were switched from intravenous to oral antibiotics in our study while almost one-third were early switch eligible. Additionally, one-third of hospitalized patients with methicillin-resistant Staphylococcus aureus complicated skin and soft tissue infections were early discharge eligible indicating opportunity for reducing intravenous therapy and days of hospital stay. These results provide insight into possible benefits of implementation of early switch/early discharge protocols in Brazil.

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

IntroductionTaking consecutive antibiotic use into account is of importance to obtain insight in treatment within disease episodes, use of 2nd- and 3rd-choice antibiotics, therapy failure and/or side effects. Nevertheless, studies dealing with consecutive antibiotic use are scarce. We aimed at evaluating switch patterns in antibiotic use in the outpatient setting in the Netherlands.MethodsOutpatient antibiotic dispensing data was processed to antibiotic treatment episodes consisting of single prescriptions or consecutive prescriptions (2006 to 2014). Consecutive prescriptions were categorised into prolongations and switches. Switches were further analysed to obtain antibiotic switch percentages and trends over time. Outcomes were compared with recommendations of Dutch guidelines.ResultsA total of 43,179,867 antibiotic prescriptions were included in the analysis, consisting of single prescriptions (95%), prolongations (2%) and switches (3%). The highest switch percentages were found for trimethoprim (7.6%) and nitrofurantoin (5.4%). For fosfomycin, ciprofloxacin, flucloxacillin and trimethoprim we found the highest yearly increase in switching. Amoxicillin/clavulanic acid was most often used as second antibiotic in a switch. A surprisingly high number of 2nd- and 3rd-choice antibiotics are prescribed as first antibiotic in a treatment.ConclusionsAlthough the actual reason for a switch is unknown, switch patterns can reveal problems concerning treatment failure and guideline adherence. In general, switch percentages of antibiotics in the Netherlands are low. The data contributes to the knowledge regarding antibiotic switch patterns in the outpatient setting.

2368. Cellulitis in Adult Patients: A Large, Multicenter, Observational, Prospective Study of 606 Episodes, and Analysis of the Factors Related to the Response to Treatment

BackgroundCellulitis is frequent cause of admission of adult patients to medical wards. Increasing prevalence of multiresistant microorganisms, comorbidities, predisposing factors, and medical and surgical therapies might affect cellulitis response and recurrence rate.MethodsProspective and observational study of 606 adult patients with cellulitis admitted to the Internal Medicine wards of several Spanish hospitals. Comorbidities, microbiological, clinical, diagnostic, treatment (surgical and antibiotic) data were analyzed according to the cellulitis response. Good response implied cure. Poor response implied failure to cure or initial cure but relapse within 30 days of hospital dischargeResultsMean age was 63.3 years and 51.8% were men. Poor responses were significantly associated with age, previous episodes of cellulitis, prior wounds and skin lesions, venous insufficiency, lymphedema, immunosuppression and lower limbs involvement No differences in ESR or CRP blood levels, leukocyte counts, pus or blood cultures positivity or microbiological or imaging aspects were observed in those with good or poor responses. Regarding antimicrobials, no differences in previous exposition before hospital admission, treatment with single or more than one antibiotic, antibiotic switch, days on antimicrobials or surgical treatment were observed regarding good or poor cellulitis response. Prior episodes of cellulitis (P = 0.0001), venous insufficiency (P = 0.004), immunosuppression (P = 0.03), and development of sepsis (P = 0.05) were associated with poor treatment responses, and non-surgical trauma (P = 0.015) with good responses, in the multivariate analysis.ConclusionPrior episodes of cellulitis, nonsurgical trauma, venous insufficiency, sepsis and immunosuppression were independently associated with treatment response to cellulitis, but not the causing microorganism, the number of antimicrobials administered or its duration.Disclosures All authors: No reported disclosures.

1050. Oral Antibiotics for the Treatment of Gram-Negative Bloodstream Infections: Prescribing Practices and Outcomes at a Large Academic Medical Center

BackgroundThere is limited data to guide the use of oral (PO) antibiotics for the treatment of Gram-negative (GN) bloodstream infection (BSI). The objective of this study was to describe the characteristics and outcomes at a large academic medical center.MethodsRetrospective observational cohort of adult patients (age ≥18 years) with at least one blood culture positive for aerobic Gram-negative organism(s) treated with antibiotic therapy (IV or oral [PO]) at University of Medical Center from November 2015 to May 2017. Oral antibiotics were described based on bioavailability. The primary outcome of interest was 30-day infection-related readmission. Secondary objectives included evaluation of patient characteristics associated with PO antibiotic use.ResultsDuring the defined study period 310 patients met inclusion; 113 (36.5%) were switched to PO antibiotic therapy for the treatment of GN BSI within a median of 5 (IQR 3–11) days. Oral antibiotics were initiated at discharge for 50 (44%) of patients switched. Patients switched to PO were less likely to have has a stay in the ICU (24.8% vs. 47.7%, P < 0.0001) and were less likely to have an ID consult (57.5% vs. 71.1%, P = 0.034). There was no difference in median Charlson Comorbidity Score (2, IQR 0–4). The most common sources of infection among those switched to PO agents were urinary (50, 44.2%) and intra-abdominal (25, 22.1%). The majority of patients were placed on a PO agent with high bioavailability (61, 54%), which included levofloxacin and moxifloxacin. There was a slightly higher proportion of use of high (vs. low) bioavailable antibiotics in patients with ID consult compared with those without (59% vs. 41%, P = 0.053). PO antibiotics were more frequently prescribed for patients discharged home (78, 69%) compared with patients discharged to Rehab/Short-term facility (28, 24.8%). Thirty-day hospital readmission was more common among the patients treated with PO antibiotics (18.6 vs. 8.1%, P = 0.006); however, ID-related readmission was rare (0.9% vs. 1%, P = 0.91).ConclusionUrinary and intra-abdominal sources and home discharge were common among those with PO antibiotic use. ID-related outcomes were similar among those treated with IV vs. PO agents. More research is necessary to determine optimal time to PO antibiotic switch.Disclosures K. Claeys, Nabriva: Scientific Advisor, Consulting fee. Melinta: Scientific Advisor, Consulting fee. E. Heil, ALK-Abelló: Grant Investigator, Research grant.

Switching Between Antibiotics Among Danish Children 0-4 Years of Age: A Nationwide Drug Utilization Study.

In Denmark, the use of amoxicillin is widespread among children, despite phenoxymethylpenicillin being recommended as first-line therapy. The reason for this apparent discrepancy is not fully understood. We aimed at evaluating prescribing patterns of antibiotics among Danish children 0-4 years of age, with emphasis on incidence of treatment episodes, choice of initial antibiotic treatment and switching patterns between different types of antibiotics. We identified all children ≤4 years of age who filled a prescription of antibiotics from 2000 to 2015 according to the nationwide Danish National Prescription Registry. We estimated the incidence rate of episodes treated with antibiotics and the choice of initial antibiotic treatment over time. Further, we assessed the cumulative risk of switching within 0-3 days after initiating therapy. We identified 3,481,684 antibiotic treatment episodes issued to 0- to 4-year-olds from 2000 to 2015. The incidence rate was stable until 2011 both among children 0-1 years of age (approximately 880/1000) and among children 2-4 years of age (approximately 610/1000), after which it dropped. Phenoxymethylpenicillin and, increasingly, amoxicillin were most frequently used as initial treatments (39% vs. 44%). Few switched from amoxicillin (1%) or phenoxymethylpenicillin (4.7%) within the first 3 days. Of those who switched from phenoxymethylpenicillin, 64% received amoxicillin as second-line treatment. The incidence of episodes treated with antibiotics among Danish children 0-4 years of age has decreased considerably since 2011. In contrast to guideline recommendations, amoxicillin is the most frequently used initial treatment. Early switching between antibiotics is uncommon. Initiatives should address the extensive use of amoxicillin.

Cellulitis in adult patients: A large, multicenter, observational, prospective study of 606 episodes and analysis of the factors related to the response to treatment.

BackgroundCellulitis is a frequent cause of hospital admission of adult patients. Increasing prevalence of multiresistant microorganisms, comorbidities, predisposing factors and medical and surgical therapies might affect cellulitis response and recurrence rate.MethodsProspective and observational study of 606 adult patients with cellulitis admitted to several Spanish hospitals. Comorbidities, microbiological, clinical, diagnostic, treatment (surgical and antibiotic) data were analyzed according to the cellulitis response. Good response implied cure. Poor response implied failure to cure or initial cure but relapse within 30 days of hospital discharge.ResultsMean age was 63.3 years and 51.8% were men. Poor responses were significantly associated with age, previous episodes of cellulitis, prior wounds and skin lesions, venous insufficiency, lymphedema, immunosuppression and lower limbs involvement. No differences in ESR or CRP blood levels, leukocyte counts, pus or blood cultures positivity or microbiological or imaging aspects were observed in those with good or poor responses. Regarding antimicrobials, no differences in previous exposition before hospital admission, treatment with single or more than one antibiotic, antibiotic switch, days on antimicrobials or surgical treatment were observed regarding good or poor cellulitis response. Prior episodes of cellulitis (P = 0.0001), venous insufficiency (P = 0.004), immunosuppression (P = 0.03), and development of sepsis (P = 0.05) were associated with poor treatment responses, and non-surgical trauma (P = 0.015) with good responses, in the multivariate analysis.ConclusionsPrior episodes of cellulitis, non-surgical trauma, venous insufficiency, sepsis and immunosuppression were independently associated with treatment response to cellulitis, but not the causative microorganism, the number of antimicrobials administered or its duration.

Self-Assembled Nanomedicines for Anticancer and Antibacterial Applications.

Self-assembly strategies have been widely applied in the nanomedicine field, which provide a convenient approach for building various structures for delivery carriers. When cooperating with biomolecules, self-assembly systems have significant influence on the cell activity and life process and could be used for regulating nanodrug activity. In this review, self-assembled nanomedicines are introduced, including materials, encapsulation, and releasing strategies, where self-assembly strategies are involved. Furthermore, as a promising and emerging area for nanomedicine, in situ self-assembly of anticancer drugs and supramolecular antibiotic switches is also discussed about how to regulate drug activity. Selective pericellular assembly can block mass transformation of cancer cells inducing cell apoptosis, and the intracellular assembly can either cause cell death or effectively avoid drug elimination from cytosol of cancer cells because of the assembly-induced retention (AIR) effect. Host-guest interactions of drug and competitive molecules offer reversible regulations of antibiotic activity, which can reduce drug-resistance and inhibit the generation of drug-resistant bacteria. Finally, the challenges and development trend in the field are discussed.

Antibiotic prescribing practices for hospitalised children with suspected bacterial infections in a paediatric hospital in Nigeria

Background: The burden of infectious diseases among Nigerian children is high. These children are often prescribed antibiotics during periods of hospitalisation. Unfortunately antibiotic resistance (ABR) threatens the availability and efficacy of antibiotics for use by vulnerable children and the future generations. Monitoring prescribing trends in our hospital as a means of identifying targets for improving prescribing is inevitable.Objective: The aim of the study was to evaluate antibiotic prescribing practices for hospitalised children with suspected bacterial infections in a Paediatric hospital in Nigeria.Methods: A retrospective survey was carried out using case notes of previously hospitalised patients admitted between January and June 2016. Data from 150 case notes of patients admitted for suspected bacterial infections were collected using a predesigned data collection form. Patients’ demographics, infection type, details of prescribed antibiotics, length of hospital stay and microbiological assessments were noted. Data were analysed using statistical package for social sciences (SPSS) version 22. Frequencies and percentages were calculated for categorical variables. Means and standard deviations were calculated for continuous (numerical) variables. Correlation was also employed in the analysis.Results: Of the 150 patients, 53.3% were males and 86% were children under 5 years of age. The mean duration of hospital stay was 7.59 (± 5.4) days. The most common infections were respiratory tract infection (32%) and sepsis (31.3%). The most common empirically prescribed antibiotics at the onset of admission were Gentamicin and a fixed dose combination of Ampicillin/Cloxacillin which were prescribed for 64.7% and 52.7% of the patients respectively. Cultures were ordered for only 7 (4.7%) of patients at the onset of hospitalisation. All antibiotics administered on admission were parenteral formulations and only 4% of the patients had their antibiotic switched to oral route on or before the third day of patients’ admission. Another 71.3% were converted to oral formulations on the day of discharge from the hospital. A total of 87.3% were discharged on antibiotics and the most commonly prescribed antibiotic at discharge was Cefixime (37.2% of antibiotics prescribed as take home medication).Conclusions: Antibiotics were started empirically in all cases and cultures were ordered for few patients at the start of antibiotic therapy. Cultures should be more frequently ordered in the hospital to guide antibiotic prescribing for patients admitted for suspected bacterial infections. In addition, timely intravenous (IV) to oral (PO) antibiotic switch should be practised whenever appropriate. Educating physicians on the benefits of early switch from IV to PO formulations when appropriate is also recommended. Initiatives such as the “Antibiotic Time out” or Start Smart-then Focus approach will be appropriate in the hospital. Introduction of an empiric antibiotic policy in the hospital is highly recommended.

A clinical decision support system algorithm for intravenous to oral antibiotic switch therapy: validity, clinical relevance and usefulness in a three-step evaluation study.

To evaluate a clinical decision support system (CDSS) based on consensus-based intravenous to oral switch criteria, which identifies intravenous to oral switch candidates. A three-step evaluation study of a stand-alone CDSS with electronic health record interoperability was performed at the Erasmus University Medical Centre in the Netherlands. During the first step, we performed a technical validation. During the second step, we determined the sensitivity, specificity, negative predictive value and positive predictive value in a retrospective cohort of all hospitalized adult patients starting at least one therapeutic antibacterial drug between 1 and 16 May 2013. ICU, paediatric and psychiatric wards were excluded. During the last step the clinical relevance and usefulness was prospectively assessed by reports to infectious disease specialists. An alert was considered clinically relevant if antibiotics could be discontinued or switched to oral therapy at the time of the alert. During the first step, one technical error was found. The second step yielded a positive predictive value of 76.6% and a negative predictive value of 99.1%. The third step showed that alerts were clinically relevant in 53.5% of patients. For 43.4% it had already been decided to discontinue or switch the intravenous antibiotics by the treating physician. In 10.1%, the alert resulted in advice to change antibiotic policy and was considered useful. This prospective cohort study shows that the alerts were clinically relevant in >50% (n = 449) and useful in 10% (n = 85). The CDSS needs to be evaluated in hospitals with varying activity of infectious disease consultancy services as this probably influences usefulness.

Does microbial resistance profile change in community-based intra-abdominal infections? Evaluation of the culture results of patients with appendicitis.

Tartar T, Sağmak-Tartar A, Saraç M, Bakal Ü, Akbulut A, Kazez A. Does microbial resistance profile change in community-based intra-abdominal infections? Evaluation of the culture results of patients with appendicitis. Turk J Pediatr 2018; 60: 520-526. Most common origin of intra-abdominal infections in children is appendicitis. Microorganisms responsible for community-based and hospital-acquired intra-abdominal infections vary. The aim of this study was to evaluate microbial culture outcomes and antibiotic susceptibilities of these microorganisms in samples obtained intraoperatively from pediatric patients with appendicitis, and to define the infectious microorganisms responsible for the community-based intra-abdominal infections in our region, and their antibiotic susceptibilities. This study included 231 patients between 0 and 16 years of age, operated on due to appendicitis between 2014 and 2017. Appendicular tissues were sampled intraoperatively. Antibiogram was studied in case of reproduction in tissue culture. Forms included information on the age and gender of the patients, intra-abdominal event, bacterial growth in microbial culture and antibiogram, antibiotic switch during follow-up, duration of the treatment, complications and outcomes were recorded. No microbial growth was observed following inoculation of the samples obtained from appendiceal tissue of 24.7% patients, whereas growth was positive in 75.3%. Gram negative bacteria were isolated in 94.3% of the patients, whereas gram positive bacteria was isolated in 5.7%. Polymicrobial growth was observed in 2.2% of the patients. E. coli in 79.9%, P. aeruginosa in 5.2%, Enterobacter cloacae in 3.4%, Coagulase-negative staphylococci in 3.4%, Klebsiella spp. in 1.7%, Citrobacter spp. in 1.7%, Enterococcus spp. in 1.7%, Comamonas testosteroni in 1.2% of patients produced. ESBL positivity is present in 51 (36.7%) of 139 E. coli strains reproducing in appendiceal tissue culture. ESBL was positivity detected in one of the reproduced 3 Klebsiella spp. strains. In E. coli, ciprofloxacin resistance as 20.86%, ampicillin-sulbactam resistance as 83.45%, and co-trimoxazole resistance as 41% were found. Our study clearly demonstrates that the resistance profile varies in community-based intra-abdominal infections. Empirical treatment protocols should be revised in especially the patients admitted with septic presentation and where the source control is not possible.

Antimicrobial treatment of urinary tract infections in children

Urinary tract infections are the most frequent documented bacterial infections in children. The antibiotic choices proposed in this manuscript are based on the guidelines published by the Pediatric Infectious Disease Group (GPIP) and the French-Language Infectious Disease Society (SPILF). Dipstick positive for leukocytes and/or nitrites must precede in most circumstances (excluding the newborns, neutropenic patients and those with sepsis), urine culture and antibiotic prescription. The proportion of extended-spectrum β-lactamase (ESBL) Escherichia coli strains has increased steadily in recent years, and the situations in which oral antibiotic switch is frequently not available are increasing. Cephalosporin resistance remains below 10% in most regions of France. However, there is no doubt that the proportion of resistant strains will increase in the coming years: the only uncertainly concerns the speed of this trend. With the aim of saving penems and promoting outpatient care, this guide proposes among the acceptable initial treatments for febrile urinary tract infections in infants, amikacin. This aminoglycoside remains active against the majority of ESBL strains and can be prescribed in once-daily dose allowing also ambulatory management of patients from pediatric emergency department.

An electronic trigger tool to optimise intravenous to oral antibiotic switch: a controlled, interrupted time series study

BackgroundTimely switch from intravenous (iv) antibiotics to oral therapy is a key component of antimicrobial stewardship programs in order to improve patient safety, promote early discharge and reduce costs. We have introduced a time-efficient and easily implementable intervention that relies on a computerized trigger tool, which identifies patients who are candidates for an iv to oral antibiotic switch.MethodsThe intervention was introduced on all internal medicine wards in a teaching hospital. Patients were automatically identified by an electronic trigger tool when parenteral antibiotics were used for >48 h and clinical or pharmacological data did not preclude switch therapy. A weekly educational session was introduced to alert the physicians on the intervention wards. The intervention wards were compared with control wards, which included all other hospital wards. An interrupted time-series analysis was performed to compare the pre-intervention period with the post-intervention period using ‘% of i.v. prescriptions >72 h’ and ‘median duration of iv therapy per prescription’ as outcomes. We performed a detailed prospective evaluation on a subset of 244 prescriptions to evaluate the efficacy and appropriateness of the intervention.ResultsThe number of intravenous prescriptions longer than 72 h was reduced by 19% in the intervention group (n = 1519) (p < 0.01) and the median duration of iv antibiotics was reduced with 0.8 days (p = <0.05). Compared to the control group (n = 4366) the intervention was responsible for an additional decrease of 13% (p < 0.05) in prolonged prescriptions.The detailed prospective evaluation of a subgroup of patients showed that adherence to the electronic reminder was 72%.ConclusionsAn electronic trigger tool combined with a weekly educational session was effective in reducing the duration of intravenous antimicrobial therapy.

Supramolecular Conjugated Polymer Systems with Controlled Antibacterial Activity.

Infections of antibiotic-resistant pathogens have caused a series of public health crises across the world. According to the latest published reports, an antibiotic switch has been recognized as a potential strategy to control antibacterial activity for combating this serious drug resistance. Thus, it is anticipated that more effective antibiotic switches should be obtained by further exploring the developed strategies. Here, we report an improved pretreatment strategy using a surfactant (Triton X-100) for constructing an effective supramolecular antibiotic switch based on a poly(fluorene-co-phenylene) derivative (PFP) and cucurbit[7]uril (CB[7]), which can regulate the aggregation state of polymers before the supramolecular self-assembly process occurs. Triton X-100 can regulate the aggregation states of conjugated polymers, which is used to successfully realize the reversible control of bactericidal activity of PFP in the dark and under white light irradiation by supramolecular assembly/disassembly between PFP and CB[7]. Specialized antibiotic switches are significantly important to fight pathogenic infections and solve the drug resistance crisis in the future.