Antimicrobial Policy Research Articles

Investigation of the Antimicrobial Resistance of Important Pathogens Isolated from Poultry from 2015 to 2023 in the United States

Foodborne pathogens cause around 47.8 million illnesses in the U.S. annually, with antimicrobial misuse in food production, particularly in poultry processing, contributing significantly to this public health challenge. Misuse of antimicrobials can contribute to antimicrobial resistance (AMR) and make the treatment of pathogens increasingly difficult. This emphasizes the need to investigate antimicrobial resistance in U.S. poultry. This study analyzes data from the NCBI Pathogen Isolates Browser (2015–2023) to explore the relationships between antimicrobial-resistant pathogens, AMR genes, and antimicrobials detected with resistance in pathogens isolated from chicken and turkey. Using principal component analysis and hierarchical clustering, we mapped and profiled regional and temporal patterns of antimicrobial resistance. Salmonella enterica was the most prevalent antimicrobial-resistant pathogen across both chicken and turkey, with notable outbreaks, particularly in the Northeast. Antimicrobial-resistant Campylobacter jejuni was more prevalent in chicken, particularly in California and Georgia, while Escherichia coli and Shigella were more prominent in turkey, with concentrated antimicrobial resistance in Texas for pathogen samples isolated from chicken. Resistance to tetracycline and streptomycin was widespread, with distinct regional clusters: antimicrobial resistance was concentrated in states like Minnesota for pathogens isolated from chicken, while AMR found in pathogens isolated from turkey was more evenly distributed across the Midwest. Key AMR genes, such as tet(A), mdsA, and mdsB, also followed similar patterns, peaking in 2019 and significantly declining by 2022. The observed decline in AMR cases may be linked to improved biosecurity measures and disruptions in detection due to the COVID-19 pandemic. This comprehensive study of antimicrobial resistance in U.S. poultry provides valuable insights into resistance trends, which provide useful information to inform targeted interventions and policies to mitigate AMR threats in the poultry production industry. For consumers, these findings emphasize the importance of proper food handling and cooking practices to reduce the risk of exposure to resistant pathogens. Regulatory authorities should focus on enforcing stricter antimicrobial usage policies and enhancing surveillance systems to sustain the reduction in AMR cases.

Genomic dynamics of high-risk carbapenem-resistant klebsiella pneumoniae clones carrying hypervirulence determinants in Egyptian clinical settings

BackgroundOngoing studies have revealed the global prevalence of severe infections caused by the hypervirulent strains of Klebsiella pneumoniae (K. pneumoniae). Meanwhile, the World Health Organization and the Centers for Disease Control declared carbapenem-resistant K. pneumoniae as an urgent public health threat, requiring swift and effective action to mitigate its spread. Low- and middle-income countries are severely impacted by such devastating infectious diseases owing to the ill implementation of antimicrobial practices and infection control policies. Having both hypervirulence and carbapenemase gene determinants, the emergence of convergent hypervirulent carbapenem-resistant K. pneumoniae is now being reported worldwide.MethodsIn this study, we sequenced 19 carbapenemase-producing K. pneumoniae strains recovered from various clinical specimens. Additionally, we evaluated the phenotypic antimicrobial susceptibility to multiple antimicrobial classes using the VITEK2 automated system. Utilizing the sequencing data, we characterized the sequence types, serotypes, pangenome, resistance profiles, virulence profiles, and mobile genetic elements of the examined isolates. We highlighted the emergence of high-risk clones carrying hypervirulence genetic determinants among the screened isolates.ResultsOur findings revealed that all carbapenem-resistant isolates exhibited either extensive- or pan-drug resistance and harbored multiple variants of resistance genes spanning nearly all the antimicrobial classes. The most prevalent carbapenemase genes detected within the isolates were blaNDM−5 and blaOXA−48. We identified high-risk clones, such as ST383-K30, ST147-K64, ST11-K15, and ST14-K2, which may have evolved into putative convergent strains by acquiring the full set of hypervirulence-associated genetic determinants (iucABCD, rmpA and/ or rmpA2, putative transporter peg-344). Additionally, this study identified ST709-K9 as a high-risk clone for the first time and uncovered that capsule types K15 and K9 carried hypervirulence genetic determinants. The most frequent Inc types found in these isolates were Col440I, IncHI1B, and Inc FII(K).ConclusionThis study highlights the emergence of high-risk, extensively carbapenem-resistant K. pneumoniae strains co-carrying hypervirulence determinants in Egyptian clinical settings. This poses an imminent threat not only to Egypt but also to the global community, underscoring the urgent need for enhanced surveillance and control strategies to combat this pathogen.

Resistance is reality: findings from the first Ukrainian cumulative antibiogram.

Antimicrobial resistance is a global health threat resulting in significant morbidity and mortality worldwide. Until recently, in Ukraine, cumulative antibiograms (CuAbgms) have never been available. To describe the first CuAbgm developed in Ukraine. We developed a CuAbgm for the Okhmatdyt National Specialized Children's Hospital using data from WHONET. Antimicrobial susceptibility testing was performed per EUCAST guidelines. The CuAbgm was developed using guidance from CLSI. For Escherichia coli, 66% and 69% of isolates were susceptible to ceftazidime and ceftriaxone, respectively, and 99% were susceptible to meropenem. For Klebsiella pneumoniae, 26% and 27% of isolates were susceptible to ceftazidime and ceftriaxone, respectively, and only 59% were susceptible to meropenem. Of the carbapenem-resistant K. pneumoniae isolates that underwent additional susceptibility testing, only 38% were susceptible to ceftazidime/avibactam. For Pseudomonas aeruginosa, only 53% were susceptible to meropenem. Of those that were resistant to meropenem and underwent additional susceptibility testing, only 12% were susceptible to ceftazidime/avibactam. Similarly, for Acinetobacter spp., only 37% of isolates were susceptible to meropenem. Susceptibility to ampicillin/sulbactam was also low at 45%. The oxacillin susceptibility rate for Staphylococcus aureus was 99%. In this first-ever CuAbgm developed in Ukraine, high levels of resistance were demonstrated among Gram-negative bacteria. CuAbgms should be prioritized in laboratories in Ukraine to guide empirical antimicrobial therapy, infection control and antimicrobial stewardship policies. This is of heightened relevance during wartime, when there is a need for healthcare systems to treat complex and infected penetrating and blast-related injuries.

Antimicrobial Stewardship Program: Time to be Focused in Speciality Settings of Leprosy Institute and Related Health Care Setup.

Leprosy, often known as Hansen's disease is a contagious chronic infectious disease caused by Mycobacterium leprae (M. leprae). Our methodology is easily repeatable in tertiary care settings with diagnostic accuracy resources and staff capable of building a stewardship team. Comprehensive antimicrobial policies and programmes are required to properly alleviate the initial issue.

An elephant in the room? Explaining agenda-setting in antimicrobial resistance policies in 30 European countries

Antimicrobial resistances (AMR) present a particularly challenging cross-sectoral policy problem, affecting human and animal health as well as the environment. Compared to the actual problem pressure, the public awareness for AMR is comparatively low and the issue has not been high on the political agenda in most. Given the rising problem pressure, we aim to find out as to what degree and under which conditions political parties bring AMR on the political agenda. By means of multilevel logit regressions based on 173 electoral manifestos in 30 European countries from 2015 to 2020, we explore the conditions that explain whether AMR are taken up in manifestos. The empirical findings indicate firstly that AMR are only addressed by political parties in Northern and Western Europe, in no case in Eastern, and only in one case in Southern Europe, though resistant bacteria are more widely spread in the latter. Secondly, Green parties are those who are most likely to address the AMR challenge. Thirdly, vote share is positively associated with AMR agenda-setting, while EU membership is insignificant and the national average on antibiotics consumption is negatively related to AMR agenda-setting. Finally, AMR are surprisingly mainly perceived as a problem of the agricultural policy subsystem despite its cross-sectoral policy character. The study makes theoretical and empirical contributions: regarding theory, the article shows that typical variables that are used for agenda-setting are less explanatory for complex intersectoral policies. This is also accompanied by the empirical contribution: since problem awareness and complexity of policy problems are correlated, AMR are reduced to an agricultural issue and as such, it is taken over by political parties that have expertise on agricultural-environmental topics.

Is Antimicrobial Stewardship Policy Effectively Implemented in Polish Hospitals? Results from Antibiotic Consumption Surveillance before and during the COVID-19 Pandemic.

The COVID-19 pandemic posed numerous challenges to public health systems, particularly in antimicrobial stewardship. This study aimed to assess antibiotic consumption before and during the COVID-19 pandemic to evaluate the effectiveness of the implemented antimicrobial stewardship program. This retrospective study was carried out at the University Hospital in Krakow, Poland, between 1 January 2019 and 31 December 2020. A total of 80,639 patients were enrolled. Antibiotic usage was measured as the percentage of patients receiving antibiotics and the number of days of therapy (DOTs). The World Health Organization (WHO) methodology and Anatomical Therapeutic Chemical (ATC) codes and AWaRe classification were utilized. The analyzed ATC antibiotic groups included penicillins (J01CA, J01CE, J01CF, J01CR, excluding piperacillin/tazobactam), piperacillin with tazobactam-beta-lactamase inhibitor (J01CR05), third- and fourth-generation cephalosporins (J01DD, J01DE), carbapenems (J01DH), macrolides (J01FA), fluoroquinolones (J01M), colistin (J01XB01), metronidazole (J01XD01) and others (J01DF, J01DI, J01E, J01G, J01XA, J01A). In the AWaRe classification, Access, Watch and Reserve groups of antibiotics were included. In 2020, 79.2% of COVID-19 patients and 40.1% of non-COVID-19 patients were treated with antibiotics, compared to 28.8% in 2019. Also, in 2020, the antibiotic consumption in non-ICU COVID-19 patients was twice as high as in non-COVID-19 patients: 50.9 vs. 38.5 DOTs/100 patient days (pds). Conversely, in the ICU, antibiotic consumption in COVID-19 patients was 112.1 DOTs/100 pds compared to 248.9 DOTs/100 pds in non-COVID-19 patients. Significant increases were observed in the usage of third- and fourth-generation cephalosporins in 2020. The analysis according to the AWaRe system revealed the highest usage of the Watch group-ranging from 61.9% to 78.7%-and very high usage of the Reserve group-from 5.8% to 11.1%-in non COVID-19 and COVID-19 patients, respectively. Our findings highlight substantial issues with antibiotic use both before and during the COVID-19 pandemic. The results underscore the urgent need for improved antimicrobial stewardship policy implementation.

Antimicrobial Susceptibility and Molecular Epidemiology of Multidrug-resistant Pseudomonas aeruginosa in Northeast of Brazil

Introduction: This study aimed to investigate the antimicrobial susceptibility profile of nosocomial strains of Pseudomonas aeruginosa isolated from inpatients of a teaching hospital in the City of Sobral, Ceará, in Northeast of Brazil (Santa Casa de Misericórdia de Sobral - SCMS) from March/2019 to March/2020, as well as to assess the occurrence of resistance genes bla-TEM, bla-SHV, bla-CTX-M 1/2, bla-IMP-1, bla-KPC, bla-GES, bla-SPM-1, bla- NDM-1, bla-VIM. Methodology: Bacterial identification and antimicrobial susceptibility tests (AST) were performed using the automated system Vitek®2. Conventional polymerase chain reaction (PCR) was used to amplify genes of interest. Results: Thirty-eight specimens of P. aeruginosa were collected. More than half of the isolates were resistant to imipenem (55.2%), and showed different rates of resistance to the other antimicrobials tested. In addition, intermediate susceptibility was also observed to gentamicin (7.8% of the isolates) and meropenem (10.52% of the isolates). The gene bla-CTX-M 1/2 was the most prevalent (41.9%), while bla-GES was highly identified among the carbapenemase-producing strains (12.9%). Conclusion: The results demonstrated considerable resistance rates to β-lactam antibiotics, which could be attributable to the indiscriminate use of these antibiotics in the analyzed hospital, whose control relies on the improvement of antimicrobial prescription policies.

294 Does the Initial Antibiotic Choice Affect the Incidence of Post-Operative Collections in Paediatric Appendicitis?

Abstract Introduction In appendicitis, antibiotics are routinely commenced prior to consideration of operative management. The choice of initial regimen depends on local antimicrobial guidelines. The presence of resistant organisms risks development of post-operative collections. In our tertiary paediatric surgery unit, antimicrobial guidelines were changed in September 2022 to recommend co-amoxiclav instead of cefuroxime/metronidazole. This study compares incidence of post-operative collections before and after the policy change. Method Patients who underwent appendicectomy between September 2021 and October 2023 were identified and contemporaneous data collected. Patients who had initial surgery elsewhere, interval/incidental appendicectomies or penicillin allergy were excluded. Comparison was made between patients receiving cefuroxime/metronidazole (Group 1) or co-amoxiclav (Group 2). Results Over the 26-month period, there were 104 patients in Group 1 (after excluding 47) and 104 in Group 2 (after excluding 46). 4 (3.8%) developed collections in Group 1 versus 13 (12.5%) in Group 2. In Group 1, 2 (50%) were treated with antibiotics alone, 1 (25%) required drain insertion and 1 (25%) had a laparotomy. In Group 2, 7 (54%) were treated with antibiotics alone, 5 (38%) required drain insertion and 1 (8%) had a laparotomy. The relative risk of developing a post-operative collection was 3.3 (p=0.023) in Group 2 versus Group 1. Conclusions The change in antimicrobial policy resulted in a significant increase in post-operative collections in our unit. This provides evidence that a regimen of cefuroxime/metronidazole is more effective at preventing collections and we are liaising with our Microbiology department with a view to amend the guidelines.

In-hospital use of antibiotics in internal medicine: A cross-sectional study before, during and after the COVID-19 pandemic in a COVID-19-free ward

BackgroundCoronavirus Disease-19 (COVID-19) pandemic impacted the use of antibiotics in hospitalized patients. However, most data on antibiotic therapy (AT) were recorded in COVID-19 settings. This study analyzed the appropriateness of AT in the real-world scenario of a COVID-19-free internal medicine ward before, during, and after the pandemic. MethodsClinical information of hospitalized patients was collected, and data related to AT prescription were analyzed. The appropriateness of AT was independently assessed by two specialists in internal medicine and infectious disease, combining evidence-based guidelines with a validated tool. ResultsRecords of 1249 patients were analyzed: AT was prescribed in 229 (55.2 %) patients before, 134 (53.2 %) patients during, and 315 (54.1 %) patients after COVID-19 pandemic. Compared to the pre-pandemic period, there was a decrease in monotherapy with 3rd and 4th generation cephalosporins and fluoroquinolones, and an increase in β-lactams + β-lactamase inhibitors and antibiotic combinations. Furthermore, AT was longer and more expensive during the pandemic, with duration and cost remaining higher after its end. The inappropriateness of AT increased during and after COVID-19 pandemic. Compared to the pre-pandemic period, inappropriate AT was longer and more expensive than appropriate AT. The COVID-19 pandemic had a significant impact on changes related to AT type and antibiotic classes. ConclusionsThe COVID-19 pandemic increased the inappropriateness of AT in a COVID-19-free internal medicine ward. Most modifications persist despite the end of pandemic, potentially leading to negative effects on in-hospital antimicrobial resistance. There is an urgent need to re-establish antimicrobial stewardship policies to address the longer-term global threat of antimicrobial resistance.

Nationwide analysis of antimicrobial prescription in Korean hospitals between 2018 and 2021: The 2023 KONAS report

Background: Data on antimicrobial use at the national level is crucial to establish domestic antimicrobial stewardship policies and enable medical institutions to benchmark against each other. This study aimed to analyze antimicrobial use in Korean hospitals. Methods: We investigated the antimicrobials prescribed in Korean hospitals between 2018 and 2021, using data from the Health Insurance Review and Assessment. Primary care hospitals (PCHs), secondary care hospitals (SCHs), and tertiary care hospitals (TCHs) were included in this analysis. Antimicrobials were categorized according to the Korea National Antimicrobial Use Analysis System (KONAS) classification, which is suitable for measuring antimicrobial use in Korean hospitals. Results: Out of more than 1,900 hospitals, PCHs and TCHs represented the largest and lowest percentage of hospitals, respectively. The most frequently prescribed antimicrobial in 2021 was piperacillin/β-lactamase inhibitor (9.3%) in TCHs, ceftriaxone (11.0%) in SCHs, and cefazedone (18.9%) in PCHs. Between 2018 and 2021, the most used antimicrobial class according to the KONAS classification was ‘broad-spectrum antibacterial agents predominantly used for community-acquired infections’ in TCHs and SCHs, and 'narrow spectrum beta-lactam agents' in PCH. Total consumption of antimicrobials has decreased from 951.7 to 929.9 days of therapy (DOT)/1,000 patient-days in TCHs and from 817.8 to 752.2 DOT/1,000 patient-days in SCHs during study period, but not in PCHs (from 504.3 to 527.2 DOT/1,000 patient-days). Moreover, in 2021, while use of reserve antimicrobials has decreased from 13.6 to 10.7 DOT/1,000 patient-days in TCHs and from 4.6 to 3.3 DOT/1,000 patient-days in SCHs, it has increased from 0.7 to 0.8 DOT/1,000 patient-days in PCHs. Conclusion: This study confirms that antimicrobial use differs by hospital type in Korea. Recent increases of use of antimicrobials, including reserve antimicrobials, in PCHs reflect the challenges that must be addressed.

Device and surgical procedure-related infections in Canadian acute care hospitals, 2018-2022.

Healthcare-associated infections (HAIs) are a significant healthcare burden in Canada. National surveillance of HAIs at sentinel acute care hospitals is conducted by the Canadian Nosocomial Infection Surveillance Program. This article describes device and surgical procedure-related HAI epidemiology in Canada from 2018 to 2022. Data were collected from over 60 Canadian sentinel acute care hospitals between January 1, 2018, and December 31, 2022, for central line-associated bloodstream infections (CLABSIs), hip and knee surgical site infections (SSIs), cerebrospinal fluid shunt (CSF) SSIs and paediatric cardiac SSIs. Case counts, rates, patient and hospital characteristics, pathogen distributions and antimicrobial resistance data are presented. Between 2018 and 2022, 2,258 device-related infections and 987 surgical procedure-related infections were reported. A significant rate increase was observed in adult mixed intensive care unit CLABSIs (1.07-1.93 infections per 1,000 line days, p=0.05) and a non-significant rate increase was observed in SSIs following knee arthroplasty (0.31-0.42 infections per 100 surgeries, p=0.45). A fluctuating rate trend was observed in CSF shunt SSIs over the time period and a significant rate decrease in paediatric cardiac SSIs was observed (68%, from 7.5-2.4 infections per 100 surgeries, p=0.01). The most commonly identified pathogens were coagulase-negative staphylococci (22.8%) among CLABSIs and Staphylococcus aureus (42%) among SSIs. Epidemiological and microbiological trends among selected device and surgical procedure-related HAIs are essential for benchmarking infection rates nationally and internationally, identifying any changes in infection rates or antimicrobial resistance patterns and helping inform hospital infection prevention and control and antimicrobial stewardship policies and programs.

Opportunities and challenges in antimicrobial resistance policy including animal production systems and humans across stakeholders in Argentina: a context and qualitative analysis

IntroductionGaps in antimicrobial resistance (AMR) surveillance and control, including implementation of national action plans (NAPs), are evident internationally. Countries’ capacity to translate political commitment into action is crucial to cope...

Impact of COVID-19 on antimicrobial stewardship activities in Italy: a region-wide assessment

BackgroundIn the region of Piedmont, in Northern Italy, formal monitoring of antimicrobial stewardship (AMS) programs has been in place since 2012. The objective of our study was to provide an updated assessment of AMS programs operating in our region, and to assess the impact of the COVID-19 pandemic on stewardship activities.MethodsA retrospective observational study was conducted to investigate AMS programs implemented in acute-care trusts participating in a broader healthcare-associated infections and antimicrobial resistance (AMR) prevention and control program, promoted by the regional health department. Within this program, structure, process, and outcome indicators of AMS programs were investigated, using a previously developed scoring system. Differences between scores prior to (2019) and during the pandemic (2021) were assessed. Linear regression was used to assess whether the 5-year trends (2017–2021) in outcome measures in relation to structure and process scores were statistically significant. Compound annual growth rates (CAGR) for each outcome were calculated to illustrate changes in outcome rates over time.ResultsAll public trusts in the Region (20) and a small number of private institutions (3) provided data for this study. A modest, non-significant improvement was found for 2021 structure, process, and total scores compared to respective 2019 scores. A significant improvement was found concerning the definition of a formal mission statement, whereas significantly less trusts included monitoring adherence to antimicrobial policy or treatment guidelines in their programs. Overall consumption of antibiotics for systemic use saw an increase in 2021, with 2021 recording the highest median overall consumption compared to all previous years considered in this study. Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant enterobacteria (CRE) rates decreased over the 5-year period. Significant downwards trends in MRSA rates were identified for high-outlier structure and process groups.ConclusionsResults of this study suggest AMS programs in Piedmont were not set back following the pandemic. This outcome was possible thanks to well-established programs, coordinated within a regional framework. Continued efforts should be dedicated to supporting AMS programs and contrasting AMR, even when the focus is shifted towards other public health emergencies.

The Practice of Prolonging Meropenem Infusion: A Narrative Review of Literatures Over the Last Decade

Background: The emergence of Antimicrobial Resistance (AMR) has forced clinicians and medical professionals to implement a strict Antimicrobial Stewardship policy. One of the pillar of Antimicrobial Stewardship is by optimizing the use of antibiotic agents. Beta-lactams demonstrate a time-dependent effect in combating bacteria. Since it is pharmacodynamically supported, a prolonged exposure via intravenous administration could be a feasible strategy to maximize the bactericidal effect. Meropenem, a beta-lactam antibiotic of carbapenems sub-class, also falls into the category above. However, there are questions to be answered regarding its stability, compatibility, safety, and clinical outcomes superiority compared to the standard intermittent infusion, before we can determine its effectiveness to be delivered as prolonged or extended infusion. Aims: This article would like to review literatures regarding the rationale behind the practice of prolonging meropenem infusion from the last decade. Method: For this narrative review we utilized articles extracted from Cochrane Library, ScienceDirect, and SageJournals databases from the last ten years. We also added complementary related articles from UpToDate®. Selected articles were limited to those published in english. Inclusion criteria specifically only including related articles to the practice of prolonging meropenem infusion on adult patients. A total of 18 articles were reviewed for the synthesis of this narrative review. Conclusion: Meropenem is eligible for prolonged infusion protocol since it is theoretically supported, adequate in stability, less concern for incompatibility, and potentially can provide better clinical outcomes compared to standard intermittent infusion.

Developing an Ethical Evaluation Framework for Coercive Antimicrobial Stewardship Policies.

Antimicrobial resistance (AMR) has been declared one of the top ten global public health threats facing humanity. To address AMR, coercive antimicrobial stewardship policies are being enacted in some settings. These policies, like all in public health, require ethical justification. Here, I introduce a framework for ethically evaluating coercive antimicrobial stewardship policies on the basis of ethical justifications (and their limitations). I consider arguments from effectiveness; duty of easy rescue; tragedy of the commons; responsibility-tracking; the harm principle; paternalism; justice and development; a precautionary approach; and professional duties. I consider how these justifications might form the basis for developing a comprehensive ethical framework, and the need for this to be context-specific and aligned with the priorities, evidence and needs of the particular jurisdictions in which a policy is to be enacted. I demonstrate how the ethical justifications might be used by reference to an example policy of the EU ban on the use of certain human-critical antibiotics for livestock, before concluding with challenges for further development of the framework.

Stewardship according to context: Justifications for coercive antimicrobial stewardship policies in agriculture and their limitations.

Antimicrobial resistance (AMR) is an urgent, global threat to public health. The development and implementation of effective measures to address AMR is vitally important but presents important ethical questions. This is a policy area requiring further sustained attention to ensure that policies proposed in National Action Plans on AMR are ethically acceptableand preferable to alternatives that might be fairer or more effective, for instance. By ethically analysing case studies of coercive actions to address AMR across countries, we can better inform policy in a context-specific manner. In this article, I consider an example of coercive antimicrobial stewardship policy in Canada, namely restrictions on livestock farmers' access to certain antibiotics for animal use without a vet's prescription. I introduce and analyse two ethical arguments that might plausibly justify coercive action in this case: the harm principle and a duty of collective easy rescue. In addition, I consider the factors that might generally limit the application of those ethical concepts, such as challenges in establishing causation or evidencing the scale of the harm to be averted. I also consider specifics of the Canadian context in contrast to the UK and Botswana as example settings, to demonstrate how context-specific factors might mean a coercive policy that is ethically justified in one country is not so in another.

The causes of bacterial bloodstream infections and antimicrobial resistance patterns in children attending a secondary care hospital in Bhaktapur, Nepal, 2017-2022: a retrospective study.

Data on antimicrobial resistance (AMR) among children in Nepal are limited. Here we have characterized the causes of bacterial bloodstream infections (BSIs), antimicrobial resistance patterns and the mechanisms of β-lactamase production in Enterobacterales among children attending outpatient and inpatient departments of a secondary care paediatric hospital in Nepal. We retrospectively collected demographic and clinical data of culture-proven bacterial BSIs between January 2017 and December 2022 among children <18 years attending a 50-bedded paediatric hospital. Stored isolates were subcultured for antimicrobial susceptibility testing against commonly used antimicrobials. Enterobacterales displaying non-susceptibility to β-lactams were phenotypically and genotypically investigated for ESBLs, plasmid-mediated AmpC (pAmpC) β-lactamases and carbapenemases. A total of 377 significant bacteria were isolated from 27 366 blood cultures. Among 91 neonates with a BSI, Klebsiella pneumoniae (n = 39, 42.4%), Pseudomonas aeruginosa (n = 15, 16.3%) and Acinetobacter baumannii complex (n = 13, 14.1%) were most common. In the non-neonates, 275/285 (96.5%) infections were community-acquired including Staphylococcus aureus (n = 89, 32.4%), Salmonella Typhi (n = 54, 19.6%) and Streptococcus pneumoniae (n = 32, 11.6%). Among the 98 S. aureus, 29 (29.6%) were methicillin-resistant Staphylococcus aureus. K. pneumoniae and Escherichia coli demonstrated non-susceptibility to extended-spectrum cephalosporins and carbapenems in both community and hospital-acquired cases. For E. coli and K. pneumoniae, blaCTX-M (45/46), blaEBC (7/10) and blaOXA-48 (5/6) were common among their respective groups. We determined significant levels of AMR among children attending a secondary care paediatric hospital with BSI in Nepal. Nationwide surveillance and implementation of antimicrobial stewardship policies are needed to combat the challenge imposed by AMR.

Antimicrobial Resistance in Escherichia coli Causing Urinary Tract Infection: A Four-Year Study

Urinary tract infections (UTIs) are among the most frequently encountered infections for which individuals seek medical attention. They are usually ascending infections and if left untreated the causative agent can ascend the ureters causing pyelonephritis and, furthermore, enter the bloodstream causing systemic infections and urosepsis. Appropriate treatment prevents progression of disease. Escherichia coli is responsible for 80-95% cases of UTI. This study was undertaken to study the antimicrobial resistance among Escherichia coli isolated from patients suffering from UTI over 4 years at a tertiary level medical facility. A retrospective case series study was conducted. All UTI with significant bacteriuria due to E. coli were included in the study. Identification, speciation and antimicrobial susceptibility testing was done as per standard laboratory practices. A total of 555 strains of Escherichia coli were included in the study. Overall highest resistance rates for E. coli were seen among cephalosporins and fluoroquinolones while least overall resistance was seen for nitrofurantoin. There was gradual rise in resistance for carbapenem over the 4 years. The predominant microorganism responsible for all types of infections affecting the urinary tract is Escherichia coli. Empirical antimicrobial therapy for urinary tract infections may be unsuccessful, as resistance rates among E. coli are constantly increasing. The present study provides information regarding the antimicrobial susceptibility pattern over a period of 4 years. It shows that there is a gradual but consistent decrease in antimicrobial susceptibility among the isolates. Hence, it has become necessary that antimicrobial therapy be based on culture reports. Also, frequent and periodic updating of antimicrobial policy is essential.

Decline in ESBL Production and Carbapenem Resistance in Urinary Tract Infections among Key Bacterial Species during the COVID-19 Pandemic.

The COVID-19 pandemic has led to significant changes in healthcare practices, including increased antibiotic usage. This study aimed to investigate the impact of the pandemic on the prevalence of extended-spectrum β-lactamase (ESBL) production and carbapenem resistance among key bacterial species causing urinary tract infections (UTIs). Conducted at King Fahad Medical City in Riyadh from January 2018 to December 2022, the study analyzed urine samples from 9697 UTI patients. Patients were categorized into 'pre-COVID-19' and 'during COVID-19' groups. Bacterial isolates were identified, and antimicrobial susceptibility testing was performed following guidelines. ESBL production was detected using the Double-Disc Synergy Test. Escherichia coli and Klebsiella pneumoniae were the main pathogens. During the pandemic, ESBL production decreased in E. coli by 1.9% and in K. pneumoniae by 6.0%. Carbapenem resistance also declined, with E. coli displaying a 1.2% reduction and K. pneumoniae and Pseudomonas aeruginosa displaying 10.7% and 7.9% reductions, respectively. Notably, logistic regression analysis revealed that the odds of ESBL presence were 10% lower during the COVID-19 pandemic (OR 0.91; 95% CI 0.83-0.99; p = 0.040), and there was a significant reduction in the odds of carbapenem resistance (OR 0.43; 95% CI 0.37-0.51; p < 0.001). This study reveals a significant decrease in ESBL production and carbapenem resistance among UTI pathogens during the COVID-19 pandemic, hinting at the impact of modified antibiotic and healthcare approaches. It emphasizes the need for persistent antimicrobial resistance surveillance and policy adaptation to address resistance challenges, offering key directions for future public health actions.

‘When I tried to explain, they shouted back at me!’: exploring how community pharmacists navigate tensions implementing antimicrobial stewardship in Vietnam

ABSTRACT Antimicrobial resistance is a major global and national health challenge, accelerated by ‘irrational’ antibiotic use. In response, Vietnam has been implementing a public health plan of antimicrobial stewardship since 2013 to reduce antibiotic sales in community pharmacies, although it has had limited effect. Given that private pharmacies are increasingly the entry point to access healthcare, reflective of the inhibited accessibility of primary healthcare, understanding how the positioning of community pharmacists shapes the delivery of antimicrobial stewardship plans warrant further investigation. This qualitative analysis draws on data from 24 in-depth interviews with licensed community pharmacists in Vietnam. Interviewees described being constrained in rationing the sale of antibiotics by tensions within their professional role, in which the delivery of antimicrobial stewardship within their public health commitments rubs up against commercial and social obligations to their livelihoods and communities respectively. The concept of ‘resistance’ provides insight into what obstructs the integration of national antimicrobial stewardship guidance and policy, hindering the transformation of local practices concerning antibiotic sales at the community level. Findings reveal opportunities to recast community pharmacists as ‘productive anchors’ who can facilitate the appropriate use of antibiotics and strengthen links to primary care within the local context. Structural changes are needed, however, so that people do not use antibiotics as a proxy for health care. Improving the accessibility of primary healthcare would also curtail the reliance on community pharmacists’ to dispense antibiotics as a local mechanism of financial protection and social care within community.