Antimicrobial Policy Research Articles

Spatial and temporal dynamics of microbiomes and resistomes in broiler litter stockpiles

Farmers apply broiler chicken litter to soils to enrich organic matter and provide crops with nutrients, following varying periods of stockpiling. However, litter frequently harbors fecal-derived microbial pathogens and associated antibiotic resistance genes (ARGs), and may be a source of microbial contamination of produce. We coupled a cutting-edge Loop Genomics long-read 16S rRNA amplicon-sequencing platform with high-throughput qPCR that targeted a suite of ARGs, to assess temporal (five time points over a 60-day period) and spatial (top, middle and bottom layers) microbiome and resistome dynamics in a broiler litter stockpile. We focused on potentially pathogenic species from the Enterobacteriaceae, Enterococcaceae and Staphylococcaceae families associated with food-borne disease. Bacterial diversity was significantly lower in the middle of the stockpile, where targeted pathogens were lowest and Bacillaceae were abundant. E. coli was the most abundant Enterobacteriaceae species, and high levels of the opportunistic pathogen Enterococcus faecium were detected. Correlation analyses revealed that the latter was significantly associated with aminoglycoside (aac(6′)-Ib(aka aacA4), aadA5), tetracycline (tetG), vancomycin (vanC), phenicol (floR) and MLSB (mphB) resistance genes. Staphylococcaceae were primarily non-pathogenic, but extremely low levels of the opportunistic pathogen S. aureus were detected, as was the opportunistic pathogen S. saprophyticus, which was linked to vancomycin (vanSA, vanC1), MLSB (vatE, ermB) and tetracycline (tetK) resistance genes. Collectively, we found that stockpile microbiomes and resistomes are strongly dictated by temporal fluctuations and spatial heterogeneity. Insights from this study can be exploited to improve stockpile management practice to support sustainable antimicrobial resistance mitigation policies in the future.

Burden of Multidrug Resistant Escherichia coli among Patients with Urinary Tract Infections in a Tertiary Care Centre- A Retrospective Analysis

Introduction: Multidrug Resistant (MDR) Escherichia coli isolates causing Urinary Tract Infections (UTIs), capable of producing Extended Spectrum Beta Lactamase (ESBL), AmpC beta lactamase and resistance to carbapenems pose serious challenges to the clinicians causing worse clinical scenarios. The detection of these isolates has prime importance in infection control and improving therapeuticmanagementofpatients,astheirprevalenceisincreasing worldwide. Injudicious use of antibiotics has led to selective pressure, resulting in the emergence of antibiotic resistance in gram negative bacteria globally. This rise in antimicrobial resistance has decreased the options for empirical therapy, causing a global health concern in infections associated with ESBL producing and AmpC producing isolates. Aim: To investigate the burden of ESBL producing, AmpC beta-lactamase producing, carbapenem resistant, and MDR Escherichia coli isolated from urine samples in a tertiary care centre. Materials and Methods: The present retrospective study conducted from January to December 2019. A total of 10,535 urine samples were received during the study period, to find out the burden of drug resistant Escherichia coli isolates in urine samples, analyse their antibiogram and patients’ socio-demographic information. Records of microscopic observations to antibiogram of each isolate was noted down from the register for urine samples, and further analysed. The data was coded, verified, entered and analysed using Statistical Package for Social Sciences (SPSS) version 18.0. Results: Among the total urine samples (10,535), 1434 (13.6%) Escherichia coli isolates were identified, of which 553 (38.6%) were found to be ESBL producing, 497 (34.6%) AmpC beta- lactamase producing, 172 (12%) Carbapenem resistant, and 765 (53.3%) MDR. Majority of the isolates were from the age group of 51-60 years 288 (20.08%). The least susceptibility of the isolates was detected against penicillin G 1410 (98.3%), followed by ampicillin 1160 (80.9%) and cephazolin 74 (67.9%). Among the MDR isolates, the maximum drug resistance (398, 52%) was seen in penicillin, cephems, quinolones and Folate pathway antagonist group of antimicrobials. Conclusion: Identification of the drug resistant isolates is of high priority and crucial for therapeutic management of the patients, and infection control. Stringent antimicrobial stewardship policies and judicious use of antimicrobials can decrease the spread of antimicrobial resistant genes in the hospital environment.

Antimicrobial resistance of bacterial isolates from the clinical and hospital environment in Gaza Strip, Palestine: A review over 20-year

Antimicrobial resistance is a serious threatening problem associated with high morbidity and mortality. The majority of pathogenic bacteria show multiple drug resistance patterns. Thus, treatment of infections caused by those bacteria become ineffective. This paper evaluates, investigates, and discusses the existing situation of antimicrobial resistance in Gaza Strip, Palestine. The data of this review considered the published articles over the period 2002-2021. Search was conducted using Google scholar, Researchgate, and PubMed search engines. Thirty five articles were included. This review discussed studies done on antibiotic resistant bacteria found in a wide range of environments including clinical samples, foods, poultry, costal water, hospital wastewater, and hospital environments. The reported dissemination and spread of antibiotic resistant bacteria is influenced by several factors like inappropriate and unwise use of antibiotics as well as the un-regulated access of these antibiotics to the environment. Palestine is in urgent need to develop, strengthen, and implement antimicrobial stewardship policy, standard treatment guidelines, a local plan for containment and reduction of antimicrobial resistance, and research related to public health aspects of antimicrobial resistance at the community and hospital level. Keywords; Antimicrobial resistance, Gaza strip, Palestine

Metronidazole in the prophylaxis and treatment of dogs and cats

Ever since their discovery, antimicrobials have helped in controlling and treating infections in both humans and animals. The control of infectious diseases is endangered by the rise of microorganisms that are resistant to this group of drugs. Limited availability of authorized veterinary drugs leads to prescription of human approved drugs. The aim of our study was to describe metronidazole use patterns and its accordance with scientific literature in Serbia. Results have shown that majority of prescriptions were written to dogs, while 27.1% prescriptions were for cats. Most common general conditions were dental and digestive disorders. Our study shows that metronidazole is available in oral and injectable form, while cats were only treated with injectable formulation. Even though pre?scription of human approved drugs for companion animals is allowed by Law, there is no official record of data on the extent or nature of off-label use in Serbia. Such information is essential for guiding antimicrobial use policy in small animal veterinary practice as well as for assessing the risk of transmission of antimicrobial resistance to humans. Recognizing the importance of antimicrobial resistance and ensuring more judicious use of antibiotics are key elements to any strategy for maintaining the usefulness of antimicrobial drugs in animals and humans.

898. Prevalence of Extended Spectrum Beta-Lactamase Producing Escherichia coli, Klebsiella Pneumoniae and Pseudomonas Aeruginosa from Hospital Acquired Surgical Site Infections in Ghana

BackgroundGlobally, ESBL-producing bacteria pose a great challenge for treating hospital acquired SSI. Currently, the prevalence of ESBL pathogens in Ghana hospitals is poorly understood. Determining the frequency ESBLs are encountered will, in turn, provide insight for antibiogram development and shape antimicrobial stewardship policies in Ghana.MethodsUsing U.S. CDC criteria for SSI, wound swabs or aspirates were collected from 112 participants who met study inclusion criteria. Specimens were plated on MacConkey and blood agar; then colonies were isolated and identified using MALDI-TOF. Antimicrobial susceptibility testing was performed using the Kirby-Bauer disk diffusion method and interpreted according to the 2018 Clinical and Laboratory Standards Institute (CLSI) guidelines. The combined disk method was used to screen for ESBLs among E.coli and K. pneumoniae isolates. Genes associated with ESBL production (SHV, TEM and CTX-M) were detected using PCR analysis.ResultsThirty-eight percent of the bacterial isolates recovered were E. coli, K. pneumonia accounted for 32%, and P. aeruginosa accounted for 16% of the total isolates; remaining isolates were gram positive pathogens not discussed here. ESBL production was detected in 50% of E. coli isolates and 73% of K. pneumoniae isolates. ESBL-producing isolates were susceptible to meropenem but resistant to cefuroxime, cefotaxime, tetracycline, trimethoprim-sulfamethoxazole, gentamicin, ciprofloxacin and chloramphenicol. P. aeruginosa isolates were only sensitive to meropenem, gentamicin, and ciprofloxacin. In our study, CTX-M was the most frequently detected gene producing the ESBL-phenotype: 33% of E. coli isolates and 73% of K. pneumoniae isolates possessed the CTX-M gene.ConclusionApproximately 70% of total bacterial isolates recovered from our SSI study were ESBL producers. The presence of these multi-drug resistant organisms raises clinical concerns due to the absence of routine antimicrobial resistance (AMR) testing and lack of suitable first-line antimicrobials for ESBL pathogens. Improved laboratory capacity to more readily detect MDROs is essential for effective clinical management of patients, antibiogram development and refining antimicrobial stewardship practices in Ghana hospitals.Disclosures All Authors: No reported disclosures

388. Multidrug Resistant Gram Negative Organisms Prevalence in Hospitalized Patients in an Italian Tertiary Level Hospital During COVID-19 Pandemia: First Detection is More Frequent in Clinical Samples than in Surveillance Rectal Swabs with Respect to the Previous 14-Month Period

BackgroundIn Italy the pandemic of COVID-19 infection has placed an enormous burden on health authorities: contact precautions are required to avoid viral transmission and people should be subjected to standard infection control procedures. This is crucial in a country experiencing a high number of confirmed cases of COVID-19 infection in Europe and where multidrug-resistant Gram-negative bacteria (MDR-GN) are endemic.The aim of this study was to compare the prevalence of MDR-GN in surveillance rectal swabs (SRS) and in clinical samples (CS) in the period March 1,2020-April, 24 2020 with respect to the previous 2-month period and to the previous year.MethodsThe first SRS and the first CS with a MDR-GN isolate detected from 01/01/2019 to 24/04/2020 were included. Analysis was made by comparing three different study periods in 2019 and 2020 (Jan-Dec 2019, Jan-Feb 2020, and Mar-Apr 2020), for medical department, surgical department and intensive care department.ResultsOverall, 612 MDR-GN organisms were identified (399 SRS and 213 CS): carbapenemase-producing Klebsiella pneumoniae and Acinetobacter baumanii (CPAB) were the most frequently detected (Figure 1). We observed an increased relative frequency of patients with MDR-GN detected in CS respect to those found in SRS (32.7% vs 44.5% vs 70.6%, p=0.0005): 5/12 CS detected in the last period were isolated from the respiratory tract (Figure 2). Nine patients with COVID-19 pneumonia had MDR-GN. All but two patients had a previous negative SRS performed 4 days before (median value) and the median interval between COVID-19 positivity and MDR-GN positivity was 7 days.The six patients with CPAB isolation were all hospitalized in the same ward, with partially overlapping hospital stays during the study period. In 5 of them, CPAB was detected in the respiratory tract (Figure 3). ConclusionThe first detection of MDR-GN in CS and the nosocomial MDR-GN acquisition despite cohorting due to COVID-19 infection underline the need to reinforce infection control measures in a high prevalence country during COVID-19 pandemia. A correct antimicrobial policy urged because, according to published data, most patients with COVID-19 infection received antimicrobial therapy: furthermore MDR-GN infection could play a role in the negative outcome of these patients.Disclosures All Authors: No reported disclosures

Acinetobacter Spp: Resistance and therapeutic decisions at the turn of the novel millennium

Background: This study was planned to evaluate sample wise isolation and antimicrobial resistant trends of Acinetobacter spp. in different departments of a tertiary care hospital. Methods and materials: This was a transversal descriptive study, carried out in the clinical microbiology laboratory of the Allama Iqbal Medical College/Jinnah Hospital, Lahore, Pakistan, during the period of January 2015 to December 2016. Every clinical specimen was processed for bacterial culture and antimicrobial susceptibly testing. A total of 3590 (2015 = 1780, 2016 = 1810) clinical specimens were processed. Results: Of the total, only 54.7% were gram-negative, among these Acinetobacter spp. were isolated from 10.1% and 16.5% samples respectively in 2015–16 with an overall rate of 24.3%. The highest occurrence of Acinetobacter spp. isolates was reported from Intensive care units (ICU) (54%) followed by surgical units (25%) and medical units (16%). It is noteworthy that ICU and internal medicine showed the highest resistance rates, whereas, lower resistance rate was observed for the outdoor patients (OPD). Although collistin showed 0% resistant while ceftriaxone, ciprofloxacin, gentamicin, and tigecycline showed 90%, 68%, 66%, 66% and 62% resistance against Acinetobacter spp. respectively. An alarming increase in the resistance rate of meropenem, cefoperazone/sulbactam, piperacillin/tazobactam, ciprofloxacin, and imipenem was observed from the year 2015 to 2016. Conclusion: This startling resistance acquired by Acinetobacter spp. within a period of one year, represent very limited therapeutic options left for the infections caused by Acinetobacter spp. Unavailability of effective drugs and limited therapeutic options enforce the health care practitioners to prescribe expensive and broad range antibiotics, which may cause harm to the patient. Therefore, it is need of an hour to better understand the antimicrobial patterns and optimize antimicrobial prescription policies for the control of multidrug-resistant Acinetobacter spp.

Global trends in antimicrobial use in aquaculture

Globally aquaculture contributes 8% of animal protein intake to the human diet, and per capita consumption is increasing faster than meat and dairy consumption. Reports have documented antimicrobial use in the rapidly expanding aquaculture industry, which may contribute to the rise of antimicrobial resistance, carrying potential consequences for animal-, human-, and ecosystem-health. However, quantitative antimicrobial use across a highly diversified aquaculture industry is not well characterized. Here, we estimate global trends in antimicrobial use in aquaculture in 2017 and 2030 to help target future surveillance efforts and antimicrobial stewardship policies. We estimate antimicrobial use intensity (mg kg−1) for six species groups though a systematic review of point prevalence surveys, which identified 146 species-specific antimicrobial use rates. We project antimicrobial use in each country by combining mean antimicrobial use coefficients per species group with OECD/FAO Agricultural Outlook and FAO FishStat production volumes. We estimate global antimicrobial consumption in 2017 at 10,259 tons (95% uncertainty interval [UI] 3163–44,727 tons), increasing 33% to 13,600 tons in 2030 (UI 4193–59,295). The Asia–Pacific region represents the largest share (93.8%) of global consumption, with China alone contributing 57.9% of global consumption in 2017. Antimicrobial consumption intensity per species group was: catfish, 157 mg kg−1 (UI 9–2751); trout, 103 mg kg−1 (UI 5–1951); tilapia, 59 mg kg−1 (UI 21–169); shrimp, 46 mg kg−1 (UI 10–224); salmon, 27 mg kg−1 (UI 17–41) and a pooled species group, 208 mg kg−1, (UI 70–622). All antimicrobial classes identified in the review are classified as medically important. We estimate aggregate global human, terrestrial and aquatic food animal antimicrobial use in 2030 at 236,757 tons (95% UI 145,525–421,426), of which aquaculture constitutes 5.7% but carries the highest use intensity per kilogram of biomass (164.8 mg kg−1). This analysis calls for a substantial scale-up of surveillance capacities to monitor global trends in antimicrobial use. Current evidence, while subject to considerable uncertainties, suggests that for some species groups antimicrobial use intensity surpasses consumption levels in terrestrial animals and humans. Acknowledging the fast-growing nature of aquaculture as an important source of animal nutrition globally, our findings highlight the urgent need for enhanced antimicrobial stewardship in a high-growth industry with broad links to water and ecosystem health.

Detection of carbapenem-resistant Klebsiella pneumoniae strains harboring carbapenemase, beta-lactamase and quinolone resistance genes in intensive care unit patients.

Aim: Carbapenem-resistant Klebsiella pneumoniae (CR-Kp) strains are important nosocomial pathogens worldwide. In this study, we aimed to reveal the antibiotic resistance of clinical CR-Kp strains and determine the presence of KPC, OXA-48, VIM and IMP carbapenemase genes. CTX-M-1, TEM-1, SHV-1 extended-spectrum beta-lactamase (ESBL) genes, qnrA, qnrB, qnrS plasmid-mediated quinolone resistance genes and sul1 and sul2 sulfonamide resistance genes provided molecular epidemiological data. Methods: A total of 175 K. pneumoniae strains were isolated from clinical samples of patients hospitalised in an intensive care unit (ICU) betweent April and October 2017. The strains were identified with conventional methods, with VITEK 2 (BioMerieux, France) and MALDI-TOF MS (Bruker, USA). Antimicrobial susceptibilities were tested using the disc-diffusion method and E-test (BioMerieux, France). Antimicrobial resistance genes were investigated via real-time PCR in strains identified as CR-Kp.Results: High frequencies of blaTEM-1 (86.36%), blaSHV-1 (86.36%), and blaCTX-M-1 (95.45%) genes were found in CR-Kp strains. Morever, all three ESBL genes coexisted in 77.3% of all strains. blaKPC was detected in 12 (54.55%) of the strains, and 4 of them which had an MIC> 16 μg/mL to imipenem showed blaOXA-48 positivity as well. The qnrS gene determinant (86.36%) had the highest frequency, and strains carrying qnrA showed higher MICs for ciprofloxacin. Conclusion: CR-Kp strains are able to develop different antimicrobial resistance patterns according to regional changes in antimicrobial therapeutic policies. Thus, it is important to monitor the regional molecular epidemiological data for efficient treatment.

Extended-spectrum Beta-lactamase and AmpC beta-lactamases producing gram negative bacilli isolated from clinical specimens at International Clinical Laboratories, Addis Ababa, Ethiopia.

BackgroundExtended spectrum Beta-lactamases (ESBLs) and AmpC beta-lactamases (AmpC) are the common enzymes produced by gram negative bacilli, which are their main mechanisms of resistance to all generations of cephalosporins. Hence, this study aimed to determine the magnitude of ESBLs and AmpC producing gram negative bacilli (GNB) isolated from clinical specimens at International clinical Laboratories in Addis Ababa, Ethiopia.MethodsA cross sectional study was conducted from January to May 2018. From different clinical specimens, 338 GNB were isolated and characterized. Bacterial species identification, antimicrobial susceptibility testing and screening for ESBLs and AmpC production were performed using Phoenix automated system (BD phoenix100). ESBLs production was confirmed using a combination disc method. All Cefoxitin resistant and confirmed ESBLs producing GNB were confirmed for AmpC beta-lactamases production by AmpC confirmatory Neo-Sensitabs discs (ROSCO tablet). Data were analyzed using SPSS version 20 software.ResultsE. coli 66.0% (224/338) followed by K. pneumoniae 12.1% (41/338) were GNB most frequently isolated. The overall magnitude of ESBLs producing GNB was 38.8% (131/338) and the extent of AmpC beta-lactamase producing GNB was 2.4% (8/338). Majority of ESBLs and AmpC beta-lactamases producing GNB were isolated from urine specimens 47.5% (116/338). Ampicillin (75.4%), amoxicillin with clavulanic acid (64.0%) and sulfamethoxazole-trimethoprim (55.6%) were most the antibiotics to which resistance was most commonly found. The multidrug resistance (MDR) level of GNB was 74.0% (250/338). Of ESBLs and AmpC beta-lactamases producing GNB, 99.3% were MDR (p < 0.05).ConclusionThe high magnitude of ESBLs and AmpC beta-lactamases producing GNB calls the needs of strong intervention to minimize further occurrence and spread of such GNB. More importantly, the MDR level was high which suggests continuous monitoring & reviewing of antimicrobial policy in hospitals and the country at large.

Device-associated infections in Canadian acute-care hospitals from 2009 to 2018.

Healthcare-associated infections (HAIs) pose a serious risk to patient safety and quality of care. The Canadian Nosocomial Infection Surveillance Program (CNISP) conducts national surveillance of HAIs at sentinel acute-care hospitals across Canada. This report provides an overview of 10 years of Canadian data on the epidemiology of select device-associated HAIs. Over 40 hospitals submitted data between 2009 and 2018 for hip and knee surgical site infections (SSIs), cerebrospinal fluid shunt SSIs, paediatric cardiac SSIs and/or central line-associated bloodstream infections (CLABSIs). Counts, rates, patient and hospital characteristics, as well as pathogen distributions and antimicrobial susceptibilities are presented. A total of 4,300 device-associated infections were reported. Central line-associated bloodstream infections were the most common device-associated HAI reported (n=2,973, 69%) and hip and knee arthroplasty infections were the most common SSIs reported (66% of SSIs). Our findings show decreasing CLABSI rates in neonatal intensive care units (4.2 to 1.9 per 1,000 line-days, p<0.0001) and decreasing knee SSI rates (0.69 to 0.30 infections per 100 surgeries, p=0.007). Rates of device-associated HAIs have remained relatively consistent over the 10-year surveillance period. Overall, 4,599 pathogens were identified from device-associated HAI; 70% of these were related to CLABSIs. Coagulase-negative staphylococci (29%) and Staphylococcus aureus (14%) were the most frequently reported pathogens. Gram-positive pathogens represented 68% of identified pathogens, gram-negative pathogens represented 22% and fungi represented 9%. Understanding the national burden of device-associated HAIs is essential for developing and maintaining benchmark rates for informing infection and prevention control and antimicrobial stewardship policies and programs.

A Brief History of the Major Rickettsioses in the Asia-Australia-Pacific Region: A Capstone Review for the Special Issue of TMID.

The rickettsioses of the “Far East” or Asia–Australia–Pacific region include but are not limited to endemic typhus, scrub typhus, and more recently, tick typhus or spotted fever. These diseases embody the diversity of rickettsial disease worldwide and allow us to interconnect the various contributions to this special issue of Tropical Medicine and Infectious Disease. The impact of rickettsial diseases—particularly of scrub typhus—was substantial during the wars and “police actions” of the last 80 years. However, the post-World War II arrival of effective antibiotics reduced their impact, when recognized and adequately treated (chloramphenicol and tetracyclines). Presently, however, scrub typhus appears to be emerging and spreading into regions not previously reported. Better diagnostics, or higher population mobility, change in antimicrobial policies, even global warming, have been proposed as possible culprits of this phenomenon. Further, sporadic reports of possible antibiotic resistance have received the attention of clinicians and epidemiologists, raising interest in developing and testing novel diagnostics to facilitate medical diagnosis. We present a brief history of rickettsial diseases, their relative importance within the region, focusing on the so-called “tsutsugamushi triangle”, the past and present impact of these diseases within the region, and indicate how historically, these often-confused diseases were ingeniously distinguished from each another. Moreover, we will discuss the importance of DNA-sequencing efforts for Orientia tsutsugamushi, obtained from patient blood, vector chiggers, and rodent reservoirs, particularly for the dominant 56-kD type-specific antigen gene (tsa56), and whole-genome sequences, which are increasing our knowledge of the diversity of this unique agent. We explore and discuss the potential of sequencing and other effective tools to geographically trace rickettsial disease agents, and develop control strategies to better mitigate the rickettsioses.

Purchase and use of antimicrobials in the hospital sector of Vietnam, a lower middle-income country with an emerging pharmaceuticals market.

Antimicrobial use is associated with emergence of antimicrobial resistance. We report hospital antimicrobial procurement, as a surrogate for consumption in humans, expenditure and prices in public hospitals in Vietnam, a lower middle-income country with a high burden of drug resistant infections. Data on antimicrobial procurement were obtained from tender-winning bids from provincial health authorities and public hospitals with detailed bids representing 28.7% (1.68 / 5.85 billion US $) of total hospital medication spend in Vietnam. Antimicrobials were classified using the Anatomical Therapeutic Chemical (ATC) Index and the 2019 WHO Access, Watch, Reserve (AWaRe) groups. Volume was measured in number of Defined Daily Doses (DDD). Antimicrobial prices were presented per DDD. Expenditure on systemic antibacterials and antifungals accounted for 28.6% (US $482.6 million/US $1.68 billion) of the total drug bids. 83% of antibacterials (572,698,014 DDDs) by volume (accounting for 45.5% of the antibacterials spend) were domestically supplied. Overall, the most procured antibacterials by DDD were second generation cephalosporins, combinations of penicillins and beta-lactamase inhibitors, and penicillins with extended spectrum. For parenteral antibacterials this was third generation cephalosporins. The average price for antibacterials was US $15.6, US $0.86, US $0.4 and US $11.7 per DDD for Reserve, Watch, Access and non-recommended/unclassified group antibacterials, respectively. Antimicrobials accounted for a substantial proportion of the funds spent for medication in public hospitals in Vietnam. The pattern of antibacterial consumption was similar to other countries. The high prices of Reserve group and non-recommended/unclassified antibacterials suggests a need for a combination of national pricing and antimicrobial stewardship policies to ensure appropriate accessibility.

Knowledge, attitude, and practices of community pharmacy staff toward antimicrobial stewardship programs: a cross-sectional study from Northeastern China

ABSTRACT Background Antimicrobial resistance is one of the most significant challenges of the twenty-first century, and the illegal sale of antimicrobial drugs at community pharmacies is a driver of antimicrobial resistance. This study explores the knowledge, attitudes, and practices (KAP) of pharmacy staff toward antimicrobial stewardship programs (ASPs). Methods We conducted a descriptive cross-sectional study among community pharmacy staff in Northeastern China, from April 1 to 31 May 2019, using a self-administered KAP questionnaire comprising 20 items. The data analysis was carried out by employing Mann-Whitney and Kruskal-Wallis tests. Results A response rate of 98.5% (394/400) was obtained. The majority of participants (94.9%) demonstrated a good understanding of antimicrobial use, but they lacked an adequate understanding of ASPs. Nearly half of the participants (40.6%) reported that they sold antimicrobials to patients without a prescription. Education level, age, occupation, and experience were all significantly associated (P < 0.05) with participants’ median ASPs scores. Besides, the presence of a licensed pharmacist (OR 46.327, 95% CI 2.443–878.451, P = 0.011) was the main factor associated with the pharmacy staff’s understanding of antimicrobial use policies. Conclusions The participants’ knowledge of antimicrobials was good, and their attitudes regarding ASPs were positive, but their practices regarding ASPs were poor.

Issues beyond resistance: inadequate antibiotic therapy and bacterial hypervirulence.

The administration of antibiotics while critical for treatment, can be accompanied by potentially severe complications. These include toxicities associated with the drugs themselves, the selection of resistant organisms and depletion of endogenous host microbiota. In addition, antibiotics may be associated with less well-recognized complications arising through changes in the pathogens themselves. Growing evidence suggests that organisms exposed to antibiotics can respond by altering the expression of toxins, invasins and adhesins, as well as biofilm, resistance and persistence factors. The clinical significance of these changes continues to be explored; however, it is possible that treatment with antibiotics may inadvertently precipitate a worsening of the clinical course of disease. Efforts are needed to adjust or augment antibiotic therapy to prevent the transition of pathogens to hypervirulent states. Better understanding the role of antibiotic-microbe interactions and how these can influence disease course is critical given the implications on prescription guidelines and antimicrobial stewardship policies.

Molecular epidemiology and the clinical impact of carbapenemase-producing Enterobacterales isolates among adult patients: aspects from a Romanian non-teaching hospital

Abstract Introduction: A dramatic increase of infections induced by carbapenemase-producing Enterobacterales (CPE) has been registered worldwide. The aim of this study was to evaluate the molecular epidemiology and the clinical impact of CPE strains isolated from adult inpatients. Material and methods: A one-year, single-center, retrospective observational study including 34 consecutive patients with 37 non-duplicate CPE strains recovered from clinical specimens was accomplished. The Vitek 2 Compact, M.I.C.Evaluator strips, the modified carbapenem inactivation method (mCIM), and the combination disks test (KPC, MBL, OXA-48 Confirm kit, Rosco Diagnostica) were applied as phenotypic tests. A multiplex polymerase chain reaction (PCR) assay was used for detection of blaKPC, blaNDM, and blaOXA-48-like genes. The clonality was assessed with pulsed-field gel electrophoresis (PFGE). Results: Klebsiella pneumoniae (n=25) was the most frequent CPE encountered. The carbapenemase types were NDM (n=13), KPC (n=12), and OXA-48-like (n=12). Two distinct clonal clusters were identified among the 12 KPC positive strains. All CPE isolates exhibited non-susceptibility to carbapenems, cephalosporins, ciprofloxacin. Respiratory tract infections (n=16) and hospitalization in the intensive care unit (ICU) (n=14) were dominant. The most common comorbidity was congestive heart failure (n=11). Monotherapy was the main strategy adopted (n=15). Death occurred in 18 patients. Conclusions: Our analysis underscores the scarcity of antibiotic solutions and high mortality. Monotherapy for urinary tract infections (UTIs) is beneficial. Inter- or intrahospital dissemination of successful epidemic clones is proved. The adequate CPE infections control programs and antimicrobial policies are essential..

Healthcare-Associated Pneumonia in a Mexican Tertiary Care Center Micro to Systemic Analysis: A 2017–2019 Case Series Study

Objectives: The aim of this study was to identify the biological, microbiological, and healthcare factors related to the occurrence of nosocomial pneumonia in our confirmed cases during 2017–2019. Methods: We conducted a case series study. For the selection of the cases we used the CDC criteria for hospital-acquired pneumonia, we collected cases from the data set for healthcare-associated infections from a tertiary-care hospital in Mexico City. For the quantitative analysis, we used Stata v14 software, and we obtained frequencies, proportions, accumulated incidence rate, lethality rate, central tendency, and dispersion metrics. This study was a secondary data set analysis; we obtained signed authorization for the use of the data from the Epidemiological Surveillance Unit. Results: During our analysis period (January 2017 to June 2019), we identified 107 cases that fulfilled the CDC criteria: 47 cases (43.93%) from 2017, 38 cases (35.51%) from 2018, and 20.56% from 2019. The month that reported the highest frequency was February, with 17 cases (15.89%). The median age was 63 years (range, 0–97 years; IQR, 36). The most affected age group was 65 years (48.60%), and the most affected 5-year age group was 75–79 years (13.08%). Moreover, 60 cases (56.07%) were men and 47 (43.93%) were women. Regarding the reason for discharge, 71% were discharged due to improvement, 27% died, and 2% were transferred to another healthcare facility. Also, 17 patients (15.89%) required readmission due to respiratory illness within 72 hours of previous discharge. The most common diagnosis was a solid malignant neoplasm (20.19%), followed by heart or vascular malformation or anomaly (12.50%). The mean inpatient hospital stay was 39.95 days (46.40; median, 27 days, range, 2–317 days; IQR 35 days). The median time elapsed until detection was 14 days. The hospitalization area with the most cases was the intensive care unit, with 24 cases (22.43%); the service with most cases was oncology with 21 cases (20.56%). The most isolated pathogen was Pseudomonas aeruginosa (14%). Moreover, 59% were gram-negative, 36% were gram-positive, 19.67% were viruses, and 14.75% were fungi. Our accumulated-incidence-rate was 0.58 cases per 1,000 patient days and our case-fatality-rate was 25.23%. Furthermore, 41% of cases required invasive mechanical ventilation, 52.34% required noninvasive mechanical ventilation, 5% cases had an endo-pleural tube, 9.35% had a nasogastric tube, and 41.12% had a central venous catheter. The most-prescribed antimicrobial was meropenem (33.33%), and meropenem-resistance was 61.54%. Conclusions: Infection prevention efforts should target oncological patients, critical-care units, and the elderly. We must reinforce our antimicrobial policy due to our overprescription of carbapenems. Early detection is needed to reduce mortality.Funding: NoneDisclosures: None

Prevalence and Antimicrobial Susceptibility Pattern of Klebsiella Pneumoniae Isolated from Various Clinical Specimens in a Tertiary Care Hospital in Bangladesh

Introduction:Klebsiella pneumoniae are common causative agents of various infections and are of great concern for developing resistance against commonly prescribed antibiotics. This study gives an account of isolation of K. pneumoniae from various clinical specimens and their antimicrobial susceptibility, in a tertiary care hospital of Bangladesh.&#x0D; Materials and Methods: Various clinical specimens like urine, wound swab, sputum, blood and endotracheal aspirates were collected and processed for isolation of K. pneumoniae followed by their antimicrobial susceptibility testing.&#x0D; Results: Among the 316 samples that yielded culture positivity, K. pneumoniae were identified as second most common organism. The highest yield of K. pneumoniae (37.33%) were observed from wound swab followed by sputum (26.67%). Most of the isolates were resistant to sulphamethoxazole-trimethoprim (90.67%) and ceftriaxone (90.67%) followed by cefotaxime (89.33%), ceftazidime (89.33%) and cefuroxime (89.33%). The most sensitive antibiotic for the isolates was tigecycline.&#x0D; Conclusion: Isolated K. pneumoniae showed resistance to commonly prescribed antibiotics, which is very alarming and showing the importance on continuous monitoring and strict antimicrobial policy.&#x0D; Medicine Today 2020 Vol.32(2): 95-99

P33 Antimicrobial prescribing point prevalence study at a paediatric tertiary/quaternary centre

AimsIncreasing antibiotic resistant organisms combined with frequent, inappropriate use of antibiotics is giving rise to infections which may no longer be able to be treated1. The aim of this prevalence study was to audit antimicrobial prescribing at a Hospital against Trust antimicrobial policies to determine whether the rising trend in antimicrobial prescribing is appropriate.MethodsThe data was collected in a point prevalence manner; prescriptions that were active at the time of auditing were included and those which were discontinued or prescribed and not yet administered were excluded. A data collection template was designed and distributed to ward pharmacists with education on how to complete. The following parameters were audited; allergy status, antibiotic name, route, indication, duration, review date as well as the ward and speciality. Ward pharmacists assessed whether the prescription was in line with Trust guidelines/ID/Micro recommendations. Data was collected into a central database, as well time taken to audit.The audit standards were90% of patients prescribed an antimicrobial for an indication in line with Trust policy or ID/Micro90% of patients prescribed an antimicrobial for a duration in line with Trust policy or ID/Micro90% of patients have an allergy status documentedResults272 inpatient charts were reviewed. 153 of these patients (56%) were prescribed an antimicrobial.398 antibiotic prescriptions were included for audit. 38% of prescriptions were for medical/surgical prophylaxis. Prophylactic prescriptions were not included for further analysis. 85% of prescriptions had an indication documented either on the electronic chart (JAC) or written in the paper medical notes. 98% of prescriptions were as per policy or in line with recommendations from ID/Micro. 61% of prescriptions had a review date documented. 100% of patients had an allergy status documented. Average duration of antibiotic prescription was 8 days, range 1–50 days, median 5. 80% of prescriptions were IV. 70% of antimicrobial prescribing takes place in the ICU/cancer/transplant setting. Respiratory tract infections were the most common indication for antimicrobial prescribing, 35%. Amikacin was the most commonly prescribed antibiotic (15%), followed by piperacillin/tazobactam (14%). The audit cost in terms of pharmacist time was £763, at a total of 33 hours.ConclusionsPolicy compliant prescribing was very high at 98%; this figure is surprisingly high and poses questions as to the accuracy of data collection and whether bias was present. As a Trust we are now interested and will focus on improving intravenous to oral switches and reviewing and documenting patients’ antimicrobial therapy regularly. As a tertiary/quaternary centre we treat complicated immunocompromised patients; we are unlikely to lower the burden of infection. Approximately 75% of antimicrobial prescribing was in the ICU and cancer and transplant setting, however we must optimise the use of antimicrobials and demonstrate good antimicrobial stewardship. This data will act as a baseline for a subsequent audits which will be carried out using the newly implemented EPIC® patient management system.ReferenceGOV.UK. 2019. Antimicrobial Resistance (AMR). [ONLINE]Available at: https://www.gov.uk/government/collections/antimicrobial-resistance-amr-information-and-resources [Accessed 2 July 2019].

National Action Plan on Antimicrobial Resistance: stakeholder analysis of implementation in Ghana

Background Understanding potential barriers to implementation of public health policy is important to ensure well-informed decisions, and stakeholders play critical roles in implementation. Stakeholder analysis is expected to shed light on Ghana’s progress with the implementation of the National Action Plan on Antimicrobial Resistance since the completion of the Global Health Security Agenda’s Joint External Evaluation. The outcome of stakeholder analysis can improve understanding of their roles and institutional capacity to promote prudent use of antibiotics in populations at the community level. Methods Eight semi-structured in-depth interviews were conducted with participants of the Joint External Evaluation process, including personnel from the policy, research, and practice programs in Ghana’s public health sector. In-person interviews were conducted between September and October 2018 in the Greater Accra and Upper West regions. Results The analysis revealed four main themes: national burden of disease and antibiotic resistance, policy development, implementation barriers, and strategies. Ghana’s national antimicrobial policy and action plans to enhance public education and awareness align with the objectives of the Global Action Plan on Antimicrobial Resistance. All respondents expressed concern about the increasing proliferation of antibiotic-resistant bacteria, which they attribute in part to the inappropriate use of antibiotics in local communities. Although Ghana has laws to regulate the sale of antibiotics, enforcement has been a major challenge. Inadequate funding for monitoring compliance comprises the greatest challenge. Stakeholders also acknowledged the importance of strengthening cross-sectoral collaboration, and the need to leverage resources from the animal and environmental sectors through a One Health approach to ensure successful implementation of the national action plan. Conclusions This study identified several opportunities for effective implementation of the Ghana’s National Action Plan on Antimicrobial Resistance. Stakeholders were enthusiastic about the effectiveness of the One Health approach, and there is strong political will to promote multisectoral partnership to advance implementation efforts.