Appropriate Use Of Antimicrobials Research Articles

Applications of machine learning on electronic health record data to combat antibiotic resistance.

There is growing excitement about the clinical use of artificial intelligence and machine learning technologies. Advancements in computing and the accessibility of machine learning frameworks enable researchers to easily train predictive models using electronic health record data. However, there are several practical factors that must be considered when employing machine learning on electronic health record data. We provide a primer on machine learning and approaches commonly taken to address these challenges. To illustrate how these approaches have been applied to address antimicrobial resistance, we review the use of electronic health record data to construct machine learning models for predicting pathogen carriage or infection, optimizing empiric therapy, and aiding antimicrobial stewardship tasks. Machine learning shows promise in promoting the appropriate use of antimicrobials, although clinical deployment is limited. We conclude by describing potential dangers of, and barriers to, implementation of machine learning models in the clinic.

The impact of meropenem shortage and post-prescription review and feedback on broad-spectrum antimicrobial use: An interrupted time-series analysis

Meropenem (MEPM) holds significance in treating severe infections and drug-resistant bacteria. There are concerns that antimicrobial shortages may lead to the use of alternative antimicrobials that are less effective and safer. We have responded to the MEPM shortage with post-prescription monitoring and feedback (PPRF) with no restrictions on MEPM initiation. We aimed to assess the impact of the MEPM shortage and the PPRF on broad-spectrum antimicrobial use and mortality. This retrospective study was conducted in a single hospital in Japan. The period from October 2021 to August 2022 was defined as the period before the MEPM shortage, and the period from September 2022 to March 2023 was defined as the period during the MEPM shortage. To support the appropriate use of antimicrobials during MEPM shortages, the antimicrobial stewardship team (AST) developed a list of alternatives to MEPM. An interrupted time series analysis was used to assess changes in use and mortality among patients receiving broad-spectrum antimicrobials over the study period. The shortage of MEPM and PPRF temporarily increased the use of alternative cefepime; however, the subsequent change in days of therapy and days of coverage of broad-spectrum antimicrobials suggests a decrease in the use of these antimicrobials. Despite these shifts, the mortality rates remained stable, suggesting that the response to the shortage did not adversely affect treatment outcomes. In the context of antimicrobial shortages, AST support plays an important role in enabling physicians to make optimal use of antimicrobials.

Explainable and Interpretable Machine Learning for Antimicrobial Stewardship: Opportunities and Challenges

There is growing interest in exploiting the advances in artificial intelligence (AI) and machine learning (ML) for improving and \\monitoring antimicrobial prescriptions in line with antimicrobial stewardship principles. Against this background, the concepts of interpretability and explainability are becoming increasingly essential to understand how ML algorithms could predict antimicrobial resistance or recommend specific therapeutic agents, in order to avoid unintended biases related to the “black box” nature of complex models. In this commentary, we review and discuss some hot topics on the use of ML algorithms for antimicrobial stewardship interventions, highlighting opportunities and challenges with peculiar attention to interpretability and explainability of employed models. As in other fields of medicine, the exponential growth of AI/ML shows the potential for improving the efficacy of antimicrobial stewardship interventions, at least in part by reducing time-consuming tasks for overwhelmed healthcare personnel. Improving our knowledge about how complex ML models work could further help to achieve crucial advances in promoting the appropriate use of antimicrobials, as well as in preventing antimicrobial resistance selection and dissemination.

Documenting the indication for antimicrobial prescribing: A retrospective observational study of long-term care homes.

Overuse of antimicrobials in residents of long-term care homes is common and can result in harm. Antimicrobial stewardship interventions are needed in the long-term care (LTC) homes setting to improve the appropriate use of antimicrobials. Previous literature has highlighted the importance of documenting antimicrobial indication as a strategy that contributes to improve antimicrobial use; however, there is a lack of evidence in LTC homes. This study examines the prevalence, clarity, and facility-level variability of antibiotic indication documentation in this setting. This is an observational retrospective study of oral antibiotic prescriptions dispensed to 218 homes between January 1, 2021 and December 31, 2022 in Ontario, Canada. Indication was obtained from reviewing antibiotic prescription data. Clarity was determined by comparing documented indication to the National Antimicrobial Prescribing Survey (NAPS). Descriptive analysis was performed to examine the prevalence and clarity of indication documentation. Funnel plots were generated to examine variability in prevalence of indication documentation and clarity at the home level. Overall, 22.9% (7998/34,867) of prescriptions had an indication documented. The proportion of indications that were clear was 37% (2984/7998). The most common indications were for urinary (45%), skin and soft tissue (19.9%) and respiratory infections (15.0%). At the home level, the median prevalence of indication was 19.6% (interquartile range [IQR]: 10.8%-31.4%) and median prevalence of clear indications was 35.1% (IQR: 23.8%-42.9%). Funnel plots revealed substantial variability in indication prevalence with 46.3% of homes falling outside of 99% limits but minimal variability in indication clarity between homes with only 8.7% of homes outside of 99% control limits. There is an opportunity to increase both the prevalence and clarity of antibiotic prescriptions in LTC homes. Future work should focus on determining how best to support prescription indication documentation in this setting with consideration being given to prescription workflow and most common antibiotic prescription indications.

Exploring knowledge, perceptions, and practices of antimicrobials, and their resistance among medicine dispensers and community members in Kavrepalanchok District of Nepal.

Inappropriate use of antimicrobials is a global public health issue, particularly in developing countries, including Nepal, where over-the-counter sales and self-medication of antimicrobials are common. To explore knowledge, perceptions, and practices of antimicrobials and their resistance among medicine dispensers and community members in Nepal. The study was conducted in three rural and five urban municipalities of the Kavrepalanchok district from May 2021 to August 2021. Data were collected using two qualitative approaches: In-Depth Interviews (IDIs) and Focus Group Discussions (FGDs). Data were analyzed using thematic analysis that combined deductive and inductive approaches to identify codes under pre-specified themes. A total of 16 In-depth interviews with medicine dispensers and 3 focus group discussions with community members were conducted. Knowledge regarding antimicrobial resistance varied among dispensers. Those with a prior educational background in pharmacy often had good knowledge about the causes and consequences of antimicrobial resistance. Meanwhile, consumers were less aware of antimicrobial resistance. Community members perceived antimicrobials as effective medicines but not long-term solution for treating diseases. They reported that dispensing without a prescription was common and that both consumers and dispensers were responsible for the inappropriate use of antimicrobials. On the contrary, several dispensers said that self-medication was common among the consumers, especially among more educated groups. The medicine dispensers and consumers expressed concerns about the weak enforcement of policies regarding pharmacy drug use and dispensing practices. Promoting and strengthening the appropriate use of antimicrobials among medicine dispensers and community members is crucial. Bold policies and collective implementation of regulations could help combat antimicrobial resistance.

ANTIMICROBIAL STEWARDSHIP: SMART APPROACH TO COMBAT ANTIBIOTIC RESISTANCE

Abstract: Antimicrobial resistance (AMR) is a major public health concern worldwide. It raises morbidity and mortality and is connected with substantial/significant economic costs. Effective prevention and treatment of an increasing number of diseases caused by pathogens that can no longer be treated with conventional drugs are threatened by antimicrobial re-sistance. AMS programme helps to encourage the appropriate use of antimicrobials. The rise and spread of antibiotic resistance and strategies to combat it are the main topics of this review. Antimicrobial stewardship programme is a healthcare strategy that optimizes the use of anti-biotics and promotes the appropriate use of antimicrobials through the adoption of evidence-based interventions. AMS programme helps to encourage the right use of antimicrobials. This coordinated approach enhances patient outcomes, reduces microbial resistance, and slows the spread of diseases brought on by multidrug-resistant organisms. The growth of antibiotic re-sistance and the strategies for battling it have been the main topics of this review.

Antimicrobial stewardship in low- and middle-income countries: Developing a broader perspective through an ethical analysis.

The increase in the number of cases of antimicrobial resistance has gained attention worldwide. The main drivers of this situation are the misuse and overuse of antimicrobials for human and animal health. The imbalance between ensuring appropriate use of antimicrobials and providing equal access in the community makes this an ethical issue. The antimicrobial stewardship programme was initiated in response to this global crisis. Its framework includes interventions targeting the optimisation of antimicrobials in hospitals. Various countries have adopted stewardship interventions, and many success stories have been published. However, the steering of this programme faces hurdles due to the complexity that surrounds decision making in antimicrobial prescription, and the challenges of health systems in lower and middle income countries like India. Addressing these issues will extend the reach of these programmes, increase their sustainability and promote health-related justice to the community.

Assessment of knowledge attitude and perception about antimicrobial stewardship program among medical students

Background: An antimicrobial stewardship program (AMSP) is defined as a coordinated intervention designed to improve and measure the appropriate use of antimicrobial agents, by promoting the selection of optimal antimicrobial drug regimen including dosing, duration of therapy, and route of administration. Understanding the knowledge, attitude, and perception (KAP) of medical students and early training about antimicrobial use and resistance will help reduce the burden of antimicrobial resistance (AMR) and further enforce the implementation of AMSP. Aims and Objectives: This study aims to assess the KAP on AMSP among medical students. Materials and Methods: A cross-sectional questionnaire-based study was carried out among the 2nd-year medical students. The data were collected using an online (Google Form) platform. The questionnaire was divided into five sections – demographic details, KAP, and miscellaneous questions. Results: A total of 139 students participated in the present study. In the knowledge section, 80% of participants responded correctly regarding the most important reason for AMR and 85% of them could answer about the goals of the antimicrobial stewardship program. Overall 113 (81%) students showed a positive attitude toward AMSP. Regarding the perception of the students about AMSP, 91% of students are aware of the fact that inappropriate use of antimicrobials is the major cause of AMR and strong knowledge about antimicrobials is necessary in a medical career. Conclusion: The majority of the students revealed a positive attitude toward learning more about the appropriate use of antimicrobials. Efforts should be made to strengthen their knowledge and awareness further about AMSP.

Drivers of antimicrobial resistance within the communities of Nepal from One Health perspective: a scoping review.

A major driver of antimicrobial resistance (AMR) is the inappropriate use of antimicrobials. At the community level, people are often engaged in behaviors that drive AMR within human, animal, and environmental (One Health) impacts. This scoping review consolidates research to determine (a) the community's knowledge, attitudes, and practices around AMR; (b) existing community-based interventions; and (c) barriers and enablers to addressing AMR in Nepal. This scoping review follows the Joanna Briggs Institute scoping review methodology. Literature indexed in PubMed, Scopus, CINAHL, Global Index Medicus, HINARI-SUMMON, Embase (Ovid), Global Health (Ovid), CAB Abstracts (Ovid), Web of Science, and Google Scholar between January 2000 and January 2023 were reviewed for inclusion. Articles were included in the review if they considered the issues of AMR at the community level in Nepal; this excluded clinical and laboratory-based studies. A total of 47 studies met these criteria, were extracted, and analyzed to consolidate the key themes. A total of 31 (66%) articles exclusively included human health; five (11%) concentrated only on animal health; no studies solely focused on environmental aspects of AMR; and the remaining studies jointly presented human, animal, and environmental aspects. Findings revealed inadequate knowledge accompanied by inappropriate practice in both the human and animal health sectors. Four community interventions improved knowledge and practices on the appropriate use of antimicrobials among community people. However, various social and economic factors were found as barriers to the appropriate use of antimicrobials in the community. Community engagement and One Health approaches could be key tools to improve awareness of AMR and promote behavioral change related to AM use in communities, as current studies have revealed inadequate knowledge alongside inappropriate practices shared in both human and animal health sectors. DOI: 10.17605/OSF.IO/FV326.

Rationally designed protein A surface molecularly imprinted magnetic nanoparticles for the capture and detection of Staphylococcus aureus.

Staphylococcus aureus (S. aureus), a commensal organism found on the human skin, is commonly associated with nosocomial infections and exhibits virulence mediated by toxins and resistance to antibiotics. The global threat of antibiotic resistance has necessitated antimicrobial stewardship to improve the safe and appropriate use of antimicrobials; hence, there is an urgent demand for the advanced, cost-effective, and rapid detection of specific bacteria. In this regard, we aimed to selectively detect S. aureus using surface molecularly imprinted magnetic nanoparticles templated with a well-known biomarker protein A, specific to S. aureus. Herein, a highly selective surface molecularly imprinted polymeric thin layer was created on ∼250 nm magnetic nanoparticles (MNPs) through the immobilization of protein A to aldehyde functionalized MNPs, followed by monomer polymerization and template washing. This study employs the rational selection of monomers based on their computationally predicted binding affinity to protein A at multiple surface residues. The resulting MIPs from rationally selected monomer combinations demonstrated an imprinting factor as high as ∼5. Selectivity studies revealed MIPs with four-fold higher binding capacity (BC) to protein A than other non-target proteins, such as lysozyme and serum albumin. In addition, it showed significant binding to S. aureus, whereas negligible binding to other non-specific Gram-negative, i.e. Escherichia coli (E. coli), Pseudomonas aeruginosa (P. aeruginosa), and Gram-positive, i.e. Bacillus subtilis (B. subtilis), bacteria. This MIP was employed for the capture and specific detection of fluorescently labeled S. aureus. Quantitative detection was performed using a conventional plate counting technique in a linear detection range of 101-107 bacterial cells. Remarkably, the MIPs also exhibited approximately 100% cell recovery from milk samples spiked with S. aureus (106 CFU mL-1), underscoring its potential as a robust tool for sensitive and accurate bacterial detection in dairy products. The developed MIP exhibiting high affinity and selective binding to protein A finds its potential applications in the magnetic capture and selective detection of protein A as well as S. aureus infections and contaminations.

A multinational survey of companion animal veterinary clinicians: How can antimicrobial stewardship guidelines be optimised for the target stakeholder?

Antimicrobial stewardship initiatives are widely regarded as a cornerstone for ameliorating the global health impact of antimicrobial resistance. Within companion animal health, such efforts have largely focused on development and dissemination of antimicrobial stewardship guidelines (ASGs). However, there have been few attempts to understand veterinarian attitudes towards and knowledge of ASGs or to determine how awareness regarding ASGs might best be increased. An online survey regarding ASGs was formulated for veterinarians who treat companion animals. The survey was distributed across 46 European and associated countries between 12 January and 30 June, 2022. In total, 2271 surveys were completed, with 64.9% of respondents (n = 1474) reporting awareness and usage of at least one ASG. Respondents from countries with greater awareness of ASGs tended to report more appropriate use of antimicrobials (Spearman's rank coefficient = 0.6084, P ≤ 0.001), with respondents from countries with country-specific ASGs tending to score highest across both awareness and appropriate use domains. Respondents prioritised guidance around antimicrobial choice (82.0%, n = 1863), duration of treatment (66.0%, n = 1499), and dosage (51.9%, n = 1179) for inclusion in future ASGs, with 78.0% (n = 1776) of respondents preferring ASGs to be integrated into their patient management system. Awareness of ASGs and their use in companion animal veterinary practice appears to be greater than previously reported, with respondents tending to report antimicrobial prescription decision making broadly in line with current clinical recommendations. However, further initiatives aimed at maximising accessibility to ASGs both within countries and individual veterinary practices are recommended.

Tackling antimicrobial resistance in primary care facilities across Pakistan: Current challenges and implications for the future

Antibiotics are gradually becoming less effective against bacteria worldwide, and this issue is of particular concern in economically-developing nations like Pakistan. We undertook a scoping review in order to review the literature on antimicrobial use, prescribing, dispensing and the challenges associated with antimicrobial resistance in primary care (PC) settings in Pakistan. Furthermore, this review aims to identify potential solutions to promote appropriate use of antimicrobials in Pakistan. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) checklist, a comprehensive scoping review was conducted to review the literature of antimicrobials used, prescribed and dispensed in PC settings in Pakistan. Google Scholar and Pub-Med were searched for the period 2000–2023. Papers were analyzed on the basis of eligibility i.e., included antimicrobial use, prescribing and dispensing practices by general population at homes, by prescribers in outpatient departments of hospitals and by pharmacists/dispensers in community pharmacies, respectively. Two researchers analyzed the articles thoroughly and disagreements were resolved through discussion with a third reviewer. Both quantitative and qualitative research studies were eligible for inclusion. Additionally, the selected papers were grouped into different themes. We identified 4070 papers out of which 46 studies satisfied our eligibility criteria. The findings revealed limited understanding of antimicrobial resistance (AMR) by physicians and community pharmacists along with inappropriate practices in prescribing and dispensing antibiotics. Moreover, a notable prevalence of self-medication with antibiotics was observed among the general population, underscoring a lack of awareness and knowledge concerning proper antibiotic usage. Given the clinical and public health implications of AMR, Pakistan must prioritize its policies in PC settings. Healthcare professionals (HCPs) need to reduce inappropriate antibiotic prescribing and dispensing, improve their understanding of the AWaRe (access, watch and reserve antibiotics) classification and guidance, monitor current usage and resistance trends, as well as implement antimicrobial stewardship (ASP) activities starting in targeted locations.

The Essential Role of Senior Care Pharmacists in Antimicrobial Stewardship: An Updated Position Statement on Behalf of the American Society of Consultant Pharmacists and the Society of Infectious Diseases Pharmacists.

Senior care pharmacists are well-positioned to lead and drive antimicrobial stewardship (AMS) initiatives, not only through audit and data collection, but also through communication, collaboration, and cooperation with prescribers and nurses to influence prescribing behaviors. Senior care pharmacists are in a unique position to take a leadership role within the interprofessional team to achieve AMS goals. They should engage with the interprofessional team to promote the judicious and appropriate use of antimicrobials at their practice sites. This position statement is an update of the 2017 version by the American Society of Consultant Pharmacists (ASCP) Antimicrobial Stewardship and Infection and Prevention Control Committee and the Society of Infectious Diseases Pharmacists (SIDP).

Hospital Pharmacy in the multidisciplinary team of COVID inpatient units

Since the implementation of the Antimicrobial Stewardship Programs, hospital pharmacy specialists have collaborated with infectious disease specialists on a regular basis in most hospitals in Spain. Cooperation between these professionals ensures the integrated management of patients with infectious diseases and the appropriate use of antimicrobials in hospitals.The COVID-19 pandemic forced hospital pharmacists to abruptly suspend all their structured activities and concentrate on the health crisis. Real-time information sharing between different medicine specialties is an effective strategy to generate and maintain treatment protocols adapted to each center, with continuous evidence-based modifications as new publications appear.Hospital pharmacies had to reorganize their activities to respond to the pandemic. On the one side were patients with COVID-19, and on the other were routine hospital pharmacy tasks, with the added difficulty of adapting to individual protection measures. New communication and collaboration strategies were adopted. Protocols were established for the management of COVID-19 patients, with continuous changes; special medications had to be prepared and distributed; circuits were designed for the home- or institution-based care of patients; internal circuits were created to minimize the movements of hospital staff and professionals caring for COVID-19 patients.The most effective antiviral drug and anti inflammatory therapy remains elusive. In this scenario, hospital pharmacists emerge as a key player, as they have a deep understanding of the mechanisms of action of drugs and potential interactions. In a setting where experimental drugs preferably tested in clinical trials are being used, the role of hospital pharmacists in interdisciplinary teams has become essential for the optimization of clinical outcomes.

Antimicrobial Resistance in Bacteria from Meat and Meat Products: A One Health Perspective.

According to the 2030 Agenda of the United Nations, one of the sustainable development goals is to ensure sustainable consumption and production patterns. The need to ensure food safety includes, other than microbiological hazards, concerns with antimicrobial-resistant (AMR) bacteria. The emergence of resistant bacteria in the food industry is essentially due to the abusive, and sometimes incorrect, administration of antimicrobials. Although not allowed in Europe, antimicrobials are often administered to promote animal growth. Each time antimicrobials are used, a selective pressure is applied to AMR bacteria. Moreover, AMR genes can be transmitted to humans through the consumption of meat-harbouring-resistant bacteria, which highlights the One Health dimension of antimicrobial resistance. Furthermore, the appropriate use of antimicrobials to ensure efficacy and the best possible outcome for the treatment of infections is regulated through the recommendations of antimicrobial stewardship. The present manuscript aims to give the current state of the art about the transmission of AMR bacteria, particularly methicillin-resistant S. aureus, ESBL-producing Enterobacteriaceae, and vancomycin-resistant Enterococcus spp., along with other ESKAPE bacteria, from animals to humans through the consumption of meat and meat products, with emphasis on pork meat and pork meat products, which are considered the most consumed worldwide.

Empiric antimicrobial therapy in the intensive care unit based on the risk of multidrug-resistant bacterial infection: a single-centre case‒control study of blood culture results in Japan

BackgroundInfections and sepsis are the leading causes of death in intensive care units (ICUs). Antimicrobial agent selection is challenging because the intervention is directly related to the outcome, and the problem of antimicrobial resistance (AMR) must be considered. Therefore, in this study, we aimed to clarify the epidemiological data and examine whether the detection rate of multidrug-resistant (MDR) bacteria differed depending on the presence or absence of the risk of MDR bacterial infections to establish guidance regarding the choice of antimicrobial therapy for ICU patients.MethodsThis retrospective case‒control study was performed in a single ICU in Japan. Patients admitted to the ICU who underwent blood culture (BC) analysis were considered for inclusion in this study; patients were at risk of MDR bacterial infections, and controls were not. The primary outcome measure was the detection rate of MDR bacteria in BCs collected from patients and controls. The secondary outcome measure was the selection rate of anti-Pseudomonas and anti-methicillin-resistant Staphylococcus aureus (MRSA) drugs for patients and controls.ResultsAmong the 1,730 patients admitted to the ICU during the study period, BCs were obtained from 186 patients, and 173 samples were finally included in the analysis (n = 129 cases; n = 44 controls). No MDR bacteria or Pseudomonas aeruginosa were detected in the controls (14 (11%) vs. 0 (0%)) (P = 0.014) However, there was no difference in empiric antimicrobials, including anti-MRSA (30 (23%) vs. 12 (27%)) (P = 0.592) and anti-Pseudomonas aeruginosa (61 (47%) vs. 16 (36%)) (P = 0.208) drugs, that were administered to the two groups.ConclusionsEven in critically ill patients in the ICU, MDR bacteria are unlikely to be detected in patients without the risk of MDR bacterial infections. Therefore, for such patients, a strategy of starting empiric narrow-spectrum antimicrobial therapy rather than empiric broad-spectrum therapy should be considered. This strategy, in conjunction with daily updates of clinical and epidemiological data at each facility, will promote the appropriate use of antimicrobials and reduce the emergence of MDR bacteria in the ICU.Trial registration: None.

ANALYSIS OF HOSPITAL ANTIBIOTIC PRESCRIPTIONS AFTER THE IMPLEMENTATION OF STEWARDSHIP: A RETROSPECTIVE OBSERVATIONAL STUDY IN TWO HOSPITALS IN NORTH-EASTERN SICILY

Introduction: Antimicrobial resistance is a global problem caused by the inappropriate use of antibiotics. To combat this phenomenon, multidisciplinary antimicrobial stewardship programmes have been initiated, the primary objectives of which include improving both the level of appropriateness of prescription and clinicians’ awareness of the correct use of antibiotics. Objective/Purpose: The objective of the work was to conduct an analysis of antibiotic consumption at hospital level to assess the appropriateness of antibiotic prescription in a number of Operational Units. Method: From 01/01/2021 to 31/12/2022, data were extracted from the Pharmacy Operational Unit’s management software on the dispensing of antibiotics (injectable and oral use), the Defined Daily Doses, and the number of dosage units dispensed to the General Medicine, Intensive Care, General Surgery and Neurorehabilitation Operational Units of two hospitals. Results: Total antibiotic consumption was 7,845 dosage units in 2021 and 10,182 in 2022. The comparison of the defined daily dose values (4,565,485 in 2021 and 5,079,671 in 2022) is indicative of the use of antibiotics with different dosages, with a percentage increase of 11.3%. A comparison was also made between the Defined Daily Doses/100 bed-days delivered in 2021 and the regional and national figures, yielding a significantly lower figure than these latter figures. Conclusions: The loss of antibiotic efficacy threatens to throw healthcare systems into crisis, leading to in an increase in morbidity and mortality from infections. The implementation of antimicrobial stewardship programmes remains, at present, the best tool to harness in order to curb the phenomenon of antimicrobial resistance. There is therefore a need for increasingly specialised professionals in the field of infectious diseases. Nurses and pharmacists play a crucial role in antimicrobial stewardship programmes, as they collaborate not only in the implementation of antimicrobial guidelines, but also in the review of individual patient regimens in order to optimise treatment and in the training of healthcare personnel on the appropriate use of antimicrobials.

Point-of-care testing in private pharmacy and drug retail settings: a narrative review

BackgroundPoint-of-care testing (POCT) using rapid diagnostic tests for infectious disease can potentially guide appropriate use of antimicrobials, reduce antimicrobial resistance, and economise use of healthcare resources. POCT implementation in private retail settings such as pharmacies and drug shops could lessen the burden on public healthcare. We performed a narrative review on studies of POCTs in low- and middle-income countries (LMICs), and explored uptake, impact on treatment, and feasibility of implementation.MethodsWe searched MEDLINE/PubMed for interventional studies on the implementation of POCT for infectious diseases performed by personnel in private retail settings. Data were extracted and analysed by two independent reviewers.ResultsOf the 848 studies retrieved, 23 were included in the review. Studies were on malaria (19/23), malaria and pneumonia (3/23) or respiratory tract infection (1/23). Nine randomised controlled studies, four controlled, non-randomised studies, five uncontrolled interventions, one interventional pre-post study, one cross-over interventional study and three retrospective analyses of RCTs were included. Study quality was poor. Overall, studies showed that POCT can be implemented successfully, leading to improvements in appropriate treatment as measured by outcomes like adherence to treatment guidelines. Despite some concerns by health workers, customers and shop providers were welcoming of POCT implementation in private retail settings. Main themes that arose from the review included the need for well-structured training with post-training certification covering guidelines for test-negative patients, integrated waste management, community sensitization and demand generation activities, financial remuneration and pricing schemes for providers, and formal linkage to healthcare and support.ConclusionOur review found evidence that POCT can be implemented successfully in private retail settings in LMICs, but comprehensive protocols are needed. High-quality randomised studies are needed to understand POCTs for infectious diseases other than malaria.

Antimicrobials in patients with hematologic malignancies and recipients of hematopoietic cell transplantation and other cellular therapies.

Appropriate use of antimicrobials for hematologic malignancy, hematopoietic stem cell transplant recipients, and other cellular therapies is vital, with infection causing significant morbidity and mortality in this unique population of immunocompromised hosts. However, often in this population the choice and management of antimicrobial therapy is complex. When selecting an antimicrobial agent, key considerations include the need for dose adjustments due to renal or hepatic impairment, managing drug interactions, the potential for additive drug toxicity among those receiving polypharmacy and therapeutic drug monitoring. Other factors include leveraging pharmacodynamic principles to enable optimization of directed therapy against challenging pathogens, as well as judicious use of antimicrobials to limit drug resistance and adverse drug reactions. This review summarizes the clinical considerations for commonly used antimicrobials in this setting, including antibacterial, antiviral, and antifungal agents.

Gut microbiology of UK care home residents: a cross-sectional analysis from a randomised controlled trial

ObjectiveTo describe the prevalence of potentially clinically relevant gut pathogens and associations with the carriage of resistant organisms in UK care home residents. MethodsStool samples were collected pre-randomisation from care home residents participating in a randomised placebo-controlled trial. Cultivable clinically relevant bacteria were analysed. Antimicrobial susceptibility testing was performed by agar dilution (amoxicillin, co-amoxiclav, gentamicin, trimethoprim, nitrofurantoin, and ciprofloxacin). We also aimed to detect resistance to third-generation cephalosporins, carbapenems, and vancomycin. ResultsStool samples were available for 159/310 residents participating in the trial (51%) from 23 care homes between 2016 and 2018. In total, 402 bacterial isolates were cultured from 158 stool samples and 29 different species were cultured. The five most common species were Escherichia coli (155/158, 98%), Pseudomonas aeruginosa (40/158, 25%), Enterococcus faecalis (35/158, 22%), Enterococcus faecium (30/158, 19%), and Proteus mirabilis (25/158, 16%). Enterobacterales isolates were cultured from 157 samples (99%), and resistance to at least one of the tested antimicrobials was found in 119 of these (76%). There were high levels of variation in outcomes by care home. DiscussionWe demonstrated that care home residents harbour significant levels of antimicrobial-resistant organisms in their stool. This work emphasises the importance of both enhanced infection control practices and antimicrobial stewardship programmes to support the appropriate use of antimicrobials in this setting.