Appropriate Use Of Antibiotics Research Articles

Caretaker knowledge, attitudes, and practices (KAP) and carriage of extended-spectrum beta-lactamase-producing E. coli (ESBL-EC) in children in Quito, Ecuador

BackgroundThe rapid spread of extended-spectrum beta-lactamase-producing E. coli (ESBL-EC) is an urgent global health threat. We examined child caretaker knowledge, attitudes, and practices (KAP) towards proper antimicrobial agent use and whether certain KAP were associated with ESBL-EC colonization of their children.MethodsChild caretakers living in semi-rural neighborhoods in peri-urban Quito, Ecuador were visited and surveyed about their KAP towards antibiotics. Fecal samples from one child (less than 5 years of age) per household were collected at two time points between July 2018 and May 2019 and screened for ESBL-EC. A repeated measures analysis with logistic regression was used to assess the relationship between KAP levels and child colonization with ESBL-EC.ResultsWe analyzed 740 stool samples from 444 children living in households representing a range of environmental conditions. Of 374 children who provided fecal samples at the first household visit, 44 children were colonized with ESBL-EC (11.8%) and 161 were colonized with multidrug-resistant E. coli (43%). The prevalences of ESBL-EC and multidrug-resistant E. coli were similar at the second visit (11.2% and 41.3%, respectively; N = 366). Only 8% of caretakers knew that antibiotics killed bacteria but not viruses, and over a third reported that they “always” give their children antibiotics when the child’s throat hurts (35%). Few associations were observed between KAP variables and ESBL-EC carriage among children. The odds of ESBL-EC carriage were 2.17 times greater (95% CI: 1.18–3.99) among children whose caregivers incorrectly stated that antibiotics do not kill bacteria compared to children whose caregivers correctly stated that antibiotics kill bacteria. Children from households where the caretaker answered the question “When your child’s throat hurts, do you give them antibiotics?” with “sometimes” had lower odds of ESBL-EC carriage than those with a caretaker response of “never” (OR 0.48, 95% CI 0.27–0.87).ConclusionCaregivers in our study population generally demonstrated low knowledge regarding appropriate use of antibiotics. Our findings suggest that misinformation about the types of infections (i.e. bacterial or viral) antibiotics should be used for may be associated with elevated odds of carriage of ESBL-EC. Understanding that using antibiotics is appropriate to treat infections some of the time may reduce the odds of ESBL-EC carriage. Overall, however, KAP measures of appropriate use of antibiotics were not strongly associated with ESBL-EC carriage. Other individual- and community-level environmental factors may overshadow the effect of KAP on ESBL-EC colonization. Intervention studies are needed to assess the true effect of improving KAP on laboratory-confirmed carriage of antimicrobial resistant bacteria, and should consider community-level studies for more effective management.

Challenges in Treatment Strategies for Management of Neonatal Sepsis

Background: Neonatal sepsis is an important cause of morbidity and mortality in newborns. The symptoms and signs of neonatal sepsis are often non-specific and similar to other common neonatal diseases, investigation results are also non-specific and low sensitivity of blood culture also causes diagnostic dilemma and often empirical antibiotic treatment is given. This is why, there is challenges in making the diagnosis and treating neonatal sepsis.
 Objectives: To find the etiology, sensitivity and specificity of clinical features and investigations and optimal and effective treatment for neonatal sepsis.
 Materials and methods: The study was a prospective study done in the neonatal ward of a tertiary hospital in Bangladesh; total 100 neonates diagnosed as neonatal sepsis, were enrolled in this study. All study subjects were fully evaluated clinically, thoroughly investigated and properly treated as per protocol.
 Results: The sensitivity and specificity of clinical features and investigations were statistically significant (i.e. p <0.05) and etiologic agents were isolated by urine culture and sensitivity to antibiotics were shown and outcome measure e.g. mortality was 22% (OR 3.54; 95% CI 2.04- 6.13; P <0.05).
 Conclusion: There are challenges in making diagnosis and treating neonatal sepsis, yet sincere approach to diagnosis and rational and appropriate use of antibiotics along with necessary adjuvant therapy can mitigate the challenges.
 J Dhaka Medical College, Vol. 29, No.1, April, 2020, Page 23-28

Management of Open Calcaneal Fractures with Medial Wounds by One-Stage Sequential Reduction and Frame Structure Fixation Using Percutaneous Kirschner Wires.

ObjectiveTo assess the clinical outcomes of open calcaneal fractures with medial wounds treated with one‐stage management, including early modern wound care, sequential reduction, and frame structure fixation using percutaneous Kirschner wires.MethodsA total of 19 patients with open calcaneal fractures admitted to our hospital from May 2016 to March 2019 were selected in this study. Twelve type‐II and seven type‐IIIA medial open injuries were identified according to the classification of Gustilo and Anderson. Fractures were stratified by Sanders classification, including nine type‐II fractures, seven type‐III fractures, and three type‐IV fractures. All patients accepted one‐stage irrigation and debridement, sequential reduction of calcaneal fractures through the open medial wound, percutaneous Kirschner wire fixation, and primary closure of wounds covered with vacuum‐assisted closure (VAC) device. The Bohler angle, the Gissane angle, and the width of the calcaneus were compared before and after surgery. The functional results were evaluated according to the Paley and Hall score system, visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot score, Maryland Foot Score, and related complications.ResultsThe follow‐up duration for all patients ranged from 14 to 28 months (mean, 22.7 months). The angle of Bohler and Giasane was increased from (−7.6° ± 15.0°) and (96.6° ± 7.6°) before surgery to (23.7° ± 6.1°) and (124.1° ± 7.1°) postoperatively (P < 0.05), respectively. Three cases of superficial infection and two cases of wound dehiscence were observed in our study, which were then successfully treated with wound debridement, VAC replacement, appropriate use of antibiotics, and delayed closure. The last follow‐up revealed three cases of lateral wall expansion and six cases of mild‐to‐moderate subtalar arthritis based on the Paley and Hall scoring system. According to the AOFAS ankle and hindfoot score, one case showed excellent results, 14 cases exhibited good results, and four cases displayed fair results, with the mean of 80.7 ± 6.7 points (range, 70–90). The Maryland Foot Score revealed one case of excellent outcomes, nine cases of good outcomes, and nine cases of fair outcomes with an average of 76.8 ± 8.6 points (range, 62–90). The mean VAS for pain was 1.8 ± 1.5 (range, 0–5), and a total of 14 patients complained of mild‐to‐moderate pain when walking for a more extended period. Severe complications, such as deep infection, osteomyelitis, and soft tissue necrosis, were not observed during follow‐up.ConclusionsCollectively, one‐stage management allowed the direct restoration of calcaneal morphology with a minimal invasion of soft tissues in most open calcaneal fractures with medial wounds, and the functional outcomes were comparable to previous data.

Native and foreign healthcare workers' knowledge of appropriate use of antibiotics: a prospective pre-post study in Danish nursing homes.

The aim was to determine the association between healthcare workers' (HCWs) country of birth and their knowledge of appropriate use of antibiotics, and whether the association changed after an educational intervention. Older residents in nursing homes have been recognized to receive excessively antibiotic treatments. HCWs often represent an important link between the older resident and the general practitioner prescribing the antibiotics, thus their knowledge of appropriate use of antibiotics is important. This study was conducted as a prospective pre-post study. Totally, 312 HCWs from 7 nursing homes in Denmark were included. For statistical analyses, χ2 test and a linear mixed regression model were applied. Native HCWs were more likely to have a higher percentage of correct responses to single statements related to knowledge of appropriate use of antibiotics. Native HCWs had a significantly higher knowledge-of-antibiotic score compared to foreign HCWs (-7.53, P < 0.01). This association remained significant after adjusting for relevant covariates (-5.64, P < 0.01). Native HCWs' mean change in knowledge-of-antibiotic score after the intervention did not differ from the foreign HCWs' mean change in knowledge-of-antibiotic score. Our findings indicate that HCWs born outside Denmark reveal a lower knowledge-of-antibiotic score than HCWs born in Denmark despite comparable educational backgrounds. All participants increased their knowledge from baseline to follow-up. Our findings also indicate that an educational seminar cannot equalize the difference in knowledge between native and foreign HCWs. Studies with larger sample size and a more detailed measurement of cultural identity should investigate this association further.

Effect of didactic educational intervention on improving knowledge of antibiotics use and resistance in Yogyakarta Community

Lack of knowledge regarding antibiotics use has been widely identified as a main reason for inappropriate antibiotics use which leads to antibiotic resistance phenomenon. This study aimed to evaluate the effects of pharmacist-initiated educational intervention on promoting appropriate use of antibiotics and reducing self-medication with antibiotics. A pre and post intervention study using two validated self-administered questionnaires was performed in Yogyakarta province. A-two hour session of course and case discussion was delivered as method of intervention. Pharmacy customers attended Gema Cermat program were invited conveniently to complete both of pre- and post-educational questionnaires. Descriptive presentation was conducted to show scores on questions. Knowledge scores were categorized as poor, adequate and high. Of 268 respondents, 34.22% respondents had poor level of knowledge before receiving educational intervention, but this number decreased into 12.21% after post-interventional phase. Another 28.23% respondents had adequate level of knowledge before and then elevated into 38.28% after receiving education about appropriate use of antibiotics. Pre-education, 37.43% participants had a high level of knowledge about antibiotics use and resistance, whereas after education the number became slightly higher (49.25%). A vast majority of respondents (75.24%) became more aware about appropriate antibiotics practice after receiving educational inter- vention. Overall, didactic educational intervention imposed higher knowledge and better practice regarding antibiotics use (p < 0.05). This study showed that using didactical education intervention towards antibiotics use and resistance can be an initial strategy that led to substantial improvement of appropriate antibiotics use. Further systemic interventions to educate people should be performed and evaluated in order to promote the appropriate use of antibiotics.

Antimicrobial Stewardship – Implementation and Improvements in Antibiotic-Prescribing Practices in a Dental School

Background and Aim: Antimicrobial stewardship (AMS) is a coordinated systematic approach aimed at educating prescribers to follow evidence-based prescription practice to reduce misuse of antimicrobials and thus antimicrobial resistance (AMR). We aimed to improve the standards of antimicrobial prescribing in a dental school by implementing AMS. Materials and Methods: A retrospective (first) clinical audit of antibiotic prescriptions (n = 200) over a 6 months' period was analyzed for the following parameters: type of antibiotic, clinical condition, compliance to national guidelines, and errors in prescriptions. In response to the results of this audit, an educational intervention workshop was conducted for clinical faculty. A validated self-administered questionnaire on perception and practice of antimicrobial prescribing was given to participants (n = 31) before and after the workshop and t-test was used to compare the mean scores of responses. Prospective clinical audits were conducted 6 months (second) and 1 year (third) after the workshop assessing the same parameters. A Strengths, Weaknesses, Opportunities, and Threats analysis of the AMS program was also done. Results: The total number of prescriptions issued was 943 in the first audit, which reduced to 552 in the second audit and further to 435 in the third audit. The most commonly prescribed antibiotic was a combination of amoxicillin and metronidazole. The percentage of prescriptions in accordance with national guidelines improved from 19% during the first audit to 54% and 79% in the subsequent audits. The percentage of erroneous prescriptions was 23% in the first audit, which reduced to 12% in the second audit and 9% in the third audit. The pre- and posttest mean values of the questionnaire when compared suggested that there is a need for uniformity in prescribing antimicrobials. Conclusions: Clinical audits with educational workshops on appropriate use of antibiotics have a positive impact on conforming with prescription guidelines. This will encourage the rational prescription of antibiotics based on clinical needs of patients, thus contributing to the fight against AMR.

Identification and Antibiotic Resistance Profile of Uropathogenic Bacteria from Sexually Active Women with Bacterial Vaginosis

Background: Urinary tract infections (UTIs) in women with bacterial vaginosis (BV) continue to pose tremendous health concerns and require appropriate use of antibiotics for effective case management. This study determined the prevalence, etiology and antibiotic resistance profile of uropathogenic bacteria isolated from sexually active women with BV in Lagos Nigeria. Method: A total of 258 sexually active women presenting with gynaecological complaints at the maternal and child unit of twenty Primary Health Care Centres in Lagos Nigeria from May 2017 to March 2018 were consecutively enrolled with consent. Bacterial vaginosis was diagnosed based on Amsel criteria. Midstream urine samples were collected aseptically, analyzed for bacterial pathogens and antibiotic susceptibility using standard microbiological methods. Results: BV was diagnosed in 184 (71.3%) with 69.2% also having UTI. Ninety four (36.4%) had UTI predominantly caused by Gram negative bacteria (96.8%). The organisms isolated were Escherichia coli 79 (84.0%), Klebsiella pneumoniae 5 (5.3%), Pseudomonas aeruginosa 4 (4.3%), Proteus mirabilis 3 (3.2%) and Staphylococcus saprophyticus 3 (3.2%). The pathogens elicited high resistance (66.7% - 100%) to tetracycline, amoxicillin-clavulanic acid, nitrofurantoin and cephalosporins, and moderate resistance (50%) to ofloxacin by P. aeruginosa strains. The isolates were susceptible (100%) to piperacillin-tazobactam and meropenem. Multi-drug resistance (MDR) was observed among 97.8% of the bacteria isolated. Conclusion: Findings from this study indicate high occurrence of UTI caused by MDR pathogens among sexually active women with BV with emerging evidence of poor clinical utility of nitrofurantoin and other commonly used first-line antibiotics against UTI. Further studies on non-bacterial aetiology of BV, molecular characterization of S. saprophyticus and Gram Negative Bacteria UTI are recommended.

291. Impact of Surveillance and Offered Infectious Diseases Consults for Staphylococcus aureus Bacteremia on Quality of Care Indicators

Background Staphylococcus aureus bacteremia (SAB) remains the leading cause of bloodstream infections and is associated with 20–40% mortality. Past studies demonstrated that Infectious Diseases (ID) consultation is associated with better adherence to quality of care indicators (QCIs), including follow-up blood cultures, echocardiography, early source control, and appropriate choice and duration of antibiotics. A 2014 quality improvement project at Medstar Washington Hospital Center (MWHC) by Narsana et al. showed significantly better adherence to SAB QCIs among patients with ID consults and a non-significant trend towards lower mortality. In 2015, MWHC instituted a policy advocating ID consultation for all SAB patients, and active surveillance was performed by the ID Section to offer prompt consults prospectively. Our study aimed to assess the impact of this policy and the proactively offered ID consults on adherence to SAB QCIs and mortality rates amongst patients with SAB with and without ID consults.MethodsWe retrospectively reviewed 557 patients diagnosed with SAB between July 1st, 2015 - June 30th, 2018. Data included follow-up blood cultures, echocardiography, presence of a focal source of infection, use of appropriate antibiotics, measurement of vancomycin levels, duration of therapy, death during hospitalization, and presence of an ID consultation. Chi-Square and Fisher exact tests, and t-test and Wilcoxon rank sum test were used to analyze categorical and continuous variables, respectively.ResultsA total of 513 patients were included in the analysis, 88% (n=453) of whom had ID consultations. Patients with ID consultations were more likely to have a focal source of infection (84% vs. 50%, p < 0.0001), echocardiography (97% vs. 56%, p < 0.0001), use of a beta-lactam antibiotic for methicillin-susceptible S. aureus (90% vs 65%, p < 0.0001), and a longer duration of therapy (33 vs 9 days, p< 0.0001). Mortality was lower among patients with ID consults (16% vs. 23%, p=0.1495), but the difference was not statistically significant.Table 1 ConclusionOur study demonstrates that ID consultation is associated with better adherence to SAB QCIs, with a trend towards lower mortality. Hospital systems should support mandatory ID consultation for patients with Staphylococcus aureus bacteremia.Disclosures All Authors: No reported disclosures

238. Novel Way to Evaluate Antibiotic Use Appropriateness: Moving Towards the “Never Event” Classification by Electronic Algorithm

BackgroundAntibiotic use is commonly tracked electronically by antimicrobial stewardship programs (ASPs). Traditionally, evaluating the appropriateness of antibiotic use requires time- and labor-intensive manual review of each drug order. A drug-specific “appropriateness” algorithm applied electronically would improve the efficiency of ASPs. We thus created an antibiotic “never event” (NE) algorithm to evaluate vancomycin use, and sought to determine the performance characteristics of the electronic data capture strategy.MethodsAn antibiotic NE algorithm was developed to characterize vancomycin use (Figure) at a large academic institution (1/2016–8/2019). Patients were electronically classified according to the NE algorithm using data abstracted from their electronic health record. Type 1 NEs, defined as continued use of vancomycin after a vancomycin non-susceptible pathogen was identified, were the focus of this analysis. Type 1 NEs identified by automated data capture were reviewed manually for accuracy by either an infectious diseases (ID) physician or an ID pharmacist. The positive predictive value (PPV) of the electronic data capture was determined.Antibiotic Never Event (NE) Algorithm to Characterize Vancomycin Use ResultsA total of 38,774 unique cases of vancomycin use were available for screening. Of these, 0.6% (n=225) had a vancomycin non-susceptible pathogen identified, and 12.4% (28/225) were classified as a Type 1 NE by automated data capture. All 28 cases included vancomycin-resistant Enterococcus spp (VRE). Upon manual review, 11 cases were determined to be true positives resulting in a PPV of 39.3%. Reasons for the 17 false positives are given in Table 1. Asymptomatic bacteriuria (ASB) due to VRE in scenarios where vancomycin was being appropriately used to treat a concomitant vancomycin-susceptible infection was the most common reason for false positivity, accounting for 64.7% of false positive cases. After removing urine culture source (n=15) from the algorithm, PPV improved to 53.8%.ConclusionAn automated vancomycin NE algorithm identified 28 Type 1 NEs with a PPV of 39%. ASB was the most common cause of false positivity and removing urine culture as a source from the algorithm improved PPV. Future directions include evaluating Type 2 NEs (Figure) and prospective, real-time application of the algorithm.DisclosuresMarc H. Scheetz, PharmD, MSc, Merck and Co. (Grant/Research Support)

156. Evaluating Antibiotic Use and Developing a Tool to Optimize Prescribing in a Pediatric HIV Clinic in Eswatini

BackgroundAntibiotic resistance is an emerging global health issue, fueled by inadequate surveillance systems and the absence of antimicrobial stewardship. In resource-limited settings, antimicrobial use is often based on clinical evaluation rather than microbiologic evidence, making treatment guidelines and the education of healthcare providers paramount to ensuring appropriate antimicrobial prescribing. In a human immunodeficiency virus (HIV) clinic for children and their families in Eswatini, we sought to understand the use of antibiotics and identify specific areas for improvement.MethodsWe performed a retrospective patient chart review as part of a quality improvement (QI) initiative to assess antimicrobial use before and after implementation of a standardized antimicrobial guide. For each prescribing period, 100 random patient encounters were selected for review to observe if the indication for antibiotics, duration, and dose were consistent with World Health Organization (WHO) guidelines. Two physicians reviewed each encounter to determine the appropriateness of antibiotic use using a structured abstraction tool, with a third resolving discrepancies. Results were analyzed using a chi-square test of proportions and a structured survey was performed to assess perceptions of the guide.ResultsAfter the implementation of an antimicrobial guide, there was a significant decrease in the proportion of clinic visits with an antibiotic prescribed (p < 0.001). Incorrect indication for antimicrobial use decreased from 20.4% in the initial period, to 10.31% and 10.2% but did not reach significance (p=.0621) in the subsequent periods after implementation. Incorrect dose/duration decreased from 10.47% in the initial period to 7.37% and 3.1% in the subsequent periods, but this was also was not significant (p = 0.139). All prescribers who completed the survey used the antimicrobial guide and felt that it positively impacted their prescribing patterns.ConclusionOur study found that an antibiotic guide reduced and improved the prescription of antimicrobials. Antimicrobial stewardship is a global problem and this data demonstrates that practical solutions can have a lasting impact on antimicrobial prescribing in low resource settings.Disclosures All Authors: No reported disclosures

173. Identification of Inappropriate Antibiotic Orders During a Pharmacy-Supported Antimicrobial Stewardship Program in the Primary Care Setting: A Retrospective Analysis

BackgroundIn Florida, the number of antibiotic prescriptions has increased from 710–779 prescription/1000 population in 2012 to 748–839 prescription/1000 population in 2017. Antimicrobial stewardship in the outpatient setting is a suggested solution to combat antibiotics misuse in ambulatory practices.MethodsThis was a retrospective review of oral antimicrobial orders generated by primary care providers. The research protocol received approval from Memorial Healthcare System’s Institutional Review Board prior to any research related analysis being conducted. Orders from January 1-December 31, 2018 were reviewed for appropriateness by pharmacy based on IDSA guidelines. Appropriateness was assessed based on the need to prescribe the antibiotic for indication, selection, dose and duration of therapy. Descriptive statistics were used to analyze data.ResultsOf 2995 orders, 50.2% were inappropriate. The most common infections associated with inappropriate antibiotic use were upper/lower respiratory tract infections (URTIs (65%) and LRTIs (61%)), oral cavity infections (61%), and skin/soft tissue infections (SSTI (54%)). Inappropriately-prescribed antibiotics were penicillin (62%), cephalosporins (56%), quinolones (50%), macrolides (49%), and sulfamethoxazole/trimethoprim (46%). Penicillin use for URTIs were inappropriate (406 orders) for the following reasons: duration of therapy only 116/137 (85%); dose and duration 36/58 (62%), drug and dose 12/58 (21%) and all three (drug, dose, duration 85/93 (91%)).ConclusionImplementation of a pharmacist-driven antibiotic stewardship program in the primary care setting identified a significant proportion of orders that were inappropriate for type of antibiotic, dose, and duration of therapy in the management of patients with URTIs. These results serve as an avenue to implement the audit feedback process to promote appropriate use of antibiotics. A process improvement plan will include sharing of the findings, educating primary care physicians per IDSA guidelines and continuous review of prescribing trends. A programmatic evaluation will continue on an on-going basis to decrease the number of inappropriately prescribed antibiotics.Disclosures All Authors: No reported disclosures

76. Optimizing Clinical Outcomes in Geriatric Patients through a Multidisciplinary Hospital Antimicrobial Stewardship Program

BackgroundAntimicrobial Stewardship Programs (ASP) aim to ensure the appropriate use of antibiotics. There is limited literature evaluating ASP outcomes in hospitalized geriatric patients who are at higher risk for developing Clostridium difficile infection (CDI) or other adverse outcomes. The primary objective of this study was to determine if ASP efforts in this age group decreases the rate of 30-day hospital readmissions due to reinfection or development of CDI, hospital length of stay (LOS) and mortality.MethodsA retrospective chart review was performed to compare the rates of 30-day hospital readmissions because of reinfection or development of CDI in patients 65 years and older who received ASP interventions between January and June 2017. A control group of patients 65 years and older who received antibiotics between January and June 2015 (pre-ASP) was analyzed for comparison. We also assessed their mortality rate and LOS. Patients were included if they received antibiotics for pneumonia (PNA), urinary tract infection (UTI), acute bacterial skin and skin structure infection (ABSSSI) and complicated intra-abdominal infection (cIAI). The ASP team consisted of an infectious diseases physician and a clinical pharmacist who met daily to review patients on broad spectrum antibiotics. ASP interventions consisted of de-escalation of empiric or definitive therapy, change in duration of therapy or discontinuation of therapy.ResultsOverall, 834 patients (540 control; 294 intervention) were included. The 30-day hospital readmission rate for all infection types decreased during the intervention period (19.6% vs 4.8%, P=0.0001). Both the development of CDI during hospital stay and 30-day readmission due to CDI during the intervention period decreased (2.6% vs 0.34%, P=0.019). There was no statistically significant decrease in 30-day hospital readmissions in the PNA (58.5% vs. 35.7%, P=0.11), UTI (18.9% vs. 35.7%, P=0.15), ABSSSI (12.3% vs. 21.4%, P=0.34) or cIAI (10.4% vs 7.1%, P=0.14) arms. There was no statically significant change in LOS (7.50 days vs 7.26 days, P=0.48) or mortality (9.6% vs 6.5%, P=0.12).ConclusionMultidisciplinary ASP efforts significantly reduced 30-day hospital readmission rates and development of CDI in hospitalized patients 65 years and older.Disclosures All Authors: No reported disclosures

Long-term positive effect of an educational antimicrobial stewardship program implemented in an Internal Medicine Department: a prospective analysis and a point prevalence survey on long-term effect

The study aims to evaluate antimicrobial consumption and appropriateness one year after the implementation of an antimicrobial stewardship (AMS) program in an Internal Medicine Department in Milan. AMS program structured in two phases: “AMS phase”, 5 months AMS-program based on an “audit-and-feedback model”; the “follow-up phase”, 5 months long point prevalence survey conducted one year later. Outcomes of the study: antimicrobial consumption and appropriateness of antimicrobial therapy. Secondary outcomes: in-hospital mortality and length of stay (LOS). During the “AMS phase”, we obtained a mean decrease of −11.4% of total antibiotic consumption as compared to the previous year (67.9 defined daily dose (DDD)/100 bed-days (bd) vs. 79.4 DDD/100bd, p = 0.07). Antibiotic consumption remained stable during “follow-up phase” (66.3 DDD/100bd, p = 0.9). Rate of appropriateness during the project increased from 48% to 85% (p < 0.01). No difference in in-hospital mortality and in LOS were observed. The study documents a positive long-term effect of AMS program on consumption and appropriate use of antibiotics.

Antimicrobial never events: Objective application of a framework to assess vancomycin appropriateness.

To address appropriateness of antibiotic use, we implemented an electronic framework to evaluate antibiotic "never events" (NEs) at 2 medical centers. Patient-level vancomycin administration records were classified as NEs or non-NEs. The objective framework allowed capture of true-positive vancomycin NEs in one-third of patients identified by the electronic strategy.

Availability of point-of-care culture and microscopy in general practice - does it lead to more appropriate use of antibiotics in patients with suspected urinary tract infection?

Background Urinary tract infection (UTI) is a common condition in general practice, and urine culture can help reduce inappropriate antibiotic prescriptions. In case of delay of the result, antibiotic treatment can be guided by one or more point-of-care (POC) tests. In Denmark, POC microscopy and POC urine culture are widely used for this purpose. Objectives To investigate if availability of POC microscopy or POC culture in general practice was associated with a more appropriate treatment decision in patients with suspected UTI while waiting for the result from the microbiological laboratory. Methods This prospective observational study was conducted in 2016 in general practice in the Copenhagen area, Denmark. Data on all patients presenting in general practice with symptoms of UTI were registered anonymously and a urine sample was sent for culture at the microbiological laboratory. The association between the availability of POC tests and the appropriateness of antibiotic prescribing was assessed with multivariable logistic regression. Results Seventy-six general practices included 1545 patients (83% female); 71% received appropriate treatment in practices with POC culture available and 65% in practices without POC culture available (p = 0.042). Having a microscope available was not associated with more appropriate treatment (70% vs. 69%, p = 0.54). Conclusion Availability of POC culture marginally increased appropriate treatment while waiting for the result from the microbiological laboratory. Practices should adopt a strategy where they either perform culture within the practice or send urine for culture at the microbiological laboratory. Trial registration number ClinicalTrials.gov NCT02698332.

Carbapenem Consumption and Rate of carbapenemresistant gram-negative bacteria: results from the Sicilian Surveillance System.

The results of the present study highlight the need for comprehensive strategies targeting the appropriate use of antibiotics and infection control measures. In the last decades, multidrug-resistant gram-negative bacteria have been increasing and they are involved in severe healthcare associated infections. In treating drug-resistant gram-negative bacterial infections, carbapenems are generally administered as a last choice. However, the rate of carbapenemresistant bacteria is constantly increasing the last years. The aim of the present study is to describe the relationship between the rate of carbapenem-resistant gram-negative bacteria and antibiotic consumption intensity. In 2017, the Sicilian Region implemented a regional surveillance system to describe and analyze consumption of antibiotics in hospital settings, as well as prevalence of antibiotic resistant microorganisms. Resistance data were retrospectively collected from routinary clinical antimicrobial susceptibility tests. Resistance rates (RRs) of carbapenems were calculated and Spearman's correlation analysis was performed to investigate the relationship between annual antibiotic consumption and rate of carbapenem resistance. In 2015, the overall prevalence of carbapenem-resistant Klebsiella pneumoniae isolates was 43.9 %, and was positively correlated with beta-lactam consumption (R=0.529, p<0.01), and with carbapenem consumption (R=0.364, p<0.05). In 2016, the overall prevalence of carbapenem-resistant Klebsiella pneumoniae isolates was 53.8 %, and was positively correlated with carbapenem antibiotic consumption (R=0.364, p<0.05). In 2017, the overall prevalence of carbapenem-resistant Klebsiella pneumoniae isolates was 58.7 %, and was significantly positively correlated with carbapenem antibiotic consumption (R=0.427, p<0.05). In 2015, the overall prevalence of carbapenem-resistant Escherichia coli isolates was 6.5 %, and was significantly positively correlated with antibiotic consumption for the ATC class J01 (i.e., antibacterial for systemic use) (R=0.402, p<0.05).

Fostering Appropriate Antibiotic Use in a Complex Intervention: Mixed-Methods Process Evaluation Alongside the Cluster-Randomized Trial ARena.

The cluster randomized trial ARena (sustainable reduction of antibiotic-induced antimicrobial resistance, 2017–2020) promoted appropriate use of antibiotics for acute non-complicated infections in primary care networks (PCNs) in Germany. A process evaluation assessed determinants of practice and explored factors associated with antibiotic prescribing patterns. This work describes its findings on uptake and impacts of the complex intervention program and indicates potential implementation into routine care. In a nested mixed-methods approach, a three-wave study-specific survey for participating physicians and medical assistants assessed potential impacts and uptake of the complex intervention program. Stakeholders received a one-time online questionnaire to reflect on network-related aspects. Semi-structured, open-ended interviews, with a purposive sample of physicians, medical assistants and stakeholders, explored program component acceptance for daily practice and perceived sustainability of intervention component effects. Intervention components were perceived to be smoothly integrable into practice routines. The highest uptake was reported for educational components: feedback reports, background information, e-learning modules and disease-specific quality circles (QCs). Participation in PCNs was seen as the motivational factor for guideline-oriented patient care and adoption of new routines. Future approaches to fostering appropriate antibiotics use by targeting health literacy competencies and clinician’s therapy decisions should combine evidence-based information sources, audit and feedback reports and QCs.

Maternal antibiotic exposure during pregnancy and the risk of allergic diseases in childhood: A meta-analysis.

Increasing studies suggest that antibiotic exposure during pregnancy may increase the risk of childhood allergic diseases; however, controversy still exists. Thus, we conducted this meta-analysis to evaluate the association between antibiotic use during pregnancy and childhood asthma/wheeze, eczema/atopic dermatitis, and food allergy. CENTRAL, EMBASE, and PubMed were searched for studies up to July 20, 2020. Cohort studies and case-control studies that estimated the association of antibiotic exposure in pregnancy with the risk of childhood asthma/wheeze, eczema/atopic dermatitis, and food allergy were included. A random-effects model or fixed-effects model was used to calculate the pooled estimates. The quality of the included studies was assessed by the Newcastle-Ottawa Scale (NOS). Stata12.0 software was used to analyze the association through a meta-analysis. A total of 26 studies were included in the meta-analysis. The results showed that maternal antibiotic exposure in pregnancy and the summary OR for the risk of childhood asthma/wheeze was 1.29 (95% CI=1.16-1.43), the summary OR for eczema/atopic dermatitis was 1.62 (95% CI=1.16-2.27), and the pooled OR for food allergy was 1.36 (95% CI=0.94-1.96). Our results indicated that maternal antibiotic use during pregnancy might increase the risk of asthma/wheeze and eczema/atopic dermatitis but not food allergy in children. Further studies with larger sample size and robust multivariable adjustment are needed to confirm our findings. Nevertheless, the appropriate use of antibiotics during pregnancy is incredibly important, and healthcare professionals should be selective when prescribing antibiotics for pregnant women.

Converting habits of antibiotic use for respiratory tract infections in German primary care (CHANGE-3) - process evaluation of a complex intervention

BackgroundAntimicrobial resistance remains a global challenge. In Germany, the national health agenda supports measures that enhance the appropriate, guideline-oriented use of antibiotics. The study “Converting Habits of Antibiotic Use for Respiratory Tract Infections in German Primary Care (CHANGE-3)” aimed at a sustainable reduction of antimicrobial resistance through converting patterns of prescribing practice and use of antibiotics and an increase in health literacy in primary care patients, practice teams, and in the general public. Embedded in a cluster-randomized trial of a multifaceted implementation program, a process evaluation focused on the uptake of program components to assess the fidelity of the implementation program in the CHANGE-3 study and to understand utilization of its educational components.MethodsA mix of qualitative and quantitative methods was used. Semi-structured telephone interviews were conducted with General Practitioners, Medical Assistants, patients treated for respiratory tract infection and outreach visitors who had carried out individual outreach visits. A two-wave written survey (T1: 5 months after start, T2: 16 months after start) was conducted in general practitioners and medical assistants. Qualitative data were analyzed using thematic framework analysis. Descriptive statistics were used to analyze survey data.ResultsUptake of intervention components was heterogenous. Across all components, the uptake reported by General Practitioners varied from 20 to 88% at T1 and 31 to 63% at T2. Medical Assistants reported uptake from 22 to 70% at T1 and 6 to 69% at T2. Paper-based components could by and large be integrated in daily practice (64 to 90% in T1; 41 to 93% in T2), but uptake of digital components was low. A one-time outreach visit provided thematic information and feedback regarding actual prescribing, but due to time constraints were received with reluctance by practice teams. Patients were largely unaware of program components, but assumed that information and education could promote health literacy regarding antibiotics use.ConclusionsThe process evaluation contributed to understanding the applicability of the delivered educational components with regards to the appropriate use of antibiotics. Future research efforts need to identify the best mode of delivery to reach the targeted population.Trial registrationISRCTN, ISRCTN15061174. Registered 13 July 2018 – Retrospectively registered

An Evaluation of Antimicrobial Prophylaxis for Dental Procedures at a Veterans Healthcare System; A Role for Senior Care Pharmacists?

OBJECTIVE: The primary objective of this study was to determine the prevalence of appropriate use of antibiotics before a dental procedure.<br/> DESIGN: Retrospective cohort study.<br/> SETTING: Veterans Healthcare Systems.<br/> PARTICIPANTS: Veterans who filled outpatient prescriptions for antimicrobial dental prophylaxis at the Veterans Administration Western New York Healthcare System from December 1, 2017, through October 1, 2019.<br/> INTERVENTIONS: None.<br/> MAIN OUTCOME MEASURES: Use of antibiotic dental prophylaxis was deemed appropriate if in accordance with guideline recommendations. Descriptive statistics were used to summarize data.<br/> RESULTS: A total of 130 veterans receiving antibiotics for dental prophylaxis were included in this evaluation. Of those who were included, only 16.9% received appropriate antibiotic dental prophylaxis. Patients with a prosthetic joint were significantly more likely to be inappropriately prescribed antibiotics for dental prophylaxis. Approximately 87% of patients who were inappropriately prescribed antibiotic prophylaxis had prosthetic joints (P < .0001).<br/> CONCLUSION: Most antibiotics for dental prophylaxis are prescribed inappropriately. The large amount of inappropriately used antibiotics in this study highlights the need for dental stewardship in our veteran population. Antibiotics for dental prophylaxis therefore represent an important stewardship target in the outpatient setting. This may be an ideal opportunity for senior care pharmacists to intervene upon.