Changes In Antibiotic Usage Research Articles

Nurturing Tomorrow's Antibiotic Stewards: An Innovative School Campaign to Combat Antimicrobial Resistance in Delhi.

Antimicrobials are lifesaving medicines, but their misuse drives antimicrobial resistance. Schools, as educational hubs wield transformative potential in fostering responsible antimicrobial behavior among students and the broader community. An online campaign targeted Delhi schools, training teachers as master trainers who, in turn, educated 359,940 students. Significant pre- to post-test score improvements were observed among teachers (6.98-8.14; P < 0.01) and students (5.20-6.56; P < 0.01). The campaign received excellent feedback (85%), with 966 students participating in the "IDEAthon" competition. While a single session improved knowledge, continuous engagement and activities are imperative for sustained behavioral change in antibiotic usage.

Taxation of veterinary antibiotics to reduce antimicrobial resistance

Routine usage of antibiotics for animal health is a key driver of antimicrobial resistance (AMR) in food-producing animals. Taxation is a possible approach to incentivise appropriate antibiotic usage in food-producing animals. Taxation can be applied flatly across all antibiotic classes, targeted to single antibiotic classes, or scaled based on resistance in each class, so called “differential” taxation. However, quantifying the potential impact of taxation is challenging, due to the nonlinear and unintuitive response of AMR dynamics to interventions and changes in antibiotic usage caused by alterations in price. We combine epidemiological models with price elasticities of demand for veterinary antibiotics, to compare the potential benefits of taxation schemes with currently implemented bans on antibiotic usage.Taxation strategies had effects comparable to bans on antibiotic usage in food-producing animals to reduce average resistance prevalence and prevent increases in overall infection. Taxation could also maximise the average number of antibiotics with a resistance prevalence of under 25% and potentially generate annual global revenues of ∼1 billion US$ under a 50% taxation to current prices of food-producing animal antibiotics. Differential taxation was also able to maintain a high availability of antibiotics over time compared to single and flat taxation strategies, while also having the lowest rates of intervention failure and highest potential revenue across all taxation strategies. These findings suggest that taxation should be further explored as a tool to combat the ongoing AMR crisis.

A sepsis risk calculator can decrease antibiotic exposure in neonatal early-onset sepsis screening.

Early-onset neonatal sepsis (EONS) can have devastating consequences. Historically, clinicians treated at-risk patients with antibiotics while awaiting blood culture results. This strategy, however, resulted in substantial antibiotic overtreatment over the last three decades.1 Consequences of early antibiotic overexposure include microbiome alterations2, 3 which are linked to development of asthma, food allergies and childhood obesity.4-7 Intrapartum antibiotic strategies have reduced the incidence of EONS since the 1990s, and clinicians now must weigh the risk of EONS with the risk of negative impacts from antibiotic overtreatment. Methods to prevent overtreatment include algorithm-based risk factor assessments to distinguish infants truly at risk for EONS. A newer tool, the SRC, is a multivariate risk assessment method that synthesises risk factors and the newborn clinical condition to provide a probability of EONS for each infant.8, 9 The authors of this study estimated that, had the SRC been applied to their cohort of 3593 infants managed with NICE guidelines over a three-month period, antibiotic therapy could have been avoided in nearly three-quarters of treated infants. However, applying a hypothetical management approach retrospectively to a cohort managed with another approach prospectively obviously does not provide the same level of evidence as head to head randomised trials. Studies such as this should be interpreted with caution. In this study, assessors of the SRC-based approach were aware of the NICE guideline-based assessment of risk, the actual use of antibiotics in study infants and the eventual clinical outcomes. Non-blinding may have led to bias in estimating the potential effects of the SRC recommendations. Additionally, the true incidence of EONS in this cohort of patients was at least 1.2/1000 live births (6 infants out of 4992), but the authors used an estimated incidence of 0.5/1000 for the SRC. Using the known EONS incidence of this cohort of patients in the SRC may have resulted in a significant change in antibiotic usage. Readers should note that several infants with EONS were deemed to be at low/no risk using either approach, but subsequently developed clinical signs of sepsis. These infants were identified by clinical vigilance, which may be the ultimate safety net for EONS detection and treatment. The authors do recommend close observation of newborns identified as high risk by NICE but not recommended antibiotics by SRC, and discharge after 12-24 hours of monitoring. One reasonable conclusion from this study is that a combination of using the SRC along with clinical vigilance offers the best approach, where antibiotic overuse is avoided, and infants who clinically deteriorate are detected and treated early. Even with promising results such as in this study, clinicians should cautiously develop local practice guidelines based on a comprehensive review of the evidence, local contextual and practice conditions (eg the feasibility of frequent clinical monitoring of infants at risk), the baseline rate of EONS and parental preferences and values. The guidelines should be accompanied by rigorous monitoring for unexpected consequences to ultimately ensure that the goal of achieving a balance between treating EONS early while avoiding needless antibiotics is met. https://ebneo.org/2016/11/admission-hypoand-hyperthermia-are-associated-with-increa None.

Omega-3 fatty acid supplementation for cystic fibrosis.

Omega-3 fatty acid supplementation for cystic fibrosis.

1046. Evaluating the outcomes of embedding Antimicrobial Stewardship order sets in the General Medicine Admission Electronic Order Set: A Retrospective Study

BackgroundThe use of facility-specific guidelines and clinical decision-making tools are recommended by a number of organizations to improve the appropriateness of empiric antimicrobial prescribing; however, how to increase usage is not clear. We evaluated the impact of embedding antimicrobial stewardship (AS) electronic order sets (EOS) into the general medicine admission EOS in the context of an established AS program.MethodsThe standalone EOS for community-acquired pneumonia (CAP), urinary tract infection (UTI) and cellulitis were reviewed and simplified to only include the antibiotic section prior to embedding. The intervention was introduced on March 30, 2017 with pre-intervention period defined as January 1, 2016 to March 29, 2017 and post-intervention period as of March 30, 2017 to June 30, 2018. The primary outcome was the change in usage of embedded AS EOS compared with the corresponding standalone EOS using counts. In addition, other standalone AS EOS (i.e., Clostridioides difficile infection (CDI), etc) were used as a control. The secondary outcomes were the change in antibiotic usage de-emphasized in embedded EOS (i.e., ceftriaxone, ciprofloxacin, clindamycin, moxifloxacin) and predicted prescribing shifts to antibiotics in the embedded EOS (i.e., amoxicillin-clavulanate, azithromycin and sulfamethoxazole-trimethoprim) using Days of Therapy (DOT)/1000 patient-days (PD). Paired t-test was used to compare antibiotic usage pre- and post-intervention.ResultsThe usage of standalone EOS remained similar pre- and post-intervention except for a 16-fold increased usage of CDI EOS. There were large increases in uptake of the embedded EOS compared with the standalone EOS: 11-fold () increase for CAP, 47-fold () increase for UTI and 24-fold () increase for cellulitis. In addition, there was a statistically significant decrease in ciprofloxacin (mean 16.6 DOT/1000-PD vs. 13.6 DOT/1000-PD, P = 0.026) and moxifloxacin usage (mean 9.3 DOT/1000-PD vs. 5.2 DOT/1000-PD) during the study time period.ConclusionOur study showed that simplifying AS EOS and embedding these into a more commonly used EOS is associated with a significant increase in EOS usage and uptake of AS recommended empiric antibiotics with a decrease in fluoroquinolone usage. Disclosures All authors: No reported disclosures.

Impact assessment of new US Food and Drug Administration regulations on antibiotic use: A post-enactment survey of swine practitioners

Following a 2016 pre-enactment survey, 42 swine veterinary practitioners were surveyed in 2017 to assess post-enactment impacts of the revised Veterinary Feed Directive (VFD). The survey evaluated veterinarian-client-patient relationships, client recruitment, VFD fees and creation, record keeping, education and training, business costs, and changes in antibiotic usage and on-farm management.

The Effect of a Piperacillin/Tazobactam Shortage on Antimicrobial Prescribing and Clostridium difficile Risk in 88 US Medical Centers.

Anti-infective shortages are a pervasive problem in the United States. The objective of this study was to identify any associations between changes in prescribing of antibiotics that have a high risk for CDI during a piperacillin/tazobactam (PIP/TAZO) shortage and hospital-onset Clostridium difficile infection (HO-CDI) risk in 88 US medical centers. We analyzed electronically captured microbiology and antibiotic use data from a network of US hospitals from July 2014 through June 2016. The primary outcome was HO-CDI rate and the secondary outcome was changes in antibiotic usage. We fit a Poisson model to estimate the risk of HO-CDI associated with PIP/TAZO shortage that were associated with increased high-risk antibiotic use while controlling for hospital characteristics. A total of 88 hospitals experienced PIP/TAZO shortage and 72 of them experienced a shift toward increased use of high-risk antibiotics during the shortage period. The adjusted relative risk (RR) of HO-CDI for hospitals experiencing a PIP/TAZO shortage was 1.03 (95% confidence interval [CI], .85-1.26; P = .73). The adjusted RR of HO-CDI for hospitals that both experienced a shortage and also showed a shift toward increased use of high-risk antibiotics was 1.30 (95% CI, 1.03-1.64; P < .05). Hospitals that experienced a PIP/TAZO shortage and responded to that shortage by shifting antibiotic usage toward antibiotics traditionally known to place patients at greater risk for CDI experienced greater HO-CDI rates; this highlights an important adverse effect of the PIP/TAZO shortage and the importance of antibiotic stewardship when mitigating drug shortages.

Rise and fall of KPC-producing Klebsiella pneumoniae in New York City.

The study objective was to examine the epidemiological trends of KPC-producing Klebsiella pneumoniae in New York City medical centres. Single patient isolates of K. pneumoniae were collected from nine medical centres in New York City during a 3 month period from 2013 to 2014. Isolates were tested for the presence of blaKPC. Results were compared with similar surveillance studies conducted in 2006 and 2009. Infection control data, including utilization of medical devices, were analysed at a subset of hospitals. There was a progressive decline in the percentage of K. pneumoniae harbouring blaKPC from 2006 to 2013-14. For the nine hospitals that participated in all three surveillance studies, the percentages of isolates with blaKPC fell from 36% in 2006 to 25% in 2009 to 13% in 2013-14. Seven of the nine hospitals had marked declines in isolates with blaKPC, while two hospitals continued to struggle with this pathogen. These two hospitals were smaller and had longer lengths of patient stay. Device utilization rates were obtained from two hospitals that successfully controlled the spread of KPC-producing K. pneumoniae; both had ∼20%-25% reduction in the usage of urinary catheters. Changes in antibiotic usage at one hospital could not explain the decline in these pathogens. Over the past decade there has been a steady decline in KPC-producing K. pneumoniae in most New York City hospitals. The reason for the decline is probably multifactorial, involving a reduction in device (catheter) utilization and possibly an improvement in infection control practices.

A three-point time series study of antibiotic usage on an intensive care unit, following an antibiotic stewardship programme, after an outbreak of multi-resistant Acinetobacter baumannii.

Antibiotic use in intensive care units (ICUs) can promote antimicrobial resistance. Outbreaks of multi-resistant bacteria significantly affect patient outcomes and delivery of care. Antibiotic stewardship programmes (ASPs), combining root-cause analyses and multi-faceted prevention strategies, are necessary, often at significant cost and time. Which elements of such strategies have the largest impact on antibiotic usage following an outbreak is unclear. The aim of this study was to investigate how antibiotic usage in a university hospital ICU changed with a non-protocolised ASP following a disruptive outbreak of multi-resistant Acinetobacter baumannii (MRAB). This was a three time-period observational cohort study. The primary endpoint was the change in overall antibiotic usage (daily defined dose, DDD, antibiotic-days, antibiotic-courses) for consecutive ICU patients staying >48 h, over three 6-month study time periods pre-MRAB (2008, n = 84) and post-MRAB (2010, n = 88; 2012, n = 122). Secondary endpoints were changes in antibiotic usage and patient demographics, in predefined admission categories (Medical Emergency, ME; Surgical Elective, SEL; and Surgical Emergency, SE). The mean age (54.6 ± 17.7, 58.1 ± 17.9, 62.8 ± 19.1 years*) and severity of illness (APACHE 14.8 ± 8.0, 16.7 ± 6.8, 18.3 ± 6.1*) increased, particularly medical admissions. There was a sustained reduction in DDD antibiotic usage [1895.1 (2008), 1224.2 (2010), 1236.6 (2012) per 1000 patient-days] but no overall change in antibiotic-days or antibiotic-courses. Antibiotic usage (antibiotic-days) fell significantly in surgical emergency admissions [20.2 ± 32.1, 4.6 ± 7.4*, 5.9 ± 7.3]. There was a sustained drop in beta-lactam, quinolone, glycopeptide and macrolide usage. Following an MRAB outbreak, and subsequent operational changes including enhanced ASPs (non-protocolised), there was a sustained overall fall in antibiotic usage in spite of an increase in disease severity over 5 years.

Analysis of interventions to reduce the incidence of Clostridium difficile infection at a London teaching hospital trust, 2003‒2011

Since 2008 there has been a substantial fall in the incidence of Clostridium difficile infection (CDI) in the UK, though it is unclear what contribution local and governmental interventions have made to this reduction. To assess the value of retrospective analysis using a segmented regression model and single factor analysis of variance (ANOVA) in assessing the impact of interventions to reduce hospital-acquired CDI. A retrospective time-series analysis of 28 interventions implemented over an eight-year period by a large teaching hospital trust. Single factor ANOVA was used to analyse the association between CDI rates and changes in antibiotic usage and hand hygiene compliance data. Whereas several interventions were associated with a reduction in CDI rates, insufficient time-points were available between interventions to allow meaningful interpretation of all the data. Reduction of cephalosporin and quinolone use was associated with reduction in CDI rates. There was little association between observed variations in hand hygiene compliance and CDI rates. Though several interventions were associated with a reduction in CDI, this study illustrates the inherent limitations of retrospective time-series methodology for the investigation of infection control measures where large numbers of interventions are introduced over a short time-period. Single factor ANOVA demonstrated an association between fall in CDI and restriction of high-risk antibiotic use. Little association was demonstrated between compliance rates documented in hand hygiene audits and CDI, though compliance was relatively high throughout the period of study.

Antibiotics in dentistry – an update

This review article considers the changes in antibiotic usage over the past 40 years. Perhaps the most significant advance is in the prophylactic use of these drugs to reduce the effect of dentally induced bacteraemia. A greater understanding of various dental infections and, in particular, the role of bacteria in the pathogenesis of periodontal disease, has led to further interest in the indications for these drugs as adjunctive measures. Whilst new indications for the use of antibiotics become more widespread, all members of the healthcare professions need to be aware that these drugs have significant adverse effects and their misuse can lead to life-threatening infection. Antibiotics have revolutionized the control of infectious diseases and have a significant role in dental practice. Dentists should be fully appraised of the benefits of these drugs and when they should be prescribed. Antibiotics usage should not be a substitute for interventional procedures, such as drainage of pus or removal of sources of infection. Indications for the use of these drugs as prophylactic measures are now reducing.

Ultrasound detection of septic jugular vein thrombosis

The two leading causes of IJVT are iatrogenic trauma secondary to jugular vein catheterization, and repeated IV injections by drug users. Lemierre syndrome is a complex and unusual clinical entity, characterized by septic thrombophlebitis of internal jugular vein. Lemierre syndrome was thought to be a rare and forgotten disease with suggested incidence of approximately one per million. However, an increase in frequency over the past years has been suggested due to changes in antibiotic usage. Unfortunately, wide spread antibiotic usage has also changed clinical picture of Lemierre syndrome and it is often difficult to recognize this unusual ilness in the Emergency Department (ED). Systemic septic complications may range from deep neck infection over septic arthritis to brain infections. Every organ system may be involved. Delays in diagnosis ranging up to 11 days after admission have been reported. When recognized and treated in early phase patients recover completely but other vise condition may be lethal. In emergency settings accurate and prompt diagnosis is crucial in satisfactory patient management. Diagnosis of Lemierre's syndrome is simple with Doppler ultrasonography but it mostly requires a high degree of clinical suspicion. It has been suggested that bedside ultrasound of the internal jugular vein in ED before other radiologic imaging, may lead to rapid diagnosis and treatment of Lemierre syndrome. In last two years we treated five patients with Lemierre’s syndrome in our department. In one case young woman died because of sepsis and multiorgan failure due to delayed diagnosis. Rapid ultrasound examination of neck veins is discussed as a part of ED evaluation of patients.

Impact of guidelines and enhanced antibiotic stewardship on reducing broad-spectrum antibiotic usage and its effect on incidence of Clostridium difficile infection

To evaluate the impact of an 'intervention' consisting of revised antibiotic guidelines for empirical treatment of common infections and enhanced stewardship on reducing broad-spectrum antibiotic usage and its effect on incidence of Clostridium difficile infection (CDI). This was a retrospective, quasi-experimental study using interrupted time series (ITS) over 12 months before and after the intervention. The setting was adult medical and surgical wards in University Hospital Lewisham, an acute general hospital in London. The intervention was introduced in April 2006. Revised guidelines avoided broad-spectrum antibiotics, e.g. fluoroquinolones, cephalosporins, clindamycin, amoxicillin and co-amoxiclav, as they were considered to be 'high risk' for CDI. Instead, 'low risk' antibiotics such as penicillin, clarithromycin, doxycycline, gentamicin, vancomycin, trimethoprim and nitrofurantoin were recommended. Changes in antibiotic usage and incidence of CDI before and after the intervention were compared using segmented regression analysis. The negative binomial model was used to analyse the time series to estimate the CDI incidence rate ratio (IRR) following the intervention. The intervention was associated with a significant reduction in the use of fluoroquinolones by 105.33 defined daily doses (DDDs)/1000 occupied bed-days (OBDs) per month [95% confidence interval (CI) 34.18-176.48, P < 0.001] and cephalosporins by 45.93 DDDs/1000 OBDs/month (95% CI 24.11-67.74, P < 0.0001). There was no significant change in total antibiotic, clindamycin, amoxicillin or co-amoxiclav use. There was a significant decrease in CDI following the intervention [IRR 0.34 (0.20-0.58), P < 0.0001]. Revised antibiotic guidelines and enhanced stewardship was associated with a significant stepwise reduction in the use of cephalosporins and fluoroquinolones and a significant decrease in the incidence of CDI.

Changes in antibiotic usage and susceptibility in nosocomial Enterobacteriaceae and Pseudomonas isolates following the introduction of ertapenem to hospital formulary

There is concern that widespread usage of ertapenem may promote cross-resistance to other carbapenems. To analyse the impact that adding ertapenem to our hospital formulary had on usage of other broad-spectrum agents and on susceptibilities of nosocomial Enterobacteriaceae and Pseudomonas isolates, we performed interrupted time-series analyses to determine the change in linear trend in antibiotic usage and change in mean proportion and linear trend of susceptibility pre- (March 2004-June 2005) and post- (July 2005-December 2008) ertapenem introduction. Usage of piperacillin-tazobactam (P=0·0013) and ampicillin-sulbactam (P=0·035) declined post-ertapenem introduction. For Enterobacteriaceae, the mean proportion susceptible to ciprofloxacin (P=0·016) and piperacillin-tazobactam (P=0·038) increased, while the linear trend in susceptibility significantly increased for cefepime (P=0·012) but declined for ceftriaxone (P=0·0032). For Pseudomonas, the mean proportion susceptible to cefepime (P=0·011) and piperacillin-tazobactam (P=0·028) increased, as did the linear trend in susceptibility to ciprofloxacin (P=0·028). Notably, no significant changes in carbapenem susceptibility were observed.

A comparative study of three methods to evaluate an intervention to improve empirical antibiotic therapy for acute bacterial infections in hospitalized patients

In order to limit the use of broad-spectrum antibiotics, standardized empirical therapy against acute bacterial infections has been advocated. Guidelines for acute bacterial infections recommending increased usage of benzylpenicillin and restricted use of fluoroquinolones and cephalosporins have been implemented in Kalmar County, Sweden. We evaluated this strategy by recording therapy in patients with bacteraemia, antibiotic requisition, and point prevalence surveys prior to this intervention and at 6 and 12 months after. Comparing the methods simultaneously, there was good agreement between them and an overall significant change in antibiotic usage. There was a significant shift from cefuroxime to cefotaxime and a borderline significant increase in the use of benzylpenicillin (p = 0.057). Based on the defined daily dose (DDD), a highly significant decrease in total cefotaxime and cefuroxime usage was observed that was not detected when applying the prescribed daily dose (PDD), which is adapted to local treatment practices. No change was found in mortality in Staphylococcus aureus bacteraemia or the incidence of Clostridium difficile infection. We conclude that the implementation of the new guidelines has resulted in a significant change in antibiotic usage, which could be conveniently monitored by antibiotic requisition if PDD is used in addition to DDD.

A pseudo-outbreak of nosocomial infections associated with the introduction of an antibiotic management programme

An abrupt and persistent 30% increase in the rate of nosocomial infections was detected at a university teaching hospital after a prolonged period with a relatively constant nosocomial infection rate. Demographic data, risk factors for nosocomial infection, features of reported cases of nosocomial infection, and policy and procedure changes were evaluated for the periods of 1 January 1997 to 30 April 1998 (endemic period) and 1 May to 31 December 1998 (epidemic period). An extensive outbreak investigation revealed no evidence of a true outbreak of nosocomial infection. The apparent outbreak involved all four major body sites, began during the same month that an antibiotic management programme was started, involved the same adult medical and surgical units where antibiotics were being controlled, and occurred months before any significant change in antibiotic usage. A greater proportion of nosocomial infection during the epidemic period was reported by the nosocomial infection surveillance nurses, based on a treating physician's diagnosis rather than on specific clinical criteria. In an attempt to justify existing antibiotic prescribing practices after the implementation of an antibiotic management programme, clinicians altered the threshold at which they documented the presence of nosocomial infection. This change in documentation produced a large pseudo-outbreak of nosocomial infection.

The effect of formulary restriction in the use of antibiotics in an Italian hospital.

To compare the expenditure and usage of antibiotics at the San Martino Teaching Hospital, a 2500-bed hospital in Genoa, Italy, before and after the implementation of an antibiotic control program that streamlined the hospital formulary and the creation of a restricted group of antibiotics requiring approval before use. Usage and expenditure data for all antibiotics were collected from 1996 to 1998. Antibiotic usage was standardised by defined daily doses (DDDs) per 100/patient-days. Cost data were expressed in Euros. Changes in antibiotic usage was determined by comparing the mean usage during 1996 and 1997, the period before the implementation of the antibiotic control program, to 1998 when the streamlined formulary and restricted group of antibiotics, controlled by the Infectious Disease Team (IDT). were initiated. The Wilcoxon rank sign test was used to determine statistical significance of the changes in overall antibiotic use; a P value of less than 0.05 was considered significant. After the implementation of the antibiotic control program, overall antibiotic usage decreased by 8.5%, 28.00 DDD/100 patient-days during 1996-1997 to 25.62 DDD/100 patient-days during 1998. The control program resulted in overall savings of 342,927 Euros after the first year of implementation. The usage and expenditure in the restricted group of antibiotics decreased by 78.5% and 53.5%, respectively, (P=0.03). Restricting the use of ceftazidime and imipenem accounted for the majority of the decreased usage and savings. In the non-restricted group of antibiotics, usage increased only by 32.6% resulting in a net reduction of 46.3% in all antibiotic use. Although antibiotic control programs have been successful in other countries, this represents the first attempt at successful antibiotic control in a large Italian teaching hospital. Streamlining the formulary to control antibiotic choices and the creation of a restriction program using the expertise of infectious disease physicians resulted in significant reductions in the use of and expenditure for antibiotics.

The epidemiology of antibiotic resistance in hospitals.

Changes in antibiotic susceptibility among different species are a function of the interaction of bacterial genomes (chromosomes, plasmids, transposons) with specific host and environmental factors. Computer-assisted surveillance of resistance patterns and plasmid fingerprinting with restriction endonucleases have facilitated resistance gene tracking. Certain nosocomial plasmids have persisted for many years within specific centres, others are widely distributed by species and location, and others may have a narrow host range or undergo rapid molecular evolution. Klebsiella pneumoniae is most often the index species for the dissemination of nosocomial plasmids, which are frequently multiresistant. Acute increases in antibiotic resistance may be due to antibiotic selection pressures, introduction of new, well-adapted species, over-crowding and other environmental changes. The most resistant organisms are found in units where patients are immunocompromised, are subject to invasive procedures or remain for long periods. Although large-scale studies have not shown uniform increases in the prevalence of resistant bacteria, acute outbreaks in specific niches have resulted in increased patient morbidity, necessitating rapid changes in antibiotic usage. Further molecular epidemiological studies are required in order to understand better how to anticipate the spread of antibiotic resistance.