Choice Of Antibiotic Treatment Research Articles

Erratum to: Revealing antibiotic cross-resistance patterns in hospitalized patients through Bayesian network modelling.

OBJECTIVES Microbial resistance exhibits dependency patterns between different antibiotics, termed cross-resistance and collateral sensitivity. These patterns differ between experimental and clinical settings. It is unclear whether the differences result from biological reasons or from confounding, biasing results found in clinical settings. We set out to elucidate the underlying dependency patterns between resistance to different antibiotics from clinical data, while accounting for patient characteristics and previous antibiotic usage. METHODS Additive Bayesian network modelling was employed to simultaneously estimate relationships between variables in a dataset of bacterial cultures derived from hospitalized patients and tested for resistance to multiple antibiotics. Data contained resistance results, patient demographics and previous antibiotic usage, for five bacterial species: Escherichia coli (n = 1054), Klebsiella pneumoniae (n = 664), Pseudomonas aeruginosa (n = 571), CoNS (n = 495) and Proteus mirabilis (n = 415). RESULTS All links between resistance to the various antibiotics were positive. Multiple direct links between resistance of antibiotics from different classes were observed across bacterial species. For example, resistance to gentamicin in E. coli was directly linked with resistance to ciprofloxacin (OR = 8.39, 95% credible interval 5.58-13.30) and sulfamethoxazole/trimethoprim (OR = 2.95, 95% credible interval 1.97-4.51). In addition, resistance to various antibiotics was directly linked with previous antibiotic usage. CONCLUSIONS Robust relationships among resistance to antibiotics belonging to different classes, as well as resistance being linked to having taken antibiotics of a different class, exist even when taking into account multiple covariate dependencies. These relationships could help inform choices of antibiotic treatment in clinical settings.

Evaluation of the impact of the Spanish Consensus Document on the approach to osteoarticular infections in Spain through the Paediatrics Osteoarticular Infections Network (RIOPED)

IntroductionIn 2014 the Consensus Document produced by the Spanish Paediatric Societies (SEIP-SERPE-SEOP) was published to help in the diagnosis and treatment of osteoarticular infections (OAI). In 2015 the RIOPed was considered as a multidisciplinary national network for the investigation into OAI. The aim of this study was to assess the level of adaption to the recommendations established in the Consensus during one year of follow-up. Material and methodsA prospective, national multicentre study was carried out in 37 hospitals between September 2015 and September 2016. The study included patients >16 years-old with a diagnosis of OAI, confirmed by microbiological isolation, or probable: septic arthritis (SA) with >40,000 white cells in synovial fluid, or osteomyelitis (OM)/spondylodiscitis (SD) with a compatible imaging test. The results were compared with those obtained in a retrospective study conducted between 2008 and 2012. ResultsA total of 235 cases were included, of which 131 were OM, 79 SA, 30 OA, and 15 SD. As regards the complementary tests that the Consensus considered mandatory to perform, radiography was carried out on 87.8% of the cases, a blood culture on 91.6%, and culture of the synovial fluid in 99% of SA. A magnetic resonance (MR) was performed on 71% of the OM cases. The choice of intravenous empirical antibiotic treatment was adapted to the recommendations in 65.1% of cases, and in 62.3% for the oral treatment. Surgery was performed in 36.8% of SA cases (85.7% arthrotomy), with a significant decrease compared to the retrospective study (P=.014). Only 58.5% of cases followed the recommendations on the duration of the treatment; however, a lower duration of intravenous treatment was observed. ConclusionsIn general, the level of adaptation to the recommendations that were set by the Expert Group, is good for the complementary tests, and acceptable as regards the choice of antibiotic treatment, although inadequate in almost 40% of cases. A decrease in hospital stay was achieved.

Revealing antibiotic cross-resistance patterns in hospitalized patients through Bayesian network modelling.

Microbial resistance exhibits dependency patterns between different antibiotics, termed cross-resistance and collateral sensitivity. These patterns differ between experimental and clinical settings. It is unclear whether the differences result from biological reasons or from confounding, biasing results found in clinical settings. We set out to elucidate the underlying dependency patterns between resistance to different antibiotics from clinical data, while accounting for patient characteristics and previous antibiotic usage. Additive Bayesian network modelling was employed to simultaneously estimate relationships between variables in a dataset of bacterial cultures derived from hospitalized patients and tested for resistance to multiple antibiotics. Data contained resistance results, patient demographics and previous antibiotic usage, for five bacterial species: Escherichia coli (n = 1054), Klebsiella pneumoniae (n = 664), Pseudomonas aeruginosa (n = 571), CoNS (n = 495) and Proteus mirabilis (n = 415). All links between resistance to the various antibiotics were positive. Multiple direct links between resistance of antibiotics from different classes were observed across bacterial species. For example, resistance to gentamicin in E. coli was directly linked with resistance to ciprofloxacin (OR = 8.39, 95% credible interval 5.58-13.30) and sulfamethoxazole/trimethoprim (OR = 2.95, 95% credible interval 1.97-4.51). In addition, resistance to various antibiotics was directly linked with previous antibiotic usage. Robust relationships among resistance to antibiotics belonging to different classes, as well as resistance being linked to having taken antibiotics of a different class, exist even when taking into account multiple covariate dependencies. These relationships could help inform choices of antibiotic treatment in clinical settings.

Current choices of antibiotic treatment for Pseudomonas aeruginosa infections.

Pseudomonas aeruginosa is one of the most feared nosocomial pathogens. Treatment of P. aeruginosa infections is challenging because of the limited choices of antibiotics and the emergent resistance of the pathogen. The present review aims at addressing the management of P. aeruginosa infections and highlighting the novel antibiotics that show a future promising role. Novel fluoroquinolones have been recently introduced and show favorable activity. New combinations of β-lactams/β-lactamase inhibitors have been studied in various indications of infections because of P. aeruginosa. Cefiderocol, a new cephalosporin, shows very promising results against P. aeruginosa. Currently, combination therapy is only recommended in limited scenarios. Extended-infusion of β-lactams exhibit clinical benefit. Bacteriophage therapy is a growing field of interest and may have an impactful effect on the treatment of resistant P. aeruginosa. Factors that guide clinical decisions for empiric and directed P. aeruginosa therapy include the epidemiology, the patient's risk factors, the site of infection, and the available treatment options. Conventional antipseudomonal antibiotics have been used successfully for a long time, but the increase in worldwide resistance necessitates the need for newer agents. Antimicrobial stewardship is essential to preserve the new drugs and prevent future development of resistance.

Acute infectious osteomyelitis in children: new treatment strategies for an old enemy.

Acute osteomyelitis still represents a significant clinical challenge, with an increasing incidence in paediatric population. A careful assessment and a rapid diagnosis with proper timing and choice of empirical antimicrobial therapy are necessary to avoid sequelae. The initial treatment should consist of empirical antibiotic therapy, to cover the major responsible pathogens in each age group. We made a literature search with PubMed and Cochrane database from 2000 to 2019 in English, French, and Spanish languages using the key words "osteomyelitis, children, clinical, diagnosis, and treatment". The child's clinical features, age, and the microbiological profile of the geographic area should be evaluated for diagnosis and in the choice of antibiotic treatment. Latest data suggest the administration of intravenous antibiotics for a short period, with subsequent oral therapy, according to the improvement of clinical status and inflammatory markers. For children older than 3 months, the shift to oral medications is already possible after a short course of intravenous therapy, until recovery. The timing for the shift from cefazolin to cephalexin or cefuroxime, intravenous clindamycin to oral clindamycin, and intravenous ceftriaxone + oxacillin to oral equivalents will be decided according to the improvement of clinical status and inflammatory markers. We also present the approach to osteomyelitis due to difficult pathogens, such as Methicillin-resistant Staphylococcus aureus (MRSA) and Panton-Valentine leukocidin (PVL)-positive S. aureus infections. In this review, we present the current approach to the clinical diagnosis and management of osteomyelitis in childhood, with an update on recent recommendations, as a useful instrument to understand the rationale of antibiotic therapy.

Diagnostic performance of the Sputum Gram Stain in predicting sputum culture results for critically ill pediatric patients with pneumonia

The sputum Gram stain is an inexpensive, rapid, and convenient laboratory method that predicts the bacterial pathogens in patients with pneumonia. This study aimed to evaluate the diagnostic performance of this method in predicting sputum culture results for critically ill pediatric patients. From June 2008 to June 2018, patients with pneumonia with an endotracheal or a tracheostomy tube in place in the Pediatric Intensive Care Unit at Changhua Christian Hospital were enrolled retrospectively. Sputum was collected from each patient via the artificial airway for Gram stain and culture evaluations of bacterial pathogens. Mixed culture results were excluded. A successful prediction was defined as a match of the sputum Gram stain and culture results. A total of 622 records were reviewed, of which 542 were analyzed. Haemophilus influenzae, Pseudomonas aeruginosa, and Streptococcus pneumoniae were the three most common pathogens found. The overall prediction success rate of the sputum Gram stain was 59.23%. The sensitivity of the method in predicting gram-negative bacilli (GNB), gram-negative cocci (GNC), and gram-positive cocci (GPC) was 0.45, 0.67, and 0.61, respectively. Its specificity in predicting GNB, GNC, and GPC was 0.87, 0.98, and 0.87, respectively. Its positive likelihood ratio in predicting GNB, GNC, and GPC was 3.46, 33.50, and 4.69, respectively. The highest prediction success rate among all pathogens was for GNC. The sputum Gram stain had high specificity and relatively low sensitivity in predicting the bacterial pathogens in critically ill pediatric patients. Its high specificity in predicting sputum culture results means that clinicians can confidently use sputum Gram stain results to guide their antibiotic choice for treatment.

Nasopharyngeal cultures in children; when, what and why?

IntroductionNasopharyngeal cultures are commonly used to determine the causative bacteria in upper airway infections. However, several bacteria can occupy the nasopharynx simultaneously and most healthy children are asymptomatic carriers of presumptive pathogens. This makes the interpretation of nasopharyngeal cultures difficult. Knowledge about which bacteria reside in the nasopharynx can assist the physician in the choice of antibiotic treatment and might also predict the risk of complications. Today, little is known about how nasopharyngeal cultures are being used in clinical practice. ObjectivesThe aim of this study was to explore how nasopharyngeal cultures are used in clinical practice, when and why they are performed, what they show, and what impact they have on the treatment of the patient. MethodsThe results of all nasopharyngeal cultures taken from children aged 0–12 years in the county of Skåne, Sweden, during 2018 were obtained. Medical charts from hospitals and primary care centres were used to determine why the cultures were taken and whether they resulted in a change of treatment. ResultsDuring 2018, 2200 nasopharyngeal cultures were taken, most of them during the winter season. Forty-one percent of children had on-going antibiotic treatment or had been treated with antibiotics in the previous two months. Acute otitis media (AOM) was the most common reason for taking a culture. The most frequently identified bacteria were Moraxella catarrhalis and Haemophilus influenzae. There was a positive correlation between M. catarrhalis on one hand and Streptococcus pneumoniae and H. influenzae on the other. Overall, bacterial resistance was rare. The presence of beta-lactamase negative ampicillin resistant H. influenzae was associated with recent or on-going antibiotics, whereas S. pneumoniae with decreased penicillin susceptibility were found less frequently in the same group of children. A positive culture resulted in a change of treatment in 29% of the cases. ConclusionApart from playing a confirmatory role and monitoring the incidence of resistant bacteria, almost a third of the nasopharyngeal cultures analysed in this study contributed to decision-making. It therefore appears that bacterial sampling have a role in clinical practice. It would be valuable to study more closely why nasopharyngeal cultures are taken in during AOM and how the result affects the treatment.

Routine pus swab - just * do it

Background: The routine use of microbiology swab in odontogenic infection has proven to rarely influence the choice of antibiotic treatment. Audits have been published questioning the practice of routine swabbing.

Profile of bacterial infectious disease and antimicrobial choices in an urban hospital at Maputo, Mozambique: a prospective observational study

Abstract Background Few antimicrobial resistance profile data exist for Mozambique. Limited antimicrobial stewardship and a lack of guidelines favour near anarchic antibiotic use. We aimed to study antibiotic selection rationale, empirical therapy, and use of cultures in Maputo Central Hospital, Maputo, Mozambique. Methods We recruited adults admitted to Maputo Central Hospital's medical wards between February and April, 2018, and who were prescribed antibiotics. We collected data from patient charts and prescription sheets and studied the profile of acute bacterial infections, antibiotic treatment choices, and possible treatment errors. Findings We included 232 patients (12·5% of admissions). Of these, 143 (61·6%) were HIV infected, more than half (64%) with a CD4 count of less than 200 cells/μL. Diagnosed infections included: community-acquired pneumonia (106 patients [44·1%]), bacterial meningitis (50 [15·1%]), aspiration pneumonia (42 [12·7%]), acute enteritis (38 [11·5%]), chronic enteritis (7 [2·1%]), urinary tract infection (19 [5·7%]), soft tissue infections (10 [3%]), sepsis (11 [3·3%]), brain abscess (3 [0·9%]), neutropenic fever (3 [0·9%]), and otitis with effusion (1 [0·9%]). Antibiotics were prescribed for 52 patients (22·4%) who did not have a recorded infection on the medical chart. Eight prescriptions were meant for infection prophylaxis in patients with hepatic encephalopathy, stroke, diabetic ketoacidosis, or haematological malignancies. Of the included inpatients, 12·1% (28) died, 77·2% (179) were discharged home improved, 10·8% (25) transferred to lower acuity hospitals, and 4·3% (10) transferred to a tuberculosis hospital. We identified 347 prescriptions for the 232 patients. One antibiotic was prescribed in 56·9% (132) of cases and two or more were prescribed to 37·1% (86) and 6% (14), respectively. Ceftriaxone (176 prescriptions [50·7%]) and metronidazole (57 [16·4%]) were most frequently prescribed. We identified 46 prescriptions (12·7%) for patients with no indication recorded on their chart. In 42 cases (12%), the antibiotic choice was not consistent with international guidelines. Incorrect duration of therapy was specified in 8 cases (2%). Glomerular filtration rate estimations were seldomly used to adjust dosage. Blood cultures were rarely ordered (2 [0·86%]). CSF was cultured in 38 patients, with no positive findings. Interpretation A scarcity of antimicrobial drugs, shortages of qualified staff, a lack of local stewardship of antimicrobial programmes, and poor laboratory capacity encourage the overuse of empirical treatment rather than treatment decisions based on evidence and laboratory findings. Findings suggest the need for continued education, and accurate and updated hospital antimicrobial resistance algorithms for best clinical practices. Funding Fogarty International Center from the NIH D43TW009343 and the UCGHI.

A High Incidence of Multidrug Resistant Strains as the Agents Causing Bloodstream Infection in Hospital in Indonesia

Background: Various bacteria have been identified as the agents causing bloodstream infection. Multidrug resistant (MDR) strains, such as Gram-negative pathogens producing extended-spectrum beta-lactamases (ESBL) and Methicillin-resistant S.aureus (MRSA) are potential bacterial agents causing bloodstream infection in the hospital setting. The increase of these MDR strains in bloodstream infection is alarming since there are limited antibiotic choices for treatment. This study aimed to investigate the agents causing bloodstream infection and to investigate their antibiotics susceptibility profiles. Subjects and Method: Samples were venous blood collected from patients admitted to hospital from January 2014 to December 2016. Bacteria were grown in-automated BACTEC® blood culture (BD, New Jersey, USA). The identification of MRSA strain was conducted using oxacillin susceptibility test. The bacterial identification and identification of ESBL-producing bacteria was conducted using colorimetric assay using Vitek2®system (bioMerieux). Results: The antibiotic profiles of all bacteria isolated from venous blood samples were analysed. The most bacteria isolated from the blood stream were K. pneumonia, A. baumannii, E. coli, P. Aeruginosa, E. cloacae, S. marcennes, S. haemolyticus, S. hominis, S.epidermidis, and S. aureus. Conclusions: The resistant profiles of bacteria isolated from blood stream showed that there was a high incidence of MDR bacteria, including potential ESBL-producing bacteria, carbapenemase-producing bacteria and MRSA strains. Keywords: Bloodstream Infection, Staphylococcus aureus, Extended Spectrum Betalactamase, Antibiotic Resistance. Correspondence: Betty Suryawati. Department of Microbiology, Faculty of Medicine, Universitas Sebelas Maret, Jl. Ir. Sutami No 36A, Surakarta 57126, Central Java, Indonesia. Email: betty.suryawati@staff.uns.ac.id. Indonesian Journal of Medicine (2019), 4(1): 28-34 https://doi.org/10.26911/theijmed.2019.04.01.05

Effects of Diagnostic Work-Up on Medical Decision-Making for Canine Urinary Tract Infection: An Observational Study in Danish Small Animal Practices.

BackgroundClinical signs of urinary tract disease in dogs often lead to prescription of antibiotics. Appropriate diagnostic work‐up could optimize treatment and reduce the risk of inappropriate use of antibiotics.Hypothesis/ObjectivesTo describe and evaluate the impact of diagnostic work‐up on decision to treat (DTT) and choice of antibiotic treatment (COT) for dogs presenting with clinical signs of urinary tract disease.AnimalsOne hundred and fifty‐one dogs presenting to 52 Danish veterinary practices.MethodsProspective, observational study. Clinical signs, diagnostic work‐up, and prescriptions were recorded. Urine samples were submitted to a reference laboratory for quantitative bacterial culture (QBC) and susceptibility testing. The laboratory results were used as reference for assessing the appropriateness of DTT and COT.ResultsIn the majority of dogs, veterinarians performed dipstick (99%), microscopic examination of urine (80%) and bacterial culture (56%). Fifty‐one percent of dogs had urinary tract infection (UTI) based on reference QBC. Appropriate DTT was made for 62% of the dogs, while 36% were over‐prescribed and 2% under‐prescribed. Inappropriate use of second‐line agents was found in 57% of the UTI cases. Performing microscopy—but not culture—significantly impacted DTT (P = 0.039) while no difference was seen in COT (P = 0.67). The accuracy of in‐house microscopy and culture were 64.5 and 77%, respectively. Conclusions and Clinical Importance: Over‐prescription of antibiotics was common among dogs with suspected UTI, regardless of the diagnostic work‐up performed. Test inaccuracy under practice conditions and incoherence between diagnostic test results and decision‐making both explained inappropriate and unnecessary use of antibiotics.

Treatment with macrolides and glucocorticosteroids in severe community-acquired pneumonia: A post-hoc exploratory analysis of a randomized controlled trial.

BackgroundSystemic corticosteroids have anti-inflammatory effects, whereas macrolides also have immunomodulatory activity in addition to their primary antimicrobial actions. We aimed to evaluate the potential interaction effect between corticosteroids and macrolides on the systemic inflammatory response in patients with severe community-acquired pneumonia to determine if combining these two immunomodulating agents was harmful, or possibly beneficial.MethodsWe performed a post-hoc exploratory analysis of a randomized clinical trial conducted in three tertiary hospitals in Spain. This trial included patients with severe community-acquired pneumonia with high inflammatory response (C-reactive protein [CRP] >15 mg/dL) who were randomized to receive methylprednisolone 0.5 mg/kg/tpd or placebo. The choice of antibiotic treatment was at the physician's discretion. One hundred and six patients were classified into four groups according to antimicrobial therapy combination (β-lactam plus macrolide or β-lactam plus fluoroquinolone) and corticosteroid arm (placebo or corticosteroids). The primary outcome was treatment failure (composite outcome of early treatment failure, or of late treatment failure, or of both early and late treatment failure).ResultsThe methylprednisolone with β-lactam plus macrolide group had more elderly patients, with comorbidities, and higher pneumonia severity index (PSI) risk class V, but a lower proportion of intensive care unit admission, compared to the other groups. We found non differences in treatment failure between groups (overall p = 0.374); however, a significant difference in late treatment failure was observed (4 patients in the placebo with β-lactam plus macrolide group (31%) vs. 9 patients in the placebo with β-lactam plus fluoroquinolone group (24%) vs. 0 patients in the methylprednisolone with β-lactam plus macrolide group (0%) vs. 2 patients [5%] in the methylprednisolone with β-lactam plus fluoroquinolone group overall p = 0.009). We found a significant difference for In-hospital mortality in the per protocol population (overall p = 0.01). We did not find significant differences in treatment failure, early or late; or In-hospital mortality after adjusting for severity (PSI), year and centre of enrolment.ConclusionsIn this exploratory analysis, we observed that the glucocorticosteroids and macrolides combination had no statistically significant association with main clinical outcomes compared with other combinations in patients with severe community acquired pneumonia and a high inflammatory response after taking account potential confounders.Trial registrationClinicaltrials.gov NCT00908713.

Diagnostic accuracy of various modalities relative to open bone biopsy for detection of long bone posttraumatic osteomyelitis.

Long bone posttraumatic osteomyelitis (PTOM) is a relatively common complication following surgical fixation of open fractures. There is a lacking consensus on ideal strategies for diagnostic evaluation of long bone PTOM. While open bone biopsy and culture is considered the 'gold diagnostic standard,' its cost and invasiveness are often prohibitive and have prompted the search for alternate diagnostic methods. To evaluate the sensitivity and specificity of various diagnostic modalities relative to open bone biopsy and culture for the detection of long bone PTOM. Retrospective cohort study; Level of Evidence, III. Urban Level I trauma center and safety-net institution. A consecutive cohort of 159 adult patients presenting with long bone PTOM at our Level I trauma center between January 1, 2004, and December 31, 2013, were retrospectively identified. All included patients fulfilled diagnostic criteria for PTOM (as defined by the Center for Disease Control and Prevention) that involved a long bone (femur, fibula, tibia, humerus, radius, and ulna). Patients with diabetic foot infection, septic arthritis, osteomyelitis of the spine/pelvis/hand, or insufficient medical records were excluded. Sensitivity and specificity of deep wound culture, soft tissue histopathologic examination, and elevated levels of acute phase reactants [C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and leukocyte count (WBC)] were determined using findings of open bone biopsy and culture as a reference standard. The most common pathogen isolated on open bone culture was staphylococci, contributing to 89 (57%) of 159 cases of long bone PTOM (p<0.001). Relative to open bone biopsy and culture as the gold diagnostic standard, soft tissue histopathology demonstrated a sensitivity of 69.8% [95% confidence interval (CI) 53.7-82.3%] and specificity of 38.9% (95% CI 18.3-63.9%) for the detection of long bone PTOM. Deep wound culture exhibited a lower sensitivity of 66.0% (95% CI 56.1-74.8%) and specificity of 28.1% (95% CI 12.9-49.5%), a difference that was statistically significant (p=0.021). Among inflammatory markers, elevated levels of CRP and ESR were equally sensitive for the detection of PTOM compared to open bone biopsy and culture, while WBC was significantly less sensitive (sensitivity 33.2%; 95% CI 25.3-43.7; p<0.001). Soft tissue histopathologic examination and deep wound culture are relatively poor substitutes for the diagnosis of long bone PTOM compared to open bone biopsy and culture. The accurate identification of causative pathogens underlying long bone PTOM is critical for diagnosis and choice of antibiotic treatment. Future studies investigating the use of higher-resolution diagnostic methods are merited.

Correction: A Cross-Sectional Study of Colonization Rates with Methicillin-Resistant Staphylococcus aureus (MRSA) and Extended-Spectrum Beta-Lactamase (ESBL) and Carbapenemase-Producing Enterobacteriaceae in Four Swiss Refugee Centres

[This corrects the article DOI: 10.1371/journal.pone.0170251.].

The most appropriate therapeutic strategy for acute lower respiratory tract infections: a Delphi-based approach

Lower respiratory tract infections (LRTIs) cause high morbidity and mortality worldwide. Empiric therapy often base the choice of antibiotic treatment on antibacterial spectrum of the agent rather than on its pharmacological properties or the pathogen resistance profile. Inappropriate prescribing leads to therapeutic failure and antibiotic resistance, with increasing direct and indirect health costs. A consensus on appropriate prescribing in LRTI therapy was appraised by this Delphi exercise, based on a panel of 70 pulmonologists, coordinated by a Scientific Committee of nine experts in respiratory medical care. Full or very high consensus was reached on several issues, including the role of oral cephalosporins in first-line treatments of LRTIs and the appropriateness of cefditoren, with balanced spectrum and high intrinsic activity, in LRTI treatment. Evidence-based medicine approach and a comprehensive process of disease management, from diagnosis to therapy and follow-up, should guide antibiotic prescribing.

A Cross-Sectional Study of Colonization Rates with Methicillin-Resistant Staphylococcus aureus (MRSA) and Extended-Spectrum Beta-Lactamase (ESBL) and Carbapenemase-Producing Enterobacteriaceae in Four Swiss Refugee Centres.

BackgroundThe recent crisis of refugees seeking asylum in European countries challenges public health on many levels. Most refugees currently arrive from Syria, Afghanistan, or Eritrea. Data about multidrug resistant bacteria (MDR) prevalence are not present for these countries. However, when entering the European heath care systems, data about colonisation rates regarding highly resistant bacterial pathogens are important.MethodsWe performed a cross-sectional screening in four Swiss refugee centres to determine the colonization rates for MRSA and ESBL- and carbapenemase-producing Enterobacteriaceae. We used pharyngeal, nasal, and inguinal swabs for MRSA and rectal swabs and urine for ESBL and carbapenemase screening using standard microbiological procedures. Whole genome sequencing (WGS) was used to determine the relatedness of MRSA isolates with high resolution due to a suspected outbreak.Results41/261(15.7%) refugees were colonized with MRSA. No differences regarding the country of origin were observed. However, in a single centre significantly more were colonized, which was confirmed to be a recent local outbreak. 57/241 (23.7%) refugees were colonized with ESBL with significantly higher colonisation in persons originating from the Middle East (35.1%, p<0.001). No carbapenemase producers were detected.ConclusionThe colonisation rate of the refugees was about 10 times higher for MRSA and 2–5 times higher for ESBL compared to the Swiss population. Contact precaution is warranted for these persons if they enter medical care. In cases of infections, MRSA and ESBL-producing Enterobacteriaceae should be considered regarding antibiotic treatment choices.

Prevalence of methicillin-resistant &lt;i&gt;Staphylococcus aureus&lt;/i&gt; and extended spectrum β–lactamase producers among bacteria isolated from infected wounds in a tertiary hospital in Ibadan City

Wound colonization by microorganisms is most frequently polymicrobial and incidences of high level resistance among bacterial isolates from wounds have been reported. Methicillin-resistant Staphylococcus aureus (MRSA) and extendedspectrum beta-lactamase (ESBL) producing Gram-negative bacteria both constitute serious challenge to physician in their choice of antibiotic treatment of infections caused by these bacteria. This study determined the antibiotic susceptibility profiles and prevalence of MRSA and ESBL producers among wound bacterial isolates from a tertiary hospital in Ibadan City. Forty (40) clinical bacterial isolates from five wound sources were collected from the Microbiology unit of the University College Hospital (UCH), Ibadan and were authenticated with standard bacteriological techniques. Antibiotic susceptibility test was done by disc-diffusion method using 19 antibiotics belonging to 12 classes. MRSA strains were detected by their resistance to cefoxitin and/or oxacillin antibiotics. Presumptive ESBL production was by double-disc synergy test using 30 μg cefotaxime and ceftazidime around 20/10 μg amoxicillin-clavulanic acid discs. ESBL confirmation was by minimum inhibitory concentration (MIC) using agar-dilution method. The authenticated isolates include Proteus spp (47.5%), Staphylococcus aureus (27.5%), Pseudomonas aeruginosa (12.5%), Klebsiella spp (7.5%), Acinetobacter baumanii (2.5%) and E. coli (2.5%). Distribution of the isolates collected according to wound sources includes: acute soft tissue wounds (35%), leg ulcer (32.5%), surgical wounds (17.5%), burn wounds (12.5%) and diabetic foot ulcer (2.5%). Distributions according to patients’ gender are: male (65%), female (35%), and according to age-groups are: 0 – 19 years (22.5%), 20 – 39 years (35%), 40 – 59 years (32.5%) and ≥ 60 years (10%). All (100%) the isolates were multidrug resistant (MDR) being resistant to ≥ 3 classes of antibiotics. Percentages of isolates resistance to each of the antibiotic include: piperacillin, piperacillin tozobactam and amoxicillin-clavulanic acid were 100%, ceftazidime, cefuroxime, cefixime, aztreonam, sulphamethoxazole-trimethoprim, erythromycin, chloramphenicol and doxycyclin were > 70%, cefoxitin (62.5%), Nitrofurantion (52.5%), ciprofloxacin (45%), ofloxacin (35%), perfloxacin (37.5%), gentamicin (32.5%) and imipenem (2.5%). Of the 11 Staphylococcus aureus collected, 54.5% were detected to be MRSA strains while ESBL production was detected in 55.2% of the Gram negative isolates. This study revealed 100% MDR phenotype constituting high level of MRSA strains (54.5%) and ESBL producers (55.2%) among Gram-positive and Gram-negative bacterial wound isolates respectively. Hence, this calls for caution in the use of extended spectrum antibiotics in treating patients with infected wounds.

PWE-047 Metronidazole is A Less Effective Therapy for Small Intestinal Bacterial Overgrowth

Introduction Choice of antibiotic treatment in patients who test positively for Small Intestinal Bacterial Overgrowth (SIBO) can be difficult. No controlled trial has examined the clinical efficacy of antibiotics in SIBO. This study aimed to identify which antibiotics are the most effective in treating SIBO in a real world retrospective cohort. Methods 520 adult patients (360 female, 160 male, mean age 49) who underwent hydrogen and glycocholate-methane breath tests for a suspicion of SIBO between the dates 01/01/2010 and 31/12/2013 were evaluated. The clinical information of patients who tested positively in both tests was recorded. Information was also gathered as to the antibiotic they were prescribed and whether they received symptomatic benefit from their treatment. Results A total of 90 patients who tested positive were prescribed antibiotics (59 female, 31 male, mean age 56). 69 (76.7%) of these patients benefitted from their management. 32 patients who tested positive were given cyclical antibiotics. The efficacy of cyclical antibiotics compared with the combined efficacy rates of other antibiotic regimes in treating patients with a positive breath test result was 93.8%. (93.8% vs 67.2%, Chi-square = 8.1, p = 0.004). 15 patients who tested positive were given rifaximin. The efficacy of rifaximin in treating patients with a positive breath test result compared with the combined efficacy of other antibiotic regimes was 80%. (80% vs 76% Chi-square = 0.112, p = 0.738). 18 patients who tested positive were given metronidazole. The efficacy of metronidazole in treating patients who tested positive in the breath tests compared with combined efficacy rates of other antibiotics was much lower at 50% (50% vs 83%, Chi-square = 8.9441, p = 0.0028). Conclusion Metronidazole appeared inferior to rifaximin monotherapy for treating SIBO. Cyclical antibiotics appeared most effective. These findings should be explored further in randomised controlled prospective trials to determine the optimal treatment regime. Disclosure of Interest None Declared

Uso de la terapia combinada en infecciones causadas por enterobacterias resistente a carbapenémicos desde un enfoque microbiológico: revisión sistemática

Introducción: las carbapenemasas representan actualmente una amenaza para la salud humana en todo el mundo y constituirán uno de los problemas más difíciles de tratar en los próximos años. Objetivo: describir del uso de la terapia combinada con carbapenémicos en las infecciones por enterobacterias resistente a carbapenémicos desde un enfoque microbiológico. Materiales y Métodos: se realizó una revisión sistemática en PubMed sobre estudios en humanos y modelos de infección múridos, publicados entre 2010 y 2016 en inglés. Los estudios debían reportar los resultados de mortalidad asociada según el esquema de monoterapia y terapia combinada con carbapenémicos. La búsqueda para la selección de los estudios se basó en las palabras clave: “Carbapenem Resistance AND carbapenems”, “treatment and outcomes carbapenems enterobacteriaceae”, “Klebsiella pneumoniae”, “carbapenemase”, “Klebsiella pneumoniae AND combination therapy”. Resultados: se seleccionaron cinco estudios que incluyeron en total 1.313 pacientes con infecciones por enterobacterias resistentes a carbapenémicos y que proporcionaban información sobre el uso de la terapia combinada con carabapenémicos frente a la monoterapia en términos de las tasas de mortalidad asociada. Conclusiones: actualmente no se dispone de estudios clínicos controlados publicados en el tema, por lo que la elección del tratamiento antibiótico frente a las infecciones por enterobacterias resistentes a carbapenémicos aún es controvertida. La evidencia clínica emergente sugiere que el uso de la terapia combinada resulta beneficioso para este tipo de infecciones. Hoy en día los clínicos optan por reutilizar viejos antibióticos como las polimixinas, a pesar de la resistencia codificada por el gen mcr-1 adquirida por plásmidos.&#x0D;

Diagnostic methods for mastitis in cows are not appropriate for use in humans: commentary.

Healthcare workers are now being targeted for marketing of diagnostic tools for mastitis that were developed for the dairy industry and which aim to provide information regarding choice of antibiotic treatment. Meanwhile, scientists are striving to understand how the human microbiome affects health and wellbeing and the importance of maintenance of bacterial balance in the human body. Breast milk supplies a multitude of bacteria to populate the baby’s intestinal tract and kick-start the immune system. Researchers propose a paradigm shift in the understanding of bacterial content in breast milk and an alternative paradigm for the understanding of lactational mastitis: there is the beginning of evidence that many cases of lactational mastitis will resolve spontaneously. An international group of researchers is attempting to answer how dietary habits, birth mode, genetics and environmental factors may impact the bacterial content of breast milk. Until we have more comprehensive knowledge about the human milk microbiome, diagnostic aids for identification of women in need of antibiotic therapy for mastitis remain unreliable. Diagnostic aids could lead to the injudicious use of antibiotic therapy, which in turn may rob the infant of bacteria valuable for development of its immune system. The marketing of diagnostic aids for use in human medicine, that were originally developed for use in cows, is neither evidence-based nor good ethical practice.