Effective Antimicrobial Use Research Articles

Escherichia coli pathotypes and Shigella sero-groups in diarrheic children in Nairobi city, Kenya.

In the present study, we investigated the prevalence of E. coli pathotypes and Shigella sero-groups and their antimicrobial profiles among diarrheic children in Nairobi city, Kenya. Although diarrheagenic E. coli pathotypes and Shigella sero-groups are leading causes of diarrhea in children under five years in developing countries, their distribution and antimicrobial resistance vary from place to place and over time in a given region. In a cross-sectional study, we enrolled diarrheic children (n=354) under five years seeking treatment at Mbagathi Hospital, Nairobi city, Kenya,. Stool samples were collected from all children for bacterial culture. Bacterial isolation and identification was performed by conventional microbiological methods. Polymerase chain amplification was used to detect aspU, aggR, andpcvd432 for EAEC, est and elt for ETEC, eae for EPEC, stx for EHEC, and ipaH for EIEC and Shigella species. Antimicrobial profile was determined by disk diffusion method. The prevalence of EAEC, ETEC, EPEC (eae), EIEC (ipaH) was 21.2%, 10.5%, 4.5%, and 0.6%, respectively, while that of mixed infection was 0.6%for ETEC/EAEC and 0.3%for EAEC/EPEC/ETEC. No EHEC strain was isolated. Pathogenetic analysis for EAEC showed that5.9% carried aspU,8.2% possessed both aspU and aggR and 7.1% had a combination of aspU, aggR andpcvd432 while that of ETEC was 2.3% for elt, 6.5% for both elt and est and 1.7% for est. The combination of aspU with aggR, elt and est, and pcvd432 with aggR, aspU and est was 0.3% for each case of ETEC/EAEC mixed infection. The aspU gene co-existed with aggR, pcvd432, eae and elt in the EAEC/EPEC/ETEC mixed infection. The prevalence of S. boydii, S. dysenteriae, S. flexneriand,S. sonnei was 0.8%, 0.6%, 1.7%, and 0.8%, respectively. No E. coli pathotype and shigella co-infection was detected. In addition, both E. coli pathotypes and Shigella species were resistant to ampicillin, trimethoprim/sulfamethoxazole, streptomycin, chloramphenicol and tetracycline while gentamycin and kanamycin resistance occurred in diarrheagenic E. coli. E. coli pathotypes and Shigella sero-groups harboring virulent genes are important causes of diarrhea in children in Kenya. The increasing spectrum of antibiotic resistance in diarrheagenic E. coli and Shigella species necessitates the development of antimicrobial stewardship education-programs to influence prescribing behavior as well as optimizing the use of effective antimicrobials in Kenya.

The challenges in creating an institution‐specific antibiogram based on blood culture isolates

AbstractEarly initiation of effective antimicrobial therapy reduces morbidity and mortality. Annual institution‐specific antimicrobial susceptibility tables or antibiograms can be used to guide empiric antimicrobial therapy and monitor resistance. This paper describes the development of an antibiogram for a metropolitan hospital based on the international standard CLSI M39 document. An antibiogram was created each year using positive blood cultures for the years 2009 to 2011, excluding coagulase‐negative staphylococcus isolates which were assumed to be contaminants. Duplicate isolates within a 30‐day interval were also excluded. Challenges included, for example, attaining all the relevant information from the laboratory information system in a usable format, and the need for significant manual manipulation of the data. The development of the antibiogram for our institution was driven by the pharmacy department as an initiative to improve appropriate and effective use of antimicrobials.

Administration of a survey to evaluate the attitudes of house staff physicians towards antimicrobial resistance and the antimicrobial stewardship programme at a community teaching hospital.

Antimicrobial stewardship programmes (ASPs) are used in numerous institutions in an effort to promote safe and effective antimicrobial use. The objectives of this study were to (i) assess physicians' perceptions, attitudes and knowledge about antimicrobial use, resistance and the ASP at The Brooklyn Hospital Center (TBHC) and (ii) measure physicians' beliefs and attitudes to the current system of prior authorisation of antimicrobials. A 75-item, anonymous, voluntary, traditional paper and pencil survey was distributed to resident physicians at TBHC. Multiple-choice, 5-point Likert scale and knowledge-based questions were utilised. Of the 261 residents, 129 (49%) completed the survey. The respondents significantly believed that antibiotics are overused more frequently nationally vs. locally [117/129 (91%) vs. 91/129 (71%); P=0.0001]. Although 49% (63/129) felt that other providers overprescribe antibiotics, only 26% (34/129) agreed that they themselves were contributing to the current problem (P=0.0003). Fifty-seven percent of respondents agreed that individual patient care is improved by having an antibiotic approval programme; however, 45% of respondents reported that the antibiotic approval programme limits their autonomy in choosing antibiotics. Compared with surgical residents, medical residents were more likely (33% vs. 13%; P=0.02) to feel that the antibiotic approval programme forced them to choose an inappropriate antibiotic. On the antibiotic knowledge assessment segment of the survey, there was no difference in score when stratified by specialty or years of postgraduate training. Based on the survey results, house staff are supportive of antimicrobial stewardship and feel that the ASP is valuable for patient care.

Reply to: Emphysematous pyelonephritis: a case report

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A Qualitative Analysis of Implementation of Antimicrobial Stewardship at 3 Academic Hospitals: Understanding the Key Influences on Success.

Inappropriate use of antimicrobials is linked to the development and spread of drug-resistant pathogens and is associated with increased morbidity, mortality, lengths of hospital stay, and health care costs. "Antimicrobial stewardship" is the umbrella term for an evidence-based knowledge translation strategy involving comprehensive quality improvement activities to optimize the use of antimicrobials, improve patient outcomes, reduce the development of antimicrobial resistance and hospital-acquired infections such as Clostridium difficile, and decrease health care costs. To assess the perceptions and experiences of antimicrobial stewardship program leaders in terms of clinicians' attitudes toward and behaviours related to antimicrobial prescribing. In this qualitative study, semistructured interviews were conducted with 6 antimicrobial stewards (2 physicians and 4 pharmacists) at 3 academic hospitals between June and August 2013. The following 3 key themes emerged from the interviews: getting the right people on board, building collegial relationships, and rapidly establishing a track record. The study results elucidated the role and mechanisms that the program leader and other antimicrobial stewards used to influence other clinicians to engage in effective utilization of antimicrobials. The results also highlighted the methods employed by members of the antimicrobial stewardship team to tailor their strategies to the local context and to stakeholders of participating units; to gain credibility by demonstrating the impact of the antimicrobial stewardship program on clinical outcomes and cost; and to engage senior leaders to endorse and invest in the antimicrobial stewardship program, thereby adding to the antimicrobial stewards' credibility and their ability to influence the uptake of effective antimicrobial use. Collectively, these results offer insight into processes and mechanisms of influence employed by antimicrobial stewards to enhance antimicrobial use among clinicians, which can in turn inform future implementation of antimicrobial stewardship and strategies for organizational change in hospitals.

New guidelines on antibiotic prescribing published

Antibiotic prescribing rates have continued to increase. The National Institute for Health and Care Excellence has issued guidance on the effective use of antimicrobials, with hopes of reducing unnecessary prescribing

Omitted doses as an unintended consequence of a hospital restricted antibacterial system: a retrospective observational study.

ObjectivesThe objective of this study was to determine the frequency of omitted doses of antibacterial agents and explore a number of risk factors, including the effect of a restricted antibacterial system.MethodsAntibacterial data were extracted from a hospital electronic prescribing and medication administration system for the period 1 January to 30 April 2014. Percentage dose omission rates were calculated. Omission rates for the first dose of antibacterial courses were analysed using logistic regression to identify any correlation between first dose omission rates and potential risk factors, including the antibacterials' restriction status and whether or not they were ward stock.ResultsThe study included 90 761 antibacterial doses. Of these, 6535 (7.2%) were documented as having been omitted; omission of 847 (0.9% of 90 761) was due to medication being unavailable. Non-restricted, ward stock antibacterials had the lowest frequency of omission, with 6.2% (271 of 4391) first doses omitted. The prevalence was 10.4% (27 of 260) for restricted, ward-stock antibacterials (OR = 1.6, 95% CI = 1.0–2.4, P = 0.027) and 15.5% (53 of 341) for non-restricted, non-ward stock antibacterials (OR = 2.7, 95% CI = 2.0–3.7, P < 0.001). Restricted, non-ward stock antibacterials had the highest frequency (30.7%, 71 of 231; OR = 6.2, 95% CI = 4.5–8.4, P < 0.001).ConclusionsAntibacterials not stocked in clinical areas were significantly more likely to be omitted. The prevalence of omitted doses increased further if the antibiotic was also restricted. To achieve safe, effective antimicrobial use, a balance is needed between promoting antimicrobial stewardship and preventing unintended omitted doses.

Outpatient parenteral antimicrobial therapy and antimicrobial stewardship: challenges and checklists.

Outpatient parenteral antimicrobial therapy (OPAT) has become, for many countries, an established form of healthcare delivery. At the same time, there have been calls to ensure the prudent use of the existing antimicrobial armamentarium. For OPAT, this presents a dilemma. On one hand, stewardship principles look for the most effective agent with minimal collateral effects. In OPAT, whilst the aims of the service are similar, convenience of dosing to optimize early hospital discharge or admission avoidance may take precedence over an agent's spectrum of activity. This brief article aims to highlight the importance and explore the challenges of antimicrobial stewardship in the context of OPAT. Within the UK, the safe and effective use of antimicrobials is modelled around the IDSA/Society for Healthcare Epidemiology of America stewardship practice guidelines with local customization where appropriate. Current UK stewardship practice principles were compared with published good practice recommendations for OPAT to identify how OPAT could support the broader antimicrobial stewardship agenda. It is essential that antimicrobial stewardship teams should understand the challenges faced in the non-inpatient setting and the potential benefits/lower risks associated with avoided admission or shortened hospital stay in this population. Within its limitations, OPAT should practise stewardship principles, including optimization of intravenous to oral switch and the reporting of outcomes, healthcare-associated infections and re-admission rates. OPAT should report to the antimicrobial stewardship team. Ideally the OPAT team should be formally represented within the stewardship framework. A checklist has been proposed to aid OPAT services in ensuring they meet their stewardship agenda.

Pharmacokinetic–pharmacodynamic (PK–PD) modeling and the rational selection of dosage regimes for the prudent use of antimicrobial drugs

One of the strategies to decrease inappropriate antimicrobial use in veterinary medicine is to apply pharmacokinetic–pharmacodynamic (PK–PD) principles to dosing regimens. If antimicrobials are used appropriately by applying these principles to attain targets for area-under-the-curve to MIC ratio (AUC/MIC), peak concentration to MIC ratio (CMAX/MIC), and time above MIC (T>MIC), more effective antibiotic therapy is possible, thus avoiding ineffective administration. Another mechanism whereby inappropriate antibiotic administration can be avoided is to use accurate Interpretive Criteria established by the Clinical Laboratory Standards Institute (CLSI) for breakpoint selection. Inaccurate breakpoints will encourage antibiotic administration that is likely to be ineffective. For newly approved antimicrobials, three criteria are used for determining breakpoints: PK–PD criteria, MIC distributions, and clinical response. For older (often generic drugs) evaluated by the CLSI, recent clinical data may not be available and breakpoints are derived from PK–PD principles, wild-type distributions, and Monte Carlo simulations. It is the goal of the CLSI subcommittee that these revised breakpoints will encourage more effective antimicrobial use and avoid unnecessary antimicrobial administration.

Achromobacter Xylosoxidans Late-onset Prosthetic Mitral Valve Infective Endocarditis: A Case Report

This is the case of a 35-year-old Filipino female who presented to the Philippine General Hospital with a chief complaint of fever. Two weeks prior to admission, she experienced high-grade fever (39 degrees Celsius) accompanied by chills, anorexia, and easy fatigability. A few hours prior to admission, she complained of slurred speech, right upper and right lower extremity weakness, and high-grade fever. She was diagnosed with rheumatic heart disease in the past, with mitral stenosis, and atrial fibrillation. She has undergone prosthetic mitral valve replacement. She denies intravenous drug use. On examination, she was awake, with stable vital signs and a body temperature of 39 degrees Celsius. Auscultation revealed an irregular heart rhythm, metallic S1, accentuated S2, and a 3/6 systolic murmur at the fourth left paqrasternal border. Motor strength was normal. She had leukocytosis (11.6 X 109 cells/L)þ and nromal coagulation profile. Transthoracic echocardiography revealed a dilated left atrium, a prosthetic mitral valve with good opening and closing motion, and a 0.2 x 0.4 cm oscillating mass in the ventricular aspect of the mitral valve. Blood cultures revealed Achromobacter xylosoxidans sensitive to piperacillina-tazobactam, co-trimoxazole, and ciprofloxacin. Piperacillin-tazobactam 4.5 g IV every 8 hrs and co-trimoxazole 800/160, 1 tab po every 8 hrs were given; however, due to resulting leukopenia, ciprofloxacin 500 mg/tab 1 ½ tab po q 12 hrs was substituted. Surveillance blood cultures were all negative. A follow-up transesophageal echocardiography revealed a prosthetic mitral valve with good opening and closing motion with no vegetations seen. CONCLUSION: A xylosoxidans is a rare human pathogen and causes invasive disease such as infective endocarditis in immunocompromised and debilitated patients resulting in high mortality. Prompt and effective use of antimicrobials improves survival, but removal of prostheses may be considered in the presence of unresponsive or recurrent infection. KEYWORDS: Achromobacter xylosoxidans, prosthetic valve, infective endocarditis

The effective use of antimicrobials

The effective use of antimicrobials

Basic Principles of Implementing an Antibiotic Optimization Program

Antimicrobial stewardship is an important and evolving aspect of patient care and safety programs in hospitals around the world. A team of involved specialists, including infectious diseases physicians, clinical microbiologists, hospital epidemiologists and others, is needed to address this complex problem. In United States a clinical pharmacist has been also claimed to collaborate in this kind of program, but in Latin America and other limited-resources areas, lack of appropiate personnel are part of the limitations to implementation. Two strategies, not to be exclusively applied, are proposed. Prospective audit with intervention and feedback is an option, while the use of formulary restriction and pre-authorization might be also used. The first strategy might be time consuming and requires a series of tools to succed. The implementation of the program requires administrative and economic support and the use of education, development of guidelines, antimicrobial order forms, de-escalation therapy (which requires an active participation of the microbiology laboratory), dose optimization, and switch to oral therapy. Effective use of antimicrobials but also prevention of resistance are the goals to achive in the individualised care of patients and new targets are being currently defined (pharmacodynamic objectives). Up to the moment more research is required to find the best ways to achieve these goals. Abstracts for SupplementInternational Journal of Infectious DiseasesVol. 14Preview Full-Text PDF Open Archive

Relation between the Antimicrobial Susceptibility of Clinical Isolates of Pseudomonas aeruginosa from Respiratory Specimens and Antimicrobial Use Density (AUD) from 2005 through 2008

To examine the relation between annual trends in the antimicrobial susceptibility of Pseudomonas aeruginosa and drug usage, we compared annual changes in the susceptibility rates of P. aeruginosa clinical isolates during a 4-year period and annual trends in the overall usage of antimicrobials during the same period. We studied annual trends in MIC(90)/MIC(50), antimicrobial use density (AUD), and antimicrobial susceptibility rates based on clinical breakpoints for 150 strains of P. aeruginosa isolated from respiratory specimens at Dokkyo Medical University Hospital from 2005 through 2008. The MIC(90)/MIC(50) of antimicrobials effective against P. aeruginosa in years 2005, 2006, 2007, and 2008 were as follows: imipenem, 32/2, 32/1, 8/2, and 16/1 microg/mL; meropenem, 8/1, 8/1, 4/0.5, and 4/0.5 microg/mL; and biapenem, 16/1, 32/0.5, 4/0.5, and 8/0.5 microg/mL, indicating that susceptibility to carbapenems increased slightly. The MIC(90)/MIC(50) was 4/0.25, 2/0.125, 1/0.125, and 2/0.25 microg/mL for ciprofloxacin, 8/4, 8/4, 4/4, and 8/4 microg/mL for amikacin, 64/16, 64/16, 64/16, and 64/16 microg/mL for sulbactam/cefoperazone, 8/2, 16/2, 32/2, and 8/2 microg/mL for ceftazidime, indicating little change. The AUDs of fourth-generation cephalosporins increased from 2005 to 2008 (16.2, 18.4, 28.0, and 23.0), while the AUDs of carbapenems decreased (25.7, 23.7, 10.9, and 12.5). The decrease in the AUDs of carbapenems was associated with increased susceptibility rates of P. aeruginosa to carbapenem derivatives. A continuous understanding of trends in the resistance of P. aeruginosa and various other pathogens is essential for designing countermeasures against nosocomial infections, including the proper and effective use of antimicrobials.

Use of Antibiotics in Agriculture

Representative Louise Slaughter (D-NY) seems to have a primary mission in Congress to eliminate the use of antibiotics in agriculture to save mankind from antibiotic-resistant bacterial infections. “Overuse of antibiotics on farms leads directly to antibiotic resistant pathogens,” as stated by Slaughter, is an oversimplification of the problem of antibiotic resistance. An opposing effect of widespread, untreated, animal diseases might be a result of Congress restricting or eliminating the use of effective antimicrobials in animals. A healthy animal is a healthy food source. Processed and USDA-inspected meat is relatively pure of bacteria; it is handling of the product that causes most contamination with bacteria. Many scientists have searched for data that would prove transmission of antibiotic-resistant bacteria from animals to humans, but significant occurrences have not been concluded. Most disturbing to me is the loss of many tons of meat to landfills from companies trying to appeal to the safety of consumers while most of the product would be greatly needed protein and nutritional source for the masses of malnourished people throughout the world. Good intentions can cause bad results, especially if made into a law.

Arzneimittelinteraktionen antimikrobieller Substanzen bei Kindern und Jugendlichen

Antimicrobial agents are among the most common therapeutics prescribed to children and adolescents with hematologic/oncologic disorders. Because of the polymorbid state of most patients, they are frequently administered concomitantly with other drugs, resulting in a considerable potential for drug interactions. While many of these interactions are of marginal clinical significance, others are associated with substantial risks of decreased therapeutic efficacy or increased drug toxicity. Prevention and recognition of drug interactions are therefore of vital importance to optimizing effective use of antimicrobials and enhancing patient outcome. Key to minimize drug interactions are a thorough understanding of the pharmacology of frequently used antimicrobial agents and a careful evaluation of risks and benefits of potentially interacting drugs. This article reviews mechanisms and clinical relevance of drug interactions of antimicrobial agents in the supportive care of children and adolescents with hematologic/oncologic disorders and provides strategies for their prevention.

Antimicrobial monitoring and evaluation

Effective antimicrobial use is an essential component of patient care. Drug use evaluation should include the prophylactic, therapeutic, and empiric use of antimicrobials. The infection control practitioner has the unique knowledge and skills in epidemiology to be effective in the monitoring and evaluation process. This review outlines a variety of techniques to monitor and evaluate trends in the use of antimicrobial agents in health care facilities. Methods related to antimicrobial monitoring and evaluation are summarized.

Policy issues concerning antimicrobials: controls on antimicrobial usage.

POUCY ISSUES CONCERNING ANTIMICROBIALS: CONTROLS ON ANTIMICROBIAL USAGE HAROLDJ. SIMON* The progressively worsening problems of microbial resistance to commonly used antimicrobials have led to continuous demands from clinicians for new ones. The pharmaceutical industry has responded with enthusiasm and imagination. In fact, by meeting design specifications, the newest agents expose our limited understanding of underlying biological principles [1-3]. As a consequence, the problem of resistance to antimicrobials, which has steadily worsened over the past three decades , may soon become insurmountable. Thus, unless drastic steps are taken in time, antimicrobial therapy as it has been practiced for the past 40 years may no longer be effective by the end of this decade [4-7]. If that comes about, the world will actually be worse off than before the advent of the antimicrobials because (1) there is now a much greater population of aged, infirm, and immunocompromised patients, (2) numerous advanced medical and surgical procedures depend for success on the appropriate use of effective antimicrobials, and (3) many other aspects of our daily lives—from food production, processing , and storage through the manufacture of vaccines—depend on antimicrobials. The problems of increasing resistance to antimicrobials are so urgent —and the traditional approaches of education and peer pressure are so ineffective in terms of limiting the promiscuous use of antimicrobials —that drastic measures are required to avert unprecedented misfortune . The far-reaching implications of resistance to the newer and newest agents necessitate a very hard look at (1) current antimicrobial treatment practices, (2) the policies and practices pertaining to the inThis paper was presented at the First International Symposium on Antimicrobial Therapy , heid in Rio de Janeiro, Brazil, in May 1983. ?Professor of international health policy and director of International Health Programs, University of California, San Diego, School of Medicine, La Jolla, California 92093.© 1985 bv The University of Chicago. All rights reserved. 003 1-5982/85/2802-0426$01 .00 Perspectives in Biology and Medicine, 28, 2 · Winter 1985 | 223 troduction and use of new drugs, (3) the education of medical students and physicians regarding the principles of antimicrobial therapy, (4) the kinds of information about antimicrobials provided to the general public, and (5) the possible need for professional and/or governmentally imposed controls on antimicrobial usage. These issues are clearly interrelated . The situation appears so urgent, however, that unusual and unusually drastic measures seem indicated to avoid the most serious consequences. Accordingly, this paper will focus on the issue of controls on antimicrobial use. A need for controls on antimicrobial use has always existed. That need has now become more urgent because abuse ofantimicrobials continues, educational efforts and governmental attempts to limit their use have largely failed, costs of antimicrobial therapy are escalating, and recently introduced antimicrobials pose entirely new threats. To a medical educator, the idea of controls on the use of antimicrobial therapy is abhorrent, as is the imposition of any external (i.e., extraprofessional ) controls on medical education or medical treatment; such measures appear to be the antithesis of education. Thus, mandatory requirements for clearance ofan antimicrobial prescription by a hospital pharmacist, or by a particular medical specialist who is not directly responsible for a patient's welfare, seem directly opposed to the tenets of professional responsibility and the objectives ofeducation. In the past 40 years, however, a period that comprises the era of modern antimicrobial therapy, the effectiveness of one antimicrobial after another has first been compromised and then destroyed within a few years after these drugs have been introduced into general use. In the industrialized countries, the selection pressures exerted by these agents have resulted in the accumulation of multiply resistant bacterial populations in hospitals. As a result, an infectious complication of a medical or surgical procedure can today be a matter of the greatest moment, causing much morbidity and significant mortality. Increasingly , community-acquired infections are also due to microorganisms resistant to those antibiotics which, until the relatively recent past, could be employed with a very high degree of assurance that the infecting agents would prove susceptible. This is especially true in the developing countries [7, 8], where the combination ofwidespread promiscuous prescribing of antimicrobials by physicians, unauthorized dispensing of these agents by pharmacists...

Acute osteomyelitis of the mandible

Antimicrobial stewardship programmes (ASPs) are used in numerous institutions in an effort to promote safe and effective antimicrobial use. The objectives of this study were to (i) assess physicians’ perceptions, attitudes and knowledge about antimicrobial use, resistance and the ASP at The Brooklyn Hospital Center (TBHC) and (ii) measure physicians’ beliefs and attitudes to the current system of prior authorisation of antimicrobials. A 75-item, anonymous, voluntary, traditional paper and pencil survey was distributed to resident physicians at TBHC. Multiple-choice, 5-point Likert scale and knowledge-based questions were utilised. Of the 261 residents, 129 (49%) completed the survey. The respondents significantly believed that antibiotics are overused more frequently nationally vs. locally [117/129 (91%) vs. 91/129 (71%); P = 0.0001]. Although 49% (63/129) felt that other providers overprescribe antibiotics, only 26% (34/129) agreed that they themselves were contributing to the current problem (P = 0.0003). Fifty-seven percent of respondents agreed that individual patient care is improved by having an antibiotic approval programme; however, 45% of respondents reported that the antibiotic approval programme limits their autonomy in choosing antibiotics. Compared with surgical residents, medical residents were more likely (33% vs. 13%; P = 0.02) to feel that the antibiotic approval programme forced them to choose an inappropriate antibiotic. On the antibiotic knowledge assessment segment of the survey, there was no difference in score when stratified by specialty or years of postgraduate training. Based on the survey results, house staff are supportive of antimicrobial stewardship and feel that the ASP is valuable for patient care.