Emergence Of Antimicrobial-resistant Pathogens Research Articles

Management of diseases in a ruminant livestock production system: a participatory appraisal of the performance of veterinary services delivery, and utilization in Ghana

IntroductionSustainable livestock production remains crucial for attainment of food security globally and for safeguarding the livelihoods of many households in low- and –middle income countries. However, the high prevalence of infectious livestock diseases, coupled with inadequate provision and adoption of effective control measures, leads to reduced livestock productivity, increased animal mortalities, and emergence of antimicrobial resistant pathogens. This study sought to assess the management strategies employed by farmers for priority diseases affecting their animals and the utilization and performance of veterinary services.MethodsWe conducted the study in three districts, namely, Mion, Pru East, and Kwahu Afram Plains South Districts, which represent the main livestock production belts in Ghana. We used questionnaires in surveys, to collect pertinent data from 350 ruminant livestock farmers and 13 professional veterinary officers (VOs) in the study districts. Additionally, we conducted seven focus group discussions (FGDs) with 65 livestock farmers in the study districts. The survey data was analyzed, and we describe the distribution of the priority livestock diseases, the disease management strategies employed, and the performance of veterinary services in Ghana. We also analyzed the raw FGD transcript texts deductively based on the study objectives. To validate findings across the different datasets, we used triangulation.ResultsAlmost all the farmers (98%) reared small ruminants, with about 25% also rearing cattle. The main priority livestock diseases identified includes pestes-des-petits-ruminants and mange infection in sheep and goats, as well as contagious bovine pleuropneumonia and foot-and-mouth-disease in cattle. We found that majority (82%) of the farmers relied on treatment, while only 20% opted for vaccination services. Additionally, the veterinary system in Ghana did not adequately regulate the antimicrobial medications employed by farmers to manage diseases. Thus, in most of the cases, the medicines applied by farmers were not useful for the target diseases. Although our findings show the farmers perceived VOs to perform highly compared to informal providers on most of the attributes evaluated including medicine availability and quality, treatment effectiveness, advisory services, service affordability, and competence, only 33% utilized VOs services. The majority of the farmers (51%) used the services of informal providers, who were better in proximity and popularity with farmers.ConclusionsThe livestock sector in Ghana faces a substantial challenge due primarily to vaccine-preventable diseases. Even though VOs demonstrated superior performance on key veterinary service performance indicators, their services are underutilized by livestock farmers. Additionally, the absence of regulatory oversight by the veterinary system over antimicrobials utilized in animal production contributes to their misapplication by livestock farmers, posing a considerable risk to both public health and food security. It is thus imperative to introduce new initiatives that enhance the uptake of animal vaccines and better antimicrobial stewardship to ensure sustainable livestock production.

The Economic Value of Antimicrobial Use in Livestock Production.

(1) Introduction: Antimicrobial agents have played an important role in improving the productivity of worldwide livestock production by reducing the impact of livestock diseases. However, a major drawback of antimicrobial use is the emergence of antimicrobial-resistant pathogens in food-producing animals. To reduce the use of antimicrobials, it is important to know the economic value of the use of antimicrobials and factors that determine that economic value. (2) Results: A theoretical framework was developed to assess the economic value of antimicrobial use. Three situations were distinguished: firstly, a baseline model for a farm with a conventional production system; secondly, an extension of the baseline model that includes the impact of production system improvements; and thirdly, an extension of the baseline model that includes the impacts of risk and risk attitude. This framework shows that the economic value of antimicrobial use is negatively affected by the price of productive inputs and damage-abatement inputs, and positively affected by the output price, the input-output combination, the damage abatement effect, risk aversion and variance in profit. (3) Conclusions: The theoretical framework presented in this study shows that there are several factors that (can) affect the economic value of antimicrobial use. The knowledge about the effect of these factors can be utilized to affect the economic value of antimicrobials and, consequently, affect antimicrobial use.

Mortality and Outcomes of Patients Infected with Extensively Drug-Resistant Bacteria Admitted to Intensive Care Units

Background: The emergence of antimicrobial-resistant pathogens in intensive care units (ICU) makes treatment of these infections very difficult. Objectives: This study aimed to survey the resistance phenotype, risk factors, and possible treatment options for hospital-acquired infections (HAI) at ICUs in a referral university hospital. Methods: Samples were prepared from ICU patients with HAIs. Pathogens were isolated, and the resistance phenotype, prescribed antibiotics, mortality rate, associated risk factors, and clonal relationship of the isolates were assessed. Results: From 100 patients admitted to ICUs, 76 (76%) showed clinical symptoms of HAIs. The most common sources of infection were lung secretions (51.8%). The isolated bacteria were Gram-negative (77, 90.6%) and Gram-positive (9.4%). The most common isolated microorganism was the Acinetobacter baumannii complex (63.5%). The most effective antimicrobials were colistin (96.1%) and linezolid (100%) for Gram-negative and Gram-positive isolates, respectively. An extensively drug-resistant (XDR) phenotype was documented in all isolates of A. baumannii, Pseudomonas aeruginosa, and Serratia marcescens. The XDR phenotype was a significant risk factor only for mortality. A. baumannii had the highest mortality rate (66.6%) among all the isolates. While A. baumannii strains had limited diversity, the other species were highly divergent. Conclusions: The results revealed a high mortality rate for Gram-negative isolates, especially in adenosine triphosphate-binding cassette (ABC). The high genetic similarities of ABC strains might be an indication of neglecting infection control prevention. The use of cotrimoxazole and colistin instead of carbapenems can be promising for mortality reduction in the studied ICUs.

Antimicrobial use in ecolabel certified and non-certified yellowtail (Seriola quinqueradiata) aquaculture in Japan

Given the emergence of antimicrobial-resistant pathogens in aquaculture worldwide, overuse of antimicrobials must be avoided to enhance sustainability in aquaculture. Although the actual usage of antimicrobials has been disclosed in some cultured species, such as salmon, this information is not always available for other species. In this study, with the cooperation of yellowtail farms in Japan, the actual usage of antimicrobials for commercially cultured yellowtail was investigated. In a survey of 28 net pens of cultured yellowtail, an average of 0.95 g (95 % confidence interval 0.78–1.11) of total antimicrobials was used per kilogram of cultured yellowtail. Each of the antimicrobials is listed as a critically or a highly important antimicrobial by the World Health Organization. A comparison of fish cultured according to the sustainability standard established by the Aquaculture Stewardship Council (ASC) with those not cultured according to the standard showed that the total quantity of antimicrobials used was significantly lower for the former than for the latter. However, the quantity of antimicrobial use even for ASC-certified yellowtail was still higher than that for other cultured species. Therefore, further and sustained efforts to reduce antimicrobial use are needed.

Antimicrobial resistance of bacteria isolated at the European Gaza Hospital before and after the Great March of Return protests: a retrospective study

BackgroundThe emergence of antimicrobial resistant pathogens is a serious health threat that leads to increased mortality. In 2019, the European Gaza Hospital released medical reports that indicated high multiresistant bacterial isolates during the period of Great March of Return (GMR) Gaza Strip border protests in 2018–19. We investigated resistance to commonly used antibiotics of bacteria isolated at the European Gaza Hospital in the Gaza Strip for 6 months before and 6 months after the GMR. MethodsThis was a retrospective study done in European Gaza Hospital, which covers three of the five governorates in Gaza Strip. We obtained routine microbiology laboratory results from pus and swab cultures recorded between Aug 1, 2017, and Aug 1, 2018. Data were cross-tabulated and assessed with the χ2 test in SPSS version 26.0. Ethics approval was obtained from the Palestinian Ministry of Health. Data were anonymised and, therefore, consent was waived for this study. Result628 clinical isolates were analysed, 310 (49%) from before and 318 (51%) from after the GMR. 192 (31%) samples were recovered from people injured during the GMR. The predominant Gram-positive isolate recovered was Staphylococcus aureus (144 [23%] of 628 samples). Among Gram-negative bacteria, Pseudomonas aeruginosa was the most common (138 [22%] of 628 samples), followed by Klebsiella sp (113 [18%]), and Acinetobacter sp (56 [9%]). Increases in resistance to antibiotics among non-injured patients were seen after the GMR compared with before. For example, resistance to amikacin was 30% before the GMR and 70% after (percentage increase 133%), to doxycycline was 35% and 65%, respectively (increase 87%), and to gentamicin was 16% and 84%, respectively (increase 421%). Striking increases in resistance were also seen among isolates from injured patients, ranging from 4% to erythromycin to 300% to aztreonam and nalidixic acid when compared with isolates from non-injured patients. InterpretationThe increase in resistance of bacterial isolates after the GMR might have been due to infections with new bacterial strains that spread easily among patients because of limited human resources, huge numbers of casualties, and improper infection control measures. Regulation of antibiotic prescriptions and use should be enforced to reduce the emergence of resistance. The indiscriminate use of antibiotics should be discouraged through awareness campaigns. FundingNone.

Residuos de antimicrobianos encontrados en aves de corral comercializadas en tiendas minoristas de la zona Metropolitana de Guadalajara, Jalisco

The increased demand to produce large quantities of meat and animal products for human consumption has promoted the indiscriminate use of antimicrobials. The increased use of these substances in the production of poultry, has negative consequences on Public Health due to the fact that the accumulation of antimicrobial residues in the organs and tissues of poultry might reach the consumer. The presence of antimicrobial residues can cause problems of hypersensitivity in humans, or the emergence of antimicrobial resistant pathogens. The purpose of this work was to assess the presence of antimicrobial residues in kidney and muscle tissue of poultry, commercialized in four municipalities of the Metropolitan Area of Guadalajara, Jalisco. The results show that kidney samples had a higher number of positive results compared to muscle tissue. Inhibitors of the folate pathway (sulfamethazine) were the antimicrobials with the highest number of positive results in kidney samples. In contrast, in muscle tissue, β-Lactam (penicillin) were the antimicrobials with the highest number of positive samples. Regarding the analysis of the results by municipalities, it was observed that one of them showed a greater number of positive samples for all the classes of antimicrobials evaluated. This work shows the presence of antimicrobial residues in kidney and muscle tissues of poultry, commercialized in retail sites. Therefore, it is necessary to increase efforts to monitor and control the use of antimicrobial in poultry farms.

SURGICAL SITE INFECTIONS AFTER NEUROSURGICAL PROCEDURES IN UKRAINE: RESULTS OF A MULTICENTER STUDY (2018-2020)

The aim: To obtain the first estimates the incidence of surgical site infection in patients undergoing neurosurgical procedures and antimicrobial resistance of responsible pathogens, and determine their impact on inpatient mortality in Ukraine. Materials and methods: We performed a multicenter prospective study was patient-based data of SSIs were according to CDC/NHSN methodology. This study included patients undergoing a neurosurgical procedure in 11 tertiary care hospitals from different regions of Ukraine from January 1st, 2018 to December 31st, 2020. Results: A total of 1697 neurosurgical procedures associated with a 90-day SSI were identified (19.4% of 8741 procedures). Of these, 69.5% SSI were identified after craniotomy and 30.5% after ventricular shunt. The Meningitis or ventriculitis (20.9%) were found to be the most common underlying condition among these patients followed by Intracranial infection (18.7%), and Osteomyelitis (14.6%) congenital malformation. Over a 90-day surveillance period, 387 died (4.4%). Fifty seven percent of deaths in SSI patients were attributable to infection. Meningitis or ventriculitis and Intracranial infection were associated with a higher mortality. Craniotomy was associated with a higher mortality more frequently than did Ventricular shunt. Escherichia coli were most commonly reported, accounting for 26.3% of all organisms, followed by Staphylococcus aureus, Enterobacter spp., Pseudomonas aeruginosa, Enterococcus spp., and Klebsiella pneumoniae. Meticillin resistance was found in 33.7% of S. aureus isolates, and vancomycin resistance was found in 12.7% of enterococci. Conclusions: The incidence of SSI and mortality after neurosurgical procedures in Ukraine is high. This is due to increase emergence of antimicrobial-resistant pathogens and risk factors in neurosurgery patients.

A Multicenter Point-Prevalence Survey of Antibiotic Use in Haiti, June–August 2019: Findings and Implications

Background: Inappropriate use of antibiotics in hospitalized settings contributes to the selection and emergence of antimicrobial-resistant pathogens. This trend is particularly challenging in resource-constrained settings where the high burden of infectious diseases, combined with suboptimal infection prevention and control measures, are further complicated by limited access to reliable microbiological services to inform antimicrobial prescription at the patient level. In this study, we describe the use of antibiotics in selected Haitian hospitals; we aimed to create a baseline to inform antimicrobial stewardship interventions. Methods: WHO/PAHO Hospital Antibiotic Use Point Prevalence Survey (HAMU-PPS) were conducted in 6 acute-care Haitian hospitals: La-Paix and Hospital-Albert (June 2019) and Hospital-Universitaire-Justinien, Hospital-Bienfaisance-de-Pignon, Hospital-Sacre-Coeur-de-Milot, and Hospital Immaculee-Conception-des-Cayes (July-August 2019) in 6 different cities. Trained data collectors completed electronic forms using REDCap software including data related to antibiotic use, indications, and utilization of laboratory services from medical records of all inpatients meeting study inclusion criteria. Analyses were done using Microsoft Excel software (v2016). Results: In total, 510 inpatients records were surveyed. Patients ages ranged from 0 to 92, with median age of 27 years (IQR, 4–47); 269 were women (57.7%) and 239 were men (46.9%). The prevalence of antibiotic use was 73% (95% CI, 68.2%–81.8 %); this prevalence was 74.5% among men (178 of 239) and 70.6% among women (190 of 269). The highest antibiotic use was observed among children aged <1 year (98 of 108, 90.7%). Of the patients on antibiotics, 63% were treated with >1 antibiotic. In addition, 384 indications for antibiotic prescription were reported. Of the indications for antibiotics therapy, 49.7% (191 of 384) were for treatment, and 49% (188 of 384) were for prophylaxis. Of the treatments, 92% were empiric with 6% reported as targeted. Only 13% (50 of 370) of the patient records indicated that samples were taken for microbiological identification. Of those, 9 had results for culture, and 1 had results for drug susceptibility. The most commonly reported antibiotic was ceftriaxone (n = 110, 23%) followed by ampicillin (n = 153, 21.4%) and metronidazole (n = 135, 20%). Conclusions: This study shows high use of antibiotics among hospitalized patients in Haitian hospitals, especially in children aged <1 year. Almost all the antibiotics were prescribed as either empiric or prophylaxis therapy, with very few microbiology samples collected. These results suggest limited laboratory corroboration across hospitals to inform antibiotic use. Implementation of antimicrobial stewardship interventions is recommended to optimize antibiotic therapy and to mitigate antimicrobial resistance in hospital care settings, but adaptation of the methodology should be done in settings with limited laboratory capacity.Funding: NoneDisclosures: None

Surveillance of organisms and their drug sensitivity patterns in orthopaedics post surgical patients at a tertiary care teaching hospital

Background: Among the Health care associated infections (HAI), orthopaedic surgical site infections (OSSI) previously termed as post-operative wound infections are one of the most common HAI in low and middle income countries. Increase in OSSI is associated with increased morbidity, as well as mortality due to emergence of antimicrobial resistant pathogens. Understanding the pathogens implicated in causing the OSSIs and their antimicrobial sensitivity place a good role in reducing the mortality and morbidity. Methods: A prospective study was conducted at a tertiary care hospital to all the patients admitted in Department of Orthopaedics for 2 years from January 2017 to December 2018. The demographic data, inclusion criteria and exclusion criteria, risk factors, clinical history, laboratory data with gram stain, culture results and antibiotic sensitivity of the isolates were collected.Results: Two hundred patients were recruited in the study and the prevalence of OSSI in the study was 3.83%. Patients who underwent emergency operations and diabetics were at higher risk of acquiring OSSI. The most commonly isolated pathogens in the study were Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa. Pseudomonas aeruginosa was most common isolate from orthopaedic cases of OSSI.Conclusions: Study clearly explains the various causes and risk factors associated in development of OSSI. The study guides in the type of the organism isolated and possible antibiotic of choice in treatment and management of OSSI. The prevalence of OSSI was 3.83%, which is comparable with some of the studies and lower than many of the studies.

A prospective study of surgical site infections in a tertiary care hospital

Background: Among the Health care associated infections (HAI), surgical site infections (SSI) previously termed as post-operative wound infections are one of the most common HAI in low and middle income countries. Increase in SSI is associated with increased morbidity, as well as mortality due to emergence of antimicrobial resistant pathogens. Understanding the pathogens implicated in causing the SSIs and their antimicrobial sensitivity place a good role in reducing the mortality and morbidity.Methods: A prospective study was conducted at a tertiary care hospital to all the patients admitted in Department of surgery, Orthopedics and Gynecology and Obstetrics for six months from January 2016 to June 2016. The demographic data, inclusion criteria and exclusion criteria, risk factors, clinical history, laboratory data with gram stain, culture results and antibiotic sensitivity of the isolates were collected.Results: Two hundred patients were recruited in the study and the prevalence of SSI in the study was 3.83%. Patients who underwent emergency operations and diabetics were at higher risk of acquiring SSI. The most commonly isolated pathogens in the study were Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa. Pseudomonas aeruginosa was most common isolate from orthopedic cases of SSI, Escherichia coli was most common isolate from intestinal surgeries and Staphylococcus aureus from LSCS. Increased rate of isolation of MRSA and ESBL strains were observed in the study.Conclusions: Study clearly explains the various causes and risk factors associated in development of SSI. The study guides in the type of the organism isolated and possible antibiotic of choice in treatment and management of SSI. The prevalence of SSI was 3.83%, which is comparable with some of the studies and lower than many of the studies.

Understanding stewardship

Calf-raising operations provide a unique microbial niche where immature intestinal flora, dense animal populations, and frequent application of antimicrobials may facilitate the emergence of antimicrobial resistant pathogens. In the US, producers report that 18% of calves receive an antimicrobial for diarrhea prior to weaning, often with antimicrobials designated as "critically important" to human medicine. The overall objective for this research was to understand the decision criteria for antimicrobial use for calf diarrhea. We hypothesized that selective antimicrobial use is associated with herd-level predictors, including the presence of veterinarian-written treatment protocols and producer attitudes about the impact of antimicrobial use in livestock.

Antibacterial and anti-biofilm effects of a polyherbal formula and its constituents against coagulase-negative and -positive staphylococci isolated from bovine mastitis

ABSTRACTConcerns about antibiotic residues in milk and emergence of antimicrobial resistant pathogens necessitate exploration of alternative therapeutic strategies for the treatment of mastitis. This study aims to investigate anti-infective properties of a Thai traditional polyherbal formula, namely Ya-Sa-Marn-Phlae (YSMP), its herbal components (Curcuma longa, Areca catechu, Oryza sativa, and Garcinia mangostana), and representative chemical constituents (catechin, α-mangostin, and curcumins). Ethanol extracts of YSMP and G. mangostana, and α-mangostin exhibited potent antibacterial effects against Staphylococcus spp. isolated from mastitis cows with MIC values of 1–32 µg/mL. These tested agents inhibited biofilm formation of the isolates on both polypropylene (hydrophobic) and glass (hydrophilic) surfaces. The current study indicated that YSMP had strong antibacterial activity and anti-biofilm abilities against the tested isolates similar to that of α-mangostin and G. mangostana. The anti-staphylococcal effects were confirmed with both scanning and transmission electron microscopes. The main abnormalities in the microstructure of the treated cells were the severe alterations of the cell wall with the formation of holes and morphological disorganization. Therefore, it might be proposed that G. mangostana is the major active component of YSMP and α-mangostin may be used as an active marker compound for YSMP to indicate its activity against bovine mastitis-isolated staphylococci.

Occurrence and antimicrobial susceptibility pattern of ESBL-producers among Gram-negative bacteria isolated from burn unit at the Al Shifa hospital in Gaza, Palestine : A short original article

AbstractBackground: Infection is an important cause of death in burns. The emergence of antimicrobial resistant pathogens like ESBL producers is leading to inappropriate/or treatment failure and increased morbidity and mortality.Objective: the purpose of this study was to determine the antimicrobial susceptibility pattern with the identification of Extended spectrum Beta-lactamase (ESBL) producers among pathogens isolated from burn patients at Al-Shifa burn unit in Gaza, Palestine.Methods: A total of 40 gram-negative bacterial isolates were obtained from burn wound patients at Al-Shifa Hospital burn unit from August 2012 to December 2012. Antibiotic susceptibility profiles were determined by the standard disc diffusion method according to CLSI guidelines. The ESBL detection was screened by using double disc diffusion method.Results: Pseudomonas aeruginosa was the predominant isolate 15 (37.5%) followed by Klebsiella pneumoniae 10 (25%), Escherichia coli 9 (22.5%), Enterobacter cloacae 4 (10%) and Acinetobacter baumannii 2 (5%). ESBL was detected in 37.5% of isolates. Most of ESBL-producing isolates were susceptible to meropenem and imipenem (80% and 73% respectively). However, ESBL producing isolates showed 100% resistance against cefotaxime, followed by ampicillin with 93.3% resistance. The resistance rate towards sulfamethoxazole/trimethoprim, tetracycline, cefepime, tobramycin and aztreonam was 80%, 73.3%, 66.7%, 60% and 60% respectively. A. baumannii isolates were resistance to all tested antibiotics.Conclusion: P. aeruginosa is the most common bacteria isolated from burn wound patients. The frequency of ESBL among gram-negative bacteria is high. Carbapenems including imipenem and meropenem remain the most effective treatment options against gram-negative producing ESBL isolated from Al-Shifa burn unit.

As C. difficile Increases, Vigilance Is Called For

NASHVILLE, TN – Clostridium difficile infection remains the primary cause of infectious diarrhea in long-term care facilities, and its incidence and severity are increasing, according to Laurie Archbald-Pannone, MD, MPH, of the University of Virginia, Charlottesville. Elderly patients on antibiotics, especially those in health care settings, are at greatest risk for C. difficile infection (CDI) and have the highest CDI mortality rate, Dr. Archbald-Pannone said at AMDA Long Term Care Medicine–2014. Historically, clindamycin and cephalosporins have been most associated with CDI in hospitals and PA/LTC facilities, but almost any antibiotic can be implicated, she said. Currently, the commonly used antibiotics – fluoroquinolones – are the drugs most frequently associated with CDI, Dr. Archbald-Pannone noted. Treating infection can be complicated, so prevention is the best strategy for combating the spread of CDI, Dr. Archbald-Pannone said. It requires a three-pronged approach including proper antibiotic prescribing, preservation of normal flora, and environmental containment. One of the most effective and important strategies for preventing CDI is minimizing the frequency, duration, and number of antibiotics prescribed. Giving antibiotics when they are not needed, continuing them beyond when they are necessary, prescribing them at the wrong dose, prescribing the wrong antibiotic for a given infection, and using broad spectrum agents to treat susceptible bacteria represent antibiotic misuse. The result can be the emergence of antimicrobial-resistant pathogens. “Antibiotics are one of those things we have to think through a little more globally than just how it impacts our one patient,” Dr. Archbald-Pannone said. She pointed out that the Centers for Disease Control and Prevention recommends a three-step “time out” approach to improving antibiotic stewardship: ensuring at the outset that dose, duration, and indication are included for all antibiotic orders; obtaining cultures anytime an antibiotic is ordered; and reassessing choice of treatment based on the culture results. Antibiotics are associated with CDI because they disrupt the normal flora – sometimes after just a single dose. Probiotics, such as Lactobacillus acidophilus and Lactobacillus casei, as well as probiotic-yogurt products, can preserve normal flora and so help prevent CDI, Dr. Archbald-Pannone said. Several studies suggest that the use of probiotics is associated with about a 20% reduction in antibiotic-associated diarrhea, she said. Evidence of probiotics’ use as treatment of CDI is lacking, Dr. Archbald-Pannone said. C. difficile spores can survive on environmental surfaces for months, and a 10% bleach solution is required to penetrate their protective armor and kill the spores, Dr. Archbald-Pannone said. Because the spores are very sticky, extra care must be taken when it comes to hand hygiene. The CDC recommends washing hands before any of the following: having direct contact with a patient, putting gloves on, inserting an invasive device, and moving from a contaminated to a clean site within the same patient encounter. Wash hands after the following: touching a patient's skin (including intact skin), touching body fluids or broken skin, touching an inanimate object in the patient's vicinity, and removing gloves. The proper hand washing technique involves wetting hands with warm water, applying soap and rubbing to make a lather that covers all surfaces, rubbing hands for 20 more seconds to physically remove the spores, and rinsing under running water. Hands should be dried using a paper towel or air dryer, and a paper towel should be used to turn the faucet off. “This is kind of getting back to basics, but it's important, because when it's something we do all the time, we can get a little lax with it,” Dr. Archbald-Pannone said. Technique is also important when using gel sanitizer. It should not be used on wet hands or wiped off before the gel has dried, she said. Alcohol-based gels work by dehydrating denatured proteins, and water on the hands fights that process, she explained.

A Call to Arms: The Imperative for Antimicrobial Stewardship

Antimicrobial resistance is a major public health crisis. The prevalence of drug-resistant organisms, such as the emerging NAP1 strain of Clostridium difficile, now highly resistant to fluoroquinolones, Acinetobacter species, Klebsiella pneumoniae carbapenemase-producing organisms, and methicillin-resistant Staphylococcus aureus, is increasing nationwide. The sources of antimicrobial resistance are manifold, but there is a well-documented causal relationship between antimicrobial use and misuse and the emergence of antimicrobial-resistant pathogens. As the development of new antimicrobial agents is on the decline, the medical community, across all specialties and in conjunction with public health services, must develop and implement programs and strategies designed to preserve the integrity and effectiveness of the existing antimicrobial armamentarium. Such strategies are collectively known as antimicrobial stewardship programs and have the potential to minimize the emergence of resistant pathogens.

Emerging Healthcare-associated Problem Pathogens in the United States

Healthcare-associated infections are a major cause of morbidity and mortality. Dramatic changes in the delivery of healthcare during the past decade have changed the definition of healthcare-associated infections. Healthcare delivery changes include a reduction in the number of general hospital beds, an increase in the proportion of patients who are in intensive care units, a larger proportion of surgical procedures performed as outpatient procedures, a marked increase in patients cared for in outpatient settings, and an increase in the delivery of healthcare in the home setting. These changes have blurred the border between hospital- and community-acquired infections, increased the challenge of controlling transmission of antimicrobial-resistant pathogens, and complicated clinicians' treatment decisions. Data from the National Nosocomial Infections Surveillance system show that between the periods of 1993-1997 and 1998, infections caused by vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant coagulase-negative staphylococci, and imipenem- or quinolone-resistant Pseudomonas aeruginosa have significantly increased. In addition, we have witnessed the emergence of vancomycin-intermediate resistant S aureus and the community transmission of MRSA. If we are to turn the tide on the continued emergence of antimicrobial-resistant pathogens, we will need to enhance and expand our infection control programs in all settings in which healthcare is provided and improve the appropriateness of antimicrobial use.

Treatment strategies for central nervous system infections

Central nervous system (CNS) infections continue to be an important cause of mortality and morbidity. Current strategies for prevention and therapy of CNS infection are compromised by incomplete understanding of the microbial–host interactions that contribute to its pathogenesis and emergence of antimicrobial-resistant microorganisms. Our development of successful strategies in prevention and treatment of bacterial meningitis requires multifactorial concepts and approaches, which include advances in vaccinology, epidemiology of meningitis, emergence of antimicrobial-resistant pathogens, knowledge of pharmacokinetics and pharmacodynamics of antimicrobial agents, as well as the pathogenesis of meningitis. Prevention of bacterial meningitis targeting microbes has been effective, such as vaccination. The introduction of the protein conjugate vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae and Neisseria meningitidis has changed the epidemiology of bacterial meningitis. Antimicrobial chemoprophylaxis is efficacious in prevention against H. influenzae type b and N. meningitidis meningitis. Suspected bacterial meningitis is a medical emergency and requires empiric antimicrobial therapy without delay, but recognition of pathogens with increasing resistance to antimicrobial agents is an important factor in selection of empiric antimicrobial regimen. A more complete understanding of the microbial–host interactions that are involved in the pathogenesis of CNS infections and associated neurologic sequelae is likely to help in developing new strategies for prevention and therapy of CNS infection.