Hospital Antibiogram Research Articles

How do residential aged care antibiograms compare with other local resistance data?

Antibiograms can optimise empirical antibiotic prescribing however they are not readily available for residential aged care facilities (RACFs) in Queensland, Australia. This study aimed to determine whether alternatively available data can be used to approximate resistance patterns for RACFs. Annual RACF-specific antibiograms were compared with local hospital antibiograms accessed through pathology providers. Additionally, composite antibiograms, of geographically united RACF data, were compared to regional hospital and private pathology RACF antibiograms. Antibiotic susceptibility rates for commonly observed bacteria (Escherichia coli, Klebsiella pneumonia, Enterococcus faecalis, Pseudomonas aeruginosa and Staphylococcus aureus) were compared amongst different antibiograms using Fisher's exact test, with a p-value ≤ 0.05 indicating statistically significant difference. The concordance amongst the antibiograms was described by percentage similarity overall, and for a subset of clinically relevant pathogen-antibiotic pairs (PAPs). Composite RACF-antibiogram was highly concordant (83-100% similarity) to private pathology RACF data when compared for clinically relevant PAPs. Mixed results were found when individual RACF-specific antibiograms were compared to local hospital all-ages and ≥65years data (50-100% and 67-100% similarity respectively). Private pathology RACF antibiograms can serve as a proxy indicator of resistance patterns for RACFs. Mixed findings were noted for comparisons with hospital data.

Trends and patterns of antimicrobial consumption at Benjamin Mkapa Zonal Referral Hospital, Dodoma, Tanzania: a cross-sectional retrospective analysis

ObjectiveThis study assessed the trends and patterns of antimicrobial consumption (AMC) from 2020 to 2021, 2021–2022 and 2022–2023 at the Benjamin Mkapa Zonal Referral Hospital (BMH) in Dodoma, Tanzania.DesignA retrospective...

'Some patients demand for a prescription of an antibiotic': an assessment of barriers and facilitators to rational antimicrobial use in a private health facility in Uganda.

Antimicrobial misuse and overuse propagate antimicrobial resistance, yet data on factors influencing antibiotic prescription decisions in low-resource settings are limited. We describe factors influencing antimicrobial prescription at a large tertiary care private not-for-profit hospital in Uganda. We conducted a descriptive phenomenology qualitative study involving face-to-face in-depth interviews of 12 purposively selected prescribers (four intern doctors, six medical officers and two Internal Medicine physicians) in a private not-for-profit hospital in Kampala, Uganda. Audio recordings and filed notes were transcribed verbatim and analysed manually by content analysis. Emerging themes and sub-themes were recorded and reported. Three broad themes emerged: experience with antimicrobial use in Uganda, barriers and facilitators to rational antimicrobial prescription and measures to address irrational antimicrobial use. Participants recognized that antibiotics are often used irrationally, prescribed even when there is uncertainty regarding clinical evidence for infection, and influenced by drug promoters, and noted high levels of antibiotic resistance. Patients' symptoms and clinical signs, previous experience using antibiotics, fear of bad outcomes, patient demand and expectations, influence from senior colleagues, the turnaround time of clinical investigations and drug marketers were the barriers and facilitators to antimicrobial prescription. Prescribers also acknowledged the need to update clinical guidelines, set up hospital antibiograms, and provide continuous medical education on rational antimicrobial use. A complex interplay of intrinsic and extrinsic factors influences antibiotic prescribing decisions in this hospital. Targeted interventions through continuous education and training for prescribers, providing local prescription guidelines and antibiograms and implementing regulations on over-the-counter antibiotic sales are needed to implement robust antimicrobial stewardship programmes to curb antimicrobial resistance successfully.

Impact of MIC Breakpoint Changes for Enterobacterales on Trends of Antibiotic Susceptibilities in An Academic Medical Center

Background: The Clinical & Laboratory Standards Institute (CLSI) recommends use of annual antibiograms to help guide empiric antibiotic therapy. Because CLSI periodically updates minimum inhibitory concentration (MIC) breakpoints, we assessed the impact of these updates on longitudinal trends in antibiotic susceptibility rates for Escherichia coli and Klebsiella pneumoniae at a single academic medical center in Atlanta, GA. Methods: Susceptibilities for cefepime, ceftazidime, and levofloxacin in E. coli and K. pneumoniae were extracted from hospital antibiograms from 1988 to 2022. Starting in 1995, intensive care units (ICUs) and wards had separate annual antibiograms, which we combined using weighted averages to create annual overall hospital antibiograms. After summarizing the frequency of isolates tested and susceptibilities using medians and interquartile ranges (IQR), we conducted an interrupted time series analysis using linear segmented regression models, to evaluate the level changes and trends in susceptibility, before and after CLSI MIC breakpoints were updated for ceftazidime (2010 and 2017), cefepime (2014 and 2017), and levofloxacin (2013). Results: Among 21,214 E. coli, there was a median of 291 [IQR: 104, 555] isolates tested annually. Similarly, among 8,686 K. pneumoniae isolates, the median was 125 per year (IQR: 76, 178). Prior to the MIC breakpoint changes, baseline susceptibility trends of both organisms to all 3 antibiotics significantly declined at a rate between 0.2% to 2.4% per year (Table 1). For cefepime (Figure 1), susceptibility decreased annually during 1988 – 2013 for both E. coli (-0.5%) and K. pneumoniae (-1.2%). There were no significant level changes but there were trend changes after 2018, for E. coli (+2.1%) and K. pneumoniae (– 5.5%). For ceftazidime (Figure 2), significant level changes occurred after 2010 for both organisms (E. coli: -5.7%; K. pneumoniae: -5.2%). For levofloxacin (Figure 3), the breakpoint update in 2013 lead to significant level change in susceptibility (E. coli: +8.4%; K. pneumoniae: +11.4%). Conclusion: Overall, we observed a consistent decrease in antibiotic susceptibility in E. coli and K. pneumoniae over three decades, with immediate increases in the level change of susceptibility when MIC breakpoints were changed, followed by a decreasing trend. These findings highlight the importance of longitudinal surveillance and MIC breakpoint changes to inform antimicrobial stewardship strategies.

Multitask Neural Networks to Predict Antimicrobial Susceptibility Results of Escherichia coli Clinical Isolates

Background: Machine-learning (ML) models, such as neural networks (NNs), have been proposed to predict antimicrobial susceptibility at the patient level while incorporating patient-level information from electronic medical record (EMR) systems. However, NNs often do not perform well in predicting rare outcomes, such as carbapenem resistance. We aimed to apply a novel multitask NN to create personalized antibiograms for individual patients with Escherichia coli clinical isolates to predict antimicrobial resistance (AMR) for four major antimicrobial classes simultaneously with improved accuracy for carbapenem resistance by using shared hidden layers (Figure 1). Methods: We analyzed all E. coli clinical isolates from the US Veterans Health Administration’s network from January 1, 2017, to December 31, 2019, focusing on AMR profiles of aminopenicillins, narrow-spectrum (NS) cephalosporins, extended-spectrum (ES) cephalosporins, and carbapenems. Patient-level clinical data (demographics, antimicrobial exposure history, previous isolates (if any), comorbidities, and recent procedures) were extracted from EMR. Antibiograms for all hospitals were generated using standard methods for the preceding calendar years. We employed logistic regression to evaluate the efficacy of conventional antibiograms in predicting AMR profiles. We adopted the ML approach using conventional NNs and novel multitask NNs on all extracted clinical data and hospital antibiograms. The models were trained with data from 2017 and 2018 and then tested on 2019 data, assessing their performance using the area under the receiver-operating curve (AUC). Results: The study included 257,968 E. coli isolates, split into 171,391 for training and 86,577 for validation. The prevalence of AMR in the test data from 2019 was 49.8% for aminopenicillins, 28.4% for NS cephalosporins, 10.7% for ES cephalosporins, and 0.2% for carbapenems, respectively. Conventional hospital antibiograms showed low prediction accuracy with AUC scores of 0.56 for aminopenicillins, 0.67 for NS cephalosporins, 0.61 for ES cephalosporin, and 0.67 for carbapenem. AUC scores from preliminary models for conventional and multitask NNs were 0.78/0.78 for aminopenicillins, 0.83/0.82 for NS cephalosporins, 0.84/0.85 for ES cephalosporins, 0.68/0.75 for carbapenems. While producing improved accuracy for carbapenem and comparable accuracies for three other classes, multitask NNs took approximately 66% less time for model training than conventional NNs. Conclusions: Integrating EMR data with NNs improved their predictive accuracy, potentially leading to a decision-support tool for better empirical antimicrobial therapy guidance in the window between species identification and confirmed susceptibilities. Multitask NNs can potentially improve the prediction accuracy of uncommon AMRs while maintaining comparable prediction accuracies for common AMRs and optimizing the efficiency of model training.Disclosure: Michi Goto: Contracted Research - Merck

Outcomes associated with initial narrow-spectrum versus broad-spectrum antibiotics in children hospitalized with urinary tract infections.

The aim of this study is to describe the proportion of children hospitalized with urinary tract infections (UTIs) who receive initial narrow- versus broad-spectrum antibiotics across children's hospitals and explore whether the use of initial narrow-spectrum antibiotics is associated with different outcomes. We performed a retrospective cohort analysis of children aged 2 months to 17 years hospitalized with UTI (inclusive of pyelonephritis) using the Pediatric Health Information System (PHIS) database. We analyzed the proportions of children initially receiving narrow- versus broad-spectrum antibiotics; additionally, we compiled antibiogram data for common uropathogenic organisms from participating hospitals to compare with the observed antibiotic susceptibility patterns. We examined the association of antibiotic type with adjusted outcomes including length of stay (LOS), costs, and 7- and 30-day emergency department (ED) revisits and hospital readmissions. We identified 10,740 hospitalizations for UTI across 39 hospitals. Approximately 5% of encounters demonstrated initial narrow-spectrum antibiotics, with hospital-level narrow-spectrum use ranging from <1% to 25%. Approximately 80% of hospital antibiograms demonstrated >80% Escherichia coli susceptibility to cefazolin. In adjusted models, those who received initial narrow-spectrum antibiotics had shorter LOS (narrow-spectrum: 33.1 [95% confidence interval; CI]: 30.8-35.4] h vs. broad-spectrum: 46.1 [95% CI: 44.1-48.2] h) and reduced costs (narrow-spectrum: $4570 [$3751-5568] versus broad-spectrum: $5699 [$5005-$6491]). There were no differences in ED revisits or hospital readmissions. In summary, children's hospitals have low rates of narrow-spectrum antibiotic use for UTIs despite many reporting high rates of cefazolin-susceptible E. coli. These findings, coupled with the observed decreased LOS and costs among those receiving narrow-spectrum antibiotics, highlight potential antibiotic stewardship opportunities.

Prevalence of Antimicrobial Resistant Bacterial Infections among Neutropenic Patients in Hiwa Cancer Hospital, Sulaimani, Iraq

Background: Febrile neutropenia (FN) is one of the most serious complications of cancer chemotherapies. To avoid life-threatening complications from treatment delays, appropriate empirical antibiotic treatment should be initiated. Objective: To highlight the common bacteria encountered at Hiwa Hospital, the current state of the hospital's antibiogram and recommendations for resistance management. Method: From January 2021 to December 2022, we retrospectively collected culture-confirmed FN cases from the Hiwa Hospital system database in Sulaimani, Iraq. Results: We collected 144 culture-confirmed cases, with ninety-four from hematology wards and fifty from oncology wards. The participants’ ages ranged from 2–79 years. Seventy-three of them were male, with a male-to-female ratio of 1:0.9. Gram-negative bacteria comprised 50.7% of the total cases, 47.9% had gram-positive bacteria, and only 1.4% had fungal growth. The most common isolated pathogens were Staphylococci species (38.9%), E. coli (29.2%), Klebsiella pneumoniae (9%), Streptococcus spp. (8.3%), and Pseudomonas spp. (8.3%). A large number of Staphylococcus spp. were resistant to amoxicillin/clavulanic acid, ceftriaxone, cefepime, and levofloxacin. In contrast, E. coli was resistant to ceftriaxone, ceftazidime, cefepime, ciprofloxacin, meropenem, and piperacillin/tazobactam. Klebsiella spp. exhibited significantly higher levels of resistance to amikacin, cefepime, and ciprofloxacin. MRS strains were found in 48.2% of Staphylococci spp., 74% of gram-negative bacteria, and 12.3% of extensive drug-resistant (XDR) isolates. Conclusions: There is a high prevalence of antibacterial resistance among cancer patients, which contributes to quinolone-induced collateral damage.

Exploring stakeholders’ perspectives on antibiogram use, development, and implementation in residential aged care settings

BackgroundKnowledge of local antibiotic resistance data provided by antibiograms (cumulative-antimicrobial-susceptibility-tests) can assist prescribers to make appropriate empirical antibiotic choices. ObjectiveThis study explored the perceptions and knowledge of key stakeholders about the role of antibiograms in residential aged care facilities (RACF), and to understand barriers and enablers of antibiogram development and implementation in this setting. MethodSemi-structured interviews were conducted with aged-care health professionals (‘end-users’) and antibiogram content experts. This study was conducted in Queensland, Australia in 2023. Using qualitative techniques, framework thematic analysis was used to identify themes, which were mapped to the ‘Integrated Promoting Action on Research Implementation in Health Services’ framework constructs. ResultsTwenty interviews were conducted comprising of five ‘content-experts’ and fifteen ‘end-users’. Five themes were identified which indicated lack of knowledge about how to use antibiograms, and its availability. Potential insufficient data was the primary issue identified by content experts with regards to feasibility of annual antibiograms. Pragmatic solutions were offered, such as pooling pathology data from facilities in the same geographical location, extending antibiogram data to two-or three-yearly, or utilising local hospital antibiograms. Presenting antibiogram data in a mode and format suiting preferences of individual users would encourage uptake and improve usability. Antimicrobial stewardship (AMS) champions and pharmacists were highlighted as drivers of educating and promoting antibiogram use. ConclusionClinicians recognised the potential role of antibiograms in improving empirical antibiotic prescribing choices. Establishing their baseline knowledge provides an essential starting point for the education needs of this group. This study provides practical recommendations regarding the presentation of antibiograms to ensure appropriate use and uptake as an AMS tool in RACFs. Pragmatic solutions suggested to overcome challenges of antibiogram development for RACFs should be applied and evaluated to determine feasibility of RACF-specific antibiograms.

Local Antimicrobial Resistance Trends in Pediatric Urinary Tract Infection: The Importance of Local Surveillance of a Global Problem.

Introduction Urinary tract infections (UTIs) are one of the most common pediatric bacterial infections and consequently a major reason for antibiotic treatment. Despite being a global problem, antimicrobial resistance is often geographically heterogeneous. Thus, it is fundamental to know local epidemiology and practice frequent surveillance of each hospital's antibiograms. The aims of this study areto determine the local antimicrobial resistance profile in pediatric UTIs, to understand its evolution over 14 years, and finally, to infer if the currently instituted antibiotic empirical therapy remains effective. Materials and methods A retrospective observational study was performed through the analysis of urine cultures and respective antibiograms of children diagnosed with UTIfrom 2017 to 2019 in Centro Hospitalar Universitário do Algarve (Faro's unit, Portugal), followed by a comparison of the obtained datawith the results of a similar study performed between 2003 and 2005. Results A total of 784 urine cultures were selected. Escherichia coli was the most frequent microorganism (n = 561; 71.56%), followed by Proteus mirabilis (n = 117; 14.92%) and Klebsiella pneumoniae (n = 40; 5.10%). The most commonly prescribed antibiotic was cefuroxime axetil (66.28%). Escherichia coli had an increase in resistance to amoxicillin-clavulanate of 6.16% to 34.76% and cefuroxime axetil of 0.73% to 4.46%. Proteus mirabilis had an increase in resistance to amoxicillin-clavulanate of 1.64% to 11.11%. Klebsiella pneumoniae had an increase in resistance to cefuroxime axetil (0%-27.50%) and nitrofurantoin (0%-47.50%). The three microorganisms showed a decrease in trimethoprim-sulfamethoxazole resistance profiles, as well as low resistance profiles to fosfomycin. In fifty cases in which antibiotic empirical therapy was instituted, the isolated microorganism revealed in vitro resistance; 37 of these cases had a good evolution, maintaining the antibiotic empirical therapy. Discussion Local surveillance of antimicrobial resistanceallows monitoring of the resistance trends and adequacy of empirical antibiotic therapy. This study's local resistance profile was distinct from other regions of the country and the world. Continuous local surveillance also potentiates the dissemination of the results to the concerned healthcare providers and the initiation of timely responsive measures, containing the increase in antimicrobial resistance. As Escherichia coli was the commonest isolated microorganism, its antimicrobial profile should dictate antibiotic empirical therapy. This study supports that in vitro is not equivalent to in vivo resistance. Conclusion There was a significant increase in antimicrobial resistance profiles, especially to amoxicillin-clavulanate. Cefuroxime axetil remains the recommended antibiotic for empirical therapy in this hospital, although fosfomycin should be considered as an alternative in non-complicated cystitis in adolescent females. This study reinforces the importance of continuous local resistance surveillance as a preventive measure against the global increase in antimicrobial resistance.

Clinicians' interpretation of thresholds in hospital antibiograms for gram-negative rod infections: A survey and contingent valuation study of hospitalists.

Clinical guidelines suggest that hospital antibiograms are a key component when deciding empiric therapy, but little is known about how often clinicians use antibiograms and how they influence clinicians' empiric therapy decisions. We surveyed hospitalists at seven healthcare systems in the United States on their reported practices related to antibiograms and their hypothetical prescribing for four clinical scenarios associated with gram-negative rod pathogens. Each was given a randomly assigned antibiogram susceptibility percentage, and we used contingent valuation analysis to assess whether the antibiogram susceptibility percentage was associated with prescribing practices. Of the 193 survey responders, only 52 (26.9%) respondents reported using antibiograms more than monthly. Across all four clinical scenarios, there was no evidence that antibiogram susceptibility levels influenced antibiotic prescribing practices. With limited utilization and no evidence that they influenced practice, antibiograms may have a limited role in hospitalist care delivery for common gram-negative rod infections.

(046) An Approach to the Thoughtful Selection of Antimicrobial Prophylaxis for Inflatable Penile Prosthesis Surgery

Abstract Introduction There is a growing body of evidence questioning the efficacy of the antibiotic prophylaxis regimens recommended by the American Urological Association (AUA) Best Practice Statement (BPS) for IPP surgery. However, since publication of the BPS the use gentamicin and vancomycin use has increased substantially. This is potentially due to a lack of other specific prophylaxis recommendations making it difficult for surgeons to know which agents to select. Objective We sought to create a simple process to enable surgeons to select an individualized prophylaxis regimen which accounts for local antibiotic resistance patterns. Methods We retrospectively collected IPP infection history from 3 surgeons from 3 different regions of the United States between 2016 and 2021. Local hospital antibiograms were obtained for each surgeons’ institution. Each surgeons IPP infection history was crossed with the resistance patterns on the local antibiograms to identify prophylactic antimicrobial regimens providing the highest level of coverage. Results The organisms causing implant infections for each surgeon during the inclusion period are reported in Table 1. Vancomycin and fluconazole provided excellent Gram-positive and fungal coverage for all surgeons, however Gram-negative coverage varied. Surgeon A had a history of ESBL-producing E. Coli and no infections from Pseudomonas sp. Gentamicin and tobramycin have poor coverage of ESBL-producing E. coli (61% and 52% respectively). However, pipercillin/tazobactam covers 92% of ESBL-producing E. coli. The only Gram-negative organism that pipercillin/tazobactam has worse coverage of than the aminoglycosides is Pseudomonas (gentamicin-92%, tobramycin-96%, pipercilin/tazobactam-80%); however, Surgeon A had no history of Pseudomonas infections. Therefore, the greatest level of coverage can be obtained with vancomycin, pipercillin/tazobactam, and fluconazole. All of Surgeon B’s infections were caused by non-ESBL producing E. coli. Gentamicin, tobramycin, and pipercillin/tazobactam all have excellent coverage of E. coli (95%, 94%, and 95% respectively). Comparing these agents to other common pathogens shows superior coverage of tobramycin over gentamicin and pipercillin/tazobactom for Pseudomonas. The highest level of coverage for Surgeon B can be obtained with vancomycin, tobramycin, and fluconazole. Surgeon C’s infection history has a predominance of Klebsiella sp., but also includes Pseudomonas. Both gentamicin and tobramycin have excellent coverage (&amp;gt;95%) of these Gram-negative organisms. The highest level of coverage can be obtained with vancomycin, an aminoglycoside, and fluconazole. Conclusions The use of local antibiograms and infection history is a simple strategy to tailor prophylaxis regimens to resistance patterns. We found a different regimen to be superior at each institution. Surgeon B’s experience demonstrates that all aminoglycosides may not be equal when factoring in local resistance patterns. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Cynosure, Antares Pharma, Clarus Pharmaceuticals, Acerus Pharma, Boston Scientific.

1243. Acceptable susceptibility thresholds reported in hospital antibiograms for Gram-negative rod infections: a survey and contingent valuation study of infectious diseases providers

Abstract Background Clinical guidelines recommend an antibiogram as a key component when making empiric therapy decisions. However, little is known about how clinicians utilize antibiograms. We aimed to assess the interpretation thresholds of hospital antibiograms among infectious diseases (ID) providers when making empiric therapy decisions for Gram-negative rods (GNRs) infections.Figure 1.Relationship between randomly generated percentages on antibiograms in each scenario and the distribution of participants willing to accept the threshold.Abbreviations: GNR-BSI, Gram-negative rod bloodstream infection; ICU, intensive care unit; UTI, urinary tract infection. Methods We conducted an email-based survey of ID providers practicing at Veterans Health Administration (VHA) facilities. We included four scenarios: i) a patient with urinary tract infection (UTI) in an outpatient setting, ii) a patient with UTI in an inpatient setting, iii) a patient with GNR bloodstream infection (GNR-BSI) in a non-intensive care unit (ICU) setting, and iv) a patient with GNR-BSI in an ICU setting. Each scenario randomly assigned antibiogram percentages and asked providers if they would feel comfortable selecting a hypothetical empiric therapy agent with the given value. Contingent valuation analyses were done by logistic regression models to evaluate the relationship between the percentages offered to providers and their willingness to use offered agents. Results In the preliminary analysis, 112 of 599 providers (18.7%) responded and 104 provided effective responses. Hospital antibiograms are generally used infrequently, and only 30.8% of providers indicated that they use antibiograms more than once a month. The estimated median interpretation thresholds, meaning half of the ID providers would prescribe the hypothetical antibiotic in each case with the values given on antibiograms, were significantly higher for patients with more severe illnesses (85.6% [95% confidence interval [CI] 83.1-88.1] for an inpatient with UTI vs 74.1% [95%CI 69.7-77.6] for an outpatient with UTI; 86.0% [95%CI 83.1-89.4] for a patient with GNR-BSI in ICU vs 77.9% [95%CI 74.2-81.2] for a patient with GNR-BSI in non-ICU) (Figure 1). Conclusion This study demonstrated that ID providers rarely utilized antibiograms and the median thresholds for hospital antibiograms influencing empiric antibiotic selection ranged from 74-86%, depending on the severity but not by the type of infection (UTI vs. BSI). Further analyses after we receive more responses will be completed. Disclosures Michihiko Goto, MD MSCI, Merck &amp; Co.: Grant/Research Support

Door-to-Needle Time for Administration of Antibiotic in Children with Cancer Within the Golden Hour- an Audit from a Tertiary Cancer Hospital in a Low-Middle Income Country

Abstract Background Fever neutropenia (FN) is the commonest complication during treatment in children with cancer. Most guidelines recommend administration of intravenous antibiotics within 60 minutes of presentation to the Emergency Room (ER) to minimize life threatening complications of FN(1). We performed a 3-month audit at our ER to see if this target was being met(2). The departmental FN management policy was revised and implemented from February 2021 based on the prevailing hospital antibiogram. All children undergoing treatment in the Paediatric Oncology Department are provided with written FN Alerts/Advice (Fig. 1). All patient prescriptions include instructions on antibiotic choice and dosage. Annual educational sessions are held with the ER staff and Paediatric Oncology Residents. A stock of essential antibiotics is maintained in the ER. Methods All children on chemotherapy or radiotherapy presenting to ER with fever (≥38°C) either at home or documented at ER had blood counts and blood cultures sent both from a peripheral vein and the indwelling central venous device (if present). The first dose of antibiotics as prescribed was administered without waiting for the blood count report or assessment by the Clinician. Time of patient’s arrival at ER and time of administration of the first antibiotic dose were obtained from ER nursing records and patient drug cards. Data was entered prospectively within 24 hours and tabulated for analysis on Microsoft Excel. Fig.1: Fever Neutropenia Sticker on Patient File Results Eighty-four children presented with 129 episodes of fever during the audit period (1st April 2022-30th June 2022). Median age was 6.4 years (IQR 3.1,12). Median time interval from last chemotherapy was 6 days (IQR 2,10). All children reporting to ER were seen by a Clinician, with 106 (82%) episodes seen within 30 minutes of reporting (median 15 minutes, IQR 5,21). All children received initial intravenous antibiotics after blood sampling. Median door-to-needle time was 45 minutes (IQR 35,60 minutes) There were 2 deaths in this cohort, one due to cancer progression and the other due to an unidentified infection of the central nervous system. Conclusions Over 80% children received the first dose of antibiotics within the target of &amp;lt;60 minutes. There were no deaths attributable to sepsis. Though the outcome was excellent in this cohort, we need to analyse the reasons for delay in administration of the first antibiotic dose and take remedial measures to improve compliance.

Risk factor and resistance profile of colistin resistant Acinetobacter baumannii and Klebsiellapneumoniae

PurposeAntimicrobial resistance is one of the major global health concerns, which is relentless despite multipronged measures. Carbapenems and colistin, drug of choice for multi drug resistant Klebsiella pneumoniae and Acinetobacter species, have also been rendered of less use. This underlines the need to decipher prevalence of colistin resistance comprehensively for formulation of hospital and country-wise antibiogram. We conducted this study to decipher the prevalence of colistin resistance in our tertiary care centre of North India. Materials and methodsThis was a prospective, case control study conducted over a period of one and half years. All carbapenem resistant Klebsiella pneumoniae and Acinetobacter isolates were included. Kirby-Bauer method of disc diffusion was used for all antibiotics, except colistin for which broth microdilution was performed and interpreted using CLSI guidelines. Demographic details, risk factors and outcome details were recorded. Genotypic characterization was performed using representative strains, for blaNDM, blaKPC and blaOXA-48. ResultsOf 103 carbapenem resistant isolates, 7 were found to be colistin resistant. Median age was 43 years, with male:female ratio of 1.1:1. 35% isolates were from pus samples, followed by endotracheal aspirate. Colistin resistance was more in ICUs than wards. Presence of indwelling devices was noted as the most common risk factor, followed by previous antibiotic exposure and use of steroids/immunosuppressants. Indwelling devices, steroids/immunosuppressants usage, length of hospital stay, COPD, prior usage of carbapenems, piperacillin-tazobactam and colistin, usage of ampicillin-sulbactam during hospital stay, were statistically significant. Mortality was noted in 4 cases, with statistical difference between control and case arm. The blaNDM and blaOXA-48 were noted in 3 and 2 isolates respectively, with absence of blaKPC. ConclusionThe present study unravels incidence, risk factors and resistance encoding genes at our centre. This is of immense help in formulation of antibiotic policies and guidance for infection control measures.

Awareness Regarding Antimicrobial Resistance and Antibiotic Prescribing Behavior among Physicians: Results from a Nationwide Cross-Sectional Survey in India.

(1) Background: Understanding the physicians' knowledge, attitudes, and antimicrobial prescribing behavior is a crucial step towards designing strategies for the optimal use of these agents. (2) Methods: A cross-sectional online survey was conducted among clinicians across India between May and July 2022 using a self-administered questionnaire in English comprising 35 questions pertaining to demographic characteristics, knowledge, attitude, and practices domains. (3) Results: A total of 544 responses were received from 710 physicians contacted. Sixty percent of participants were males, with mean age of 34.7 years. Mean ± Standard Deviation scores for knowledge, attitude, and practices domains were 8 ± 1.6, 20.2 ± 3.5, and 15.3 ± 2.1, respectively. Higher scores were associated with basic [odds ratio (95% Confidence Interval), p value: 2.95 (1.21, 7.2), 0.02], medical and allied sciences [2.71 (1.09, 6.67), 0.03], and central zone [3.75 (1.39, 10.12), 0.009]. A substantial proportion of dissatisfactory responses were found regarding hospital antibiograms, antibiotics effective against anaerobes, WHO AWaRe (access, watch, and reserve) classification of antibiotics, and the role of infection prevention and control (IPC) measures in the containment of antimicrobial resistance (AMR). (4) Conclusions: There is a need to sensitize and educate clinicians on various issues related to antimicrobial use, such as antibiograms, double anaerobic cover, IPC practices, and guideline-based recommendations, to curb the AMR pandemic.

Development and application of WHONET software in hospital antibiogram

Antibiotic resistance is an emerging issue that requires a track on antimicrobial resistance pattern in an institution to prescribe appropriate empirical therapy. Antibiogram that's an aggregate of antimicrobial susceptibility profile within an institution provides a better understanding of empirical and prophylactic use of antimicrobials. It also focuses on M39 guidelines published by Clinical and Laboratory Standard Institute for developing accurate and reliable data of antibiograms. The data for this review has been extracted from literature databases such as Medline/PubMed, Scopus, Web of Science, Embase and the Cochrane Library. This literature highlights the importance of clinical pharmacists in developing antibiogram by preventing antimicrobial resistance, types of antibiogram, history and development, need, role of hospital and microbiological laboratory and Clinical and Laboratory Standard Institute guidelines. Additionally, the significance of WHONET software for developing and analysis of results rather than using old/traditional methods, limitations, and future considerations of antibiogram has also been described.

Development of a multiyear pediatric antibiogram in Georgia identifies antibiotic resistance trends

Background: Antibiograms are used to monitor antibiotic resistance trends and help guide empiric antibiotic treatment. Community pediatricians may not have access to or be comfortable using children’s hospital antibiograms. Creating and disseminating a statewide pediatric antibiogram can help inform antibiotic stewardship efforts.Objective: To develop a pediatric-specific antibiogram for the state of Georgia. Methods: Annual pediatric antibiograms for the 5 children’s hospitals in Georgia from 2014 through 2021 were collected. All sites complied with the Clinical and Laboratory Standards Institute guidelines for antibiomicrobic breakpoints and antibiogram development. Antibiogram data were combined, and the most common bacteria were selected to incorporate into the statewide antibiogram: Staphylococcus aureus, Streptococcus pneumoniae, Enterococcus faecalis, Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae complex, and Pseudomonas aeruginosa. Antibiogram data were reported as percentage susceptible and total number of isolates. Interhospital susceptibility differences were compared for methicillin-susceptible S. aureus (MSSA), methicillin-resistant S. aureus (MRSA), E. coli, and K. pneumoniae from 2018 through 2021. P &lt; .05 was considered significant. The combined antibiogram data from 2014 through 2021 were used to show antibiotic susceptibility trends over time. Results: The 2021 antibiogram is shown in the Table. For MSSA and MRSA, clindamycin susceptibility was 80% and 85%, respectively. K. pneumoniae susceptibility to amoxicillin-clavulanate was 91%. For E. coli, using urine-specific breakpoints, susceptibility to cefazolin was 89%. A few statistically significant differences in antibiotic susceptibility were detected between hospitals, but most were unlikely to be clinically relevant (all susceptibilities ≥90% or &lt; 80%). A notable exception was trimethoprim-sulfamethoxazole susceptibility for K. pneumoniae, which ranged from 74% to 98% in 2020 and from 74% to 86% in 2021. From 2014 to 2021, the percentage of MRSA decreased from 49% to 34%. Over the 8 years, susceptibility to ceftriaxone for E. coli ranged from 93% to 95% and from 90% to 95% for K. pneumoniae. Susceptibility to meropenem for E. coli and K. pneumoniae ranged from 99% to 100%. Conclusions: Antibiotic susceptibility for pediatric bacterial isolates in Georgia remained stable over time and supported the narrow-spectrum empiric antibiotic treatment recommended in national evidence-based guidelines for skin and soft-tissue infections, community-acquired pneumonia, and uncomplicated urinary tract infections. MRSA rates decreased over time and multidrug-resistant gram-negative bacilli were uncommon and remained stable.Disclosures: None

Treatment of intractable cholangitis in children with biliary atresia: Impact on outcome.

To evaluate the response and outcome with prolonged intravenous antibiotics including home-based intravenous antibiotics in children with intractable cholangitis (IC) after Kasai portoenterostomy (KPE) for biliary atresia (BA). A retrospective review of treatment and outcome of children with IC post KPE (no resolution after fourweeks of antibiotics) was donebetween 2014 and 2020. A protocol-based antibiotic regimen was used based on sensitivity and hospital antibiogram. Children afebrile for more than threedays were discharged on home intravenous antibiotics (HIVA). Twenty children with IC were managed with prolonged antibiotic regimen, including HIVA. All patients were initially listed for liver transplantation (LT) with indication being IC (n = 20) with portal hypertension (n = 12). Seven patients had bile lakes of which four underwent percutaneous transhepatic biliary drainage. Bile culture grew Klebsiella in four and Escherichia coli and Pseudomonas one each. There were eight children with IC who had positive blood culture with most of these organisms being gram-negative (Escherichia coli: 5, Klebsiella pneumoniae: 2, Enterococcus: 1). Median duration of antibiotics was 58days (interquartile range [IQR] 56-84). Median follow-up period post cholangitis was threeyears (IQR 2-4). Following treatment, 14 patients were successfully delisted from LT waitlist and are presently jaundice-free. Two of the five patients undergoing LT died of sepsis. One patient died awaiting LT. Timely and aggressive step-up antibiotic regimen may successfully treat IC and prevent/delay LT. HIVA provides a cost-effective and comfortable environment for a child which might improve compliance with intravenous antibiotics.

Analysis of Cumulative Antibiotic Sensitivity Testing Data (Antibiogram) of Anwer Khan Modern Medical College Hospital

Background: Monitoring of antimicrobial resistance at local level is a very crucial aspect for clinical decision making, infection control interventions and antimicrobial-resistance containment strategies in this era of rising superbugs. The hospital antibiogram constructed by standardized method is a summary of antimicrobial susceptibilities of local bacterial isolates, with periodic review.&#x0D; Methods: This is a prospective observational study conducted in Microbiology Laboratory of Anwer Khan Modern Medical College Hospital (AKMMCH) over a period of three months from January to March 2021. All the samples which were received in the microbiology laboratory for aerobic bacterial culture and antibiotic sensitivity testing were considered in this study. The bacterial isolates from diagnostic clinical samples were subjected to culture in appropriate media for isolation of pathogens by standard methods and antibiotic sensitivity test (AST) was performed according to CLSI guidelines by modified Kirby Bauer disk diffusion techniques.&#x0D; Results: A total of 2917 samples were analysed in the microbiology department of AKMMCH for a period of three months of which 513(17.59%) were culture positive.Among the cultured samples of urine, respiratory sample, blood and pus, wound swabs, the rate of bacterial isolation was 266 (51.85%) ,161 (31.38%), 31 (6.04%) and 33 (6.4%) respectively. Most of the clinical isolates were Gram-negative bacilli404 (78.75%). The predominant isolate was Escherichia coli 186(36.26%) followed by Pseudomonas spp 102 (19.88%), Klebsiellaspp 79 (15.4%) and S. aureus 66 (12.87%). Antibiotic sensitivity in case of Gram-negative bacteria ranges from 30%-61% to amoxicillin-clavulanic acid, 18%-94% to third generation cephalosporin, 47%-75% to aminoglycosides, 27% -70% to ciprofloxacin, 26-70% to cotrimoxazole, 33-73% to nitrofurantoin, 27-69% to piperacillin- tazobactam and 100% to colistin. However, 53% of Escherichia coli and 58% of Klebsiella spp. were resistant to 3rd generation cephalosporins due to extended-spectrum beta-lactamase (ESBL) production. The carbapenem resistance in Escherichia coli was found 12%, Klebsiella spp 26%, Pseudomonas spp 29% and highest in Acinetobacter 46%. No superbug was detected in this study period.&#x0D; Conclusions: Antimicrobial susceptibility of various pathogen for different antibiotic is variable. Prompt antimicrobial therapy in an infection makes a lot of difference between recovery and death and most of the time prevents long term disability. Hence, antibiotic policy is one of the mandatory requirements and making an antibiogram is the first step before framing antibiotic policy.&#x0D; AKMMC J 2021; 12(2): 70-75

Acute management of pneumonia in adult patients.

Acute management of pneumonia in adult patients.