Inappropriate Antibiotic Administration Research Articles

Pattern of Antibacterial Resistance in Urinary Tract Infections: A Systematic Review and Meta-analysis.

Background:Urinary tract infection (UTI) is one of the most common infectious diseases ranking next to upper respiratory tract infections. UTIs are often significantly associated with morbidity and mortality. The inappropriate administration of antibiotics to treat these infections increased infection resistance to antibiotics. The aim of this study is to determine the frequency of antibiotic resistance pattern in UTIs.Methods:We searched several databases including PubMed, Web of Science, Scopus, Google Scholar, Iran Medex, Magiran, IranDoc, MedLib, and Scientific Information Database to identify the studies addressing antibacterial resistance patterns of the most common uropathogenic bacteria in UTIs in Iran. A total of 90 reports published from different regions of Iran from 1992 to May 2015 were involved in this study.Results:It is shown that the most common pathogen causing UTIs is Escherichia coli with 62%. The resistance among the isolates of E. coli was as follows: ampicillin (86%), amoxicillin (76%), tetracycline (71%), trimethoprim-sulfamethoxazole (64%), cephalexin (61%), and cefalothin (60%). The highest sensitivity among isolates of E. coli was as follows: imipenem (86%), nitrofurantoin (82%), amikacin (79%), chloramphenicol (72%), and ciprofloxacin (72%).Conclusions:The results of this study showed that the most common resistance are antibiotics that are commonly used. The most effective antibiotics for E. coli were imipenem, nitrofurantoin, amikacin, chloramphenicol, and ciprofloxacin. Considering this study, it had better, use less gentamicin, second-generation cephalosporins, and nalidixic acid in the initial treatment of infections caused by E. coli, and no use penicillins, tetracyclines, cotrimoxazole, and first-generation cephalosporins.

Sepsis calculator to support antibiotic stewardship in early-onset neonatal sepsis: a meta-analysis

Background Establishing a diagnosis of neonatal sepsis is difficult. As such, appropriate timing of antibiotic therapy remains the biggest challenge. As a consequence of non-definitive diagnoses, inappropriate antibiotic administration is common. Recently, a sepsis calculator to estimate risk of early-onset sepsis (EOS) based on both maternal risk factors and infants’ clinical presentation was established.
 Objective To determine the impact of the sepsis calculator in daily clinical settings, especially with regards to antibiotic usage.
 Methods A literature search of Pubmed, EBSCO, Embase, and Scopus database from January 2011 (after sepsis calculator was established) to June 2018 was performed. We included observational studies that compared the sepsis calculator to recent neonatal sepsis guidelines in terms of antibiotic administration, blood culture, and admission to the neonatal intensive care unit (NICU). The literature search, validation study, and assessment risk of bias were done independently by our four authors, while the first author did the statistical analysis.
 Results Of the 35 studies identified, 5 cohort studies met the criteria, with a total sample size of 18,352 infants from various countries. We developed a fixed-effect meta analysis of the data. The use of the sepsis calculator significantly reduced inappropriate use of antibiotics [RR 0.46; 95%CI 0.41 to 0.51; z=13.57; P<0.001], blood culture sampling [RR 0.46; 95%CI 0.40 to 0.52; z=12.11; P<0.001), and higher neonatal care level admissions [RR 0.68; 95%CI 0.59 to 0.78); z=5.47; P<0.001). No safety issues were reported from studies using the sepsis calculator.
 Conclusion The new EOS risk estimation using a neonatal sepsis calculator is an easy, effective, and safe tool to improve appropriate antibiotic use and outcomes. This calculator is ready to be implemented in all levels of neonatal care units.

1008. Cluster Analysis to Define Distinct Clinical Phenotypes Among Septic Patients With Bloodstream Infections

BackgroundPrior attempts at identifying outcome determinants associated with bloodstream infection have employed a priori determined classification schemes based on readily identifiable microbiology, infection site, and patient characteristics. We hypothesized that even amongst this heterogeneous population, clinically relevant groupings can be described that transcend old a priori classifications.MethodsCluster analysis was applied to variables from three domains: patient characteristics, acuity of illness/clinical presentation, and infection characteristics.ResultsAmong 3,715 patients with bloodstream infections from Barnes-Jewish Hospital (2008 to 2015), the most stable cluster arrangement occurred with the formation of four clusters. This clustering arrangement resulted in an approximately uniform distribution of the population: Clusters One (21.5%), Two (27.9%), Three (28.7%), and Four (21.9%). Staphylococcus aureus distributed primarily to Clusters Three (40%) and Four (25%), while Enterobacteriaceae were divided predominantly into Clusters Two (34%), Three (30%), and Four (22%). Nonfermenting Gram-negative bacilli grouped mainly in Clusters Four and Two (30% and 31%). More than half of the pneumonia cases occurred in Cluster Four. Clusters One and Two contained 33% and 31%, respectively, of the individuals receiving inappropriate antibiotic administration. Mortality was greatest for Cluster Four (33.8%, 27.4%, 19.2%, 44.6%; P < 0.001), while Cluster One patients were most likely to be discharged to a nursing home.ConclusionOur results support the potential for machine learning methods to identify homogenous groupings in infectious diseases that transcend old a priori classifications. These methods may allow new clinical phenotypes to be identified potentially improving the severity staging and treatment of complex infectious diseases.Disclosures All authors: No reported disclosures.

Appropriateness of antibiotic prescribing in the Emergency Department.

BackgroundAntibiotics are some of the most commonly prescribed drugs in the Emergency Department (ED) and yet data describing the overall appropriateness of antibiotic prescribing in the ED is scarce.ObjectivesTo describe the appropriateness of antibiotic prescribing in the ED.MethodsA retrospective, observational study of current practice. All patients who presented to the ED during the study period and were prescribed at least one antibiotic were included. Specialists from Infectious Disease, Microbiology and Emergency Medicine and a Senior Pharmacist assessed antibiotic appropriateness against evidence-based guidelines.ResultsA total of 1019 (13.6%) of patient presentations involved the prescription of at least one antibiotic. Of these, 640 (62.8%) antibiotic prescriptions were assessed as appropriate, 333 (32.7%) were assessed as inappropriate and 46 (4.5%) were deemed to be not assessable. Adults were more likely to receive an inappropriate antibiotic prescription than children (36.9% versus 22.9%; difference 14.1%, 95% CI 7.2%–21.0%). Patients who met quick Sepsis-related Organ Failure Assessment (qSOFA) criteria were more likely to be prescribed inappropriate antibiotics (56.7% versus 36.1%; difference 20.5%, 95% CI, 2.4%–38.7%). There was no difference in the incidence of appropriate antibiotic prescribing based on patient gender, disposition (admitted/discharged), reason for antibiotic administration (treatment/prophylaxis) or time of shift (day/night). ConclusionsInappropriate administration of antibiotics can lead to unnecessary adverse events, treatment failure and antimicrobial resistance. With over one in three antibiotic prescriptions in the ED being assessed as inappropriate, there is a pressing need to develop initiatives to improve antibiotic prescribing to prevent antibiotic-associated patient and community harms.

Appropriateness of Surgical Antibiotic Prophylaxis in Pediatric Patients in Italy.

OBJECTIVES Appropriate use of surgical antibiotic prophylaxis (SAP) reduces intraoperative wound contamination in pediatric surgery, thus minimizing the risk of surgical site infection (SSIs). Conversely, inappropriate use of SAP exposes patients to the risk of antibiotic side effects and contributes to the emergence of antimicrobial resistance. Our aims were to describe SAP administration and to analyze factors associated with nonadherence in pediatric patients. DESIGN Descriptive study. SETTING Overall, 955 pediatric patients underwent 1,038 surgical procedures. METHODS We assessed adherence to SAP international guidelines for surgical procedures performed on children aged <18 years in 2015 in 4 randomly selected hospitals in Calabria (Italy). The clinical records of these patients were retrospectively reviewed. RESULTS Appropriate SAP administration or nonadministration pertained to 754 surgical procedures (72.6%). Surgical antibiotic prophylaxis was administered in 88.5% of 358 procedures with an SAP indication. Adherence to guidelines for appropriate drug choice were followed in 5.7% of cases, for route of administration in 76.7% of cases, for timing in 48.6% of cases, for duration in 14.5% of cases, and for dose in 91.5% of cases, and for all components in only 5 cases (1.6%). Among 680 procedures without SAP indication, 35.7% case patients received antibiotics. Inappropriate administration of antibiotics in procedures without SAP indication was associated with surgical specialty wards (P=.008), ordinary admission (P<.001), head and neck surgical procedures (P=.020), clean surgery (P=.017), and surgical duration (P=.010). CONCLUSIONS Discrepancies between SAP guidelines and actual practice behavior more frequently indicate excessive use of antibiotics than underuse. Increased awareness of SAP guidelines is required. Infect Control Hosp Epidemiol 2017;38:823-831.

The influence of contaminated urine cultures in inpatient and emergency department settings

We retrospectively evaluated 131 patients with contaminated urine cultures during a 12-month period. Sixty-four patients (48.8%) experienced 139 potential complications related to these specimens. The most common complication was inappropriate antibiotic administration (noted in 58 patients [44.3%]). Contaminated urine cultures led to additional diagnostic evaluation and unnecessary antibiotic use.

Tackling blood culture contamination rates in the acute setting

Contaminated blood cultures cause a diagnostic and therapeutic challenge for microbiologists and physicians. There is potential risk to patients and expense to hospital trusts from inappropriate antibiotic administration and further tests. Data collection by the director of infection prevention and

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.

Russian Respiratory Society Interregional association on clinical microbiology and antimicrobial chemotherapy Clinical guidelines on diagnosis, treatment and prevention of severe community!acquired pneumonia in adults

Severe communityacquired pneumonia (CAP) is a particular type of the disease with high mortality and healthcare cost. The need in such practi cal guidelines is due to a high frequency of misdiagnosis of severe CAP and frequent cases of inappropriate administration of antibiotics in Russian Federation. These guidelines run epidemiology and etiology of severe CAP including current findings of antibacterial resistance of pathogens; pathogenesis; diagnosis; general management of patients including antibacterial and nonantibacterial treatment and respiratory support; and prevention. Adherence of practitioners to this document is expected to improve outcomes of severe CAP in adults. These guidelines could underlie local clinical guidelines, protocols and medical care standards of management of adult patients with severe CAP in RF.

Community-acquired acute bacterial meningitis in the elderly in Turkey

This investigation aimed both to delineate the current status of community-acquired acute bacterial meningitis and to produce data on the interrelationships between clinical, laboratory and therapeutic parameters in the elderly. This retrospective cohort study was conducted in 28 Turkish institutions in 159 culture-positive patients over the age of 50 years. Streptococcus pneumoniae was the most common pathogen (69.2%), followed by Listeria monocytogenes (8.8%). For this reason, antilisterial antibiotics such as ampicillin or benzylpenicillin should be added to the therapeutic regimen. Pathogen-specific mortality did not vary between S. pneumoniae and L. monocytogenes. The overall mortality was 2.5% at the third day, 12.6% at the seventh day, 20.1% at the 14th day and 21.4% at the 21st day. The risk factors for fatality were increasing age, the presence of stupor, sepsis and inappropriate antibiotic administration. Cerebrospinal fluid (CSF) leukocyte counts and CSF/blood glucose ratios were lower in patients who died. Fever did not differ between survivors and fatal cases. The mean duration of antibiotic therapy in survivors was 16.3 +/- 6.4 days. One-fifth of the patients had complications, and in 5.7% of the patients sequelae persisted at follow-up.

Diarrhoea management: An evaluation of the appropirateness of the home treatment given by caregivers

Background: Diarrhoea often starts at home. Early and appropriate treatment by caregivers will go a long way towards reducing the morbidity and mortality from diarrhoea. Aim: To document how acute diarrhoea is managed at home by caregivers and to determine the appropriateness of such treatment. Methods: A prospective study of children less than 5 years with diarrhoea attending the Diarrhoea Training Unit (DTU) and Children Emergency Ward (CHEW) of the University of Port Harcourt Teaching Hospital (UPTH) was conducted using a structured questionnaire administered to the caregivers. Results: A total number of 250 children were recruited for the study. Twenty-four (9.6%) children had blood in stool (dysentery) while 226(90.4%) had acute watery diarrhoea. Thirty-six (14.4%) gave oral rehydration therapy (ORT) as the only home treatment, 60 (24.0%) gave both drugs and ORT, while 151 (60.4%) gave drugs alone and 3 (1.2%) children received no treatment. The drugs given included antibiotics in 188 (89.1%), adsorbents in 53 (25.1%), antiemetic in 12 (5.7%), antispasmodic in 8 (3.8%), antihelminthics in 7 (3.3%), and antacid in 6 (2.8%). None of the cases with blood in the stool (dysentery) received the appropriate antibiotics. Parental education and social class did not seem to have an effect on the appropriateness of the care given to these children. Conclusion: Diarrhoea management at home is inadequate in terms of low utilization of oral rehydration therapy, inappropriate administration of antibiotics for cases with bloody stool, and unnecessary use of antibiotics/antidiarrhoeals for acute watery diarrhoea. Key words: Acute watery diarrhoea, Dysentery, Oral rehydration therapy (ORT), Drugs

Impact of Reporting Gram Stain Results From Blood Cultures on the Selection of Antimicrobial Agents

The reporting of Gram stain results from positive blood culture bottles clearly impacts the early selection of proper antimicrobial treatment. Mackenzie et al1 recognized that bacteremia is associated with serious morbidity and mortality, especially in certain groups of patients. Despite the broad range of antimicrobial agents available, a delay in inappropriate antibiotic administration can result in “progressive deterioration and the development of intractable complications.”2 Criteria for determining the appropriate antibiotic treatment for the specific clinical situation must include spectrum of activity, achievable blood levels, toxic effects, dosing and duration of therapy, and cost-effectiveness.3 Clinicians often face difficult therapy decisions that must be made well before a definitive identification of the pathogen causing the bacteremia is determined. Blood cultures in conjunction with the initial Gram stain of positive cultures have often been considered the “gold standard” for the diagnosis of bacteremia.4 The Gram stain, developed in 1884 by Hans Christian Gram, is one of the most important and most useful laboratory tests used in the clinical microbiology setting.5 Physicians continue to rely on the Gram stain result during the first 24 to 48 hours for the selection of appropriate antibiotic treatment for patients with positive blood cultures because susceptibility results usually cannot be provided in less than 48 to 72 hours. Gram-negative sepsis results in death 50% of the time during the first 2 days of the illness, demonstrating the importance of immediate and appropriate treatment.6 To be useful in guiding …

Review of Clinical Trials of Skin Antiseptic Agents Used to Reduce Blood Culture Contamination

False-positive blood culture results may lead to prolonged hospitalization, inappropriate antibiotic administration, and increased healthcare costs. We conducted a review of the literature to assess the effect of skin antiseptic agents on the rate of false-positive blood culture results. We found no clear evidence to suggest which antiseptic should be used to prevent false-positive results. Studies suggest, however, a possible benefit from the use of prepackaged skin antiseptic kits and alcohol-containing antiseptics.

Active Surveillance of Nosocomial Infections in Urologic Patients

ObjectivesWe report the results of a 4-month survey implemented at the urologic clinic of an Italian university hospital, with the following aims: (1) to describe the incidence of nosocomial infections (NI) in our setting for comparison within and between urologic wards and (2) to provide relevant information to monitor and target infection control policies. MethodsA 4-month prospective survey was performed from April to July 2004, preceded by the 1-month surveillance pilot study; both performed in accordance with the methods, protocols and definitions of the National Nosocomial Infections Surveillance System. The following indicators were included site-specific incidence rates and device-adjusted infection rates. For surgical site infections, rates were calculated by operative procedure and risk index category. Antimicrobial usage was also monitored. ResultsIncidence of symptomatic urinary tract infections was 1.4 per 1000 patient-days, 1.3 per 100 catheterized patients and 3.0 per 1000 urinary catheter-days. Incidence and incidence density of surgical site infections were respectively 1.3 per 100 patients and 1.8 per 1000 patient-days. ConclusionsOur study represents a contribution to improve the quality of care in our urologic ward by monitoring the size of the NI problem using standardized definitions, data collection and indicators to compare the results of the unit with possible future ones, and by identifying practices that should be changed. This study supports close surveillance of antibiotic administration among urologists who may be unaware of the inappropriate antibiotic administration in their patients. Two major items were identified for planning future intervention: focusing on the use of closed urinary drainage systems and on appropriate antimicrobial prophylaxis.