Judicious Use Of Antibiotics Research Articles

946. Establishing Antimicrobial Stewardship Programme at Four Secondary Care Hospitals in India through Hub and Spoke Model with Christian Medical College, Vellore as Guiding Centre

Abstract Background The high burden of antimicrobial resistance in India necessitates an urgent implementation of Antimicrobial Stewardship programs (ASP). Most ASP are based at tertiary care centres, with sparse data available regarding the effectiveness of an ASP in a low resource primary/secondary care setting. Methods We adopted a hub and spoke model to implement ASP in these low resource settings. The study consisted of three phases. Initial phase captured baseline antimicrobial days of therapy DOTs data with no feedback, followed by intervention phase wherein a few chosen interventions were implemented. Physicians of four chosen hospitals were trained via a blended customized distance education training programme, assisted with development of antibiogram based on their local hospital microbial resistance patterns via WHONET, followed by development of hospital specific antibiotic policy and augmentation of the existing laboratory skills by training personnel at the central facility. This was followed by a post intervention phase with a prospective review and feedback by trained personnel with assessment of DOTs. Results During the baseline phase, 1459 patients from all four sites were enrolled; 1233 patients were enrolled in the intervention phase. Both groups had comparable baseline characteristics. The key outcome, DOT per 1,000 patient days, was 1952.63 in the baseline phase. The DOT/1000 patient days was significantly lower in the post intervention period, at 1483.06 (P =0.001). Quinolones, Macrolides, Cephalosporins, Clindamycin, and Nitroimidazole use significantly decreased in the post intervention phase. Rate of de-escalation was significantly higher in the intervention phase compared to the baseline phase (44% vs 12.5%; P < .0001), suggesting a definite trend with regard to the judicious use of antibiotics. Post intervention phase revealed that 79.9% of antibiotic use was justified. Overall, the recommendations given by the ASP team were fully followed in 946 cases (77.7%), partially followed in 59 cases (4.8%), and not followed in 137 cases (35.7%). No adverse events were noted. Conclusion Our Hub and Spoke model of ASP was successful in implementing ASP in secondary care hospitals in India which is the need of the hour. Disclosures Priscilla Rupali, MD, DTM&H, PFIZER: Grant/Research Support|PFIZER: Grant/Research Support.

410. Characteristics of Patients with Extended-Spectrum Beta-Lactamase (ESBL) Producing Enterobacterales, Tennessee, 2019-2020

Abstract Background Currently, data on the incidence of Enterobacterales bacteria that produce extended-spectrum beta-lactamases (ESBL) within community settings is lacking. We set out to describe patient characteristics for healthcare-associated (HA) and community-associated (CA) ESBL-producing Enterobacterales in Tennessee. Methods ESBL cases were defined as isolation of Escherichia coli, Klebsiella pneumoniae, or Klebsiella oxytoca, resistant to cefotaxime, ceftriaxone, or ceftazidime, non-resistant to all tested carbapenems, from a normally sterile body site, or urine, within Maury, Lewis, Marshall, or Wayne Counties, with a specimen collection date from July 1st, 2019, to the end of 2020. Patient data was collected by reviewing patients’ medical records. HA cases were defined as those with previous healthcare exposures, of any kind, in the year preceding specimen collection. All analysis was performed using SAS 9.4. Results 566 cases were included in this study. Demographically, 459 (81.1%) cases identified as white with an equal number (81.1%) of patients being female. The average age was 66.2 years. 560 (98.94%) specimens were collected from urine, 468 (85.1%) patients had a urinary tract infection (UTI), and 174 (37.2%) of those patients had a record of recurrent UTIs. 243 (49.6%) cases were identified as CA. 138 (24.4%) cases were identified as being hospitalized within 29 days of their specimen collection and 247 (50.4%) cases were determined to be HA. 142 (25.1%) patients were treated with antibiotic in the month before specimen collection. Cephalosporins (31.7%), fluroquinolones (29.6%), doxycycline (7.7%), and sulfonamides (7.7%) were the most common antibiotics used to treat the patients. Among patients prescribed these antibiotics (N=109), 19 (17.4%) patients had specimens resistant. Figure 1:Characteristics of patients with extended-spectrum beta-lactamases (ESBL) producing Enterobacterales isolated from 2019-2020Figure 2:Characteristics of patients with extended-spectrum beta-lactamases (ESBL) producing Enterobacterales isolated from 2019-2020, continued Conclusion Most cases were described in white women with UTIs, often recurrent, coming from private residences. With approximately 50% of cases described as CA, targeted intervention outside of healthcare facilities is necessary to reduce spread of ESBL infections. As 17.4% of cases were treated with antibiotics that the organism was resistant, there is an opportunity to improve judicial use of antibiotics based on susceptibility data. Disclosures All Authors: No reported disclosures.

963. Perceived Antimicrobial Stewardship Roles of Pharmacists and Residents in US Intensive Care Units

Abstract Background Antimicrobial stewardship programs (ASPs) were developed as a way of addressing antibiotic resistance by promoting the judicious use of antibiotics. Pharmacist and resident perspectives of their own roles within antimicrobial stewardship are relatively unknown. An ethnographic study of intensive care units (ICU) was conducted to understand the perceptions and attitudes surrounding pharmacist and resident roles relative to stewardship. Methods A research assistant with medical anthropology training performed semi-structured interviews with intensive care pharmacy specialists and residents at a medical center in Cleveland, Ohio, USA between June 2021 and August 2021. Data analysis centered on the understandings of ASPs and antibiotic prescribing present in multidisciplinary groups where certain members are not primary antibiotic decision-makers. The data were analyzed using thematic coding aided by NVivo qualitative analysis software. Results Intensive care pharmacy specialists (N=5) and residents (N=6) were interviewed, accruing > 518 minutes of semi-structured interview data. Pharmacy specialists described their contributing role as serving stewardship goals such as “decreasing mortality” and believed that they should have input in antibiotic decision making. Residents also emphasized the importance of consulting pharmacists before antibiotic decisions were made. Both groups felt limited in their ability to contribute to final antibiotic decisions. Pharmacists regularly referred to their input as a “recommendation” and described their actions as “suggestions”. Residents expressed that physicians were better suited to make decisions due to the residents’ limited experience, acknowledging that they “don’t know everything.” Table 1.Key Themes and Perceived Roles in Intensive Care Conclusion This study found that ICU pharmacists and residents have an awareness of stewardship that might aid in antimicrobial prescribing. Both groups expressed an appreciation for stewardship goals despite being bounded by hierarchies of medical practice. Providing these groups with greater autonomy over prescribing practices might improve ASP effectiveness. Future studies may focus on analysis on the social dynamics of hospital spaces and the corresponding impact on decision-making and expert practices. Disclosures All Authors: No reported disclosures.

Prevalence of macrolide-lincosamide-streptogramin resistant lactic acid bacteria isolated from food samples.

Lactic acid bacteria (LAB) being a reservoir of antibiotic resistance genes, tend to disseminate antibiotic resistance that possibly pose a threat to human and animal health. Therefore, the study focuses on the prevalence of macrolide-lincosamide-streptogramin- (MLS) resistance among LAB isolated from various food samples. Diverse phenotypic and genotypic MLS resistance were determined among the LAB species (n = 146) isolated from fermented food products (n = 6) and intestine of food-producing animals (n = 4). Double disc, triple disc diffusion and standard minimum inhibitory concentration (MIC) tests were evaluated for phenotypic MLS resistance. Specific primers for MLS resistance genes were used for the evaluation of genotypic MLS resistance and gene expressions using total RNA of each isolate at different antibiotic concentrations. The isolates identified are Levilactobacillus brevis (n = 1), Enterococcus hirae (n = 1), Limosilactobacillus fermentum (n = 2), Pediococcus acidilactici (n = 3), Enterococcus faecalis (n = 1). The MIC tests along with induction studies displayed cMLSb, L phenotype, M phenotype, KH phenotype, I phenotype resistance among MLS antibiotics. Genotypic evaluation tests revealed the presence of ermB, mefA/E, msrA/B and msrC genes. Also, gene expression studies displayed increased level of gene expression to the twofold increased antibiotic concentrations. In the view of global health concern, this study identified that food samples and food-producing animals represent source of antibiotic resistant LAB that can disseminate resistance through food chain. This suggests the implementation of awareness in the use of antibiotics as growth promoters and judicious use of antibiotics in veterinary sectors in order to prevent the spread of antibiotic resistance.

Minnesota One Health Antibiotic Stewardship Collaborative: A Reproducible Approach to Facilitate Antimicrobial Stewardship Progress.

The Minnesota One Health Antibiotic Stewardship Collaborative (MOHASC) was launched in 2016 with the mission of providing a collaborative environment to promote judicious antibiotic use and antibiotic stewardship (AS) and to reduce the impact of antibiotic-resistant pathogens of human, animal, and environmental health importance. MOHASC goals include improving AS programs in healthcare and veterinary medicine, advancing understanding of environmental impacts of antibiotic use, and promoting a One Health (OH) approach to AS. These goals are accomplished through quarterly meetings of 4 work groups, field trips, collaborative research, an annual member meeting, and public education events. This novel OH approach has strengthened multidisciplinary relationships within Minnesota and led to procurement of funding to enhance AS initiatives beyond the Collaborative. This perspective serves as a blueprint for other jurisdictions, and we advocate for use of this reproducible OH strategy to facilitate broad AS goals.

Drowning Induced Acute Respiratory Distress Syndrome (ARDS): A Case Report

Introduction: Drowning is still one of the leading causes of accidental deaths worldwide while Acute Respiratory Distress Syndrome (ARDS) is the main component of drowning pathophysiology. During drowning which often leads to aspiration, pneumonitis may develop an inflammatory response and release of inflammatory mediators and activation of immune mediated responses. This cascade of events causes the development of Acute Respiratory Distress Syndrome, (ARDS). Case: We received a case of a male patient in the emergency room having a history of an accidental fall in the well and drowning for 5 minutes. When rescued he was conscious and after an hour, he developed cough and breathlessness. On arrival, his routine clinical examination and laboratory and radiological investigation were performed and in view of Acute Respiratory failure patient was shifted to the intensive care unit for further managementas. As per his chest radiogram with clinical signs of hypoxia he immediately required endotracheal intubation and mechanical ventilation. Result and Conclusion: Appropriate invasive mechanical ventilation and sound intensive care with judicial use of antibiotics can benefit such cases of drowning and ARDS.

Parents’ awareness of antimicrobial resistance: a qualitative study utilising the Health Belief Model in Perth, Western Australia

ObjectiveThis study aimed to determine local factors that promote or prevent parents’ responsible use of antibiotics for their children in Perth, Western Australia. MethodsThe Health Belief Model was used to guide this study. Four focus group discussions were conducted, with 26 participants. Participants were recruited purposively through a parent group organisation. The Framework Method was utilised to analyse the data. ResultsParticipants agreed that antimicrobial resistance (AMR) is a serious health problem. However, participants admitted that they lacked awareness of AMR, inhibiting their ability to assess the risks of developing AMR infections among their children. Participants knew the indications and risks of antibiotic use but still viewed antibiotics as a time‐saving solution that minimised disruption to their routine. Participants’ previous experiences in managing their children's illness increased their confidence and linked their positive and negative experiences with their general practitioners in their judicious use of antibiotics. ConclusionsWhile parents demonstrated awareness of the indications of antibiotics, they continue to lack AMR awareness and overvalue antibiotics. Implications for public healthThe findings highlight that incorporating parent empowerment and participation in decision‐making regarding antibiotics use, and maintaining a positive relationship with healthcare providers, were important strategies to encourage the appropriate use of antibiotics.

Perioperative antimicrobial prophylaxis in clean-contaminated head and neck squamous cell cancer surgeries: Is less better?

Judicious use of antibiotics and stringent adherence to practice guidelines is the need of the hour as antibiotic resistance is a rampant problem. Despite several reports in the literature describing the optimal duration of antibiotics, there is no consensus. A "one for all" protocol may be impractical and hence the guidelines need to be tweaked to take into consideration local factors. We designed a protocol for prophylactic antibiotics in clean-contaminated head and neck cancer squamous cell carcinoma (HNSCC) surgeries to prevent unchecked abuse and evaluated its feasibility. Two hundred consecutive patients who underwent a clean-contaminated surgery for HNSCC between January 2017 and December 2019 were included. Single-dose intravenous amoxicillin-clavulanate at induction followed by three doses of amoxicillin-clavulanate, metronidazole, and amikacin in the postoperative period was used. Adherence to the antibiotic protocol was assessed from a prospectively maintained database. The mean age was 55.99 ± 11.71 years. The protocol was effective in 70% of the patients with an acceptable surgical site infection (SSI) rate of 12%. Flap-related complications (9.5%) and oro-cutaneous fistula (5%) were common causes of prolonged antibiotics. On univariate analysis, blood transfusion (P = .014), clinical stage at presentation (P = .028), patients undergoing reconstruction (P = .001), longer operative time (P = .009), and pathological T stage (P = 0.03) were at higher chance of deviating from the protocol. On multivariate analysis, age more than 50 years (OR: 2.14, 95% CI: (1.01, 4.52); P value = 0.047) and reconstruction (OR: 3.36, 95% CI: (1.21, 9.32); P value = 0.020) were found to be significant. A three-dose perioperative antibiotic prophylaxis in clean-contaminated HNSCC surgeries is feasible. Similar protocols should be developed and validated at other major centers to limit the unnecessary use of antibiotics and prevent the emergence of antibiotic resistance.

Effects of hydrogen-rich saline in neuroinflammation and mitochondrial dysfunction in rat model of sepsis-associated encephalopathy

BackgroundSepsis-associated encephalopathy (SAE) is one of the most common types of sepsis-related organ dysfunction without overt central nervous system (CNS) infection. It is associated with higher mortality, low quality of life, and long-term neurological sequelae in suspected patients. At present there is no specific treatment for SAE rather than supportive therapy and judicious use of antibiotics, which are sometimes associated with adverse effects. Molecular hydrogen (H2) has been reported to play crucial role in regulating inflammatory responses, neuronal injury, apoptosis and mitochondrial dysfunction in adult models of SAE. Here we report the protective effect of hydrogen-rich saline in juvenile SAE rat model and its possible underling mechanism(s).Materials and methodsRats were challenged with lipopolysaccharide (LPS) at a dose of 8 mg/kg injected intraperitoneally to induce sepsis and hydrogen-rich saline (HRS) administered 1 h following LPS induction at a dose of 5 ml/kg. Rats were divided into: sham, sham + HRS, LPS and LPS + HRS. At 48 h, rats were sacrificed and Nissl staining for neuronal injury, TUNEL assay for apoptotic cells detection, immunohistochemistry, and ELISA protocol for inflammatory cytokines determination, mitochondrial dysfunction parameters, electron microscopy and western blot analysis were studied to examine the effect of HRS in LPS-induced septic rats.ResultsRats treated with HRS improved neuronal injury, improvement in rats’ survival rate. ELISA analysis showed decreased TNF-α and IL-1β and increased IL-10 expression levels in the HRS-treated group. Apoptotic cells were decreased after HRS administration in septic rats. The numbers of GFAP and IBA-1positive cells were attenuated in the HRS-treated group when compared to the LPS group. Subsequently, GFAP and IBA-1 immunoreactivity were decreased after HRS treatment. Mitochondrial membrane potential detected by JC-1 dye and ATP content were decreased in septic rats, which were improved after HRS treatment, while release of ROS was increased in the LPS group reverted by HRS treatment, ameliorating mitochondrial dysfunction. Further analysis by transmission electron microscopy showed decreased number of mitochondria and synapses, and disrupted mitochondrial membrane ultrastructure in the LPS group, while HRS administration increased mitochondria and synapses number.ConclusionThese data demonstrated that HRS can improve survival rate, attenuate neuroinflammation, astrocyte and microglial activation, neuronal injury and mitochondrial dysfunction in juvenile SAE rat model, making it a potential therapeutic candidate in treating paediatric SAE.

Assessment of the knowledge and behavior of backyard and small-scale producers in California regarding disease prevention, biosecurity practices and antibiotics use.

The number and popularity of backyard poultry and livestock farming have rapidly increased in California as well as other states in the United States following consumers' preference for local and organic products in the last few years. This study aimed to investigate current on-farm management and farmers' understanding of Veterinary Feed Directive (VFD) and California Senate Bill (SB) 27 implications for disease prevention, biosecurity procedures, and antimicrobial use in small-scale and backyard farms in California. The survey consisted of 38 questions. The responses of 242 backyard and small-scale livestock owners were investigated in this study. Descriptive statistics summarized survey responses, and multivariable logistic regression evaluated the association of antibiotics purchase and use, and the impact of VFD and SB27 on antibiotic use with demographics and on-farm management. Backyard and small-scale farmers in California mostly raised chickens or small ruminants with small herd sizes kept for personal use. Antibiotics were generally used for individual treatment of a sick animal with the guidance of a veterinarian. VFD and SB27 implementation promoted the judicious use of antibiotics, specifically, by enhancing the relationship between backyard and small-scale farmers with veterinarians and treating fewer animals with antibiotics under veterinary oversight. Therefore, better access to veterinary service in backyard and small-scale farms will improve the farmer's knowledge of good husbandry practices with judicious antimicrobial use in livestock and finally contribute to reducing the risk of antimicrobial resistance in California.

Construction of Scale to Measure the Attitude of Veterinarians towards Antimicrobial Resistance and Stewardship

Antimicrobial resistance has become one of the major health problems in human and animals. This threat is increasing daily and is fueled by a range of factors. Indiscriminate use of antibiotics in animals is one of the greatest source for provoking the global threat. In developing countries, veterinarians are the main driving forces towards use of antibiotics appropriately in the field conditions. Presently there is no provision to monitor the type and quantum of antibiotics prescribed by veterinarians. Here in India, their attitude plays an important role to combat on antimicrobial resistance by promoting judicious use of antibiotics in animals. To know the attitude of veterinarians in Kerala, an effort was made to develop a scale using equal appearing interval method to measure their attitude towards antimicrobial resistance and stewardship. Final scale consisted 15 statements comprising 7 favourable and 8 unfavourable statements to measure attitude of veterinarians towards antimicrobial resistance and stewardship.

Prevalence of metallo beta-lactamase and Amp C beta-lactamase producing pathogens causing surgical site infection in a tertiary care teaching centre in Southern India

Abstract Background: Surgical site infection (SSI) is the most common type of hospital-acquired infection-causing public health problems. The study was undertaken to know the aerobic bacteriology of SSI with special reference to the detection of metallo-beta-lactamase (MBL) and AmpC beta-lactamases among Gram-negative bacilli. Methods: The present cross-sectional study was conducted in 140 patients clinically suspected to have SSIs. Samples were collected from patients after considering inclusion and exclusion criteria. Results: Out of 85 Gram-negative bacilli, 9 isolates (10.6%) were Amp C producers. Out of a total of 85 Gram-negative bacilli, 3 isolates (3.5%) were MBL producers. Two isolates of Pseudomonas aeruginosa and 1 isolate of Acinetobacter spp. were positive for MBL production. In the present study, MBL production was seen in 3.5%, of Gram-negative bacilli. Conclusions: Early identification of such resistant strains is important to plan the appropriate antibiotic therapy. Strict infection control practices and judicious use of available antibiotics are essential to prevent the emergence of multidrug-resistant strains.

Rising Threat of Antimicrobial Resistance: Judicious Use of Antibiotics is the Way Forward

Rising Threat of Antimicrobial Resistance: Judicious Use of Antibiotics is the Way Forward

Procalcitonin: In diagnosis of paediatric infections

Although there are many diagnostic tests available for the diagnosis of infections, all have their own limitations with regard to time, sensitivity and specificity. As a result, there is an unnecessary and prolonged use of antibiotics, leading to multidrug resistance and antibiotic misuse. Increasing evidence supports the use of procalcitonin (PCT) in diagnosing bacterial infections as early as possible and titrating the antibiotics according to the dynamics of PCT value. PCT helps in the early diagnosis of the upper and lower respiratory tract infections, meningitis, post-operative cases, sepsis in intensive care units and the judicial use of antibiotics according to PCT algorithms. PCT is a reliable marker as compared to the other markers such as C-reactive protein, interleukin 1, 6, IF-gamma and tumour necrosis factor-alfa. PCT value is not affected by neutropenia, immunodeficiency disorders and with the use of steroid and non-steroid anti-inflammatory drugs. The aim of this review article is to summarise the current evidence for PCT in different infections and clinical settings and discusses the diagnostic and prognostic value of PCT in different types of infections, its limitations and the economics of usage of PCT.

Knowledge, Attitude and Practice of Pharmacy Professionals Against Dispensing Antibiotics Without Prescription in Ethiopia.

Antibiotic resistance is a global public health threat that warrants immediate intervention. Dispensing of antibiotics without prescription (DAWP), is an inappropriate practice that contributes significantly to the emergence and spread of antibiotic resistance. The current study aimed to assess the knowledge, attitude and practice of community pharmacists and pharmacy assistants towards DAWP. A cross-sectional study was conducted, and data was collected from community pharmacists and pharmacy assistants during the eighth national pharmacist's day, which was held on December 4, 2021, in Addis Ababa, Ethiopia. A pre-tested self-administered questionnaire comprise of four sections (socio-demographic characteristics, and knowledge, attitude and practice towards DAWP) was used. The data was analyzed using SPSS version 26 and descriptive statistics (mean, percentage, standard deviation) were computed. Binary logistic regression was used to predict determinates of DAWP. A total of 175 community pharmacy professional were invited in the study, with 158 (111 pharmacists and 47 pharmacy assistants) completing the survey for 90.3% response rate. Most of the participants (86.7%) were aware that DAWP is illegal in Ethiopia. Despite their knowledge, the extent of DAWP was found to be 67.7%. The most common reason given by study participants for DAWP was that most patients do not want to consult prescribers unless the infection appears serious (53.2%). Pharmacy professionals with educational background of masters and above (AOR= 0.354, 95% CI: 0.013-0.744, P= 0.045), and with two to five years of working in community pharmacy (AOR= 0.745, 95% CI: 0.595-0.933, P= 0.010) had a lower tendency to DAWP, respectively. Despite majority of pharmacy professional are aware that DAWP is illegal and contributes to antibiotic resistance, they commonly DAWP for common cold and diarrheal diseases. Strict enforcement of existing antibiotic supply policies, and ongoing educational support for community pharmacy professionals on the judicious use of antibiotics is recommended.

Conservative treatment with mouthwashes followed by tongue photo biomodulation therapy in Covid-19: a case report

BackgroundOral manifestations of coronavirus disease 2019 (COVID-19), including ulcers, herpetiform lesions, macules, and petechiae, among others, are becoming increasingly recognized, but there is little guidance on their treatment. Reported cases have described treatment with various mouthwashes containing antivirals, antifungals, antibiotics, anesthetics, or steroids. Our case report is unique in that we provide guidance on the judicious use of these medications, followed by photobiomodulation therapy if the manifestations are treatment resistant.Case presentationWe describe a 30-year-old Caucasian woman who tested positive for COVID-19 after developing nasal congestion and cough. Ten days after testing positive, she developed a systemic rash on her extremities and torso. At the same time, she developed swelling of the tongue lasting 1 hour, with subsequent appearance of oral lesions that resembled geographic tongue. She also had an irritable sensation on her tongue and some mild loss of sense of taste. We opted for conservative therapy, including mouth rinses containing lidocaine to be used every 6 hours. The patient used the mouth rinse therapy for 1 month and experienced a 90% improvement in her oral lesions and tongue sensitivity. However, she had repeated flares every 3 weeks over a 6-month period, and the steroid mouthwash achieved incomplete resolution. After three sessions of photobiomodulation therapy, she had no further flares or tongue sensitivity and the lesions healed.ConclusionsThe implication of our report is that we promote the judicious use of topical antibiotics, antivirals, antifungals, and steroids for when they are indicated. We propose lidocaine-containing mouth rinses and steroid mouthwash as an initial, symptomatic treatment regimen for ‘COVID-19 tongue.’ If there is failure of resolution, we recommend photobiomodulation therapy.

Antibiotic Prescribing Practices for Treating COVID-19 Patients in Bangladesh.

Although national and international guidelines have strongly discouraged use of antibiotics to treat COVID-19 patients with mild or moderate symptoms, antibiotics are frequently being used. This study aimed to determine antibiotics-prescribing practices among Bangladeshi physicians in treating COVID-19 patients. We conducted a cross-sectional survey among physicians involved in treating COVID-19 patients. During September–November 2021, data were collected from 511 respondents through an online Google Form and hardcopies of self-administered questionnaires. We used descriptive statistics and a regression model to identify the prevalence of prescribing antibiotics among physicians and associated factors influencing their decision making. Out of 511 enrolled physicians, 94.13% prescribed antibiotics to COVID-19 patients irrespective of disease severity. All physicians working in COVID-19–dedicated hospitals and 87% for those working in outpatient wards used antibiotics to treat COVID-19 patients. The majority (90%) of physicians reported that antibiotics should be given to COVID-19 patients with underlying respiratory conditions. The most prescribed antibiotics were meropenem, moxifloxacin, and azithromycin. Our study demonstrated high use of antibiotics for treatment of COVID-19 patients irrespective of disease severity and the duty ward of study physicians. Evidence-based interventions to promote judicious use of antibiotics for treating COVID-19 patients in Bangladesh may help in reducing an overuse of antibiotics.

ACQUIRED BRONCHOBILIARY FISTULA PRESENTING AS COUGH

ACQUIRED BRONCHOBILIARY FISTULA PRESENTING AS COUGH

Survey of the Knowledge, Attitudes and Practice towards Antibiotic Use among Prospective Antibiotic Prescribers in Serbia.

The complex issue of antibacterial resistance (ABR) requires actions taken with the One Health approach, involving both human and veterinarian medicine. It can spread from animals to humans through the food chain or through direct contact. Health profession students, as the future antibiotic providers, can greatly impact antibiotic-related issues in the future. The study was conducted to evaluate knowledge, attitudes and practice of future antibiotic prescribers in relation to judicious use of antibiotics. This cross-sectional, questionnaire-based study was performed on 400 students of health professions who were allowed to prescribe antibiotics of the University of Novi Sad, Serbia. Students of medicine and students of dentistry showed a significantly higher knowledge score compared to students of veterinary medicine (p = 0.001). Multivariate regression identified predictors of adequate antibiotic knowledge: being a female student (B = 0.571; p = 0.020), higher grade average (B = 1.204; p = 0.001), students of medicine (B = 0.802; p = 0.006) and dentistry (B = 0.769; p = 0.026), and students who used a complete package of antibiotics during the last infection (B = 0.974; p = 0.001) or for the period recommended by the doctor (B = 1.964; p = 0.001). Out of the total sample, self-medication was reported among 42.8% of students. The identified predictors of self-medication were: more frequent (B = 0.587; p = 0.001) and irregular (B = 0.719; p = 0.007) antibiotic use, taking antibiotics until symptoms disappeared (B = 2.142; p = 0.001) or until the bottle was finished (B = 1.010; p = 0.001) during the last infection. It seems prudent to reevaluate the educational curricula regarding antibiotic use and ABR of prospective prescribers in Serbia.

Urinary tract infections in children: building a causal model-based decision support tool for diagnosis with domain knowledge and prospective data

BackgroundDiagnosing urinary tract infections (UTIs) in children in the emergency department (ED) is challenging due to the variable clinical presentations and difficulties in obtaining a urine sample free from contamination. Clinicians need to weigh a range of observations to make timely diagnostic and management decisions, a difficult task to achieve without support due to the complex interactions among relevant factors. Directed acyclic graphs (DAG) and causal Bayesian networks (BN) offer a way to explicitly outline the underlying disease, contamination and diagnostic processes, and to further make quantitative inference on the event of interest thus serving as a tool for decision support.MethodsWe prospectively collected data on children present to ED with suspected UTIs. Through knowledge elicitation workshops and one-on-one meetings, a DAG was co-developed with clinical domain experts (the Expert DAG) to describe the causal relationships among variables relevant to paediatric UTIs. The Expert DAG was combined with prospective data and further domain knowledge to inform the development of an application-oriented BN (the Applied BN), designed to support the diagnosis of UTI. We assessed the performance of the Applied BN using quantitative and qualitative methods.ResultsWe summarised patient background, clinical and laboratory characteristics of 431 episodes of suspected UTIs enrolled from May 2019 to November 2020. The Expert DAG was presented with a narrative description, elucidating how infection, specimen contamination and management pathways causally interact to form the complex picture of paediatric UTIs. Parameterised using prospective data and expert-elicited parameters, the Applied BN achieved an excellent and stable performance in predicting Escherichia coli culture results, with a mean area under the receiver operating characteristic curve of 0.86 and a mean log loss of 0.48 based on 10-fold cross-validation. The BN predictions were reviewed via a validation workshop, and we illustrate how they can be presented for decision support using three hypothetical clinical scenarios.ConclusionCausal BNs created from both expert knowledge and data can integrate case-specific information to provide individual decision support during the diagnosis of paediatric UTIs in ED. The model aids the interpretation of culture results and the diagnosis of UTIs, promising the prospect of improved patient care and judicious use of antibiotics.