National Antibiotic Policy Research Articles

Microbiology of Klebsiella with extended-spectrum β-lactamases production

Extended-spectrum β-lactamases (ESBL) producing Klebsiella represents one of the greatest challenges in therapeutic management of the patients. Hence, the objective was to determine ESBL producing Klebsiella species and its molecular characterization in clinical samples of tertiary-care hospital. Klebsiella isolated from various samples were included and by using disc diffusion method ESBL detection amongst the Klebsiella isolates along with molecular detection of blaTEM, blaSHV, blaCTX-M genes which are associated with ESBL production was done. Results revealed that out of 3194 samples, 200 Klebsiella species were isolated. The ratio of Klebsiella species isolated from inpatient and outpatient departments was 75.5% and 24.5% respectively. The maximum isolates were obtained from men consisting of 57.50% and aged between 31-40 years with 26.50%. Majorly Klebsiella species were isolated from sputum including 30.5%, followed by urine consisting of 28% and pus samples with 19.5%. From the 200 isolates, 197 were Klebsiella pneumonia and 32.5% were ESBL producers with majorly having the blaTEM gene incorporated. Being Multidrug and Pan-drug resistant, Klebsiella with ESBL strains are a threat to mankind. This can be overcome by adhering to strict hospital policies to avoid irrational use of antibiotics, strictly following institutional and National antibiotic policies and by prescribing antibiotics according to the culture and sensitivity reports.

A STUDY OF OCCURRENCE OF ANTIBIOTIC RESISTANCE REPORTED AGAINST STAPHYLOCOCCUS AUREUS IN THE DEPARTMENT OF MICROBIOLOGY IN A TERTIARY CARE HOSPITAL IN HAPUR

Objective: The aim of the study is to evaluate the occurrence of antibiotic resistance reported against Staphylococcus aureus in the department of microbiology in a tertiary care hospital in Hapur. Methods: Urine, pus, blood, throat swab, and sputum samples of 15–60-year-old patients were collected and cultured. 100 samples were selected where S. aureus had grown. Bacteria were identified and the antimicrobial sensitivity testing was carried out. Results: The strain of resistant bacteria originates from an environment where several antibiotics are used. The bacteria were seen to be resistant frequently to 2–5 antibiotics. This indicates earlier exposure of the isolated bacteria to these drugs. Conclusion: The high multiple antibiotic resistance is identified in this study and it is necessary to make changes to national antibiotic policy.

A Prospective Study on Cephalosporin Consumption Pattern at Trust-Based Tertiary Care Hospital

This study aimed to evaluate the Drug usage of 3 rd generation cephalosporins and its effectiveness against particular diagnosis. A Prospective cross-sectional study was conducted at 40 Bedded Pediatric wards of Sukkur Blood Bank, Donating Society and Hospital, Sukkur to evaluate the antibiotic usage pattern among all admitted in-patients. Patients’ demographic details were recorded from the Patient Bedside File (PBF). Data were analyzed using an excel sheet and Microsoft SPSS 20. Among all admitted patients, 1710 patients met the inclusion criteria and their PBF were evaluated for antibiotics. A total of 2155 cephalosporins were prescribed. The most commonly prescribed cephalosporins among the study population were Ceftriaxone 51.55% followed by Cefotaxime Sodium (26.50%). Among all, 74.34% pediatric patients were prescribed antibiotics through the parenteral route and 25.66% through the oral route. Antibiotics were being used without having any official national antibiotic policy or institutional protocols, which are currently lacking in the country. The study findings shall assist the health department and hospital management to devise the official guidelines to ensure rational usage of antibiotics. It is therefore recommended that the government should immediately address the irrational and overuse of antibiotics by implementing, national antibiotics policy, antibiotic stewardship programs, and training of healthcare staff. Novelty of this paper consists of collection of large-scale data, also data from diversified population was collected, as this study was conducted in public, private, and also charity-based hospitals. Keywords: pediatrics, antibiotics, cephalosporins, consumption pattern, culture sensitivity test. https://doi.org/10.55463/issn.1674-2974.50.1.29

Progress towards antibiotic use targets in eight high-income countries.

ObjectiveTo compare antibiotic sales in eight high-income countries using the 2019 World Health Organization (WHO) Access, Watch and Reserve (AWaRe) classification and the target of 60% consumption of Access category antibiotics.MethodsWe analysed data from a commercial database of sales of systemic antibiotics in France, Germany, Italy, Japan, Spain, Switzerland, United Kingdom of Great Britain and Northern Ireland, and United States of America over the years 2013–2018. We classified antibiotics according to the 2019 AWaRe categories: Access, Watch, Reserve and Not Recommended. We measured antibiotic sales per capita in standard units (SU) per capita and calculated Access group sales as a percentage of total antibiotic sales.FindingsIn 2018, per capita antibiotic sales ranged from 7.4 SU (Switzerland) to 20.0 SU (France); median sales of Access group antibiotics were 10.9 SU per capita (range: 3.5–15.0). Per capita sales declined moderately over 2013–2018. The median percentage of Access group antibiotics was 68% (range: 22–77 %); the Access group proportion increased in most countries between 2013 and 2018. Five countries exceeded the 60% target; two countries narrowly missed it (> 55% in Germany and Italy). Sales of Access antibiotics in Japan were low (22%), driven by relatively high sales of oral cephalosporins and macrolides.ConclusionWe have identified changes to prescribing that could allow countries to achieve the WHO target. The 60% Access group target provides a framework to inform national antibiotic policies and could be complemented by absolute measures and more ambitious values in specific settings.

Community acquired paediatric pneumonia; experience from a pneumococcal vaccine- naive population

BackgroundChildhood pneumonia continues to be a disease that causes severe morbidity and mortality among children mainly in South-East Asia and Africa though it is not so in the developed world. Pneumonia accounts for 16% of all deaths of children under 5 years old in the world, killing nearly one million children in 2015. In Sri Lanka, there were 21,000 reported cases of pneumonia in 2006, 40% were in the age group of less than 4 years.MethodsThis was a retrospective study done on the children aged 1 month to 14 years who were admitted to the Professorial Paediatric unit of Teaching Hospital, Peradeniya between 1st of March 2016 and 30th of July 2017 fulfilling diagnostic criteria for community-acquired pneumonia. Data including diagnosis, clinical details, management details and other relevant data were collected from patient records by using a data collection sheet.ResultsIn this study, 48% of 127 patients admitted with community-acquired pneumonia had bronchopneumonia. About 2/3 of the patients neededa secondline of intravenous antibiotics while 51/ 127 needed care in the high dependency unit with supplemental oxygen. No mortality was observed in the group.ConclusionsCommunity- acquired paediatric pneumonia has a significant associated morbidity but not mortality in the studied population. The need for the second-line treatment with intravenous antibiotics in a significant proportion of patients may indicate a high degree of antibiotic resistance. Introduction of national antibiotic policy will help the cause.

Health care-associated infections in pre-transplant liver intensive care unit: Perspectives and challenges.

Health care-associated infections (HAIs) threaten patient's safety worldwide especially in the intensive care units (ICU). In end-stage liver disease (ESLD), the condition is much more complicated. Data regarding HAIs among ESLD patients is lacking. We aimed to assess the incidence of HAIs, risk factors, causative micro-organisms, antimicrobial susceptibilities and mortality rates among patients with end-stage liver disease (ESLD) admitted to pre-transplant liver intensive care unit (LICU). This prospective observational study included 337 ESLD patients admitted to LICU, Al-Rajhi liver center, Assiut University Hospital, Assiut, Egypt between January 2016 and June 2016 and they were followed up for the development of HAI manifestations. The medical history, physical examination and severity of underlying disease were determined. Clinical samples were taken from patients who developed HAIs for microbiological diagnosis and antimicrobial susceptibility testing. A total of 57 (16.9%) ESLD patients developed HAIs with the incidence density of 26.8 per 1000 patient-days. Blood stream infection was the most common (49.1%). Escherichia coli (21.1%) followed by methicillin-resistant Staphylococcus aureus (MRSA) (15.8%) were the commonest bacteria. Multidrug resistant organisms were reported in 52.6% of the isolates. Fungal causes were 15.8% with Candida species dominance. Sphingomonas paucimobilis and Achromobacter dentrificans were reported for the first time as pathogens for HAIs in LICU. Prolonged hospital stay, intravenous line duration, prolonged use of proton pump inhibitors and paracentesis were predictors for HAIs. No significant difference between ESLD patients with and without HAIs regarding mortality (36.8% vs. 48.6%, P=0.2). High HAI rate among ESLD patients is a matter of worry. Effective surveillance program, active infection control measures and national antibiotic policies are necessary to reduce the burden of HAIs.

The ethics of setting national antibiotic policies using financial incentives.

Antimicrobial resistance (AMR) is an increasingly urgent global public health issue. Data from Public Health England — from the English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) — quantifies the scale of antibiotic resistance in key bacterial pathogens. The Department of Health’s 5-year strategy to reduce morbidity and mortality associated with AMR (2013–2018) focused on optimising antibiotic prescribing and improving infection prevention and control.1 In April 2015 NHS England introduced a Quality Premium (QP) focusing on reducing antibiotics. QPs are financial rewards, with a maximal value equivalent to £5 per patient, intended to reward clinical commissioning groups (CCGs) for improvements in the quality of the services that they commission and for associated improvements in health outcomes and reducing inequalities. The AMR QP provided commissioners with financial incentives to reduce antibiotic prescribing; 80% were linked to primary care quality measures (reduction in absolute number of antibiotic prescriptions by 1%, decrease in use of broad spectrum antibiotics by 10%) and 20% linked to improving availability of antibiotic prescribing data from secondary care.2 Incentives are a tool that governments use to help support behaviour change, are a recognised domain in behaviour change methodology, and can be considered a form of trade. CCGs are offered an incentive in the form of additional funds for investment if they have reduced antibiotic prescribing. However, the CCG also has to show that it manages public funds responsibly and will only receive a QP if it has managed its funds according to the ‘Managing Public Money’ guidelines and does not require financial support during the financial year (nor deviate substantially from expected surpluses/deficits).2 In 2014/2015 only 27% of the total available QP was achieved by CCGs. Although the financial incentive is directed towards CCGs, the behavioural change being targeted is at the level of …

Bacteriological profile of neonatal sepsis in a secondary care hospital in rural Tamil Nadu, Southern India.

Introduction:Neonatal sepsis is a leading cause of neonatal mortality and morbidity in the world. The objective of the current study was to detect the common causative microorganisms of neonatal sepsis and their antimicrobial resistance patterns in a rural secondary hospital in Tamil Nadu, India.Materials and Methods:Neonates (0–28 days) admitted to this newborn care unit from October 2013 to September 2015, with a diagnosis of probable sepsis were studied. All the enrolled babies had blood cultures taken and were followed up till final outcome, which was discharge or death, irrespective of culture result. Univariate analysis was performed for factors associated with culture positivity, generating odds ratios, and confidence intervals.Results:Among the 107 babies with a diagnosis of probable sepsis, 28 (26.2%) had shown bacteria in culture. The majority (94.4%) were of early-onset sepsis. The predominant organisms were Staphylococcus aureus (10/28) and Klebsiella (6/28). 100% of Gram-negative bacilli and 90% of Staphylococcus were resistant to Ampicillin. Gentamicin resistance among Gram-negative bacilli and Staphylococcus was 52.9% and 20%, respectively, while third-generation cephalosporin resistance was 31.2% and 20%, respectively. Among the neonates diagnosed as probable sepsis, idiopathic prematurity (P = 0.007) was found to have a statistically significant association with culture-positive sepsis.Conclusion:The culture positivity rate among the neonates with probable sepsis in the current study was 26%. An alarmingly high degree of antibiotic resistance observed calls for robust infection control practices and an urgent evaluation and development of individual and national antibiotic policies for neonatal sepsis.

Reduction in post-operative acute kidney injury following a change in antibiotic prophylaxis policy for orthopaedic surgery: an observational study.

Evidence has shown that a prophylactic antibiotic regimen of flucloxacillin and gentamicin for orthopaedic surgery was associated with increased rates of post-operative acute kidney injury (AKI). This resulted in changes in the national antibiotic policy recommendation for orthopaedic surgical prophylaxis. This study aimed to assess whether this change from flucloxacillin and gentamicin to co-amoxiclav was associated with changes in the rates of AKI and Clostridium difficile infection (CDI). An observational study and interrupted time series analyses were used to assess rates of post-operative AKI separately in patients undergoing neck of femur (NOF) repair and other orthopaedic operations that required antibiotic prophylaxis. Incidence rate ratios were used to evaluate changes in CDI rates. Following the change in policy, from flucloxacillin and gentamicin to co-amoxiclav, there was a relative change in rates of post-operative AKI of -63% (95% CI -77% to -49%) at 18 months in the other orthopaedic operations group. In the NOF repair group, there was no change in the rate of post-operative AKI [-10% (95% CI -35%-15%)] at 18 months. The incident rate ratio for CDI in the other orthopaedic operations group was 0.29 (95% CI 0.09-0.96) and in the NOF repair group was 0.76 (95% CI 0.28-2.08). The use of co-amoxiclav for antibiotic prophylaxis in orthopaedic surgery was associated with a decreased rate of post-operative AKI compared with flucloxacillin and gentamicin and was not associated with increased rates of CDI.

Antimicrobial Resistance Patterns of Acinetobacter baumannii, Pseudomonas aeruginosa and Staphylococcus aureus Isolated From Patients With Nosocomial Infections Admitted to Tehran Hospitals

Background: Nosocomial infections constitute a global health problem, leading to a high rate of morbidity and mortality. The choice of antimicrobial treatment for nosocomial infections is often empirical and based on the knowledge of local antimicrobial activity patterns of the most common bacteria causing such infections. Objectives: The aim of this study was to determine the 3 most prevalent bacterial pathogens including Acinetobacter baumannii, Pseudomonas aeruginosa and Staphylococcus aureus causing nosocomial infections and their antimicrobial resistant profiles in patients admitted to three hospitals in Tehran city, Iran. Materials and Methods: In this cross-sectional study, the A. baumannii, P. aeruginosa and S. aureus isolates were obtained from different samples of patients with nosocomial infections admitted to different wards of three hospitals including Milad, Motahary and Loghman from November 2014 to April 2015. Nosocomial infections were defined as a culture-proven infection, which occurred more than 48 hours after admission. Antimicrobial susceptibility testing was performed using the disk diffusion method according to Clinical and Laboratory Standards Institute (CLSI) guidelines. Results: In total, 539 samples were collected during the study period from patients with nosocomial infections. Overall, 198, 75 and 98 A. baumannii, P. aeruginosa and S. aureus isolates were obtained, respectively. Cefepim and meropenem were found to be the most effective antibiotics for nosocomial infections caused by S. aureus with only 1 resistant isolate. Resistance to gentamicin and amikacin and susceptibility to cefepim was the highest compared to other antibiotics amongst P. aeruginosa isolates which is in consistent with the fact that cephalosporins remain useful agents for the management of nosocomial infections caused by P. aeruginosa. Acinetobacter baumannii isolates showed lower susceptibility rates to imipenem and ciprofloxacin than other antibiotics with 189 and 187 resistant isolates, respectively; however 155 isolates were susceptible to co-trimoxazole and ceftazidime. The high resistant rate amongst A. baumannii to carbapenems is likely consequence of heavy empirical usage of this group of antibiotics. Conclusions: The high prevalence of antimicrobial resistance in the hospitals highlights the need for further infection control programs. Future regional epidemiological data on antimicrobial resistance patterns will be required to implement strict national antibiotic policies to restrict the spread of these resistance bugs.

O009: “The Chennai declaration”- a historic document (for the high impact paper session)

There is currently no functioning national antibiotic policy or a national policy to contain antimicrobial resistance in India.

Antibiotic Policy of India: Need to Act Now

Antimicrobial resistance has become a global challenge and needs to be tackled at the earnest. India lacks a functioning antibiotic policy and there is an urgent need to develop such a policy. A national antibiotic policy was published a couple of years back but lack of political will and complex practical issues have delayed its implementation. Various Indian medical societies have now put their efforts together for defining a roadmap to tackle the problem of infection control and prevention of antimicrobial resistance. A practicable functioning antibiotic policy is the need of the hour.

Pattern of antibiotic abuse – a population based study in Cairo

BackgroundInappropriate use of antibiotics is a significant public health problem. The unnecessary use of antibiotics exposes the community to unwarranted medication and contributes to the development of antimicrobial resistance. ObjectiveIs to define pattern of usage of unprescribed antibiotics in Cairo and various contributing factors for such behavior including level of education, occupation and socioeconomic level. MethodsAn interview questionnaire was held with 1057 subjects exploring their behavior toward antibiotic use in a 3month-period. Descriptive statistics was used to analyze the data. FindingsAmong 1006 completed questionnaires, usage of unprescribed antibiotics in the 3month period was 29.8%. Most antibiotics were used to treat respiratory infections (55.7%). The most common antibiotics used were penicillins. Behavior of seeking medical advice is affected significantly by different age groups but not by gender. Rates of consulting a physician were 69%, 60%, 41.3% and 29.9% among children, elderly, youth and adults respectively. Different socioeconomic levels among the surveyed sample preferred ways other than consulting physicians based on the belief that common diseases do not worth physician’s consultation 47.3%. ConclusionThis study showed high rates of antibiotic abuse among Cairo population. This needs to be guided through different strategies. An easy access to an affordable health care service with a considerable quality is the first step side by side with establishing a national antibiotic policy to be followed by all healthcare workers.

Antibiotic use and resistance in public-sector hospitals in KwaZulu-Natal

To investigate a possible association between level of care, antibiotic use and antimicrobial resistance in 16 public-sector hospitals providing different levels of care in KwaZulu-Natal. A multicentre surveillance study was undertaken in 16 hospitals at three progressive levels of health care (district, regional, tertiary) where each hospital submitted 100 consecutive, non-repetitive isolates judged in the laboratory to be of potential clinical significance. Isolates were identified and susceptibility testing was undertaken using the Kirby-Bauer disc diffusion method with minimum inhibitory concentrations (MICs) extrapolated on an automated reading system. Isolates were grouped according to their natural resistance profiles, and percentage susceptibility, mean percentage susceptibility and standard deviation to each antibiotic were stratified within and across hospital levels. Antibiotic use data were expressed as the number of daily divided doses (DDDs) per 1000 patient-days. Two tertiary, 9 regional and 5 district public hospitals in KwaZulu-Natal. Percentage susceptibility. There was a general trend among the 1 270 isolates of highest susceptibility in district hospitals, followed by regional and then tertiary hospitals. This is consistent with the referral system where health conditions become increasingly severe/complex requiring greater antibiotic use and broader-spectrum agents at progressive hospital levels, with statistical significance (p < 0.05) evident where sample numbers were relatively large. Trend variations could be associated with the qualitative and quantitative differences in antibiotic use, albeit without statistical corroboration. Three per cent of the total number of isolates were sensitive to all antibiotics tested and 6% were resistant to a single agent only. The remaining 91% showed acquired resistance to more than one drug. The standard deviation ranged from 0% to 55%. This study showed that resistance profiles among bacteria varied greatly within and across hospital levels. While antibiotic use varied as much, a statistically significant correlation between use and resistance could not be established. It was therefore postulated that the effect of selection pressure was obscured by other resistance determinants apparent in public hospitals in resource-poor settings. On a clinical level, the study showed that resistance profiles among bacteria vary too much to allow a national antibiotic policy as proposed in the standard treatment guidelines. Rather, such guidelines should be directed to specific profiles found in different hospitals and at different levels of health care. Regular surveillance to adjust such guidelines is essential.

National and Local Antibiotic Policies in Central and Eastern Europe

To assess the antibiotic policies of Central European countries, we performed an overview of antibiotic stewardship, prescription habits and antibiotic prescription regulatory procedures. Since most Central European countries have had centralized health care and drug policies, the situation 10 years after decentralization is surprising. Only 3 of 10 Central European countries have some regulation of prescription of antibiotics, only 4 restrict some antibiotics, only 5 have hospital and only 3 national antibiotic policies. In all but 3 countries physicians can prescribe quinolones and/or 3rd generation oral cephalosporins as first-line antibiotics. Information on local and national antibiotic policies in Central and Eastern European countries is given including prescription guidelines for antibiotic use in community and hospital.