Oral Cephalosporin Research Articles

1785. Regional Variation of Antimicrobial Use in Japan From 2013 to 2016

BackgroundSince antimicrobial resistance (AMR) is a global threat, judicious antimicrobial usage is required. Compared with European countries, antimicrobial use (AMU) is relatively low in Japan; however, the use of oral broad-spectrum antimicrobials is relatively high. Although the Japanese national action plan on AMR targets a 50% reduction in use of these oral broad-spectrum antimicrobials by 2020 from the level in 2013, regional variation in AMU in Japan is not well known.MethodsNational antimicrobial sales data from 2013 to 2016 was obtained from IQVIA Japan (Tokyo, Japan), which captures 99% of total sales in Japan. Antimicrobials were classified by the World Health Organization (WHO) defined Anatomical Therapeutic Chemicals (ATC) classification. WHO measures the number of antimicrobial use by Defined Daily Dose per 1,000 inhabitant-days (DID). From 2013 to 2016, the difference in DID amongst each prefecture was analyzed, and comparison amongst the three major regions of East, Central, and West Japan was performed using Mann–Whitney U test.ResultsFrom 2013 to 2016, the median (max, min) AMU (DID) change was −0.4 (2.8, −1.6). During the study period, 34 prefectures showed increasing trends and 13 prefectures showed decreasing trends. Median (max, min) AMU (DID) for total antimicrobials, oral cephalosporins, macrolides, and quinolones in 2016 was 14.4 (18.7, 11.2), 3.5 (6.9, 2.5), 4.5 (6.3, 3.2), and 2.8 (3.7, 1.9), respectively. The median total AMU (DID) in East, Central, and West Japan in 2016 was 13.2, 14.4, and 15.8, respectively. Median oral cephalosporins AMU (DID) in Central Japan (3.69) was significantly higher than that in East Japan (3.33) (P = 0.025). Median oral macrolides AMU (DID) in East Japan (4.11) was significantly smaller than that in Central (4.61) and West Japan (4.70) (P < 0.01). Median oral quinolones AMU (DID) in West Japan (3.28) was significantly higher than that in East (2.29) and Central Japan (2.73) (P < 0.01) (figure).ConclusionFrom 2013 to 2016, significant regional variations of oral AMU were observed in Japan. Further studies are needed to specify the appropriate targets of antimicrobial stewardship intervention to reduce oral broad-spectrum AMU in Japan. Disclosures All authors: No reported disclosures.

173. Nationwide Outpatient Oral Antimicrobial Utilization by Children in Japan

BackgroundAntimicrobial resistance (AMR) is a major public health concern across the world. Japanese government set goals in national AMR action plan to reduce oral cephalosporins, macrolides, and quinolones into a half of the 2013 use by 2020. We evaluated the nationwide antimicrobial use (AMU) of children in Japan using the dispensing receptive from the national administrative database in regard to the national AMR action plan.MethodsThe national health claims database was interrogated for oral antibiotics dispensed from outpatient pharmacies in Japan to children under 15 years of age from January 2013 to December 2016. Information obtained from each prescription included age, residence area, days of therapy (DOT) for each antimicrobial from dispensing receptive. DOT was corrected by the resident population in area and calculated as DOT/1,000 pediatric inhabitants/day (DOT/PID). Chi-squared test for trend was performed to evaluate the annual changes of DOT/PID.ResultsA total of 1,3869,332 oral antibiotic prescriptions were identified during 2013–2016. Total amount of antimicrobial used in children did not change (2013: 28.54 DOT/PID, 2016: 28.70 DOT/PID, Ptrend = 0.25). No statistically significant changes were observed in prescriptions of third-generation cephalosporin (2013:10.21DOT/PID, 2016:9.87DOT/PID, Ptrend = 0.50), macrolide (2013:11.04 DOTID, 2016:10.72 DOT/PID, Ptrend = 0.52), and quinolone (2013:1.46DOT/PID,2016:1.86DOT aged <5 years compared with older infants, with the highest rate among children aged 1 year. Targeted antimicrobials for AMR action plan showed similar distribution by age (Figure 2).ConclusionInterim assessment of the national AMR action plan revealed that the goals were not attainable without significant interventions in children by 2020. Overall antibiotic prescription as well as cephalosporins, macrolides, and quinolones prescription were most prevalent in children aged 1 year. Antimicrobial stewardship targeting infants and younger children is necessary. Disclosures All authors: No reported disclosures.

Prescription and non-prescription antibiotic dispensing practices in part I and part II pharmacies in Moshi Municipality, Kilimanjaro Region in Tanzania: A simulated clients approach.

Antibiotic dispensing without a prescription poses a threat to public health as it leads to excessive antibiotic consumption. Inappropriate antibiotic availability to the community has been documented to be amongst drivers of antimicrobial resistance emergence. Community pharmacies are a source of antibiotics in low and middle-income countries (LMICs). We aimed at assessing antibiotic dispensing practices by community pharmacy retailers in Moshi urban, Kilimanjaro, Tanzania and recommend interventions to improve practice. Using a Simulated Client (SC) Method, an observational cross-sectional survey of antibiotic dispensing practices was conducted from 10th June to 10th July 2017. Data analysis was done using Stata 13 (StataCorp, College Station, TX, USA). A total of 82 pharmacies were visited. Part I pharmacies were 26 (31.71%) and 56 (68.29%) were part II. Overall 92.3% (95% CI 77.8–97.6) of retailers dispensed antibiotics without prescriptions. The antibiotics most commonly dispensed without a prescription were ampiclox for cough (3 encounters) and azithromycin for painful urination (3 encounters). An oral third generation cephalosporin (cefixime) was dispensed once for painful urination without prescription by a part I pharmacy retailer. Out of 21, 15(71.43%) prescriptions with incomplete doses were accepted and had antibiotics dispensed. Out of 68, 4(5.9%) retailers gave instructions for medicine use voluntarily. None of the retailers voluntarily explained drug side-effects. In Moshi pharmacies, a high proportion of antibiotics are sold and dispensed without prescriptions. Instructions for medicine use are rarely given and none of the retailers explain side effects. These findings support the need for a legislative enforcement of prescription-only antibiotic dispensing rules and regulations. Initiation of clinician and community antibiotic stewardship and educational programs on proper antibiotic use to both pharmacists and public by the regulatory bodies are highly needed.

Nationwide study of outpatient oral antimicrobial utilization patterns for children in Japan (2013-2016).

Antimicrobial resistance (AMR) is a major multinational public health concern. The Japanese government set goals in its AMR action plan to reduce use of oral cephalosporins, macrolides, and quinolones by half between 2013 and 2020. We aimed to evaluate antimicrobial use in children in Japan by observing prescription patterns as an interim assessment of the national AMR action plan. Using the national health claims database, we retrospectively analyzed all oral antimicrobials dispensed from outpatient pharmacies in Japan to children under 15 years old from 2013 to 2016 by age, prefecture, type of antimicrobial, and year. Data were presented as days of therapy (DOTs) per 1000 pediatric inhabitants per day (DOTs/PID). The χ2 test for trends was performed to evaluate annual changes in DOTs/PID overall as well as within each stratum. A total of 721,627,553 oral antimicrobial DOTs were identified during 2013-2016. No statistically significant changes were observed in total antimicrobial use in children (2013: 28.54 DOTs/PID; 2016: 28.70 DOTs/PID; Ptrend=0.25) and amount of cephalosporins, macrolides, and quinolones prescribed. Prescription rates of all antimicrobials were highest among children 1-5 years old, peaking at 1 year old. Targeted antimicrobials for the AMR action plan showed similar distribution by age. The amount of antimicrobials prescribed to children in Japan is not decreasing. Overall antimicrobial prescriptions, as well as prescriptions of cephalosporins, macrolides, and quinolones, were most prevalent in children ≤5 years old. Rigorous antimicrobial stewardship interventions targeting infants and younger children are necessary.

Risk analysis of antimicrobial resistance in outpatient urinary tract infections of young healthy adults.

Most studies addressing community-acquired urinary tract infections (UTIs) pertain to mixed cohorts, in which young healthy adults are under-represented. We aimed to dissect the intricate interrelation between exposures and subsequent antimicrobial resistance (AMR) patterns in a unique setting of young healthy adults, allowing further guidance in this group. We carried out a retrospective cross-sectional study of all Enterobacteriaceae-associated outpatient UTIs during 2014-16 in soldiers, representing the young fit population in Israel. Electronic medical records were reviewed for demographic and clinical data, antimicrobial exposures and prescriptions. Risk factors for AMR were analysed by multivariate logistic regression. Of 1207 cases, 1144 (94.8%) were females, with a median age of 20.2 years. Escherichia coli was the predominant species (83.2%). Only 686 (56.8%) isolates were fully susceptible. AMR rates were as follows: trimethoprim/sulfamethoxazole, 19.6%; oral cephalosporins, 9.7%-16.7%; amoxicillin/clavulanate, 12.1%; ciprofloxacin, 11.1%; and nitrofurantoin, 12.6%. Predictors of AMR were recurrent UTIs, past-year hospitalization, male gender and non E. coli strains. Antimicrobials prescribed >6 months preceding the culprit infection were not related to AMR. Fluoroquinolone and cephalosporin exposures were highly predictive of further AMR, yet nitrofurantoin and, to a lesser extent, amoxicillin/clavulanate had fewer associations with AMR induction and resistance to these antimicrobials was less associated with any exposure. This nationwide study of community-related UTIs shows significant AMR rates for commonly used oral antimicrobials even in young fit adults. Nitrofurantoin proved once more to be an adequate empirical choice regardless of previous exposures, having a less detrimental effect on future AMR. Conversely, both resistance to fluoroquinolones following previous exposures and the associated heavy ecological burden should deter their common use as first-line agents for UTIs.

THUR 217 Salmonella gives you wings

A 35-year-old British man based in Pakistan presented with a febrile illness, associated with hepatosplenomegaly. Salmonella paratyphi A was isolated from blood cultures and he was treated with oral and intravenous cephalosporins. 3 weeks later, he developed polyarthralgia and right scapular winging. 5 weeks after the initial episode, fevers recurred with new right upper limb neuropathic pain. Examination showed weakness of right serratus anterior, deltoid and triceps, and reduced sensation in left lateral cutaneous nerve of forearm (LCNF) distribution. Neurophysiology showed abnormal sensory responses in the left LCNF and right superficial peroneal nerve, and abnormal EMG in right serratus anterior and right pronator teres. MRI brachial plexus showed no abnormal enhancement in the plexus. CSF was normal. Salmonella paratyphi A was again cultured from blood and he was re-treated. 10 months’ later, he has residual, mild weakness of right deltoid.Salmonella typhi has been associated with Guillain-Barre syndrome, and can have neuropsychiatric manifestations. The association with a post-infectious polyneuropathy has not previously been reported.

Temporal Dynamics and Risk Factors for Bloodstream Infection With Extended-spectrum β-Lactamase-producing Bacteria in Previously-colonized Individuals: National Population-based Cohort Study.

Little is known of the long-term risks of bloodstream infection (BSI) with extended spectrum β-lactamase-producing Enterobacteriaceae (EPE) in previously-colonized individuals. We investigated EPE-BSI risks and associated risk factors during 6 years following EPE colonization. We performed a population-based cohort study in Sweden using national health registers. Subjects were followed from their first EPE finding in feces (n = 5513) or urine (n = 17189). The effects of co-morbidity, sociodemography, and outpatient antibiotic dispensation on EPE-BSI risks were assessed. The EPE-BSI risks were compared to those of 45161 matched population-based reference subjects. The cumulative 6-year EPE-BSI incidences were 3.8%, 1.6%, and 0.02% in the urine, feces, and reference cohorts, respectively. The incidences decreased exponentially during the first 6-12 months. Among EPE-exposed subjects, urological disorders were associated with the highest adjusted cause-specific hazard ratio (aCSHR) for subsequent EPE-BSIs (3.40, 95% confidence interval 2.47-4.69). The aCSHRs were between 1.62-2.20 for male sex, immunosuppression, diabetes, malignancy, lung disease, baseline urine source, and Klebsiella pneumoniae, compared to the Escherichia coli baseline sample. Antibiotics with selective activity against gram-negative bacilli-but mostly not EPE (trimethoprim-sulfamethoxazole, fluoroquinolones, oral cephalosporins, and penicillins with extended spectrums)-and pivmecillinam were associated with doubled EPE BSI risk during the 3 months after antibiotic dispensation in EPE-colonized subjects. EPE in urine or feces is a substantial risk factor for subsequent EPE-BSIs, but the risk declines rapidly during the first year after detection. In EPE-colonized individuals, specific risk factors can be used to identify subgroups for targeted interventions, such as eradication therapy.

Phase 1 multicenter trial to assess the maximum tolerated dose, safety, pharmacokinetics, and pharmacodynamics of pazopanib in combination with irinotecan and temozolomide (PAZIT) for children and young adults with advanced sarcoma.

TPS10576 Background: Sarcomas express pro-angiogenic factors that may represent therapeutic targets. Pazopanib, an oral multi-kinase inhibitor of VEGFR-(1-3), c-kit, and PDGFR, is FDA-approved for the treatment of advanced soft tissue sarcomas. In a phase 1 study of single-agent pazopanib in children with recurrent or refractory solid tumors, this agent was well tolerated and the clinical activity was encouraging in this heavily pre-treated population. Preclinical studies have demonstrated a potential additive or synergistic interaction between anti-angiogenic agents and cytotoxic chemotherapy. The combination of irinotecan and temozolomide is well tolerated and provides a modest degree of antitumor activity in heavily pre-treated sarcoma patients, thus making it a useful platform onto which new compounds may be tested. Methods: This is a phase 1, open-label, multicenter trial of pazopanib in combination with irinotecan and temozolomide (PAZIT) in children and young adults ages 6-30 years with relapsed or refractory sarcomas (NCT03139331). The primary objectives are to determine the recommended phase 2 dose, describe toxicities, and describe pharmacokinetic parameters in this population. Secondary and exploratory objectives include evaluation of disease response and exploration of pharmacodynamic effects of PAZIT. Pazopanib is administered orally on days 1-21 of 21-day cycles according to assigned dose level. All patients receive fixed doses of irinotecan IV (50 mg/m2/day) or PO (90 mg/m2/day) and temozolomide 100 mg/m2/day PO on days 1-5. Oral cephalosporin diarrhea prophylaxis is required. Dose escalation follows a standard 3+3 design evaluating up to three pazopanib dose levels. Following dose escalation, up to 10 additional patients will be enrolled to the dose expansion cohort to obtain additional toxicity and efficacy data. Correlative studies include changes in plasma angiogenic factors and circulating tumor DNA. Enrollment began in May 2017 and is ongoing. Clinical trial information: NCT03139331.

Prospective evaluation of the management of urinary tract infections in 134 French nursing homes

ObjectiveProspective assessment of the management of urinary tract infections (UTI) in the nursing homes of the Hauts-de-France region. Patients and methodsA 50-question form had to be filled in for up to five consecutive residents treated for UTI in each nursing home. If necessary, diagnoses were reclassified according to the 2014 French Infectious Diseases Society guidelines. Analyses were presented per supposed (reported) and reclassified diagnoses. ResultsOf 397 contacted facilities, 134 participated and informed 444 UTI episodes. Reported diagnostic criteria were burning urination (32%), malodorous urine (29%), confusion (28%), and turbid urine (19%). Twenty-one percent of diagnoses were based on erroneous criteria. Less than 50% of residents had a urine dipstick test performed and 94% a urine culture. The main pathogen was Escherichia coli. Reported indications were uncomplicated cystitis (32%), unspecified UTI (26%), complicated cystitis (9%), while no reason was given in 25% of cases. Only 10% of diagnoses were consistent with the guidelines: complicated cystitis (49%), asymptomatic bacteriuria (21%), acute pyelonephritis (21%), male UTI (9%). Almost 85% of prescriptions were active on the isolated bacteria. The empirical antibiotic therapy was consistent with the diagnosis in 16% of cases (30% for reclassified diagnoses). The two most prescribed antibiotic classes were fluoroquinolones (22.1%) and oral third-generation cephalosporins (19.1%). Only two of 157 possible de-escalations were performed. Duration of treatment was adequate for 19% of UTIs (9.6% of reclassified cases). ConclusionOur study revealed multiple deficiencies in diagnosis, antibiotic choice, treatment duration, and reevaluation.

A rare cause of ptosis in emergency medicine practice: acute sinusitis case report

Objective: Paranasal sinus infections are one of the most frequent causes of emergency service admissions. With increased incidence, complications are often local and classified according to the effecting side. Early identification of complication leads to reduce mortality and morbidity. Case: A 22 year old male patient was admitted to our emergency department with ptosis on his right eyelid. Firstly he was admitted to the family doctor and received oral cephalosporin treatment for upper respiratory tract infection. Within three days, the ptosis was progressively occurred. No additional systemic sign was detected. The eyelid has slightly edema, not have redness, conjunctival hyperemia and loss of brow not observed. Eye movements were naturally, display pain in the outward view. For differential diagnosis central nervous system imaging was performed. Patient referred to otorhinolaryngology surgeon with prediagnosis of orbital cellulite and acute sinusitis. The patient was admitted to the otorhinolaryngology clinic for operation because of complicated sinusitis. Conclusion: In the presence of acute sinusitis, infections may enter the orbital periosteum and spread to neighboring tissues. Computed tomography is a highly effective imaging modality for the evaluation of both paranasal infections and their complications. Patients with orbital complications must be hospitalized and immediate intravenous antibiotic therapy should be started.

Diagnosis and management of asymptomatic bacteriuria in kidney transplant recipients: a survey of current practice in Europe.

Asymptomatic bacteriuria is frequent in kidney transplant recipients (KTRs). However, there is no consensus on diagnosis or management. We conducted a European survey to explore current practice related to the diagnosis and management of asymptomatic bacteriuria in adult KTRs. A panel of experts from the European Renal Association-European Dialysis Transplant Association/Developing Education Science and Care for Renal Transplantation in European States working group and the European Study Group for Infections in Compromised Hosts of the European Society of Clinical Microbiology and Infectious Diseases designed this cross-sectional, questionnaire-based, self-administered survey. Invitations to participate were e-mailed to European physicians involved in the care of KTRs. Two hundred and forty-four participants from 138 institutions in 25 countries answered the survey (response rate 30%). Most participants [72% (176/244)] said they always screen for asymptomatic bacteriuria in KTRs. Six per cent (15/240) reported never treating asymptomatic bacteriuria with antibiotics. When antimicrobial treatment was used, 24% of the participants (53/224) said they would start with empirical antibiotics. For an episode of asymptomatic bacteriuria caused by a fully susceptible microorganism and despite no contraindications, a majority of participants (121/223) said they would use a fluoroquinolone (n = 56), amoxicillin/clavulanic acid (n = 38) or oral cephalosporins (n = 27). Screening for and treating asymptomatic bacteriuria are common in KTRs despite uncertainties around the benefits and harms. In an era of antimicrobial resistance, further studies are needed to address the diagnosis and management of asymptomatic bacteriuria in these patients.

Resistance patterns of gram negative bacteria in urinary tract infections and efficacy of empirical treatment in noncomplicated cases: Retrospective cohort study of 2180 women

Aim: Community and hospital acquired urinary tract infections (UTI) are the most common bacterial infections in all age groups. In this study, the women diagnosed UTI, which complicated and uncomplicated, were referred to outpatient clinics between 2011 and 2015 were selected. The suitability of empirical antimicrobial therapy prescribed with resistance patterns of Gram negative bacteria isolated from these patients was investigated. Methods: UTI complaining and urine culture ≥10⁵ cfu / ml of bacteria that women aged 18-65 were comprised the study group. HIS (Hospital Information System Software) was scanned for these patients and uncomplicated and complicated UTI distinction was made according to the criteria set by Infectious Diseases Society of America (IDSA, 2016). Of the 2180 patients studied, 836 were complicated and 896 were noncomplicated. Identification of Gram negative isolates in urine culture; Conventional methods and Matrix-Assisted Laser Desorption and Ionization Time-Of-Flight Mass Spectrometry (MALDI-TOF MS), (Biotyper, Bruker, Germany) systems were used. The antimicrobial susceptibilities of the isolated strains from 2011 to 2014 were determined according to the Clinical Laboratory Standards Institute (CLSI) and the isolated strains in 2015 were determined according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST). Results: The distribution of 2180 female patients (18 to 65 years old) was urology polyclinic (68%), family medicine, infectious disease and physical medicine and rehabilitation polyclinics (19.1%), and emergency medicine polyclinic (12.6%). E. coli (84%), K. pneumonia / oxytoca (7%) and Enterobacter spp (2.6%) were the most frequently detected agents in the uncomplicated UTIs, while complicated UTI E. coli (91%), K. pneumonia / oxytoca (5.7%) and P. aeruginosa (1%) were found to be the first, second and third in the patients. Quinolones were prescribed 18.2%, phosphomycin 16.7%, nitrofurantoin 15.6%, nitrofurantoin and phosphomycin combined 16.3%, second generation oral cephalosporins 9.6% and third generation oral cephalosporins 10.7%. Resistance to quinolones, the most commonly prescribed antibiotic, was found in 19% of E. coli, 21% of Klebsiella spp., 13% of Enterobacter spp. and 9% of Proteus spp. Conclusion: When these prescriptions were compared with the results of antimicrobial susceptibility, it was observed that 38 (14%) were incompatible with the sensitivity results. It was found that 42% of cefuroxime prescriptions, 28% of quinolone prescriptions and 17% of ceftriaxone prescriptions were incompatible with the antibiogram results.

MP26-07 IN-OFFICE FREEHAND TRANSPERINEAL TEMPLATE MAPPING BIOPSY PERFORMED UNDER LOCAL ANESTHESIA USING A NOVEL NEEDLE GUIDE: FEASIBLE, SAFE, AND EFFECTIVE FOR CANCER DETECTION

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology I1 Apr 2018MP26-07 IN-OFFICE FREEHAND TRANSPERINEAL TEMPLATE MAPPING BIOPSY PERFORMED UNDER LOCAL ANESTHESIA USING A NOVEL NEEDLE GUIDE: FEASIBLE, SAFE, AND EFFECTIVE FOR CANCER DETECTION Matthew Lee, Shaan Setia, Adam Cole, Michael Fenstermaker, Chandy Ellimoottil, Lindsey Herrel, John Wei, Srinivas Vourganti, and Arvin George Matthew LeeMatthew Lee More articles by this author , Shaan SetiaShaan Setia More articles by this author , Adam ColeAdam Cole More articles by this author , Michael FenstermakerMichael Fenstermaker More articles by this author , Chandy EllimoottilChandy Ellimoottil More articles by this author , Lindsey HerrelLindsey Herrel More articles by this author , John WeiJohn Wei More articles by this author , Srinivas VourgantiSrinivas Vourganti More articles by this author , and Arvin GeorgeArvin George More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.865AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Sepsis following transrectal ultrasound-guided (TRUS) biopsy is rising with numerous strategies aimed at curbing its incidence. Transperineal prostate biopsy has negligible rates of sepsis but has traditionally been reserved for saturation sampling, required general anesthesia, and use of a brachytherapy grid/stepper. Additionally, the adequacy of modified 12-core transperineal template mapping biopsy (TMB) is debated. Herein, we describe our initial experience with completely in-office free-hand transperineal prostate biopsy (TPBx) performed under local anesthesia. METHODS A retrospective review was performed of patients who underwent TPBx at 2 institutions. TPBx was performed in lithotomy under TRUS guidance using a BK8848 biplanar probe after oral cephalosporin prophylaxis. Local anesthesia was administered via transperineal puncture and bolus delivery of anesthetic at the pelvic floor and through the endopelvic fascia anterior to the prostatic apex, bilaterally. The PrecisionPointTM device was used to access the left and right prostatic lobes to complete a modified barzell 12-core TMB. Patient characteristics and pathologic outcomes were collected and analyzed. RESULTS A total of 87 biopsies were performed with data available for 30 biopsies performed on protocol. Patient characteristics and pathologic data are summarized in Table 1. Mean age and PSA of the cohort were 63.4 years and 6.9ng/ml. Six men had a prior prostate cancer diagnosis and underwent biopsy on surveillance. The overall cancer detection rate (CDR) was 57% and clinically significant CDR (Gleason ≥7) was 33%. There were no complications noted within 30 days of biopsy. CONCLUSIONS Transperineal freehand prostate biopsy is effective for detection of prostate cancer. It is safe and well tolerated under local anesthesia, and can be performed in an office setting. Larger studies are required to validate this early experience. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e338 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Matthew Lee More articles by this author Shaan Setia More articles by this author Adam Cole More articles by this author Michael Fenstermaker More articles by this author Chandy Ellimoottil More articles by this author Lindsey Herrel More articles by this author John Wei More articles by this author Srinivas Vourganti More articles by this author Arvin George More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Improving Antibiotic Prescribing for Children With Urinary Tract Infection in Emergency and Urgent Care Settings.

Children with urinary tract infection (UTI) are often diagnosed in emergency and urgent care settings and increasingly are unnecessarily treated with broad-spectrum antibiotics. This study evaluated the effect of a quality improvement intervention on empiric antibiotic prescribing for the treatment of uncomplicated UTI in children. A local clinical pathway for uncomplicated UTI, introduced in June 2010, recommended empiric treatment with cephalexin, a narrow-spectrum (first-generation) cephalosporin antibiotic. A retrospective quasi-experimental study of pediatric patients older than 1 month presenting to emergency and urgent care settings from January 1, 2009, to December 31, 2014, with uncomplicated UTI was conducted. Hospitalized patients and those with chronic conditions or urogenital abnormalities were excluded. Control charts and interrupted time-series analysis were used to analyze the primary outcome of narrow-spectrum antibiotic prescribing rates and the balancing measures of 72-hour revisits, resistant bacterial isolates, and subsequent inpatient admissions for UTI. A total of 2134 patients were included. There was an immediate and sustained significant increase in cephalexin prescribing before (19.2%) versus after (79.6%) pathway implementation and a concurrent significant decline in oral third-generation cephalosporin (cefixime) prescribing from 50.3% to 4.0%. There was no significant increase in 72-hour revisits, resistant bacterial isolates, or inpatient admissions for UTI. A clinical pathway produced a significant and sustained increase in narrow-spectrum empiric antibiotic prescribing for pediatric UTI. Increased empiric cephalexin prescribing did not result in increased treatment failures or adverse patient outcomes. Future studies on implementing clinical pathways for children outside a pediatric hospital network are needed.

Empyema Caused by Streptococcus constellatus: Atypical Presentation of a Typical Pneumonia

A 27-year-old man, with no known diseases, was admitted to our hospital with respiratory insufficiency and sepsis after 21 days of low-grade fever and non-productive cough without any other symptoms. He was diagnosed with fever of intermediate duration and doxycycline was initiated. An X-ray showed severe pleural effusion and a right lower lobe atelectasis. A pleural effusion sample study revealed an empyema, and an emergent thoracic tube was placed. Five days of empyema sample culture did not show pathological findings; thus, we performed a timeextended culture. After 8 days, Streptococcus constellatus was isolated. We completed 10 days of intravenous empiric treatment followed by oral cephalosporin. The patient required two thoracic drainages; there were no complications. He was completely asymptomatic 3 months after discharge. This report summarises the importance of oral microbiota as pathogens involved in community-acquired pneumonia among healthy young people and the atypical presentation of a typical complicated pneumonia.

Susceptibility to first-generation Cephalosporins in Enterobacteriaceae isolated from urine culture according to CLSI and EUCAST breakpoints

Currently, the use of cefazolin is recommended to determine the susceptibility to first-generation oral cephalosporins in strains of enterobacteria in uncomplicated UTI. We determined susceptibility differences to oral cephalosporins in urinary strains according to cefazolin or cefalotin breakpoints and the correlation of susceptibility between cefazolin and cefadroxil. We studied 52 strains with cefalotin and cefazolin by disk-diffusion and MIC (Kirby-Bauer and Vitek XL) and a subgroup by disk-diffusion for cefadroxil. Agreement among different methods was 100% for K. pneumoniae and Proteus spp. In Escherichia coli, agreement for Vitek and disk-diffusion were 0 and 50% respectively. Susceptibility to first generation cephalosporins in E. coli should be determined with cefazolin. Agreement between cefazolin and cefadroxil suggests that cefazolin could also predict the susceptibility of cefadroxil.

Proper Cut-off Levels of Serum Specific IgE to Cefaclor for Patients with Cefaclor Allergy.

PurposeCefaclor, a second-generation oral cephalosporin, is known to cause IgE-mediated hypersensitivity. Assays of serum-specific IgE (sIgE) to cefaclor are commercially available via the ImmunoCAP system (Thermo Fisher Scientific). While serum levels of sIgE >0.35 kU/L are considered indicative of an allergy, some patients with cefaclor allergy show low serum IgE levels. This study aimed to evaluate the proper cut-off levels of sIgE in the diagnosis of immediate hypersensitivity to cefaclor.Materials and MethodsA total of 269 patients with drug allergy history, who underwent assays of sIgE to cefaclor at Ajou University hospital and Dong-A University Hospital, were reviewed retrospectively. Among them, 193 patients exhibited cefaclor-induced immediate hypersensitivity with certain or probable causality of an adverse drug reaction according to the WHO-UMC (the World Health Organization-the Uppsala Monitoring Centre) algorithm, and 76 controls showed delayed hypersensitivity reactions to non-antibiotics.ResultsIn total, 126 of the 193 patients (65.3%) experienced anaphylaxis; they had higher serum sIgE levels than patients with immediate hypersensitivity who did not experience anaphylaxis (6.36±12.39 kU/L vs. 4.28±13.61 kU/L, p<0.001). The best cut-off value for cefaclor-induced immediate hypersensitivity was 0.11 kU/L, with sensitivity of 80.2% and specificity of 81.6%. A cut-off value of 0.44 kU/L showed the best sensitivity (75.4%) and specificity (65.7%) for differentiating anaphylaxis from immediate hypersensitivity reactions.ConclusionPatients with cefaclor anaphylaxis exhibit high serum IgE levels. A cut-off value of 0.11 kU/L of sIgE to cefaclor is proper for identifying patients with cefaclor allergy, and 0.44 kU/L may be useful to detect anaphylaxis.

Relooking at Nitrofurantoin as drug of choice for empiric treatment of community acquired uncomplicated urinary tract infections: An effective and economic treatment option

Introduction: Urinary tract infections (UTI) caused by multidrug resistant bacteria necessitate the use of broad spectrum expensive antibiotics, which enhance antibiotic pressure. It would be ideal to look at older less commonly prescribed antibiotics like nitrofuratoin and assess its sensitivity for treatment of community acquired UTIs. Nitrofurantoin has been used successfully for prophylaxis and treatment of acute lower UTIs in adults, children and pregnant women. Aim & objectives: This study aims to assess the in-vitro sensitivity of common uropathogens to nitrofurantoin including ESBL producers. Materials and methods : Urine culture and bacterial identification was by standard tests and antibiotic sensitivity was assessed by Kirby Bauer disc diffusion method. ESBL producers were identified by CLSI recommended double disk synergy test. Results: 226 (29.89) % of 756 urine samples showed significant bacteruria, of which 122 (53.98%) were E.coli , 32 (14.15%) K.pneumoniae , 23 (10.17%) P.aeruginosa , 14 (6.19%) Enterococcus spp., 12 (5.30%) Acinetobacter spp, 10 (4.42%) S.saprophyticus and 5 (2.3%) were Candida species. 111/122 (90.98%) of E.coli were sensitive to nitrofurantoin, of which 40 were ESBL producers. 37/40 (92.5%) ESBL producing E.coli and all isolates of S.saprophyticus and Enterococcus spp. were sensitive to nitrofurantoin. Conclusions: Nitrofurantoin is an oral antibiotic with minimal adverse effects, having high in-vitro sensitivity against common community acquired uro-pathogens and is reasonably priced. Hence there is a need to reconsider nitrofurantoin as drug of choice for treatment of community acquired uncomplicated lower UTIs. This could ease the antibiotic pressure, off oral cephalosporins and fluoroquinolones which are currently overused in the community

Models of antimicrobial pressure on intestinal bacteria of the treated host populations.

Antimicrobial drugs are used to treat pathogenic bacterial infections in animals and humans. The by-stander enteric bacteria of the treated host's intestine can become exposed to the drug or its metabolites reaching the intestine in antimicrobially active form. We consider which processes and variables need to be accounted for to project the antimicrobial concentrations in the host's intestine. Those include: the drug's fraction (inclusive of any active metabolites) excreted in bile; the drug's fractions and intestinal segments of excretion via other mechanisms; the rates and intestinal segments of the drug's absorption and re-absorption; the rates and intestinal segments of the drug's abiotic and biotic degradation in the intestine; the digesta passage time through the intestinal segments; the rates, mechanisms, and reversibility of the drug's sorption to the digesta and enteric microbiome; and the volume of luminal contents in the intestinal segments. For certain antimicrobials, the antimicrobial activity can further depend on the aeration and chemical conditions in the intestine. Model forms that incorporate the inter-individual variation in those relevant variables can support projections of the intestinal antimicrobial concentrations in populations of treated host, such as food animals. To illustrate the proposed modeling framework, we develop two examples of treatments of bovine respiratory disease in beef steers by oral chlortetracycline and injectable third-generation cephalosporin ceftiofur. The host's diet influences the digesta passage time, volume, and digesta and microbiome composition, and may influence the antimicrobial loss due to degradation and sorption in the intestine. We consider two diet compositions in the illustrative simulations. The examples highlight the extent of current ignorance and need for empirical data on the variables influencing the selective pressures imposed by antimicrobial treatments on the host's intestinal bacteria.

The most appropriate therapeutic strategy for acute lower respiratory tract infections: a Delphi-based approach

Lower respiratory tract infections (LRTIs) cause high morbidity and mortality worldwide. Empiric therapy often base the choice of antibiotic treatment on antibacterial spectrum of the agent rather than on its pharmacological properties or the pathogen resistance profile. Inappropriate prescribing leads to therapeutic failure and antibiotic resistance, with increasing direct and indirect health costs. A consensus on appropriate prescribing in LRTI therapy was appraised by this Delphi exercise, based on a panel of 70 pulmonologists, coordinated by a Scientific Committee of nine experts in respiratory medical care. Full or very high consensus was reached on several issues, including the role of oral cephalosporins in first-line treatments of LRTIs and the appropriateness of cefditoren, with balanced spectrum and high intrinsic activity, in LRTI treatment. Evidence-based medicine approach and a comprehensive process of disease management, from diagnosis to therapy and follow-up, should guide antibiotic prescribing.