Broad-spectrum Antibiotic Prescribing Research Articles

Temporal trends in antibiotic prescribing and serious and nonserious infections in children presenting to general practice: a registry-based longitudinal cohort study of 162 507 individuals.

It is crucial to understand the trends in paediatric antibiotic prescribing and serious and nonserious infections to improve antibiotic prescribing practices for children in ambulatory care. Assessing trends in paediatric antibiotic prescribing and infection incidence in general practice from 2002 to 2022. In this retrospective cohort study using INTEGO network data from 162 507 patients in Flanders (Belgium), we calculated antibiotic prescribing rates and proportions alongside incidence rates of serious and nonserious infections, stratified by age (0-1, 2-6, 7-12 years) and municipality. We performed autoregressive moving average time-series analyses and seasonality analyses. From 2002 to 2022, antibiotic prescribing rate decreased significantly: 584/1000 person-years (PY) (95% CI 571-597) to 484/1000PY (95% CI 478-491); so did antibiotic overall prescribing proportion: 46.3% (95% CI 45.1-47.6) to 23.3% (95% CI 22.9-23.7) (59.3% amoxicillin and 17.8% broad spectrum). Prescribing proportions dropped significantly for nonserious (45.6% to 20.9%) and increased for serious infections (64.1% to 69.8%). Proportions significantly dropped for acute suppurative otitis media (74.7% to 64.1%), upper respiratory tract infections (44.9% to 16.6%), bronchitis/bronchiolitis (73.6% to 44.1%) and acute tonsillopharyngitis (59.5% to 21.7%), while significantly increasing for pneumonia (65.2% to 80.2%). Nonserious and serious infection incidence rates increased from 785/1000PY and 34.2/1000PY to 1223/1000PY and 64.1/1000PY, respectively. Blood and CRP testing proportions increased significantly. Antibiotic prescribing in general practice for children declined from 2002 to 2022. Further targeted antibiotic stewardship initiatives are needed to reduce the use of broad-spectrum antibiotics and antibiotic prescribing for conditions such as otitis media and bronchitis/bronchiolitis.

The straight and narrow: A game theory model of broad- and narrow-spectrum empiric antibiotic therapy

Physicians prescribe empiric antibiotic treatment when definitive knowledge of the pathogen causing an infection is lacking. The options of empiric treatment can be largely divided into broad- and narrow-spectrum antibiotics. Prescribing a broad-spectrum antibiotic increases the chances of covering the causative pathogen, and hence benefits the current patient’s recovery. However, prescription of broad-spectrum antibiotics also accelerates the expansion of antibiotic resistance, potentially harming future patients. We analyse the social dilemma using game theory. In our game model, physicians choose between prescribing broad and narrow-spectrum antibiotics to their patients. Their decisions rely on the probability of an infection by a resistant pathogen before definitive laboratory results are available. We prove that whenever the equilibrium strategies differ from the socially optimal policy, the deviation is always towards a more excessive use of the broad-spectrum antibiotic. We further show that if prescribing broad-spectrum antibiotics only to patients with a high probability of resistant infection is the socially optimal policy, then decentralization of the decision making may make this policy individually irrational, and thus sabotage its implementation. We discuss the importance of improving the probabilistic information available to the physician and promoting centralized decision making.

Prevalence of Antibiotic Prescription in Primary Healthcare Settings in the Municipality of Prishtina, Kosovo

Background: Antibiotics remain among the most prescribed drugs in primary healthcare, contributing to increased antibiotic resistance in the community and prevailing as an emerging global health concern. We aimed to quantify the prevalence and quality of antibiotic prescription in primary healthcare settings in the Municipality of Prishtina to identify targets for quality improvement.Methods and Results: This study represents a population-based, retrospective cohort, including data from eight randomly selected family medical centers in the Municipality of Prishtina. Each 150th patient on medical records was assessed for demographic data, diagnosis (ICD-10), antibiotic prescription, antibiotic class, and antibiotic form. In total, the study included 1614 cases reviewed. The antibiotic prescription rate was 16%. The health condition for which most of the cases received antibiotics was J18 - Pneumonia, unspecified organism (67%), followed by J03 - Acute tonsillitis (54%), J42 - Unspecified chronic bronchitis (46%), and N39 - Other disorders of the urinary system (43%) Broad-spectrum antibiotics, such as co-amoxiclav (17.7%), amoxicillin (16.5%), and ceftriaxone (12.6%), featured among the most routinely prescribed antibiotics. The antibiotic prescription rate was the highest for cases in the 3-5 age group, of whom 27% received an antibiotic prescription. In 73% of cases, oral antibiotics were prescribed, 69% of which belong to the WHO AWaRe (Access, Watch, Reserve) essential medicines list. Only 18% of antibiotics were prescribed with their generic names. Conclusion: The prevalence of antibiotic prescription in primary healthcare settings in Prishtina is moderately low. These data cannot be extrapolated to other municipalities in Kosovo or other countries due to different organizational levels. High antibiotic prescription rates for young age groups, prescription of broad-spectrum antibiotics, and high rates of parenteral antibiotics were identified as targets for quality improvement.

Trends of antibiotic use at the end-of-life of cancer and non-cancer decedents: a nationwide population-based longitudinal study (2006–2018)

Abstract Objective: This study aimed to assess the actual burden of antibiotic use among end-of-life (EOL) patients in South Korea and to compare trends between cancer and non-cancer decedents. Design: Population-based mortality follow-back study. Setting: Data from the Korean National Health Insurance Database, covering the period from January1, 2006, to December 31, 2018, provided for research by the National Health Insurance Service (NHIS), were used. Participants: All decedents from 2006 to 2018 were included and categorized as cancer decedents or non-cancer decedents. Methods: Annual antibiotic consumption rates and prescription rates were calculated, and Poisson regression was used to estimate their trends. Results: Overall antibiotic consumption rates decreased slightly among decedents in their final month with a less pronounced annual decrease rate among cancer decedents compared to non-cancer decedents (0.4% vs 2.3% per year, P <.001). Over the study period, although narrow spectrum antibiotics were used less, utilization and prescription of broad-spectrum antibiotics steadily increased, and prescription rates were higher in cancer decedents compared to non-cancer controls. Specifically, carbapenem prescription rates increased from 5.6% to 18.5%, (RR 1.087, 95% CI 1.085–1.088, P <.001) in cancer decedents and from 2.9% to 13.2% (RR 1.115, 95% CI 1.113–1.116, P <.001) in non-cancer decedents. Conclusions: Our findings show that patients at the EOL, especially those with cancer, are increasingly and highly exposed to broad-spectrum antibiotics. Measures of antibiotic stewardship are required among this population.

Knowledge and Perceptions of Final-Year Nursing Students Regarding Antimicrobials, Antimicrobial Resistance, and Antimicrobial Stewardship in South Africa: Findings and Implications to Reduce Resistance.

Antimicrobial resistance (AMR) is being increasingly seen as the next pandemic due to high morbidity and mortality rates, with Sub-Saharan Africa currently having the highest mortality rates driven by high rates of inappropriate prescribing in ambulatory care. In South Africa, nurses typically provide a range of services, including prescribing, in public ambulatory care clinics. However, little is currently known about the perception of final-year nursing students regarding antibiotic use, AMR, and antimicrobial stewardship (AMS). Consequently, we sought to address this important evidence gap. A quantitative descriptive study using a self-administered online questionnaire via Google Forms® was undertaken among six universities in South Africa offering a Baccalaureus of Nursing. Knowledge on the classes of antibiotics, organisms covered, and mechanism of action was lacking. The sample size to achieve a confidence interval of 95% with a 5% error margin was 174, increased to 200 to compensate for possible attrition. Only 15.3% of nurses knew that ceftazidime is not a fourth-generation cephalosporin, and only 16.1% knew that clavulanic acid does not decrease inflammation at the site of infection. In addition, only 58.9% and 67.7% agreed that the prescribing of broad-spectrum antibiotics and poor infection control, respectively, increase AMR. AMS was also not a well-known concept among final-year nurses. The lack of knowledge regarding antibiotics, AMR, and AMS among final-year nurses could have important repercussions in practice once these nurses are qualified. Consequently, this information gap needs to be urgently addressed going forward with updated curricula and post-qualification educational activities to reduce AMR in South Africa.

Impact of a public commitment charter, a non-prescription pad and an antibiotic information leaflet to improve antibiotic prescription among general practitioners: A randomised controlled study

BackgroundThis study evaluated the effect of a multifaceted antibiotic stewardship intervention on the overall prescription of systemic antibiotics in primary care. Secondary objectives evaluated the effect on the prescription of broad-spectrum antibiotics and the seasonal variation of both total antibiotic and quinolone prescriptions, as a proxy for unnecessary prescribing. MethodsThis pragmatic, randomised, controlled, before-after intervention study was conducted among general practitioners (GPs) who over prescribe antibiotics in Lorraine, France (Intervention group, n = 109; Control group, n = 236; Before period, 01/10/2017–30/09/2018; After period, 01/10/2018–30/09/2019). The intervention included a public commitment charter, a patient information leaflet and a non-prescription pad. Health Insurance data was obtained to calculate overall and broad-spectrum prescription rate (defined daily doses/1000 consultations) and the seasonal variation of prescriptions (%), by period. The intervention effect was measured with general linear mixed models including three independent variables (group, period and group x period interaction). ResultsOverall, compared to the Before period, GPs in both groups prescribed significantly fewer systemic antibiotics (p < 0.001) and broad-spectrum antibiotics (p < 0.001) after the intervention was implemented. However, the group x period interaction did not show any evidence that the intervention had an effect on these outcomes. Nevertheless, the intervention did result in a trend towards less seasonal variation in total systemic antibiotic prescription (p = 0.052). ConclusionsA tendency towards an effect of the intervention to reduce unnecessary antibiotic prescribing during winter months was observed. No effect was observed on the overall volume of systemic antibiotic prescription. This study invites discussion about the challenges faced when evaluating non-pharmacological interventions in primary care.

UK clinicians' attitudes towards the application of molecular diagnostics to guide antibiotic use in ICU patients with pneumonias: a quantitative study.

Molecular diagnostic tests may improve antibiotic prescribing by enabling earlier tailoring of antimicrobial therapy. However, clinicians' trust and acceptance of these tests will determine their application in practice. To examine ICU prescribers' views on the application of molecular diagnostics in patients with suspected hospital-acquired and ventilator-associated pneumonia (HAP/VAP). Sixty-three ICU clinicians from five UK hospitals completed a cross-sectional questionnaire between May 2020 and July 2020 assessing attitudes towards using molecular diagnostics to inform initial agent choice and to help stop broad-spectrum antibiotics early. Attitudes towards using molecular diagnostics to inform initial treatment choices and to stop broad-spectrum antibiotics early were nuanced. Most (83%) were positive about molecular diagnostics, agreeing that using results to inform broad-spectrum antibiotic prescribing is good practice. However, many (58%) believed sick patients are often too unstable to risk stopping broad-spectrum antibiotics based on a negative result. Positive attitudes towards the application of molecular diagnostics to improve antibiotic stewardship were juxtapositioned against the perceived need to initiate and maintain broad-spectrum antibiotics to protect unstable patients.

706 An Audit of Antibiotic Prescribing in Acute Pancreatitis and Introduction of a Patient Safety and Cost Saving Diagnostic Tool

Abstract Background In managing acute pancreatitis it is challenging to distinguish systemic inflammatory response syndrome (SIRS) from bacterial infection, contributing to inappropriate use of antibiotics, which are only recommended in cases of infected pancreatitis. Over prescribing of broad-spectrum antibiotics is associated with C. difficile, adverse reactions and antibiotic resistance, and has a cost implication. Procalcitonin (PCT) is sensitive (93%) and specific (79%) for diagnosing infected pancreatitis and recommended to guide antibiotic therapy. Method We performed a retrospective audit of the care received by 88 acute pancreatitis patients over 12-months. Results 19/52 (36.5%) with uncomplicated pancreatitis were prescribed antibiotics. 22/36 (61.1%) with infected pancreatitis or a secondary infection source received antibiotics. 36/41 (87.8%) were prescribed broad-spectrum IV antibiotics. Seven days of IV co-amoxiclav costs £15.80, excluding consumables or nursing staff/pharmacy time. A single PCT costs £9.64. Conclusions These results suggest inappropriate prescribing of antibiotics in managing acute pancreatitis. Where diagnostic uncertainty lies between acute uncomplicated pancreatitis with SIRS versus infected pancreatitis, PCT is a useful diagnostic tool to help guide antibiotic therapy, therefore improving patient safety and antibiotic stewardship, with cost benefits. Following this audit, our trust has approved PCT for use in acute pancreatitis, and future audits will assess ongoing antibiotic prescribing in this cohort.

Impact of COVID-19 on broad-spectrum antibiotic prescribing for common infections in primary care in England: a time-series analyses using OpenSAFELY and effects of predictors including deprivation.

The COVID-19 pandemic impacted the healthcare systems, adding extra pressure to reduce antimicrobial resistance. Therefore, we aimed to evaluate changes in antibiotic prescription patterns after COVID-19 started. With the approval of NHS England, we used the OpenSAFELY platform to access the TPP SystmOne electronic health record (EHR) system in primary care and selected patients prescribed antibiotics from 2019 to 2021. To evaluate the impact of COVID-19 on broad-spectrum antibiotic prescribing, we evaluated prescribing rates and its predictors and used interrupted time series analysis by fitting binomial logistic regression models. Over 32 million antibiotic prescriptions were extracted over the study period; 8.7% were broad-spectrum. The study showed increases in broad-spectrum antibiotic prescribing (odds ratio [OR] 1.37; 95% confidence interval [CI] 1.36-1.38) as an immediate impact of the pandemic, followed by a gradual recovery with a 1.1-1.2% decrease in odds of broad-spectrum prescription per month. The same pattern was found within subgroups defined by age, sex, region, ethnicity, and socioeconomic deprivation quintiles. More deprived patients were more likely to receive broad-spectrum antibiotics, which differences remained stable over time. The most significant increase in broad-spectrum prescribing was observed for lower respiratory tract infection (OR 2.33; 95% CI 2.1-2.50) and otitis media (OR 1.96; 95% CI 1.80-2.13). An immediate reduction in antibiotic prescribing and an increase in the proportion of broad-spectrum antibiotic prescribing in primary care was observed. The trends recovered to pre-pandemic levels, but the consequence of the COVID-19 pandemic on AMR needs further investigation. This work was supported by Health Data Research UK and by National Institute for Health Research.

P04 Assessment of antibiotic resistance formation predictors among medical students in developing countries

Abstract Background According to CDC (2019), antibiotic-resistant infections affect more than 2 million people. By 2030, 100 million people will die prematurely as a result of uncontrolled antibiotic use, and in 35 years, this figure will reach 300 million (BSAC, 2018). Despite of modern patient target approach to curing majority of diseases, the problem of antibiotics over usage is still urgent in middle-income countries due to non-profile prescription, absence of microbiological confirmation and the ease of availability of antibiotics. Objectives To investigate antibiotic usage expedience for a 1-year duration among Ukrainian and foreign medical students. Subjects and methods A total of 150 (Ukrainians 46%, foreigners 54%; aged 18–25 years) medical students were examined by questionnaire for antibiotic usage during last year with specification of reasons, course frequency and duration, expediency of appointment, treatment outcomes, possible reason for cancellation/replacement of antibiotic therapy and preventable usage cases. Results The majority of foreigners [60.5% (n = 49)] and 33.8% (n = 25) Ukrainians used antibiotics for different reasons during February 2022–January 2023 (P &amp;lt; 0.01). Antibiotic usage by physician’s prescription was held among 24.49% (n = 12) foreign students and 68.18% (n = 12) Ukrainian ones (P &amp;lt; 0.05). The frequency of antibiotic application due to positive result of bacteriological investigation was significantly lower among foreign responders: 27.27% versus 4.00% in Ukrainians (P &amp;lt; 0.05). In the Ukrainian students sample 36.3% (n = 8) responders predisposed to antibiotic usage for infectious condition appearance [versus 6.1% (n = 3) in the foreign sample, P &amp;lt; 0.01]. The frequency of ≥3 antibiotic courses per year prevailed in the foreign student group [12.25% (n = 6), P &amp;lt; 0.05]. The analysis of post-antibiotic adverse events found out allergic reaction in 1.2% (n = 1) in the foreign sample, diarrhoea 1.56% (n = 1) and change of antibiotic due to ineffectiveness 1.56% (n = 1) in the Ukrainian sample. Conclusions Possible predictors of the formation of resistance to antibiotics among young people living in developing countries, such as incorrect clinical use, lack of control over the prescription of antibiotics, ease of availability of antibiotics and as a result of self-medication, were evaluated. The prophylactic prescription of broad-spectrum antibiotics for routine procedures, such as preparation for surgical interventions and in the postoperative period, also draws attention.

Initial blood culture collection practices and the associated factors upon continued empiric piperacillin-tazobactam usage

Background: Approaches to the prescription behavior of broad-spectrum antibiotics, including preauthorization and prospective audit and feedback (PAF), are a focus of antimicrobial stewardship (ASP). However, preprescription behavior, such as blood-culture collection before empiric prescription, is understudied and merits more attention given its influence on the usage of broad-spectrum antibiotics. At the University of Tokyo Hospital, carbapenems are subject to PAF, which has resulted in a compensatory increase in piperacillin-tazobactam use. To evaluate the inherent preprescription behavior associated with a broad-spectrum antibiotic, we investigated the initial blood-culture collection practices upon hospitalization in patients who were continued on empiric piperacillin-tazobactam. Methods: A retrospective observational study was conducted at the University of Tokyo Hospital, a tertiary-care hospital in Tokyo, Japan. Patients who were administered piperacillin-tazobactam on the day of hospitalization between April 2016 and December 2017 were included. Patients aged &lt;=18 years and/or patients who discontinued piperacillin-tazobactam within two days were excluded. Only 1 admission per patient was kept for analysis. The medical records of 250 randomly selected patients were reviewed to obtain data on demographics, blood-culture collection, severity, specialties, and risk factors for multidrug-resistant organisms. A multivariable logistic regression analysis was used to identify factors associated with blood-culture collection. Results: In total, 960 discrete patients fulfilled the study criteria. Of the randomly selected 250 patients, blood cultures were collected from 162 patients (64.8%), and microbial growth was observed in 30 cases (18.5%). Enterobacterales and anaerobes accounted for 73.3% of the microbial population. Gastroenterologists (94, 37.6%) and general surgeons (52, 20.8%) were the most common prescribers. Hepatobiliary (83, 33.2%), respiratory (58, 23.2%), and intra-abdominal infections (IAI; 34, 13.6%) were the major suspected diagnoses. Blood-culture collection was associated with the use of immunosuppressive agents (OR, 3.48; 95% CI, 1.49–8.99), intrabdominal infection (OR, 0.28; 95% CI, 0.12–0.67), systemic inflammatory response syndrome criteria ≥ 2 (OR, 4.50; 95% CI, 2.25–9.42), and surgical specialty (OR, 0.33; 95% CI, 0.18–0.60). Conclusions: More than one-third of patients requiring hospitalization and empiric piperacillin-tazobactam did not undergo blood-culture collection. The finding that blood cultures were less likely to be obtained in patients with suspected IAI requiring hospitalization and by surgical specialties raises a concern regarding suboptimal evaluation. Further assessment of the appropriateness of blood-culture collection in the setting of broad-spectrum antibiotic prescription and tailored promotion of blood-culture collection to surgical specialties may be warranted.Disclosures: S.K.: The author (during graduate school (PhD) was involved in antiviral research relevant to a neglected tropical disease and favipiravir. During this graduate school research, favipiravir was provided by FUJIFILM Toyama Chemical Co. Ltd

Current Antibiotic Use Among Hospitals in the sub-Saharan Africa Region; Findings and Implications.

The rapid rise in antimicrobial resistance (AMR) globally, impacting on morbidity, mortality and costs with sub-Saharan African countries reporting the greatest burden is a concern. Instigation of antimicrobial stewardship programs (ASPs) can improve antibiotic use in hospitals and reduce AMR. Implementing ASPs requires knowledge of antibiotic utilization against agreed quality indicators with the data obtained from point prevalence surveys (PPS), hence the need to document antibiotic utilization patterns in sub-Saharan Africa. A narrative review to document current utilization patterns, challenges, indicators and ASPs across sub-Saharan Africa based on previous reviews by the authors, supplemented by the considerable knowledge and experience of the co-authors. Results from multiple PPS studies showed a high prevalence of antibiotic use among hospitals, mostly over 50%. Prevalence rates ranged from as low as 37.7% in South Africa to as high as 80.1% in Nigeria. There was also considerable prescribing of broad-spectrum antibiotics which could be due to lack of facilities within hospitals, alongside concerns with co-payments to perform microbiological tests, resulting in empiric prescribing. This is a concern alongside lack of guidelines or adherence to guidelines, which was as low as 4% in one study. Another concern was the high rates of extended prophylaxis to prevent surgical site infections (SSIs), with antibiotics often prescribed for longer than 24 hours, usually multiple doses. Several quality indicators have been used to evaluate antibiotic utilization providing exemplars for the future. Among the initiatives being instigated to improve antibiotic use, ASPs have proved effective. For ASPs to be successful objectives and indicators must be agreed, and regular audits undertaken. Antibiotic prescribing across Africa is characterised by high prevalence, usually empirical. Various prescribing and quality indicators are being employed to assess antibiotic use, and ASPs have shown to improve antibiotic prescribing providing direction to reduce AMR.

Impact of selective reporting of antibiotic susceptibility testing results for urinary tract infections in the outpatient setting: a prospective controlled before-after intervention study

ObjectivesThe use of selective reporting of antibiotic susceptibility testing (AST) results is a recommended antimicrobial stewardship strategy to improve the appropriateness of antibiotic prescriptions. We conducted a large, pragmatic, prospective, multicentre, controlled (selective reporting versus complete reporting) before-after intervention study to assess the impact of selective reporting of AST results for Escherichia coli–positive urine cultures on the prescription of broad-spectrum antibiotics carrying a higher risk of selection of resistance (i.e. amoxicillin-clavulanate, third-generation cephalosporins, and quinolones) in the outpatient setting. We also looked for possible unintended clinical consequences of the intervention leading to consultations and/or hospitalizations. MethodsWe compared two groups of laboratories located in a French region. We collected data from the health insurance databases before (2017) and after the implementation of the intervention (2019). The primary outcome was the prescription proportion of broad-spectrum antibiotics. ResultsWe included 42,956 Escherichia coli–positive urine cultures with AST. The decrease in the proportion of broad-spectrum antibiotic prescriptions between 2017 and 2019 was significantly higher for selective reporting of AST, attributable to a decrease in the prescription proportion of third-generation cephalosporins (-8.5% for selective reporting versus -0.1% for complete reporting, p < 0.001). This impact was more marked for targeted therapy and female patients. Requests from clinicians for the complete reporting of AST results were infrequent (1.2% of all the selective AST results reported in 2019). No unintended consequences were observed. DiscussionThe results showed a positive impact of the selective reporting of AST results, but room for improvement is still important.

Microbiological blood profile among COVID-19 patients hospitalized in a tertiary care hospital: An observational study

Background: Bacterial coinfection contributes to increase morbidity and morbidity of viral respiratory infections and may lead to fatal outcome during its course of illness. Aims and Objectives: The main objective of this study was to determine the bacteriological profile of COVID-19 patients admitted in hospital, their antibiotic susceptibility, and their association with severity. Materials and Methods: The present study was retrospective observational cross-sectional study of all patients admitted for COVID-19 at Gandhi Medical College and Hamidia Hospital, Bhopal (MP) between (March 2020 and December 2020). Demographic, comorbid conditions, and microbiological data were compared HBD and intensive care unit (ICU) admissions and role secondary coinfection in severity and mortality. Results: Thirty percentages of percent of patients showed bacterial growth, Staphylococcus aureus was most common, followed by Pseudomonas aeruginosa. Mean±SD of age was 43.6±21.6. Antibiotic resistance of cefoxitin, cotrimoxazole, and azithromycin was seen in maximum Gram-positive growth, whereas sensitivity for linezolid and gentamicin was present in 10–16% cases. Highest antibiotic resistance in Gram-negative growth was seen for ceftozidime, amikacin, imipenem, and meropenem, whereas sensitivity of colistin antibiotic was highest in Gram-negative growth. Conclusion: Coinfection rates increase in patients admitted to the ICU, despite frequent prescription of broad-spectrum antibiotics. Infectious diseases practitioners carry the burden of life-saving and provide for societal trust that is effective antibiotic therapy in the face of these changes. With a growing body of evidence supporting short-course, antimicrobial therapy “Shorter Is Better” should be the new mantra.

Impact of guidelines implementation on empiric antibiotic treatment for pediatric uncomplicated osteomyelitis and septic arthritis over a ten-year period: Results of the ELECTRIC study (ostEomyeLitis and sEptiC arThritis tReatment in children).

Due to the growing evidence of the efficacy of intravenous (IV) cefazolin with an early switch to oral cefalexin in uncomplicated pediatric osteomyelitis (OM) and septic arthritis (SA) in children, we changed our guidelines for empiric antibiotic therapy in these conditions. This study aims at evaluating the impact of the guidelines' implementation in reducing broad-spectrum antibiotic prescriptions, duration of IV antibiotic treatment and hospital stay, treatment failure and recurrence. This is a retrospective, observational, quasi-experimental study. The four years pre-intervention were compared to the six years, ten months post-intervention (January 2012, through December 2015; January 2016, through October 31st, 2022). All patients aged 3 months to 18 years with OM or SA were evaluated for inclusion. Each population was divided into three groups: pre-intervention, post-intervention not following the guidelines, and post-intervention following the guidelines. Differences in antibiotic prescriptions such as Days of Therapy (DOT), activity spectrum and Length of Therapy (LOT), length of hospital stay (LOS), broad-spectrum antibiotics duration (bsDOT), treatment failure and relapse at six months were analyzed as outcomes. Of 87 included patients, 48 were diagnosed with OM (8 pre-intervention, 9 post-intervention not following the guidelines and 31 post-intervention following the guidelines) and 39 with SA (9 pre-intervention, 12 post-intervention not following the guidelines and 18 post-intervention following the guidelines). In OM patients, IV DOT, DOT/LOT ratio, and bsDOT were significantly lower in the guidelines group, with also the lowest proportion of patients discharged on IV treatment. Notably, significantly fewer cases required surgery in the post-intervention groups. Considering SA, LOS, IV DOT, DOT/LOT ratio, and bsDOT were significantly lower in the guidelines group. The treatment failure rate was comparable among all groups for both OM and SA. There were no relapse cases. The overall adherence was between 72 and 100%. The implementation of guidelines was effective in decreasing the extensive use of broad-spectrum antibiotics and combination therapy for both OM and SA. Our results show the applicability, safety, and efficacy of a narrow-spectrum IV empirical antibiotic regimen with cefazolin, followed by oral monotherapy with first/second-generation cephalosporins, which was non-inferior to broad-spectrum regimens.

Outpatient treatment of pneumonia in a setting with and without an infectious disease doctor

To compare the outpatient treatment of community acquired pneumonia (CAP) by infectious disease doctors (IDDs) and doctors of other specialties (nIDDs). We retrospectively identified 600 outpatients with CAP: 300 treated by IDDs and 300 by nIDDs in two tertiary hospitals during 2019. The two groups were compared in terms of adherence to guidelines, antibiotic group prescription, frequency of combined treatment, and treatment duration. IDDs prescribed significantly more first-line treatment (P<0.001) and alternative treatment (P=0.008). NIDDs prescribed more reasonable (P<0.001) and unnecessary (P=0.002) second-line treatment, and inadequate treatment (P=0.004). IDDs significantly more frequently prescribed amoxicillin (P<0.001) for typical and doxycycline (P=0.045) for atypical CAP, while nIDDs significantly more frequently prescribed amoxicillin-clavulanate (P<0.001) for typical and fluoroquinolones for both typical (P<0.001) and atypical (P<0.001) CAP. No significant differences were found in the frequency of combined treatment, which exceeded 50% in both groups, or in treatment duration. Outpatient treatment of CAP in the absence of IDDs meant more broad-spectrum antibiotic prescription and more disregard for national guidelines. Our results highlight the need for antibiotic stewardship, especially in settings with no IDDs.

DOP20 The impact of early life antibiotics on the occurrence of paediatric inflammatory bowel disease - a nationwide study from 1995 – 2018

Abstract Background Early–life antibiotic exposure has been associated with a decreased richness of the microbiome, which is associated with the development of inflammatory bowel disease (IBD). The aim of this study was to assess the risk of developing paediatric-onset IBD (pIBD) after being exposed to systemic antibiotics during the first five years of life. Methods We identified all patients &amp;lt; 18 years old diagnosed with pIBD in Denmark between 1995-2018 in the National Patient Registry. Data on antibiotic prescriptions during first five years of life were retrieved from the National Prescription Register. PIBD patients were matched with up to ten healthy controls. Risk estimates were presented by Hazard ratios (HR). Results We identified 1,808 patients with pIBD (989 Crohn’s disease [CD]/819 ulcerative colitis [UC]) and 17,234 matched controls. An increased risk of developing pIBD was associated with prescription of antibiotics during first five years (HR = 1.32 [95%CI: 1.2-1.5], p= &amp;lt;0.0001), and risk was further increased if the patient had ≥ 4 antibiotic prescriptions compared to no antibiotic prescription (HR = 1.43 [95%CI: 1.2-1.6], p= &amp;lt;0.0001). Prescription of broad-spectrum antibiotics increased the risk of pIBD compared to prescription of only narrow-spectrum antibiotics (HR: 1.19, [95%CI 1.0-1.4], p=0.04). When stratified by IBD subtypes, only CD was significantly associated with exposure to antibiotics (HR = 1.43 [95%CI: 1.2-1.7], p=0.0003). Conclusion In this nationwide registry-based study, we found that antibiotic exposure during first five years of life, was associated with an increased risk of pIBD. Repeated antibiotic exposures increased risk estimates.

Antimicrobial stewardship program: Fighting antimicrobial resistance in India

Antimicrobial resistance (AMR) is a significant concern in India, contributing to increased medical costs, prolonged hospital stays, and mortality. Antimicrobial stewardship programs (AMSP) are organizational strategies in health-care systems designed to promote, monitor, and evaluate the rational use of antimicrobials to preserve their future effectiveness. The Indian council of medical research recognizes the need for AMS structures in healthcare institutions and has initiated actions to support this. These include developing an AMS curriculum, conducting workshops for increased awareness and education, and expanding surveillance of antimicrobial usage and resistance trends. However, many hospitals in India still lack structured processes for AMS, requiring a multidisciplinary approach involving various experts. AMSP contribute significantly to improving antibiotic use without compromising patient outcomes, such as optimal selection of agents, correct dosing, appropriate administration routes, and proper therapy duration. The aim is to enhance patient care and outcomes, reduce infection complications, and minimize the emergence of AMR. Key challenges faced in implementing AMS programs in India include lack of infrastructure and personnel, limited resources and funds, limited laboratory capability, absence of antibiotic prescription policy, irrational prescription and excessive use of broad-spectrum antibiotics, self-medication, inappropriate disposal of leftover antibiotics, lack of regulation, and treatment non-compliance. These challenges necessitate robust, collaborative, and multifaceted responses, including policy reform, investment in infrastructure development, expanded surveillance, improved professional practices, and public education.

Impact of Penicillin Allergy Labels on Children Treated for Outpatient Respiratory Infections.

Penicillin allergy is the most common antibiotic allergy, yet most children labeled as allergic tolerate penicillin. The impact of inaccurate penicillin allergy labels (PALs) on pediatric outpatients is unknown. The objective of this study was to compare outcomes between children with and without a PAL after treatment for outpatient respiratory tract infections (RTI). A retrospective, longitudinal birth cohort study was performed in children who received care in 90 pediatric primary care practices in Philadelphia and Houston metropolitan areas. Prescribing and clinical outcomes of children with a PAL at the time of an RTI were compared to non-allergic children, adjusting for potential confounders. Antibiotics were prescribed for 663,473 non-recurrent RTIs among 200,977 children. Children with a PAL (5% of cohort) were more likely than non-allergic children to receive broad-spectrum antibiotics (adjusted relative risk (aRR) 3.24, 95% CI 3.22-3.26) and second-line antibiotics (aRR 4.87, 95% CI 4.83, 4.89). Compared to non-allergic children receiving first-line antibiotics, children with a PAL were more likely to return with adverse drug events (aRR 1.28, 95% CI 1.18-1.39). There was no difference in treatment failure between groups (aRR 0.95, 95% CI 0.90-1.00). PALs lead to higher rates of broad-spectrum and second-line antibiotic prescribing in children treated for RTIs in primary care and contribute to unnecessary healthcare utilization through increased adverse events. Given the frequency of PALs, efforts to prevent inappropriate penicillin allergy labeling and promote de-labeling of existing inaccurate allergy labels may improve care of children treated for common bacterial infections.

Broad spectrum antibiotic stewardship by quality improvement methods.

With the majority of antibiotics being prescribed in primary care it is of utmost importance that antimicrobial stewardship principles are adhered to in order to slow down the incidence of antimicrobial resistance. Broad spectrum antibiotic prescribing is often seen as a proxy marker of increasing resistance within a population and so it is important that they are used sparingly, to avoid drug-resistant bacteria developing. In Tameside and Glossop a novel approach, using quality improvement methods, was employed to allow the behaviour change to be sustained for a longer period. Practices submitted monthly broad spectrum usage data, and if over a set target they were required to submit a "deep dive". A 10.6% reduction of broad spectrum antibiotic usage was seen over the 2019-20 financial year. Over time the number of practices submitting a deep dive reduced and clinicians saw the deep dive as method to peer review their prescribing. Putting the practice staff in control of their own prescribing, allowed for a better method to sustain the improvement.