Prophylactic Use Of Antimicrobials Research Articles

Antimicrobial prescribing in acute pancreatitis: Too much for too many?

BackgroundAcute pancreatitis (AP) is an inflammatory condition of the pancreas that varies widely in both clinical presentation and severity. Current international guidelines do not recommend the use of prophylactic antimicrobials in AP. AimTo review the compliance of antimicrobial prescribing in AP with international guidelines. MethodWe conducted a retrospective review of patients admitted with AP between 1st January 2021 and 31st December 2021, in Beaumont Hospital, Dublin, Ireland. For each case identified, the 2012 Revised Atlanta Criteria for AP were then applied on review of medical, laboratory and radiology records. ResultsThere were 98 patients, 52 % male (n = 51) with a median age of 53 years (range 18–88) who met the Revised Atlanta Criteria accounting for 1,032 hospital bed days inclusive of 82 critical care bed days. Gallstones were the most common aetiology; 48 % (n = 47). Antimicrobials were prescribed for 55 (56 %) patients with AP. Of those, only 38 % (n = 21) met the American Gastroenterological Association criteria for antimicrobials. The most common classes of antimicrobials prescribed were beta-lactams and carbapenems. Procalcitonin testing was conducted on just one patient (1 %). There were no cases of inpatient or 90-day mortality. ConclusionsOur findings are consistent with previously published reports of low mortality in mild acute AP and an excessive prescription of antimicrobials, highlighting this as an area for a targeted antimicrobial stewardship (AMS) intervention, including an increased use of procalcitonin as a biomarker.

Antimicrobial agent usage patterns and their role in preventing surgical site infections at a tertiary care teaching hospital: A comprehensive study

Background: Surgical site infections (SSIs) present a formidable challenge in contemporary healthcare, impacting patient well-being and contributing to escalating healthcare costs. The judicious utilization of antimicrobial agents is paramount in effectively combating SSIs. This study, conducted at a Tertiary Care Teaching Hospital in Kerala, seeks to unravel the intricate patterns of antimicrobial agent usage within the General Surgery Department over 10 months. Aims and Objectives: The primary aim is to thoroughly examine antimicrobial agent patterns within the General Surgery Department, focusing specifically on patients undergoing surgical procedures. The study aims to assess the appropriateness of antimicrobial agent usage, encompassing the choice for prophylactic purposes, timing of pre-operative dosing, the occurrence of intraoperative dosing, and the selection appropriateness for post-operative prophylaxis. Materials and Methods: Crafted for robust analysis, the study included 150 cases, implementing specific inclusion and exclusion criteria to ensure data quality. The emphasis was placed on patients undergoing surgical procedures, focusing on prophylactic antimicrobial use. Data collection involved meticulously evaluating appropriateness across critical parameters, including the choice of prophylactic antimicrobial agent, pre-operative dosing timing, intraoperative dosing, and selection appropriateness for post-operative prophylaxis. Results: Analysis of 150 cases provided valuable insights into the age and gender distribution, predominantly within the 41–60 age groups. Prevalent surgical procedures, such as hernia and appendicitis, underscored the necessity for tailored antimicrobial protocols. Cephalosporins emerged as the dominant class, raising concerns about potential overuse and resistance. Pre-exposure prophylactic antibiotics, predominantly cephalosporins, were administered in 88 cases. Post-exposure prophylaxis mirrored this trend, necessitating a critical evaluation of antibiotic selection and duration. Detailed analysis of cephalosporin pre- and post-exposure prophylaxis identified prevalent choices such as Cefotaxime and Cefoperazone + Sulbactam, emphasizing the importance of scrutinizing cephalosporin selection. Conclusion: This study furnishes valuable insights into the appropriateness of antimicrobial agent usage for preventing SSIs, serving as a model for analogous healthcare settings. It underscores the significance of local antibiotic stewardship, guideline adherence, and the ongoing commitment to optimizing prophylactic antimicrobial usage for ensuring patient safety and advancing healthcare quality amidst evolving challenges.

Metagenomic comparison of the faecal and environmental resistome on Irish commercial pig farms with and without zinc oxide and antimicrobial usage

BackgroundAntimicrobials and heavy metals such as zinc oxide (ZnO) have been commonly used on Irish commercial pig farms for a 2-week period post-weaning to help prevent infection. In 2022, the prophylactic use of antimicrobials and ZnO was banned within the European Union due to concerns associated with the emergence of antimicrobial resistance (AMR) and contamination of the environment with heavy metals. In this study, faecal and environmental samples were taken from piglets during the weaning period from ten commercial farms, of which five farms used antimicrobial or ZnO prophylaxis (AB-ZnO farms) and five which had not used antimicrobials or ZnO for the previous 3 years (AB-ZnO free farms). A total of 50 samples were compared using a metagenomic approach.ResultsThe results of this study showed some significant differences between AB-ZnO and AB-ZnO free farms and suggested positive selection for AMR under antimicrobial and ZnO treatment. Moreover, strong differences between environmental and faecal samples on farms were observed, suggesting that the microbiome and its associated mobile genetic elements may play a key role in the composition of the resistome. Additionally, the age of piglets affected the resistome composition, potentially associated with changes in the microbiome post-weaning.ConclusionsOverall, our study showed few differences in the resistome of the pig and its environment when comparing AB-ZnO farms with AB-ZnO free farms. These results suggest that although 3 years of removal of in-feed antimicrobial and ZnO may allow a reduction of AMR prevalence on AB-ZnO farms, more time, repeated sampling and a greater understanding of factors impacting AMR prevalence will be required to ensure significant and persistent change in on-farm AMR.

Development and application of WHONET software in hospital antibiogram

Antibiotic resistance is an emerging issue that requires a track on antimicrobial resistance pattern in an institution to prescribe appropriate empirical therapy. Antibiogram that's an aggregate of antimicrobial susceptibility profile within an institution provides a better understanding of empirical and prophylactic use of antimicrobials. It also focuses on M39 guidelines published by Clinical and Laboratory Standard Institute for developing accurate and reliable data of antibiograms. The data for this review has been extracted from literature databases such as Medline/PubMed, Scopus, Web of Science, Embase and the Cochrane Library. This literature highlights the importance of clinical pharmacists in developing antibiogram by preventing antimicrobial resistance, types of antibiogram, history and development, need, role of hospital and microbiological laboratory and Clinical and Laboratory Standard Institute guidelines. Additionally, the significance of WHONET software for developing and analysis of results rather than using old/traditional methods, limitations, and future considerations of antibiogram has also been described.

Antimicrobial prophylaxis is not indicated for horses undergoing general anaesthesia for elective orthopaedic MRI.

Post-anaesthetic fever is a known complication of general anaesthesia, however, its incidence in horses undergoing elective magnetic resonance imaging (MRI) is unknown. To determine the incidence of post-anaesthetic fever in horses undergoing elective orthopaedic MRI and determine whether prophylactic antimicrobial therapy would be associated with a reduction in the incidence of post-anaesthetic fever. We hypothesised that prophylactic antimicrobials would be associated with a reduction in the incidence of post-anaesthetic fever. Retrospective cross-sectional study. This retrospective study included 791 elective orthopaedic MRIs in systemically healthy horses between June 2006 and March 2020 that recovered from general anaesthesia and did not undergo surgery or intensive medical therapy soon after recovery. Potential factors associated with post-anaesthetic fever were evaluated using multivariable logistic regression. Case signalment, travel time, preanaesthetic haematology and fibrinogen abnormalities, use of prophylactic antimicrobials, peri-anaesthetic nonsteroidal anti-inflammatories, anaesthesia time and recovery time were all evaluated for association with post-anaesthetic fever. Of 791 MRI cases, 44 (5.6%) developed a post-anaesthetic fever. Horses that received prophylactic antimicrobials were [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.98-7.46; p ≤ 0.001] more likely to develop a post-anaesthetic fever than those that did not receive antimicrobials. Young horses (1-4 years of age) were (OR 2.8, 95% CI 1.26-6.17; p = 0.01) more likely to develop fever compared with adult horses (≥5 years of age). Limitations of this study pertain to retrospective analysis including nonrandomised case selection and incomplete data records. While fever may indicate infection, the majority of early post-anaesthetic fevers resolved before discharge from the hospital with no identified cause. The use of prophylactic antimicrobials to reduce the risk of post-anaesthetic fever for elective MRI is not supported by this study.

Evidence-based guideline for the prevention and management of perioperative infection.

We have updated the guideline for preventing and managing perioperative infection in China, given the global issues with antimicrobial resistance and the need to optimize antimicrobial usage and improve hospital infection control levels. We conducted a comprehensive evaluation of the evidence for prevention and management of perioperative infection, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Revisions were made to the guidelines in response to feedback from the experts. There were 17 questions prepared, for which 37 recommendations were made. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the meta-analysis results, recommendations were graded using the Delphi method to generate useful information. This guideline provides evidence to perioperative antimicrobial prophylaxis that increased the rational use of prophylactic antimicrobial use, with substantial improvement in the risk-benefit trade-off.

Comparison of antimicrobial resistant Escherichia coli isolated from Irish commercial pig farms with and without zinc oxide and antimicrobial usage

BackgroundThe prophylactic use of antimicrobials and zinc oxide (ZnO) in pig production was prohibited by the European Union in 2022 due to potential associations between antimicrobial and heavy metal usage with antimicrobial resistance (AMR) and concerns regarding environmental pollution. However, the effects of their usage on the bacterial AMR profiles on commercial pig farms are still not fully understood and previous studies examining the effect of ZnO have reported contrasting findings. The objective of this study was to examine the effects of antimicrobial and ZnO usage on AMR on commercial pig farms. Faecal and environmental samples were taken on 10 Irish commercial farms, of which 5 farms regularly used ZnO and antimicrobials (amoxicillin or sulphadiazine-trimethoprim) for the prevention of disease. The other 5 farms did not use ZnO or any other form of prophylaxis. Escherichia coli numbers were quantified from all samples using non-supplemented and supplemented Tryptone Bile X-glucuronide agar.ResultsIn total 351 isolates were phenotypically analysed, and the genomes of 44 AmpC/ESBL-producing E. coli isolates from 4 farms were characterised using whole-genome sequencing. Phenotypic analysis suggested higher numbers of multi-drug resistant (MDR) E. coli isolates on farms using prophylaxis. Furthermore, farms using prophylaxis were associated with higher numbers of isolates resistant to apramycin, trimethoprim, tetracycline, streptomycin, and chloramphenicol, while resistance to ciprofloxacin was more associated with farms not using any prophylaxis. Thirty-four of the 44 AmpC/ESBL-producing E. coli strains harboured the blaCTX-M-1 resistance gene and were multi drug resistant (MDR). Moreover, network analysis of plasmids and analysis of integrons showed that antimicrobial and biocide resistance genes were frequently co-located on mobile genetic elements, indicating the possibility for co-selection during antimicrobial or biocide usage as a contributor to AMR occurrence and persistence on farms.ConclusionsThe results of this study showed evidence that antimicrobial and ZnO treatment of pigs post-weaning can favour the selection and development of AMR and MDR E. coli. Co-location of resistance genes on mobile genetic elements was observed. This study demonstrated the usefulness of phenotypic and genotypic detection of antimicrobial resistance by combining sequencing and microbiological methods.

Antimicrobial Prophylaxis in Lower Uterine Segment Caesarean Section: A Prospective Observational Data-based Study

Introduction: Any major surgery like lower uterine Caesarean Section (CS) can be hazardous due to postoperative nosocomial infection. Pregnant mothers are at greater risk during such surgical intervention as compared to vaginal delivery. Prophylactic antibiotic administration is a standard practice across the globe to prevent such anticipated postoperative infection. Aim: To evaluate the prophylactic antimicrobial use with regards to the choice of antimicrobials, dose, route, timing and duration, any possible Adverse Drug Reaction (ADR) as well as to assess the frequency of the postoperative morbidity due to infection (if any). Materials and Methods: A prospective observational databased study was conducted in the Department of Pharmacology in collaboration with Department of Obstetrics and Gynaecology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India, from February 2016 to October 2017. Study was conducted on 1944 pregnant women of reproductive age group planned or scheduled for elective/emergency lower segment CS, but otherwise healthy and received prophylactic antimicrobials for the surgery. They were prospectively observed regarding the treatment they received with focus on antimicrobial agents from the period of antimicrobial prophylaxis during their stay at hospital to till their discharge. Demographic data, vital signs, indication of CS, postoperative infections and ADR if any were recorded in predesigned proforma. The study population was divided into two groups: group A included 995 mothers, who received ceftriaxone sodium (1 g intravenously) and metronidazole (15 mg/kg) infusion and group B included 949 mothers, who received ampicillin (2 g intravenously), metronidazole (15 mg/kg) infusion and injection gentamycin (5 mg/kg) for 0.5 hour before initiation of CS. The data were statistically analysed by standard statistical software Microsoft Excel 2010 and Statistical Package for the Social Sciences (SPSS) sotware version 27.0 (SPSS Inc., Chicago, IL, USA) expressed as mean and standard deviation and percentage. Independent t- test and Chi-square test were used for analysis. Results: The mean age of group A was 22.36±3.07 years and group B was 22.76±2.47 years. Endomyometritis was documented in 4 (0.4%) from group A and 2 (0.21%) from the group B. Wound infection was present in 3 (0.3%) for group A and five (0.5%) for the group B. Infection related complications like chest infection seen in 7 (0.7%) for group A and in 3 (0.31%) for group B and urinary tract infection was noticed in 6 (0.6%) for group A and 5 (0.52%) for group B. Any incidence of maternal mortality was not evident among the two study groups and statistically insignificant ADR like vomiting and maculopapular rash (p-value=0.324) was observed in both the study groups with the use of above-mentioned antimicrobial therapy. Conclusion: Prophylactic use of ceftriaxone plus metronidazole and combination of triple antimicrobial therapy of ampicillin, metronidazole, and gentamycin therapy at the usual standard dose were commonly used antimicrobials at the present set up and they are safe and equally effective in decreasing considerably the incidence of post caesarean maternal infection thereby reducing their morbidity and mortality

Analysis of risk factors for infection after transrectal ultrasound-guided prostate biopsy and analysis of the value of preoperative prophylactic antimicrobial use

Analysis of risk factors for infection after transrectal ultrasound-guided prostate biopsy and analysis of the value of preoperative prophylactic antimicrobial use

Multi-Drug Resistant Staphylococcus aureus Carriage in Abattoir Workers in Busia, Kenya.

Abattoir workers have been identified as high-risk for livestock-associated Staphylococcus aureus carriage. This study investigated S. aureus carriage in abattoir workers in Western Kenya. Nasal swabs were collected once from participants between February-November 2012. S. aureus was isolated using bacterial culture and antibiotic susceptibility testing performed using the VITEK 2 instrument and disc diffusion methods. Isolates underwent whole genome sequencing and Multi Locus Sequence Types were derived from these data. S. aureus (n = 126) was isolated from 118/737 (16.0%) participants. Carriage was higher in HIV-positive (24/89, 27.0%) than HIV−negative participants (94/648, 14.5%; p = 0.003). There were 23 sequence types (STs) identified, and half of the isolates were ST152 (34.1%) or ST8 (15.1%). Many isolates carried the Panton-Valentine leucocidin toxin gene (42.9%). Only three isolates were methicillin resistant S. aureus (MRSA) (3/126, 2.4%) and the prevalence of MRSA carriage was 0.4% (3/737). All MRSA were ST88. Isolates from HIV-positive participants (37.0%) were more frequently resistant to sulfamethoxazole/trimethoprim compared to isolates from HIV-negative participants (6.1%; p < 0.001). Similarly, trimethoprim resistance genes were more frequently detected in isolates from HIV-positive (81.5%) compared to HIV-negative participants (60.6%; p = 0.044). S. aureus in abattoir workers were representative of major sequence types in Africa, with a high proportion being toxigenic isolates. HIV-positive individuals were more frequently colonized by antimicrobial resistant S. aureus which may be explained by prophylactic antimicrobial use.

Effects of administration of tylosin on the duration of protective immunity induced by the novel Mycoplasma gallisepticum vaccine strain, Vaxsafe MG ts-304, in chickens

Prophylactic use of antimicrobials after administration of live vaccines is a common practice in the poultry industry, but the impact of this on the efficacy and duration of protection induced by the vaccines is unknown. The effect of treatment with tylosin on the efficacy of vaccination with the live attenuated M. gallisepticum strain, Vaxsafe MG ts-304, was examined. This vaccine has previously been shown to provide protection for at least 57 weeks. Ten-week-old specific-pathogen-free chickens were vaccinated with Vaxsafe MG ts-304 and then treated with tylosin at a therapeutic dose in drinking water from 6 weeks after vaccination. Tylosin was withdrawn 5 days before challenge with M. gallisepticum strain Ap3AS at 6, 10, 14, 18 or 22 weeks after vaccination. Air sac lesions, tracheal mucosal thickening and the concentrations of serum antibodies against M. gallisepticum were assessed at 2 weeks after challenge. The protection induced by the vaccine in the 6 weeks before initiation of tylosin treatment persisted for 18 weeks after vaccination, with lesions only observed in the air sacs of vaccinated birds that had been treated with tylosin after challenge at 22 weeks after vaccination. Concentrations of serum antibodies against M. gallisepticum began to decrease in vaccinated birds that had been treated with tylosin from 16 weeks after vaccination. This study has suggested that treatment of chickens with tylosin after vaccination with a live attenuated mycoplasma vaccine reduces the duration of protective immunity afforded by the vaccine.

Supportive Care Strategies in Myelodysplastic Syndromes and Acute Myeloid Leukemia in Older Adults: A National Survey of Canadian Hematologists

BACKGROUND: Myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) represent a spectrum of severe myeloid disorders characterized by marrow failure, cytopenias, and complications related to bleeding and infection. Due to patient and disease factors, many patients are treated with less-intensive therapy, such as transfusion support, erythropoietin stimulating agents, luspatercept, lenalidomide and hypomethylating agents. However, optimal supportive care strategies to minimize bleeding and infectious complications among older adults receiving less intensive therapy have not been systematically evaluated. OBJECTIVES: The objectives of the survey were to: a) evaluate self-reported use of tranexamic acid (TXA) and antimicrobial prophylaxis; b) identify perceived barriers and facilitators to the use of TXA and antimicrobial prophylaxis; c) characterize the degree of uncertainty regarding the benefits and harms of TXA and prophylactic antimicrobials in this patient population; and d) assess physician interest in future clinical trials of TXA and/or prophylactic antimicrobials. METHODS: We conducted a national cross-sectional survey of Canadian hematologists to explore current practice variation regarding the use of TXA and prophylactic antimicrobials in patients with MDS and AML treated with less intensive therapy, and evaluate equipoise for future trials. Survey items were generated iteratively through a combination of literature review and discussion with content experts until thematic saturation was achieved. The questionnaire was pilot-tested by collaborators prior to dissemination to assess the required completion time and provide feedback on flow, clarity, redundancy and comprehensiveness. The electronic platform REDCap was used to create and disseminate the survey tool. The survey was distributed to all hematologists affiliated with a Canadian university, representing both key knowledge users and potential participants in an investigative network for future clinical trials. RESULTS: The survey response rate was 52% (159/304 invited participants). Of the 159 hematologists, 105 indicated that they treated MDS/AML patients with less intensive therapy and responded to the further questions about this patient population. Most (97/105; 92%) hematologists worked in an academic/tertiary care setting; 8% (n=8/105) worked in a community setting. Prophylactic TXA was used by 57% (n=60/105) of hematologists; the most frequent reason for not using TXA was uncertainty about the benefits or harms. Nearly all (95%; 100/105) hematologists agreed that a trial of TXA is needed (n=78), or potentially needed (n=22). Use of prophylactic antimicrobials varied by the chemotherapy treatment regimen. The most frequently prescribed antibacterials were fluroquinolones (36% of respondents; n=38), trimethoprim/sulfamethoxazole (9%; n=9), and amoxicillin-clavulanate (5%; n=5). The most commonly used antifungals were fluconazole (35% of respondents; n=37) and voriconazole (19%; n=20). Valacyclovir (29% of respondents; n=30) and acyclovir (15%; n=16) were the antivirals prescribed. The most common reason for not using prophylactic antimicrobials was an insufficient level of evidence (70%; n=73). The majority (78%, n=82) of respondents agreed that a trial is needed to evaluate optimal antimicrobial prophylaxis in this at-risk patient population. CONCLUSIONS: Among survey respondents, there was variation in the use of supportive case strategies to address bleeding and infection risk in older adults with MDS/AML. Most hematologists who treat MDS/AML with less intensive therapy felt that clinical trials are needed to define the use of TXA and prophylactic antimicrobials in this patient population.

Surgical Site Infection in Spine and Spinal Cord Surgery

Surgical site infection(SSI)is among the most serious complications of spinal surgery in terms of patient health status and clinical outcomes. The use of prophylactic antimicrobials does not eliminate SSIs. Risk factors for SSI exist during not only the intraoperative period, but also all perioperative periods. In addition to intraoperative surgical risk factors, patient-related factors such as age, nutritional status, diabetes, smoking, obesity, coexistent infections in a remote part of the body, and colonization with microorganisms have also been reported. Therefore, it is important to reduce the risk of SSIs even before surgery, which requires knowledge about SSIs and prevention efforts. Spinal surgery can cause deep SSIs, instrumented infections, and meningitis resulting from cerebrospinal fluid infection. Spinal SSIs can be predicted by detecting changes in wound sites, pain and fever, and trends in hematological examination. However, special attention should be given to instrumented surgeries because of the subclinical nature of bacterial biofilm formation on the surface of implants. Therefore, it is important to aim for early detection and treatment of SSIs while reducing perioperative risks to decrease the potential for poor outcomes due to spinal SSIs.

Chinese expert consensus on the management of lower respiratory tract infections of Pseudomonas aeruginosa in adults(2022)

Pseudomonas aeruginosa (PA) is the second common Gram-negative bacterium for hospital acquired pneumonia (HAP) in China (16.9%-22.0%). The proportion of PA in community acquired pneumonia (CAP) was about 1.0%, while increased to 1.8%-8.3% in severe CAP. PA accounted for 67.0% of CAP in patients with a history of PA infection, bronchiectasis, very severe chronic obstructive pulmonary disease (COPD) or tracheotomy. Considering the high disease burden of lower respiratory tract infections (LRTIs) caused by PA, together with the progress in this field in recent years, the Pulmonary Infection Assembly of Chinese Thoracic Society updated the "Chinese expert consensus on the management of lower respiratory tract infections of Pseudomonas aeruginosa in adults (2014 version)", focusing on pathogen detection, diagnosis, antimicrobial therapy, comprehensive management, infection prevention and control.PA causes both acute and chronic LTRIs. Acute LRTIs mainly include pneumonia (CAP, HAP and ventilator-associated pneumonia), tracheobronchitis, lung abscess and empyema. The diagnosis of chronic LTRIs should be based on a comprehensive assessment of (1) underlying chronic structural lung diseases, such as bronchiectasis, cystic fibrosis, COPD, or immunocompromised conditions; (2) the presence of clinical manifestations of LRTIs; and (3) ≥ two times (at least 3 months apart) of PA detected from eligible lower respiratory tract specimens within 1 year. It is important to distinguish infection from colonization when PA is isolated from lower respiratory tract specimens. Drug susceptibility test is a conventional method for PA resistance detection and serves as a basis for target therapy. When drug susceptibility test shows limited activity of available agents, combined susceptibility test is suggested to select antimicrobial drugs with additive or synergistic effect in vitro for combination therapy. Rapid test of resistance mechanisms of PA isolates, such as carbapenemase phenotype confirmation tests, is recommended if available. It is recommended not to routinely detect resistance genes for choosing therapeutic agents.For patients with acute LRTIs in critical condition or with high risk factors for PA infection, empirical antimicrobial therapy covering PA should be initiated after collecting specimens for microbiological tests. In patients with suspected PA pneumonia who are not critically ill, single antimicrobial drug of anti-PA activity with high lung concentration should be selected for empirical treatment. However, for patients with a serious condition such as sepsis or with risk factors for multidrug-resistant (MDR) PA, a combination of two different classes of antimicrobial drugs that are both potentially susceptible should be used. The antimicrobial regimen should follow pharmacokinetics/pharmacodynamics principles to ensure adequate dosage and administration frequency. For confirmed PA LRTIs, antibiotics should be selected based on drug sensitivity. In patients without significant underlying diseases, single therapy of an active antimicrobial with adequate pulmonary concentration is recommended rather than combination therapy; when all the available active agents have poor intrapulmonary concentrations, combination therapy is obligatory. For LRTIs caused by carbapenem-resistant PA (CRPA) or difficult-to-treat resistance PA (DTR-PA), if an agent of new enzyme inhibitor, such as ceftolozane/tazobactam, ceftazidime/avibactam, and imipenem/cilastatin/relebactam shows in vitro sensitivity, it is recommended as the first-line choice; cefiderocol may serve as the second-line treatment. Combination therapy based on polymyxins may also be considered. Other potentially successful approaches for drug-resistant PA LRTIs include extended infusion time of β-lactams, combination therapy and inhaled antimicrobial therapy.In patients with underlying chronic structural lung diseases, the antimicrobial regimen (drug, dosage, route of administration, and duration of therapy) should be decided according to clinical features, drug sensitivity, and treatment goals (control of exacerbated symptoms, eradication of new-emerging PA, or prevention of flare-ups in patients with frequent exacerbation).Along with antimicrobial therapy, comprehensive care including airway clearance therapy (ACT), oxygen therapy, nutritional support and organ function protection should be provided. From the perspective of nosocomial infection prevention and control, isolation and prophylaxis of contact transmission are recommended to block PA transmission in addition to standard prevention measures. Targeted active screening, timely monitoring and feedback can help the prevention and control of MDR-PA. The systemic and topical use of prophylactic antimicrobials is not recommended.

重症急性膵炎に対する予防的抗菌薬使用の現況 第49回日本救急医学会総会・学術集会より(Current status of prophylactic antimicrobial use for severe acute pancreatitis: in the 49th Annual Meeting of the Japanese Association for Acute Medicine)

要旨【背景】急性膵炎診療における予防的抗菌薬投与に関して，世界のガイドラインでは投与は非推奨となりつつあるが，日本の多くの施設では重症度に関わらず予防的抗菌薬は投与されている。施設ごとの診療パターンや，投与を支持するかしないかの背景にある根拠や臨床的動機は不明であり，第49回日本救急医学会総会学術集会で本命題に関するセッションが開催された。【目的】各演者の発表・討論内容，会場の投票結果を提示し，予防的抗菌薬投与の是非を検討する。【方法】発表要旨と質疑，投票結果の推移を記述した。【結果】Pros：抗菌薬の予防的投与と治療的投与を明確に区別するのは難しく，胆石性膵炎疑い例，医療暴露（耐性菌）（高感染リスク）例には，厳選して短期間（3日間）使用するべき。Cons：感染の証拠が明確でなければ使用するべきではない。投票結果推移：（軽症膵炎）非投与派が80%から90%に増加。（重症膵炎）投与派が77%から42%に減少。【考察】ガイドライン遵守率の低さと予防的抗菌薬投与の臨床的動機が判明した。世界のエビデンスやガイドライン推奨を正しく提示することで，行動変容が可能であることが示唆された。今後のガイドラインには，無菌性急性膵炎と胆管炎・敗血症併発の鑑別に関する指針や，その遵守率の定期的調査が求められる。【結論】予防的抗菌薬投与が推奨されなくなった事実を理解し，日本の最新版ガイドラインの遵守に努めるべきである。

Cross-Sectional Survey of Prophylactic and Metaphylactic Antimicrobial Use in Layer Poultry Farming in Cameroon: A Quantitative Pilot Study.

An evaluation of the patterns of antimicrobial use in livestock can help understand the increasing level of antimicrobial resistance worldwide. This study aimed at evaluating antimicrobial usage in modern layer poultry farms in the West Region of Cameroon. In this light, 70 layer poultry farms and 4 veterinary pharmacies were surveyed. Data on antimicrobial use were collected through interviews using a quantitative-frequency questionnaire and consultation of medical records. The four veterinary pharmacies sold a total of 2.8 tons of antimicrobials (active ingredients) during 2011. At the level of farms, 297 kg of antimicrobials (active ingredients) were used in the 50 layer poultry farms surveyed. Tetracycline, sulfonamides, quinolones, and β-lactams (aminopenicillins) were the most sold and used drugs in layer farms. As for treatment indication, metaphylactic (58.1%) and prophylactic (41.9%) treatments were the most observed practices, and nearly all (99%) treatments were administered per os as remedies to respiratory (33.4%) and digestive (24.7%) tract symptoms. Overall, 78.2% of antimicrobials sold in pharmacies and 67.3% used in the farms belonged to the class of critically important antimicrobials of the WHO categorization of antimicrobials according to their importance to human medicine. Doxycycline, sulfonamide, ampicillin, and streptomycin, which have been banned for layer poultry in the production of eggs for human consumption, were still used in Cameroon. The treatment incidences based on the used daily dose (TIUDD) and animal daily dose (TIADD) were 11.59 and 10.45, respectively. In regard to dosage correctness based on the UDD/ADD ratio, aminoglycosides (100%), macrolides (90.6%), and tetracyclines (74.5%) were the most underdosed, while trimethoprim sulfonamides (45.8%) and β-lactams (35.7%) were overdosed. This study highlights an irrational antimicrobial usage in layer poultry farms. Regulation of the use of antimicrobials and the education of farmers on adequate antimicrobial use are essential to preserve the effectiveness of drugs in both humans and animals.

Mastitis Control and Intramammary Antimicrobial Stewardship in Ireland: Challenges and Opportunities.

The Veterinary Medicines Regulation (EU 2019/6) came into force in all EU member states on 28 January 2022. This regulation places particular emphasis on prudent and responsible antimicrobial use in food animal production. Key changes include restrictions on the prophylactic use of antimicrobials in animals, and the possibility to reserve certain antimicrobials for humans only. The Regulation presents challenges to the Irish dairy industry, particularly with respect to current approaches to dry cow therapy. In response, the CellCheck technical working group (TWG, a technical group working in support of CellCheck, the national mastitis control programme) have developed pragmatic national and farm-level recommendations in support of improved mastitis control and intramammary antimicrobial stewardship in the Irish dairy industry. This paper outlines these recommendations, and provides an overview of the evidence considered to inform the TWG during its work (including the Regulation, policy perspectives, international best-practice, international scientific reviews and specific Irish challenges). In many key areas of concern, the TWG recognises the challenges in seeking to shape recommendations in the absence of robust and practical scientific evidence. For this reason, some of the recommended actions are pragmatic in nature, informed by national and international experiences. Periodic programme review will be needed, informed by ongoing monitoring of key performance indicators, to identify those actions that are most effective in an Irish context.

Applying Machine Learning Techniques to the Audit of Antimicrobial Prophylaxis

High rates of inappropriate use of surgical antimicrobial prophylaxis were reported in many countries. Auditing the prophylactic antimicrobial use in enormous medical records by manual review is labor-intensive and time-consuming. The purpose of this study is to develop accurate and efficient machine learning models for auditing appropriate surgical antimicrobial prophylaxis. The supervised machine learning classifiers (Auto-WEKA, multilayer perceptron, decision tree, SimpleLogistic, Bagging, and AdaBoost) were applied to an antimicrobial prophylaxis dataset, which contained 601 instances with 26 attributes. Multilayer perceptron, SimpleLogistic selected by Auto-WEKA, and decision tree algorithms had outstanding discrimination with weighted average AUC &gt; 0.97. The Bagging and SMOTE algorithms could improve the predictive performance of decision tree against imbalanced datasets. Although with better performance measures, multilayer perceptron and Auto-WEKA took more execution time as compared with that of other algorithms. Multilayer perceptron, SimpleLogistic, and decision tree algorithms have outstanding performance measures for identifying the appropriateness of surgical prophylaxis. The efficient models developed by machine learning can be used to assist the antimicrobial stewardship team in the audit of surgical antimicrobial prophylaxis. In future research, we still have the challenges and opportunities of enriching our datasets with more useful clinical information to improve the performance of the algorithms.

Impact of antimicrobial stewardship intervention in clean and clean-contaminated surgical procedures at a Vietnamese national hospital.

We investigated the characteristics of prophylactic antimicrobial use in clean and clean-contaminated surgical procedures and assessed the efficacy of a prophylactic antimicrobial stewardship intervention at Thong Nhat Hospital, Ho Chi Minh City, Vietnam. A cross-sectional study was conducted on 354 patients who underwent either clean or clean-contaminated surgical procedures at Thong Nhat Hospital. Eligible patients were classified with respect to three periods of intervention from 2017 to 2020. Data collection included surgical procedures, patient characteristics, and prophylactic antimicrobial usage. We determined the efficacy of antimicrobial stewardship intervention based on comparisons among the primary outcome (the appropriateness of prophylactic antimicrobials) and secondary outcomes (postoperative antimicrobial prophylaxis (AP) prolongation, length of postoperative hospital stay, and cost of antimicrobials). The mean age of patients in periods 1, 2, and 3 was 54.5 ± 16.6, 50.2 ± 16.5, and 52.8 ± 17.3years, respectively, with an overall male/female ratio of 1.1/1. No significant differences were detected in basic patient characteristics during the three periods. Majority of the surgical procedures were clean (56%-59%) and scheduled (85%-86%). Prophylactic antimicrobial stewardship intervention enhanced AP appropriateness (by 12.7%, 12.7%, and 39.0% in periods 1, 2, and 3, respectively, p < 0.001), decreased postoperative prophylactic antimicrobial duration [3.0 (0-6), 1.5 (0-5), and 0.0 (0-1) days, respectively, p < 0.001], and reduced average antimicrobial expenses (p < 0.001). The prophylactic antimicrobial stewardship interventions introduced at Thong Nhat Hospital had several positive impacts on the appropriateness of prophylactic antimicrobial use and treatment costs.

Association between duration of antimicrobial prophylaxis and postoperative outcomes after lumbar spine surgery.

To describe the association between duration of antimicrobial prophylaxis (AMP) and 30-day surgical site infection (SSI), 7-day acute kidney injury (AKI), 90-day Clostridioides difficile infection (CDI), prolonged hospitalization, and 30-day reoperation after lumbar spine surgery for noninfectious indications, and to report adherence to current guidelines. Survey. The study cohort comprised 6,198 patients who underwent lumbar spine surgery for noninfectious indications across 137 Veterans' Health Administration surgery centers between 2016 and 2020. Used univariate and multivariate logistic regression to determine the association between type and duration of AMP with 30-day SSI, 7-day AKI, 90-day CDI, prolonged hospitalization, and 30-day reoperation. Only 1,160 participants (18.7%) received the recommended duration of AMP. On multivariate analysis, the use of multiple prophylactic antimicrobials was associated with increased odds of 90-day CDI (adjusted odds ratio [aOR], 5.5; 95% confidence interval [CI], 1.1-28.2) and 30-day reoperation (aOR, 2.3; 95% CI, 1.2-4.4). Courses of antimicrobials ≥3 days were associated with increased odds of prolonged hospitalization (aOR,1.8; 95% CI, 1.4-2.3) and 30-day reoperation (aOR, 3.5; 95% CI, 2.2-5.7). In univariate analysis, increasing days of AMP was associated with a trend toward increasing odds of 90-day CDI (cOR, 1.4; 95% CI, 1.0-1.8 per additional day; P = .056). Longer courses of AMP after lumbar spine surgery were associated with higher odds of CDI, prolonged hospitalization, and reoperation, but not with lower odds of SSI. However, adherence to the recommended duration of AMP is very low, hinting at a wide evidence-to-practice gap that needs to be addressed by spine surgeons and antimicrobial stewardship programs.