Reduction In Antibiotic Usage Research Articles

Broad host range phages target global Clostridium perfringens bacterial strains and clear infection in five-strain model systems.

Clostridium perfringens causes foodborne illness worldwide, and 95% of human infections are linked to the consumption of contaminated meat, including chicken products. In poultry, C. perfringens infection causes necrotic enteritis, and associated mortality rates can be up to 50%. However, treating infections is difficult as the bacterium is becoming antibiotic-resistant. Furthermore, the poultry industry is striving toward reduced antibiotic usage. Bacteriophages (phages) offer a promising alternative, and to progress this approach, robust suitable phages and laboratory models that mimic C. perfringens infections in poultry are required. In our study, we isolated phages targeting C. perfringens and found that many lyse C. perfringens strains isolated from chickens worldwide. Consistent with other published studies, in the model systems we assayed here, when some phages were combined as cocktails, the infection was cleared most effectively compared to individual phage use.

Short-term effects of antimicrobial stewardship programs on antibiotics usage, clinical outcomes, and multidrug resistant organisms in the post COVID-19 era

BackgroundAntimicrobial resistance is associated with increasing mortality rates and the emergence of multidrug-resistant (MDR) organisms. There is scarcity of data on the short-term impact of Antimicrobial Stewardship Programs (ASP) on antibiotic usage, clinical outcome and MDR organisms’ pattern following the COVID-19 pandemic. This study evaluated the short-term effects of ASP on antibiotic usage, clinical outcomes and MDR organisms’ pattern in the post COVID-19 era. MethodsConducted at a tertiary academic health center, this observational study involved adult patients (≥18 years) in the general medical unit, treated with oral or intravenous antibiotics from May 1, 2021, to April 30, 2022. The applied ASP strategy was a prospective audit and feedback where a weekly meeting was held to discuss the antimicrobial therapy of admitted patient, after which recommendations were made regarding antimicrobial use. ResultsThe study included 301 patients with 166 (55.1%) pre-ASP and 135 (44.9%) post-ASP. The median (IQR) age was 69 (55−77) years with 56.1% were female. Antibiotic usage dropped by 25.2% post-ASP. The length of hospital stay (LOS) was longer post-ASP (7 days vs. 7.9 days, p = 0.001), with MDR infections being a significant predictor (OR: 0.486, p < 0.001). There were no significant differences in 28-day readmission, recurrence of infections and all-cause mortality. Post-ASP, MDR pathogens increased (17.0% vs. 6.6%, p = 0.013), however, after separating post-ASP into two three-months periods, MDROs numbers decreased slightly (13 vs. 10). ConclusionShort-term ASP implementation post COVID-19 reduced antibiotic usage while other clinical outcomes remained unchanged. Nonetheless an increase in MDR pathogens and LOS was observed. Further research is required to assess ASP’s long-term impact on MDR infections rates and specific patient group outcomes.

Comparison of vonoprazan-based dual therapy with vonoprazan-based bismuth quadruple therapy for treatment-naive patients with Helicobacter pylori infection: A propensity score matching analysis.

Vonoprazan, a novel acid suppressant and the first potassium-competitive acid blocker, has the potential to enhance the eradication rate of Helicobacter pylori due to its robust acid-suppressing capacity. This study aimed to compare the efficacy of vonoprazan-based dual therapy (vonoprazan-amoxicillin, VA) with vonoprazan-based bismuth quadruple therapy (VBQT) as a first-line treatment for H pylori infection. This retrospective single-center non-inferiority study was conducted in China. Treatment-naive H pylori-positive patients aged 18 to 80 received one of the 2 treatment regimens at our center. The VA group received vonoprazan 20 mg twice daily and amoxicillin 1000 mg 3 times daily for 14 days, whereas the VBQT group received vonoprazan 20 mg, amoxicillin 1000 mg, clarithromycin 500 mg, and bismuth potassium citrate 220 mg twice daily for 14 days. The eradication rate was evaluated 4 to 6 weeks after treatment using the carbon-13/14 urea breath test. Propensity score matching was used to analyze eradication rates, adverse events (AEs), and patient compliance between the 2 groups. Initially, 501 patients were included, and after propensity score analysis, 156 patients were selected for the study. Intention-to-treat analysis showed eradication rates of 87.2% (95% CI, 79.8-94.6%) for the VA group and 79.5% (95% CI, 70.5-88.4%) for the VBQT group (P = .195). Per-protocol analysis demonstrated rates of 94.4% (95% CI, 89.2-99.7%) for the VA group and 96.8% (95% CI, 92.4-100%) for the VBQT group (P = .507). Non-inferiority was confirmed between the 2 groups, with P values < .025. The VA group showed a lower rate of AEs (10.3% vs 17.9%, P = .250) compared to the VBQT group. There were no significant differences in patient compliance between the 2 groups. In treatment-naive patients with H pylori infection, both the 14-day VA and VBQT regimens demonstrated comparable efficacy, with excellent eradication rates. Moreover, due to reduced antibiotic usage, lower rate of AEs, and lower costs, VA dual therapy should be prioritized.

Wait and watch: A trachoma surveillance strategy from Amhara region, Ethiopia.

Trachoma recrudescence after elimination as a public health problem has been reached is a concern for control programs globally. Programs typically conduct district-level trachoma surveillance surveys (TSS) ≥ 2 years after the elimination threshold is achieved to determine whether the prevalence of trachomatous inflammation-follicular (TF) among children ages 1 to 9 years remains <5%. Many TSS are resulting in a TF prevalence ≥5%. Once a district returns to TF ≥5%, a program typically restarts costly mass drug administration (MDA) campaigns and surveys at least twice, for impact and another TSS. In Amhara, Ethiopia, most TSS which result in a TF ≥5% have a prevalence close to 5%, making it difficult to determine whether the result is due to true recrudescence or to statistical variability. This study's aim was to monitor recrudescence within Amhara by waiting to restart MDA within 2 districts with a TF prevalence ≥5% at TSS, Metema = 5.2% and Woreta Town = 5.1%. The districts were resurveyed 1 year later using traditional and alternative indicators, such as measures of infection and serology, a "wait and watch" approach. These post-surveillance surveys, conducted in 2021, were multi-stage cluster surveys whereby certified graders assessed trachoma signs. Children ages 1 to 9 years provided a dried blood spot and children ages 1 to 5 years provided a conjunctival swab. TF prevalence in Metema and Woreta Town were 3.6% (95% Confidence Interval [CI]:1.4-6.4) and 2.5% (95% CI:0.8-4.5) respectively. Infection prevalence was 1.2% in Woreta Town and 0% in Metema. Seroconversion rates to Pgp3 in Metema and Woreta Town were 0.4 (95% CI:0.2-0.7) seroconversions per 100 child-years and 0.9 (95% CI:0.6-1.5) respectively. Both study districts had a TF prevalence <5% with low levels of Chlamydia trachomatis infection and transmission, and thus MDA interventions are no longer warranted. The wait and watch approach represents a surveillance strategy which could lead to fewer MDA campaigns and surveys and thus cost savings with reduced antibiotic usage.

Reducing Surgical Site Infections Post-Caesarean Section.

Surgical Site Infections (SSI) are one of the most common complications after a caesarean with significant morbidity. Evidence suggests that SSI rates can be reduced post caesarean by using a Leukomed® Sorbact® (Essity) bacteria binding wound dressing, thereby reducing bacterial wound colonisation. Barking, Havering & Redbridge University Hospitals NHS Trust, London, UK (BHRUT) maternity unit sought change their clinical practice by using Leukomed Sorbact and evaluate if this reduced their SSI rate, SSI readmission rate, antibiotic usage and evaluate any associated cost savings. From January 1st 2022, Mepore® (Molnlycke) wound dressings were replaced with Leukomed Sorbact for all caesareans. Retrospective and prospective audits were undertaken to compare SSI incidence pre- and post- implementation of the dressing. No changes were made to wound cleaning products, prophylactic antibiotic use or surgical technique. Wound closure technique remained the choice of the individual surgeon. Prior to this practice change, the baseline SSI rate between January-December 2021 was 6.1% and the SSI readmission rate was 1.27%. Comparative data for January-December 2022 showed a 38% reduction in SSI rates (overall SSI rate = 3.8%), a 31% reduction in readmission rate for SSI (overall rate = 0.88%), a 38% reduction in readmission bed days and a 30% reduction in antibiotic use. There was a reduction in SSI rates in all body mass index (BMI) categories. Total savings due to the reduction in SSI rates over twelve months were £234,784. The cost savings to BHRUT solely attributable to the reduction in readmissions was £49,750 or £21 per Caesarean, which will be an ongoing saving. The use of Leukomed Sorbact dressings after Caesarean resulted in improved clinical outcomes with reduced SSI and readmission rates. Investment in the new dressing was cost effective when considering bed days freed, the reduction in antibiotic usage, reduced morbidity and improved patient experience.

Tailored Approach to Evaluation and Management of Early Onset Neonatal Sepsis in a Safety-Net Teaching Hospital in Northeast Florida.

Objective Early onset neonatal sepsis (EONS) remains a significant cause of morbidity and mortality in newborns in the immediate postnatal period. High empiric antibiotic use in well-appearing infants with known risk factors for sepsis led the American Academy of Pediatrics (AAP) to revise its 2010 guidelines for the evaluation and management of EONS to avoid overuse of antibiotics. In this recent clinical report, the AAP provided a framework that outlined several evidence-based approaches for sepsis risk assessment in newborns that can be adopted by institutions based on local resources and structure. One of these approaches, the sepsis risk calculator (SRC) developed by Kaiser Permanente, has been widelyvalidated for reducing unnecessary antibiotic exposure and blood work in infants suspected of having EONS. In order to determine the utility and safety of modifying our institution's protocol to the SRC, we implemented a two-phased approach to evaluate the use of SRC in our newborn nursery. Phase 1 utilized a retrospective review of cases with SRC superimposition. If results from Phase 1 were found to be favorable, Phase 2 initiated a trial of the SRC for a six-month period prior to complete implementation. Methods Phase 1 consisted of retrospectively applying the SRCto electronic medical records (EMR) of infants ≥ 35 weeks' gestational age admitted to the newborn nursery with risk factors for EONS between June 2016 and May 2017. We compared actual antibiotic use as determined by the unit's EONS protocol for evaluation and management based on 2010 Centers for Disease Control and Prevention (CDC) and AAP guidelines to SRC-recommended antibiotic use. We used EMR to determine maternal and infant data, blood work results, and antibiotic usage as well asused daily progress notes by the clinical team to determine the clinical status of the infants retrospectively. Based on the projected reduction in blood work and antibiotics use with the retrospective superimposition of SRC on this cohort of infants and identification of our high-risk patient subset, we developed a novel, hybrid EONS protocol that we implemented and assessed throughout Phase 2, a six-month period from August 2018 to January 2019, as a prospective observational study. Results Phase 1 (SRC superimposition) demonstrated that the use of the SRC would have reduced empiric antibiotic use from 56% to 13% in the study cohort when compared with 2010 CDC/AAP guidelines. However, these same findings revealed use of the SRC would have resulted in delayed evaluation and initiation of antibioticsin 2 of 4 chorioamnionitis-exposed infants with positive blood cultures. During Phase 2 (n=302), with the implementation of our tailored approach (SRC implementation with additional blood culture in chorioamnionitis-exposed infants), 12 (4%) neonates received empiric antibiotic treatment compared to nine (3%) neonates who would have been treated per strict adherence to SRC recommendations. No neonate had culture-positive EONS. Continued use of 2010 CDC/AAP guidelines would have led to empiric antibiotic use in 38 (12.6%) infants in this cohort. Conclusion We developed a novel hybrid approach to the evaluation and management of neonates at increased risk of EONS by tailoring SRC recommendations to our safety-net population. Our stewardship effort achieved a safe and significant reduction in antibiotic usage compared to prior usage determined using CDC/AAP guidelines.

Reducing antimicrobial use in chicken production in Vietnam: Exploring the systemic dimension of change.

Antibiotic use in livestock production is one of the drivers of antibiotic resistance and a shift towards better and reduced antibiotic usage is urgently required. In Vietnam, where there are frequent reports of the misuse and overuse of antibiotics, little attention has been paid to farmers who have successfully changed their practices. This qualitative study aims to understand the transition process of Vietnamese chicken farmers toward reduced antibiotic usage. We conducted semi-structured interviews with 18 chicken farmers, 13 drug sellers, and 5 traders using participatory tools and a socio-anthropological approach. We explored the farmers' histories, current and past antibiotic usage, methods used to reduce antibiotic use, and motivations and barriers to changing practices. Through the thematic analysis of the farmers' transcripts, we identified technical, economic, and social factors that influence change. Out of eighteen farmers, we identified ten farmers who had already reduced antibiotic usage. The main motivations included producing quality chickens (tasty and safe) while reducing farm expenditures. Barriers were related to poor biosecurity in the area, market failures, and the farmers' lack of knowledge. Innovation led to overcome these obstacles included the local development of handmade probiotics and the organization of farmer cooperatives to overcome economic difficulties and guarantee product outlets. Knowledge was increased by workshops organized at the communal level and the influence of competent veterinarians in the area. We showed that the transition process was influenced by several components of the system rather than by any individual alone. Our study demonstrated that local initiatives to reduce antibiotic use in Vietnamese chicken production do exist. As changes depend on the system in which stakeholders are embedded, systemic lock-ins must be removed to allow practices to change. The promotion of locally-developed solutions should be further encouraged.

Restrictive Use of Empirical Antibiotics Is Associated with Improved Short Term Outcomes in Very Low Birth Weight Infants: A Single Center, Retrospective Cohort Study from China.

Antibiotics are essential for treating neonatal sepsis, but abuse or inappropriate use of antibiotics have harmful adverse effects. The inappropriate use of antibiotics has led to the significant increase in bacterial antimicrobial resistance in the neonatal intensive care unit (NICU). The aim of this study was to retrospectively analyze the changes in antibiotic usages in a NICU after the implementation of an antibiotic stewardship program and to determine the impact of this implementation on the short-term clinical outcomes of very low birth weight (VLBW) infants. The antibiotic stewardship program was initiated in the NICU in early 2015. For analysis, all eligible VLBW infants born from 1 January 2014 to 31 December 2016 were enrolled, and we classified the year 2014 as pre-stewardship, 2015 as during stewardship, and 2016 as post-stewardship. A total of 249 VLBW infants, including 96 cases in the 2014 group, 77 cases in the 2015 group, and 76 cases in the 2016 group, were included for final analysis. Empirical antibiotics were used in over 90% of VLBW infants in all three groups during their NICU stay. Over the 3-year period, the duration of an initial antibiotic course was significantly reduced. The proportion of patients receiving an initial antibiotic course for ≤3 days gradually increased (2.1% vs. 9.1% vs. 38.2%, p < 0.001), while the proportion of babies treated with an initial antibiotic course >7 days significantly decreased (95.8% vs. 79.2% vs. 39.5%, p < 0.001). The total days of antibiotic usage during the entire NICU stay also showed a significant reduction (27.0 vs. 21.0 vs. 10.0, p < 0.001). After adjusting for confounders, the reduction in antibiotic usage was associated with decreased odds of having an adverse composite short-term outcome (aOR = 5.148, 95% CI: 1.598 to 16.583, p = 0.006). To assess the continuity of antibiotic stewardship in the NICU, data from 2021 were also analyzed and compared to 2016. The median duration of an initial antibiotic course further decreased from 5.0 days in 2016 to 4.0 days in 2021 (p < 0.001). The proportion of an initial antibiotic course in which antibiotics were used for ≤3 days increased (38.2% vs. 56.7%, p = 0.022). Total antibiotic usage days during the entire NICU stay also decreased from 10.0 days in 2016 to 7.0 days in 2021 (p = 0.010). The finding of this study strongly suggests that restricting antibiotic use in VLBW infants is beneficial and can be achieved safely and effectively in China.

COST ANALYSIS FOR USE OF PROCALCITONIN AND INFLAMMATORY MARKERS IN COVID-19 VENTILATOR-ASSOCIATED PNEUMONIA

TYPE: Abstract TOPIC: Chest Infections PURPOSE: Procalcitonin has been used to differentiate between bacterial infections and other inflammatory processes in COVID-19. The goal of this study is to observe if procalcitonin use is associated with decreased duration of antibiotics and potential cost savings. Additionally, secondary objectives include if procalcitonin use is associated with ventilator changes, inflammatory markers, and mortality. METHODS: In this retrospective study, 287 patient records were selected based on the diagnosis of positive SARS-CoV-2 by PCR test and patients requiring mechanical ventilation. Lab values were obtained based on ventilator associated events (VAE) or sputum collections. RESULTS: There was no significant difference in those who received antibiotics between the procalcitonin cohort and non-procalcitonin cohort. The average duration of antibiotics was not statistically significant for vancomycin (2.2d v 1.8d), piperacillin-tazobactam (5.6d v 4d), azithromycin (2.7d v 2.5d), or meropenem (3d v 3.3d), between the procalcitonin and non-procalcitonin groups, respectively. Secondary outcomes were similarly not significant for ventilator changes and inflammatory markers. Lactic acid was lower in the procalcitonin group (1.8 v 3,1, p=0.01) along with overall 30-day mortality (45% v 76%, p=0.02). CONCLUSIONS: The use of procalcitonin did not have a significant correlation with duration of antibiotic use, ventilator changes, or inflammatory markers. Overall, the cost of inflammatory markers was approximated to be $377 daily, without reduction of antibiotic usage. CLINICAL IMPLICATIONS: The use of procalcitonin did not reduce antibiotic usage in the setting of COVID-19 ventilator-associated pneumonia and results in greater costs. DISCLOSURE: Nothing to declare. KEYWORD: procalcitonin

Management of Recurrent Cystitis in Women: When Prompt Identification of Risk Factors Might Make a Difference

BackgroundManagement of recurrent urinary tract infection (rUTI) is still challenging. A better understanding of the natural history of rUTI could help us reduce antibiotic use and improve antibiotic stewardship. ObjectiveTo describe the effect of risk identification, stratification, and counseling on the natural course of the disease in women with rUTI. Design, setting, and participantsA total of 373 women affected by recurrent cystitis were enrolled in this longitudinal cohort study between December 2014 and December 2019. A systematic and standardized identification of risk factors was performed. InterventionAs intervention, risk factors were treated or removed where possible. Patients with nonremovable risk factors were included in the control group. All patients were scheduled for follow-up visits every 6 mo. Outcome measurements and statistical analysisThe main outcome measures were the rate of symptomatic recurrences and improvement in questionnaire results from baseline to the end of the follow-up period. Reduction of antibiotic usage was regarded as a secondary outcome measure. Results and LimitationsFinally, 353 women were analyzed: 196 in the study group and 157 in the control group. At the end of the follow-up period, a statistically significant reduction in the symptomatic recurrence rate was found between the two groups (0.9 ± 0.2 and 2.6 ± 0.5; p < 0.001), as well as in quality of life and anxiety according to mean questionnaire results: quality of life (0.88 ± 0.06 and 0.63 ± 0.09; p < 0.001) and Spielberger State-Trait Anxiety Inventory-Form Y (32.7 ± 9.3 and 47.5 ± 14.3; p < 0.001). The use of antibiotics was significantly lower in the study group: 4410 versus 9821 (p < 0.001). A limitation to consider is the lack of a randomized design for the active approach in the high-risk group. ConclusionsIdentification, counseling, and removal of risk factors, where possible, are able to change the natural history of rUTI, by reducing the number of symptomatic episodes and antibiotic use and improving quality of life. Patient summaryIn this report, we analyzed a large cohort of women affected by recurrent urinary tract infections and followed for a long time period. We found that risk factor identification and counseling may change the natural history of recurrent urinary tract infections, concluding that this approach is able to reduce the number of symptomatic episodes, reduce antibiotic usage, and improve patients’ quality of life.

Clinical Utility of Procalcitonin on Antibiotic Stewardship: A Narrative Review.

Procalcitonin (PCT) was discovered as a useful marker for bacterial infection. Following its discovery, there have been a substantial number of clinical studies conducted to evaluate the presence of bacterial infections, and to guide antibiotic treatment by the stratified levels of PCT. Clinical evidence suggests that antibiotic treatment by PCT-guided antibiotic stewardship has been associated with a reduction in antibiotic usage without an increase in adverse outcomes. The use of PCT was approved by the Food and Drug Administration in the United States of America in 2017 to guide antibiotic treatment in sepsis and lower respiratory tract infections (LRTIs). In Korea, the use of PCT for sepsis and for pneumonia was approved in 2015 and 2022, respectively. This review will discuss the clinical utility of PCT on antibiotic stewardship in the management of sepsis and LRTIs including pneumonia.

Elimination of Routine Urinalysis before Elective Orthopaedic Surgery Reduces Antibiotic Utilization without Impacting Catheter-associated Urinary Tract Infection or Surgical Site Infection Rates.

PurposeRoutine preoperative urinalysis has been the standard of care for the orthopedic population for decades, regardless of symptoms. Studies have demonstrated antibiotic overuse and low concordance between bacteria cultured from the surgical wound and the urine. Testing and treatment of asymptomatic urinary tract colonization before total joint arthroplasty (TJA) is unnecessary and increases patient risk. We investigated reducing antibiotic use by (1) modifying testing algorithms to target patients at risk, (2) modifying reflex to culture criteria, and (3) providing treatment guidelines.Materials and MethodsA pre-post study was conducted to determine identify the impact of eliminating universal urinalysis prior to TJA on surgical site infection (SSI) and catheter-associated urinary tract infection (CAUTI) rates and number of antibiotic prescriptions. Patients who underwent primary hip or knee TJA or spinal fusions from February 2016 to March 2018 were included. Patient data was collected for pre- and post-practice change period (February 2016-October 2016 and August 2017-March 2018). Patient demographics, urinalysis results, cultures, and prescriptions were analyzed retrospectively from every tenth chart in the pre-period and prospectively on all patients in the post-period.ResultsA total of 4,663 patients were studied. There was a 96% decrease in urinalyses performed (P<0.0001), and a 93% reduction rate in antibiotic utilization (P<0.001). No significant difference in SSI and CAUTI rates was observed (P>0.05).ConclusionThe elimination of routine urinalysis before orthopedic surgery resulted in a reduction in antibiotic utilization with no significant change in the SSI or CAUTI rates. Cost savings resulted from reduced antibiotic usage.

Marked reduction in antibiotic usage following intensive malaria control in a cohort of Ugandan children

BackgroundIntensive malaria control may have additional benefits beyond reducing the incidence of symptomatic malaria. We compared antibiotic treatment of children before and after the implementation of highly effective malaria control interventions in Tororo, a historically high transmission area of Uganda.MethodsTwo successive cohorts of children, aged 0.5 to 10 years, were followed from September 2011 to October 2019 in a dedicated study clinic. Universal distribution of long-lasting insecticidal nets was conducted in 2013 and 2017. Sustained indoor residual spraying of insecticide (IRS) was initiated in December 2014. Generalized linear mixed-effects models were used to compare the incidence of antimalarial and antibiotic treatments before and after vector control measures were implemented.ResultsComparing the period prior to the implementation of IRS to the period after IRS had been sustained for 4–5 years, the adjusted incidence of malaria treatments decreased from 2.68 to 0.05 per person-year (incidence rate ratio [IRR] = 0.02, 95% CI 0.01–0.03, p < 0.001), and the adjusted incidence of antibiotic treatments decreased from 4.14 to 1.26 per person-year (IRR = 0.30, 95% CI 0.27–0.34, p < 0.001). The reduction in antibiotic usage was primarily associated with fewer episodes of symptomatic malaria and fewer episodes of fever with sub-microscopic parasitemia, both of which were frequently treated with antibiotics.ConclusionsIn a historically high transmission setting, the implementation of highly effective vector control interventions was followed by a marked reduction in antibiotic treatment of children. This added benefit of malaria control could have important implications for antibiotic prescribing practices, efforts to curtail antimicrobial resistance, and health system costs.

The Use Of Sepsis Calculator In Neonatal For Diagnosis And Management Early Onset Sepsis: a Meta-Analysis

Neonatal sepsis has non-specific and variable clinical manifestations that can worsen rapidly. Thus clinicians will tend to have a low threshold for giving antibiotics. Early diagnosis of sepsis based on clinical and laboratory manifestations is required to initiate antibiotics without waiting for culture results. The sepsis calculator is a validated tool used and researched in various countries to predict the risk of early-onset sepsis. This systematic review and meta-analysis study used secondary data from articles between 2015 to 2020 from the PubMed database, Google Scholar. There were six lead articles that matched the inclusion and exclusion criteria. By analyzing using the Revman Review Manager 5.4. the results showed that the implementation of the sepsis calculator was associated with reduced antibiotic usage (N=172385; OR=0,22;p<0,00001) heterogeneity I²=99%). From this study, it was found that there was an association between sepsis calculators with antibiotic usage in neonatal with early-onset sepsis.

Antibiotic Resistance Profiles and Molecular Characteristics of Extended-Spectrum Beta-Lactamase (ESBL)-Producing Escherichia coli and Klebsiella pneumoniae Isolated From Shrimp Aquaculture Farms in Kerala, India.

This study was undertaken to evaluate the prevalence of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae in selected shrimp aquaculture farms (n = 37) in Kerala, South India and to characterize the isolates using molecular tools. Overall, a low prevalence of ESBL-producers was found in the farms, most likely due to the reduced antibiotic usage in the shrimp farming sector. Out of the 261 samples (77 shrimp and 92 each of water and sediment), 14 (5.4%) tested positive for ESBL-E. coli or ESBL-K. pneumoniae. A total of 32 ESBL-E. coli and 15 ESBL- K. pneumoniae were recovered from these samples. All ESBL isolates were cefotaxime-resistant with minimal inhibitory concentration (MIC) ≥32 μg/ml. Of all isolates, 9 (28.1%) E. coli and 13 (86.7%) K. pneumoniae showed simultaneous resistance to tetracycline, ciprofloxacin, and trimethoprim-sulfamethoxazole. PCR analysis identified CTX-M group 1 (blaCTX–M–15) as the predominant ESBL genotype in both E. coli (23, 71.9%) and K. pneumoniae (15, 100%). Other beta-lactamase genes detected were as follows: blaTEM and blaSHV (11 K. pneumoniae), blaCTX–M group 9 (9 E. coli), and blaCMY–2 (2 E. coli). Further screening for AMR genes identified tetA and tetB (13, 40.6%), sul1 (11, 34.4%), sul2 (9, 28.1%), catA and cmlA (11, 34.4%), qepA and aac(6′)-Ib-cr (9, 28.1%) and strAB and aadA1 (2, 6.3%) in E. coli, and qnrB (13, 86.7%), qnrS (3, 20%), oqxB (13, 86.7%), tetA (13, 86.7%), and sul2 (13, 86.7%) in K. pneumoniae isolates. Phylogenetic groups identified among E. coli isolates included B1 (4, 12.5%), B2 (6, 18.8%), C (10, 31.3%), D (3, 9.4%), and E (9, 28.1%). PCR-based replicon typing (PBRT) showed the predominance of IncFIA and IncFIB plasmids in E. coli; however, in K. pneumoniae, the major replicon type detected was IncHI1. Invariably, all isolates of K. pneumoniae harbored virulence-associated genes viz., iutA, entB, and mrkD. Epidemiological typing by pulsed-field gel electrophoresis (PFGE) revealed that E. coli isolates recovered from different farms were genetically unrelated, whereas isolates of K. pneumoniae showed considerable genetic relatedness. In conclusion, our findings provide evidence that shrimp aquaculture environments can act as reservoirs of multi-drug resistant E. coli and K. pneumoniae.

Rationalising antibiotic use after low-risk vaginal deliveries in a hospital setting in India

BackgroundIn 2017, a postoperative multidrug resistant case of urinary tract infection made obstetricians at Sitaram Bhartia Institute of Science and Research introspect the antibiotic usage in labouring mothers. Random case...

Decreasing antibiotic over-use by implementation of an antibiotic stewardship programme in preterm neonates in resource limited settings – a quality improvement initiative

ABSTRACT Background Antibiotics play a critical role in neonatal sepsis but excessive use is associated with adverse outcomes and the current prescribing rates of antibiotics are unacceptably high. Aim To reduce antibiotic over-use in preterm neonates by implementing an antibiotic stewardship programme using a quality improvement (QI) initiative. Methods This study was conducted at a neonatal intensive care unit in a resource-limited setting. The reasons for antibiotic over-use were analysed and an antibiotic stewardship programme was implemented by using a QI initiative. The duration of the QI was a 1-month baseline phase followed by 3 months of implementation which was undertaken in the form of Plan-Do-Study-Act (P-D-S-A) cycles. The sustainment phase was observed for 2 months. All neonates admitted to the preterm unit were included. The outcome measure was the antibiotic usage expressed as days of therapy (DOT)/1000 patient days. Results In the baseline phase, DOT/1000 patient days was 1464 which fell to 706, 511, and 442 DOT/1000 patient days, respectively, over 3 months, resulting in a 65% reduction in antibiotic usage. This was achieved by a combination of efforts directed towards defining the conditions for no antibiotics, revising existing antibiotic policy, stopping orders at 48 hours, de-escalation to the narrowest spectrum antibiotic, stopping prophylactic antifungal agents and limited use of broad-spectrum antibiotics. The results were achieved without an increase in culture-positive sepsis or mortality. Conclusions Implementation of a tailored antibiotic stewardship programme through a QI initiative was effective and safe in reducing antibiotic use in preterm neonates in a resource-limited setting. Abbreviations AIIMS, All India Institute of Medical Sciences; DOT, days of therapy; HIC, high-income countries; ICMR, Indian Council of Medical Research; LMIC, low- to middle-income countries; LOS, late-onset sepsis; NICU, neonatal intensive care unit; NNF, National Neonatology Forum; P-D-S-A, plan-do-study-act; QI, quality improvement; SNCU, Special newborn care unit.

A comparison between risk-factor guidance for neonatal early-onset sepsis and Kaiser Permanente sepsis risk calculator in a Greek cohort

BackgroundThe management of neonates with early-onset sepsis (EOS) is based on maternal risk factors and infant clinical indications. An online sepsis risk calculator (SRC) has been established taking into consideration how clinical appearance modifies the initial risk for EOS. AimsTo compare our clinical practice based on risk-factor guidance with that projected through the application of the SRC. Study designRetrospective cohort study. MethodsAll neonates ≥34 weeks' gestation, during 01/2019–8/2020. The SRC was applied retrospectively to determine the recommendation. EOS was defined based on a positive blood or cerebrospinal fluid culture-proven infection within 72 h of age. Clinical sepsis was defined according to the European Medicine Agency criteria. Outcome measuresDifferences on antibiotic administration and management. ResultsOverall, 2084 infants were identified, of whom 150 (7%) received antibiotics. Of them, 34 infants were diagnosed with clinical sepsis, while one was diagnosed with culture positive-proven EOS.Applying SRC, 87 (4%) infants would have received antibiotics. Clinical sepsis was diagnosed in 29 infants, while one infant had culture positive-proven EOS. Sixty-seven of 150 (45%) infants that received antibiotics would not have been treated based on SRC; five infants that developed clinical sepsis would have been missed with SRC. A 99.7% agreement between both guidance was found regarding infants not indicated for antibiotics. SRC application led to an absolute reduction of antibiotic administration by 2.93% (95% CI 2.19–3.75), p < 0.0001. ConclusionsThe adoption of SRC would have significantly reduced antibiotic usage; however, a significant portion of cases with clinical EOS would have been missed.

Oedema disease: a review of the disease and control and preventative measures

Oedema disease is caused by a toxin produced by Shiga toxin-encoding Escherichia coli. The susceptibility of pigs to oedema disease is often increased shortly after weaning due to stress and an increase of presence of specific receptors, susceptible for F18, needed for the colonisation of the small intestine and also due to change of feed, mainly from sow milk-based carbohydrates (milk sugar) to starch from grains, which are not so easily digested. The correct diagnosis of oedema disease is important in order to determine the control or preventative measures that can be implemented on farm. Vaccination has been shown to be the most successful method for preventing clinical oedema disease and a reduction in mortality. Vaccination can also have a positive effect on the reduction of antibiotic usage and ZnO on a farm, which is extremely important in ensuring livestock industries are meeting reduction targets. By ensuring effective hygiene and biosecurity measures are in place alongside vaccination, the negative impacts of oedema disease on production can be minimised.

Phenotypic antimicrobial resistance in Escherichia coli strains isolated from swine husbandries in North Western Germany \u2013 temporal patterns in samples from laboratory practice from 2006 to 2017

BackgroundSince 2011, antibiotic usage has decreased continuously in livestock in Germany. Whether this is accompanied by a reduction in bacterial antimicrobial resistance has not been proven so far. In this study 3054 Escherichia coli (E. coli) isolates from pigs which had suffered from disease on 2161 farms in North Western Germany were evaluated retrospectively from 2006 to 2017 for trends in their antimicrobial resistance pattern. Data were substantially related to the “pre-reduction period” and were therefore suggested as a basis for this task.Minimal inhibitory concentrations for selected antimicrobial substances were evaluated for E. coli strains isolated from different organs of diseased swine sampled for routine diagnostic. In total, 81% of E. coli were isolated from faeces or the gastrointestinal tract, 11% from the genito-urinary tract and 8% from other organs. Susceptibility testing and classification of isolates in accordance with clinical cut-offs followed the Clinical and Laboratory Standards Institute (CLSI). If no clinical cut-offs were available for the respective combination of species, substance and organ, other published clinical cut-offs were used.ResultsDifferences in susceptibility patterns between isolates from the gastrointestinal and genito-urinary tract were found for most substances. Isolates from the genito-urinary tract were less frequently resistant to ampicillin, apramycin, colistin, neomycin, spectinomycin and tetracycline and more frequently resistant to enrofloxacin and florfenicol.A multifactorial logistic regression model revealed time-dependent decreases in frequency of resistant isolates for neomycin, spectinomycin and tetracycline. For colistin, the highest percentage of resistant isolates with 16.0% was found in 2015 followed by a decrease to the level of 2009–2010 in 2017. A decrease in frequencies of ampicillin-resistant isolates was dependent on the age-group and time period. Irrespective of the year, less than 15% E. coli isolates were resistant to apramycin, cephalosporins, colistin, enrofloxacin, florfenicol, gentamicin and neomycin.ConclusionAn overall time-dependent decrease in the percentage of resistant E. coli isolates was found for some substances. These data from diseased animals indicate an impact of a general reduction in antibiotic usage on development of bacterial antimicrobial resistance in the field and can support the decision-making of swine practitioners for treatment options in swine.