Watch Group Research Articles

Pattern of Antibiotic Use among Hospitalized Patients according to WHO Access, Watch, Reserve (AWaRe) Classification: Findings from a Point Prevalence Survey in Bangladesh.

For supporting antibiotic stewardship interventions, the World Health Organization (WHO) classified antibiotics through the AWaRe (Access, Watch, and Reserve) classification. Inappropriate use of antimicrobials among hospital-admitted patients exposes them to the vulnerability of developing resistant organisms which are difficult to treat. We aimed to describe the proportion of antibiotic use based on the WHO AWaRe classification in tertiary and secondary level hospitals in Bangladesh. A point prevalence survey (PPS) was conducted adapting the WHO PPS design in inpatients departments in 2021. Among the 1417 enrolled patients, 52% were female and 63% were from the 15–64 years age group. Nearly 78% of patients received at least one antibiotic during the survey period. Third-generation cephalosporins (44.6%), penicillins (12.3%), imidazoles (11.8%), aminoglycosides (7.2%), and macrolides (5.8%) were documented as highly used antibiotics. Overall, 64.0% of Watch, 35.6% of Access, and 0.1% of Reserve group antibiotics were used for treatment. The use of Watch group antibiotics was high in medicine wards (78.7%) and overall high use of Watch antibiotics was observed at secondary hospitals (71.5%) compared to tertiary hospitals (60.2%) (p-value of 0.000). Our PPS findings underscore the need for an urgent nationwide antibiotic stewardship program for physicians including the development and implementation of local guidelines and in-service training on antibiotic use.

Changes in antibiotic consumption patterns after the implementation of the National Action Plan according to the Access, Watch, Reserve (AWaRe) classification system

ObjectiveThe Korean government published the first National Action Plan (NAP) on antimicrobial resistance (AMR) in August 2016, followed by a second plan in November 2021. The objective of this study was to analyze changes in antibiotic use patterns after the implementation of the NAP in South Korea. MethodsWe analyzed National Health Insurance claims data for hospitals and clinics from January 2011 to December 2020. Consumption was measured using a defined daily dose per 1000 inhabitants per day (DID). We analyzed data for each year, dimension, and category of the Access, Watch, Reserve classification system by the World Health Organization. Monthly inpatient and outpatient antibiotic use were calculated, and an interrupted time-series (ITS) analysis to assess the trend in antibiotic use was conducted. ResultsThe consumption of antibiotics increased from 25.78 DID in 2011 to 29.06 DID in 2016, then decreased in 2017 after the implementation of the NAP on AMR. The watch group showed a temporal decrease after the implementation of the NAP; however, these figures increased until 2019, and the reserve group showed a downward trend beginning in 2017. According to the ITS analysis, the level (β2) and the slope of the trend (β3) of total antibiotic use decreased by 0.17 and 0.001, respectively. After implementation of the NAP, antibiotic use was reduced from 7.18 DID in 2016 to 4.84 DID in 2017 for amoxicillin and beta-lactamase inhibitors, 0.86 DID to 0.70 DID for ciprofloxacin, and 0.66 DID to0.66 DID for levofloxacin. ConclusionAfter the implementation of the NAP in South Korea, antibiotic use in terms of total antibiotics and fluoroquinolone in the watch and reserve groups decreased. Further policies to improve the use of antibiotics in the watch and reserve groups are needed.

P06 The use of procalcitonin testing to improve antibiotic stewardship in all cause respiratory admissions: a retrospective analysis

BackgroundImproving antibiotic stewardship whilst simultaneously optimizing patient safety is a perpetually vexing clinical conundrum, which has been compounded by the current COVID-19 pandemic. Procalcitonin (PCT) measurement has previously demonstrated utility in this regard, when combined with routine clinical investigation, in certain patient populations.ObjectivesTo assess whether the inclusion of PCT measurement as part of routine clinical care, instituted during a quality improvement project (QIP), increases the appropriateness of antibiotic administration.MethodsA retrospective analysis was performed on 6 month interim data obtained from May to October 2021 during a QIP, which assessed the effect of PCT measurement on antimicrobial stewardship. All patients included had a primary diagnosis of respiratory illness and were analysed both together and as COVID-19 and non-COVID-19 subgroups to assess how often antibiotics were commenced on admission, duration of treatment and appropriateness of use. Finally, as sending microbiological samples made up part of the protocol, sample sending frequency was also studied.ResultsThirty patients were included in both the COVID-19 and non-COVID-19 baseline subgroups who did not have PCT testing performed. Fifty-two patients were included in the PCT subgroup (27 COVID-19 positive and 25 COVID-19 negative). Following introduction of PCT testing, commencement of antibiotics on admission was reduced overall and in the COVID-19 positive subgroup (P = 0.0426 and P = 0.0446, respectively) with a significant decrease in inappropriate antibiotic prescribing in these two groups (P = 0.011 and P = 0.0157, respectively) and a trend towards reduced prescribing of AWaRe watch group antibiotics such as ceftriaxone. However, once prescribed, there was no difference in duration of antibiotic treatment or the frequency of microbiological sampling.ConclusionsThe data from this interim data analysis demonstrate that PCT measurement, when combined with routine clinical investigations in the acute respiratory setting, can be used to reduce inappropriate antibiotic prescribing. This was significantly reduced overall and in the COVID-19 positive subgroup but lost statistical significance in the COVID-19 negative subgroup, where it could be hypothesized that heterogeneity and inclusion of respiratory diseases where PCT has previously encountered difficulty in determining the presence of acute bacterial infection may be the cause. The significant effect demonstrated in the COVID-19 positive subgroup suggests particular utility in this patient population.

Associations between antimicrobial use and antimicrobial resistance of Escherichia coli isolated from poultry litter under field conditions in Cameroon

Lack of hygiene and biosecurity measures in poultry farms has influence on the emergence of pathogens and antimicrobial use. Antimicrobial residues in poultry meat and their excretion by poultry can exert a selective pressure and the occurrence of multidrug resistant bacteria in litter. The objective of this study was to investigate the relationship between antimicrobial use and antimicrobial resistance using Escherichia coli as indicator isolated from poultry litter.From January to August, 2019, antimicrobial use was measured in 47 broiler farms based on daily dose (TIUDD) and animal daily dose (TIADD) methods. Antimicrobial susceptibility testing was performed on Escherichia coli isolated from poultry litter using the disk diffusion method.Overall, an average of 143.8 mg (ranging from 0.5 to 2061.79 mg/kg) of antimicrobials was used per kg of chicken produced, and treatment incidences of 69.7 daily doses per 1,000 broilers (44.44–106.35) and 87.3 daily doses per 1,000 broilers (1.74–376.43) were obtained for TIUDD and TIADD, respectively. After a susceptibility testing, 18 E. coli strains were resistant with a prevalence of 56.3% [95% CI: 39.1–73.5]. High levels of resistance were observed with doxycycline, ampicillin and norfloxacin which were observed to be mostly overdosed in farms. The high resistance of E. coli to ciprofloxacin (4/32: 13%), imipenem (6/32: 19%), levofloxacin (12/32: 38%) and ceftriaxone (22/32: 69%) which are second line treatment in hospital settings in Cameroon, and classified as Watch group by WHO, was associated to high AMR risk for public health in Cameroon. Intensification of health and educational sensitisation of farmers is essential to reduce widespread antimicrobial use in poultry farms and its impact public health.

Retention, engagement, and binge-eating outcomes: Evaluating feasibility of the Binge-Eating Genetics Initiative study.

ObjectiveUsing preliminary data from the Binge‐Eating Genetics Initiative (BEGIN), we evaluated the feasibility of delivering an eating disorder digital app, Recovery Record, through smartphone and wearable technology for individuals with binge‐type eating disorders.MethodsParticipants (n = 170; 96% female) between 18 and 45 years old with lived experience of binge‐eating disorder or bulimia nervosa and current binge‐eating episodes were recruited through the Recovery Record app. They were randomized into a Watch (first‐generation Apple Watch + iPhone) or iPhone group; they engaged with the app over 30 days and completed baseline and endpoint surveys. Retention, engagement, and associations between severity of illness and engagement were evaluated.ResultsSignificantly more participants in the Watch group completed the study (p = .045); this group had greater engagement than the iPhone group (p's < .05; pseudo‐R 2 McFadden effect size = .01–.34). Overall, binge‐eating episodes, reported for the previous 28 days, were significantly reduced from baseline (mean = 12.3) to endpoint (mean = 6.4): most participants in the Watch (60%) and iPhone (66%) groups reported reduced binge‐eating episodes from baseline to endpoint. There were no significant group differences across measures of binge eating. In the Watch group, participants with fewer episodes of binge eating at baseline were more engaged (p's < .05; pseudo‐R 2 McFadden = .01–.02). Engagement did not significantly predict binge eating at endpoint nor change in binge‐eating episodes from baseline to endpoint for both the Watch and iPhone groups.DiscussionUsing wearable technology alongside iPhones to deliver an eating disorder app may improve study completion and app engagement compared with using iPhones alone.

Use of WATCH antibiotics prior to presentation to the hospital in rural Burkina Faso

BackgroundIn low- and middle-income countries, the prevalence of antimicrobial resistance (AMR) is increasing. To control AMR, WHO recommends monitoring antibiotic use, in particular Watch antibiotics. These are critically important antibiotics, with restricted use because at risk of becoming ineffective due to increasing AMR. We investigated pre-hospital antibiotic use in rural Burkina Faso.MethodsDuring 2016–2017, we collected data from patients aged > 3 months presenting with severe acute fever to the rural hospital of Nanoro Health District, Burkina Faso, including antibiotic use in the two weeks prior to consultation or hospitalization. We analysed reported antibiotic use by applying the WHO Access, Watch, Reserve classification.ResultsOf 920 febrile participants (63.0% ≤ 14 years), pre-hospital antibiotic use was reported by 363 (39.5%). Among these 363, microbiological diagnoses were available for 275 (75.8%) patients, of whom 162 (58.9%) were non-bacterial infections. Use of more than one antibiotic was reported by 58/363 (16.0%) participants. Of 491 self-referred patients who did not previously visit a primary health care center, 131 (26.7%) reported antibiotic use. Of 424 antibiotics reported, 265 (62.5%) were Access and 159 (37.5%) Watch antibiotics. Watch antibiotic use was more frequent among patients > 14 year olds (51.1%) compared to those 0–14 year old (30.7%, p < 0.001) and among referrals from the primary health care centers (42.2%) compared to self-referred patients (28.1%, p = 0.004). Most frequently reported Watch antibiotics were ceftriaxone (114, 71.7%) and ciprofloxacin (32, 20.1%).ConclusionThe reported frequent use of Watch group antibiotics among febrile patients prior to presentation to the hospital in rural Burkina Faso highlights the need to develop targeted interventions to improve antibiotic use in community settings as part of strengthening antibiotic stewardship in low- and middle-income countries. This should include facilitating referral, access to qualified prescribers and diagnostic tools in rural primary health care centers.Trial registration ClinicalTrials.gov identifier: NCT02669823. Registration date was February 1, 2016.

Preventing Potentially Inappropriate Use of Antibiotics Using the World Health Organization AWaRe Tool

Background To avert the rise in antimicrobial resistance, the World Health Organization (WHO) introduced the AWaRe (Access, Watch, Reserve) tool to its Essential Medicines List in 2017. In India, only few studies analyzing the antibiotic prescribing pattern according to AWaRe tool were conducted, most of which included data from wholesale databases. Aim This study was aimed at analyzing the antibiotic prescriptions in the outpatient (OP) clinic of a quaternary care hospital as per the WHO AWaRe tool. Method This observational study collected the details of patients who received at least 1 oral/intravenous antibiotic and visited the OP clinic during August 2018 to August 2019. The data were collected from electronic medical record, and it included patient demographics, department, and name of antibiotics prescribed. The proportion of antibiotic use was measured as per WHO AWaRE tool. Results A total of 23,088 antibiotic prescriptions were collected from 58 departments. It was found that 41.32% of antibiotics were from the Access group, whereas 51.01% were from the Watch group and 1.19% from the Reserve group. Amoxicillin-clavulanic acid (Access), azithromycin (Watch), and linezolid (Reserve) were the commonly prescribed antibiotics in the OP department. Conclusions Considering the overall use, the Watch group antibiotics were used to a great extent compared with that of the Access antibiotics, which contradicts the recommended WHO AWaRe criteria. This simple and easy-to-apply antibiotic use monitoring tool, “AWaRe,” must be aligned with the local antibiogram to serve the patient best.

Pattern of Antibiotic Dispensing at Pharmacies According to the WHO Access, Watch, Reserve (AWaRe) Classification in Bangladesh.

The WHO Essential Medicines List Access, Watch, and Reserve (AWaRe) classification could facilitate antibiotic stewardship and optimal use. In Bangladesh, data on antibiotic dispensing in pharmacies according to the AWaRe classification are scarce. We aimed to explore antibiotic dispensing pattern in pharmacies according to the WHO AWaRe classification to aid pharmacy-targeted national antibiotic stewardship program (ASP). From January to July 2021, we interviewed drug-sellers from randomly selected pharmacies and randomly selected customers attending the pharmacies. We collected data on demographics and medicines purchased. We classified the purchased antibiotics into the Access, Watch, and Reserve groups among 128 pharmacies surveyed, 98 (76.6%) were licensed; 61 (47.7%) drug-sellers had pharmacy training. Of 2686 customers interviewed; 580 (21.6%) purchased antibiotics. Among the 580 customers, 523 purchased one, 52 purchased two, and 5 purchased three courses of antibiotics (total 642 courses). Of the antibiotic courses, the Watch group accounted for the majority (344, 53.6%), followed by the Access (234, 36.4%) and Reserve (64, 10.0%) groups. Approximately half of the antibiotics (327/642, 50.9%) were purchased without a registered physician’s prescription. Dispensing of non-prescribed antibiotics was higher in the Access group (139/234, 59.4%), followed by Watch (160/344, 46.5%) and Reserve (28/64, 43.8%) groups. These findings highlight the need to implement strict policies and enforce existing laws, and pharmacy-targeted ASP focusing on proper dispensing practices to mitigate antimicrobial resistance in Bangladesh.

Antibiotic Prescription for Adult with Acute Respiratory Tract Infections (ARTI) in Public Health Care Center in Denpasar Area during COVID-19 Era

Restriction of antibiotic prescribing in pandemic COVID-19 is a dilemma. Establishing an acute respiratory tract infection (ARTI) may underdiagnosed due to limited doctor-patient communication and physical examination. Antibiotics are live saving drug and antibiotics should be prudently used to avoid antibiotic resistance. Understanding the trend of antibiotics prescribing in primary health care services is needed to support antibiotics use appropriate. The aim of this study is at profiling of antibiotics prescriptions for adults with ARTI during COVID-19 era. The qualitative descriptive study was designed at the primary health care services in Denpasar area. Data of antibiotic use were collected from out-patients prescription between April-December 2020. Antibiotic prescription were assessed for the appropriateness based on the Ministry of Health of the Republic of Indonesia (MHRI) and World Health Organization (WHO) “AWaRe” criteria. The study found those Amoxicillin (43.3%) and Ciprofloxacin (31.4%) were the most utilized antibiotics. In spite of the overall duration of antibiotic prescriptions appropriately use based on the MHRI’s, there were two types of antibiotics prescriptions used inappropriately based on the level of health-care services. Based on the AWaRe WHO’s criteria, It was found the use of the Access group and Watch group antibiotics. The maximum period of antibiotic therapy was not exceeded in this trial, and the appropriateness based on the levels of health care service reached 89.5%. Antibiotic use was 55.8% in the Access group and 43.5% in the Watch group. Keywords: antibiotics, covid-19 era, profile of antibiotics prescription.

Access–Watch ratio based on access, watch, and reserve classification of antibiotics in public health facilities of Tamil Nadu

The rise in cases of antibiotic resistance can be mainly attributed to the overuse and misuse of antibiotics. To address this issue, the WHO launched Access, Watch, and Reserve (AWaRe) classification of antibiotics in 2017 as a surveillance tool. Many countries have adopted it to monitor and optimize their antibiotic usage. However, implementation of it is yet not seen at a very appreciable level. Through this survey, we tried to explore the prescribing pattern of antibiotics based on the WHO AWaRe classification in selected secondary and tertiary care health facilities of Tamil Nadu. In-patient case sheets were audited in selected departments across 18 health facilities in six districts. Proportionately higher use of the watch group of antibiotics was found in all the districts. A lower access-watch ratio suggests the need for judicious implementation of such tools to safeguard this life-saving good and ensuring its sustainability.

NEIGHBORHOOD CHARACTERISTICS AS PREDICTORS OF PERCEIVED SAFETY AND NEIGHBORHOOD VIOLENT CRIME

Neighborhood violent crime is an issue that plagues many communities in the U.S. and throughout the world. In this study the authors examine some of the major predictors of violent crime and perceived safety in a small municipality in a region of the Great Lakes region of the US that has experienced significant population loss and blight. Applying Social Disorganization Theory, neighborhood watch group members in five census tracts; approximately 500 residents were surveyed concerning the characteristics of their neighborhoods and how these characteristics may influence their perceived safety and the violent crimes in their immediate blocks. Using multiple regression and MANOVA this study tested seven hypotheses. The results of this study were consistent with previous research and found that neighborhood disorder significantly predicted perceived safety, neighborhood violent crime severity and neighborhood violent crime frequency. Additionally, neighborhood cohesion was found to increase the perceived safety of residents in this study.

Evaluation of antibiotic consumption and compliance to hospital antibiotic policy in the surgery, orthopedics and gynecology wards of a tertiary care hospital

ObjectivesTo evaluate antibiotic consumption and compliance to hospital antibiotic policy in the surgery, orthopedics and gynecology wards of a tertiary care hospital. MethodsA prospective observational study was conducted over eight months on adult inpatients prescribed with antibiotics. Data were collected using a predesigned antibiotic form and evaluated using Defined Daily Dose per 100 bed-days. Antibiotics prescribed were classified using World Health Organization Access, Watch and Reserve classification (WHO AWaRe) and assessed for compliance to the hospital antibiotic policy which is in accordance with the National Treatment Guidelines for Antimicrobial use in Infectious Diseases (version 1.0.2016). ResultsOut of 2653 patients enrolled, 44.3% were males and 55.7% were females. The antibiotic usage rate was 29%. Cephalosporins were the most frequently prescribed class of antibiotics. The top three antibiotics prescribed were cefuroxime, metronidazole, and ceftriaxone. Classification of antibiotics using WHO AWaRe policy showed that 36% of antibiotics were prescribed from the Access group and 53% from the Watch group. The use of antibiotic combinations from the not recommended group of AWaRe was also observed. Total compliance observed towards the hospital's antibiotic policy was 77.7%. The most common reason for non-compliance to hospital policy was inappropriate duration of antibiotic therapy. ConclusionsThe use of watch group of antibiotics over access group due to concerns of antimicrobial resistance shows the need for local adaptation of WHO AWaRe classification. Despite good adherence to the hospital's antibiotic policy, extended duration of antibiotic therapy requires special attention. Further optimization of antibiotic use can be achieved by timely revision and implementation of hospital antibiotic policy.

Pharmacovigilance Data as a Trigger to Identify Antimicrobial Resistance and Inappropriate Use of Antibiotics: A Study Using Reports from The Netherlands Pharmacovigilance Centre.

(1) Background: Antimicrobial resistance (AMR) requires urgent multidisciplinary solutions, and pharmacovigilance has the potential to strengthen current antimicrobial stewardship strategies. This study aimed to characterize AMR-relevant adverse drug reaction (ADR) reports submitted to The Netherlands Pharmacovigilance Centre; (2) Methods: We carried out a descriptive analysis of ADR reports submitted to Lareb, coded with AMR-relevant MedDRA Preferred Terms (PTs); (3) Results: Between 1998 and January 2019, 252 AMR-relevant ADR reports were submitted to Lareb. The most frequent antibiotics were tobramycin (n = 89; 35%), colistin (n = 30; 11.9%), cipro-floxacin (n = 16; 6.3%), doxycycline (n = 14; 5.5%), and aztreonam (n = 12; 4.8%). The PTs used included off label use (n = 91; 36.1%), drug ineffective (n = 71; 28.2%), product use in unapproved indication (n = 28; 11.1%), pathogen resistance (n = 14; 5.6%), and drug resistance (n = 13; 5.2%). 54% of the reports were on Watch antibiotics and 19% were involved in the Reserve group. In the Watch group, “off label use” and “product use in unapproved indication” were the most frequent PTs and the majority of reports on Reserve antibiotics were coded as “Off label”. A sharp increase in the number of reports was observed in the three consecutive years with 21 in 2013, 54 in 2014, and 83 in 2015; (4) Conclusions: In addition to existing AMR monitoring strategies, pharmacovigilance databases can serve as a source of data on suspected resistance and inappropriate use. Future research should explore how these AMR-relevant MedDRA Terms are used in resource-limited settings with less capacity to generate laboratory-confirmed resistance data.

152. Use of Antimicrobials among Suspected COVID-19 Patients at Selected 12 Hospitals in Bangladesh: Findings from the First Wave of COVID-19 Pandemic

BackgroundAntimicrobials are empirically used in COVID-19 patients resulting in inappropriate stewardship and increased antimicrobial resistance. Our objective was to assess antimicrobial use among suspected COVID-19 in-patients while waiting for the COVID-19 test report. MethodsFrom March to August 2020, we collected data from in-patients of 12 tertiary-level hospitals across Bangladesh. We identified suspected COVID-19 patients; collected information on antimicrobial received within 24 h before and on hospitalization; and tested nasopharyngeal swab for SARS-CoV-2 using rRT-PCR. We used descriptive statistics and a regression model for data analysis. ResultsAmong 1188 suspected COVID-19 patients, the median age was 34 years (IQR:2–56), 69% were male, 40% had comorbidities, 53% required oxygen, and 1% required ICU or ventilation support after admission. Antibiotics were used in 92% of patients, 47% within 24 h before, and 89% on admission. Patients also received antiviral, mostly favipiravir (1%) and antiparasitic drugs particularly ivermectin (3%). Third-generation cephalosporin use was the highest (708;60%), followed by macrolide (481;40%), and the majority (853;78%) who took antibiotics were SARS-CoV-2 negative. On admission, 77% mild and 94% moderately ill patients received antibiotics. Before admission, 3% patients had two antibiotics, and on admission, 27% received two to four classes of antibiotics at the same time. According to WHO AWaRe classification, the Watch group antibiotics were mostly used before (43%) as well as on admission (80%). Reserve group antibiotic particularly linezolid was used in 1% patients includes mild cases on admission. Antibiotic use on admission was higher among severely ill patients (AOR = 11.7;95%CI:4.5–30.1) and those who received antibiotics within 24 h before hospital admission (AOR = 1.6;95%CI:1.0–2.5). Antimicrobials used among suspected COVID-19 patients and SARS-CoV-2 positive and negative patients 24 h before and on hospital admission at 12 selected hospitals in Bangladesh, March–August 2020 Antimicrobials used on admission among suspected COVID-19 patients according to disease severity at 12 selected hospitals in Bangladesh, March–August 2020ConclusionAntimicrobial use was highly prevalent among suspected COVID-19 in-patients in Bangladesh. Initiating treatment with Watch group antibiotics like third-generation cephalosporin and azithromycin among mild to moderately ill patients were common. Promoting antimicrobial stewardship with monitoring is essential to prevent blanket antibiotic use, thereby mitigating antimicrobial resistance.Disclosures All Authors: No reported disclosures

Antimicrobial use among hospitalized patients: A multi-center, point prevalence survey across public healthcare facilities, Osun State, Nigeria.

In order to inform sub-national action plan for control of antimicrobial resistance (AMR) and benchmark interventions to improve antibiotic use, it is essential to define situations on antibiotic use using standardized tools. We sought to assess quality of antimicrobial prescription across all government healthcare facilities with capacities for in-patient care in the first of the 36 states in Nigeria as part of ongoing state-wide situation analysis on AMR. A survey was conducted between 10-27 June 2019 using the WHO methodology for point prevalence survey on antibiotic use in hospitals. Data was collected from hospital administrators and records of hospitalized patients. Data analysis was done using Microsoft Excel 2010 (Redmond Washington). Prevalence of antibiotic use amongst all 321 included patients was 76.6% (246/321). Of all indications recorded, the highest was surgical prophylaxis (96/260, 36.9%) for which there were multiple doses beyond 24 hours in almost all cases (91/96, 94.8%). The largest volume of prescribing took place in the surgical wards, and the most common prescriptions were metronidazole (142/564, 25.2%), cefuroxime (104/564, 18.4%), and ceftriaxone (77/564, 13.7%). Overall, 46.3% of the antibiotics used belong to Access group, 53.5% to watch and only 0.2% to Reserve. Treatment in almost all instances 544/563 (96.6%) was empiric. The majority of patients received multiple antibiotics mostly without compliance to guidelines. There was low prescribing of Access antibiotics and excessive use of antibiotics in the Watch group. Antibiotics were used most commonly for surgical prophylaxis but inappropriately. Inappropriate use of antibiotics in this study underscores the crucial need for an action plan incorporating antimicrobial stewardship.

Analysis of Antibiotic Consumption by AWaRe Classification in Shandong Province, China, 2012-2019: A Panel Data Analysis.

Introduction: This study aims to examine the changes in trends and patterns of clinical consumption of antibiotics in Shandong, China based on Access, Watch, and Reserve (AWaRe) Classification after 10-years national antibiotic stewardship. Methods: Antibiotic consumption data of all health care institutions for the period of 2012–2019 were obtained from the Drug Centralized Bidding Procurement System of Shandong. Shandong is a province that has the second-largest population in China. Five of the 16 cities in Shandong were high-income areas (HIAs) and the other 11 cities were grouped into upper-middle-income areas (UMIAs). The main outcome measures were the antibiotic consumption rates (DDD per 1,000 inhabitants per day, DID) and the proportions of different groups of antibiotics. Results: The overall antibiotic consumption rate increased from 12.859–15.802 DID between 2012 and 2014, then continuously decreased to 9.771 DID in 2019. The consumption rate of access, watch, and reserve antibiotics have reduced since 2014 with a compound annual growth rate of −10.1, −9.0, and −8.1%, respectively. During 2012–2019, the access group proportion reduced from 50.0 to 44.9%, while the proportion of the watch group increased from 42 to 45.2%. The antibiotic consumption rate increased from 2012 to 2019 (from 7.38 to 9.12 DID) in the HIAs but sharply decreased in the UMIAs from 2014 to 2019 (from 17.94 to 10.05 DID). The watch antibiotics had the highest proportion of consumption in the HIAs (55.3% in 2019), while the access group had the highest proportion of consumption in the UMIA (49.5% in 2019). Conclusion: The antibiotic stewardship policies launched in the last 10 years have contributed to reducing the clinical antibiotic consumption in Shandong. These policies have different effects on areas with different economic levels. The pattern of antibiotic consumption is still inappropriate in China as the watch group of antibiotics was consumed the most.

Antibiotic use for empirical therapy in the critical care units in primary and secondary hospitals in Vietnam: a multicenter cross-sectional study

SummaryBackgroundThe high rate of infections among patients admitted to critical care units (CCUs) is associated with high rate of antibiotic consumption, especially broad-spectrum antibiotics. This study is to describe the antibiotics use in CCUs in primary and secondary hospitals in Vietnam, a setting with high burden of antibiotic resistance.MethodsThis was a 7-day observational study in 51 CCUs in hospitals from 5 provinces in Vietnam from March to July 2019. Patients aged ≥ 18 years admitted to the participating CCUs was enrolled consecutively. We collected data on patient's demographics, initial diagnosis and antibiotic therapy within the first 24 hours. Antibiotic therapy was classified by the Anatomical Therapeutic Chemical (ATC) Index and the 2019 WHO Access, Watch, Reserve (AWaRe) groups.FindingsOut of 1747 enrolled patients, empirical antibiotic treatments were initiated in 1112 (63.6%) patients. The most frequently prescribed antibiotics were cefotaxime (22.3%), levofloxacin (19%) and ceftazidime (10.8%). Antibiotics were given in 31.5% of patients without diagnosis of infection. Watch and/or Reserve group antibiotic were given in 87.3% of patients and associated with patient's age (aOR 1.01 per 1-year increment, 95%CI 1.00-1.02) and the presence of SIRS on admission (aOR 2.1, 95%CI 1.38-3.2).InterpretationWe observed a high frequency use and a substantial variation in patterns of empirical antibiotic use in the CCUs in Vietnam. It highlights the importance of continuous monitoring antibiotic consumption in CCUs.

Antimicrobial resistance in neonates with suspected sepsis.

SETTING:Nobel Medical College and Teaching Hospital, Biratnagar, Nepal.OBJECTIVE:To determine the pattern of antimicrobial resistance and hospital exit outcomes in neonates with suspected sepsis in a tertiary neonatal intensive care unit (NICU).DESIGN:This hospital-based cohort study was conducted to follow patients from January to December 2019. All identified cases of suspected sepsis were enlisted from hospital records.RESULTS:Sepsis was suspected in 177 (88%) of the 200 cases admitted in the NICU; 52 (29%) were culture-positive. Pseudomonas was the predominant organism isolated (n = 40; 78%), followed by coagulase negative staphylococcus (n = 12, 23%). Nine (17%) of the 52 isolates were resistant to the Access and Watch group of antibiotics, including some resistance to Reserve group drugs such as imipenem and linezolid. Most treated cases (n = 170, 96%) improved, although 7 (4%) left against medical advice.CONCLUSION:Most of the pathogens were resistant to WHO Access and Watch antibiotics and occasional resistance was observed to Reserve group drugs. Most sepsis was caused by Gram-negative bacilli. Improving turnaround times for antibiotic sensitivity testing using point-of-care testing, and a greater yield of culture-positive results are needed to enhance the management of neonatal sepsis.

High antibiotic resistance and mortality with Acinetobacter species in a tertiary hospital, Nepal.

Nepal Mediciti Hospital, Bhainsepati, Lalitpur, Nepal. To determine antimicrobial resistance patterns, and the number and proportion of multidrug-resistant (MDR-) and extensively drug-resistant (XDR-) cases among all patients with Acinetobacter isolates between September 2018 and September 2019. This was a hospital laboratory-based, cross-sectional study. Acinetobacter spp. (n = 364) were more common in respiratory (n = 172, 47.3%) and invasive samples such as blood, body fluids (n = 95, 26.1%). Sensitivity to AWaRe (Access, Watch and Reserve) Group antibiotics (tigecycline, polymyxin B, colistin) remained high. MDR (resistance to at least three classes of antimicrobial agents) (n = 110, 30.2%) and XDR (MDR plus carbapenem) (n = 87, 23.9%) isolates were most common in the Watch Group of antibiotics and found in respectively 99 (31.0%) and 78 (24.5%) patients (n = 319). Infected patients were more likely to be aged >40 years (n = 196, 61.4%) or inpatients (n = 191, 59.9%); 76 (23.8%) patients had an unfavourable outcome, including death (n = 59, 18.5%). A significant proportion of MDR and XDR isolates was found; nearly one patient in five died. Robust hospital infection prevention and control measures (particularly for respiratory and invasive procedures) and routine surveillance are needed to reduce infections and decrease the mortality rate. Tigecycline, polymyxin B and colistin should be cautiously used only in MDR and XDR cases.

Assessment of antimicrobial consumption in food animals in Dar es Salaam, Tanzania

Monitoring antimicrobial use in food-producing animals is one of the global strategies to tackle antimicrobial resistance. The purpose of the present study is to generate quantitative information on antimicrobial use pattern in Dar es Salaam, which will be used as an approach for future monitoring and surveillance of antimicrobial quantities consumed in food animals. A 3 years (2016-2018) retrospective survey of antimicrobial usage in food-producing animals in three selected districts of Dar es Salaam city, Eastern Tanzania was conducted. Data on antimicrobial quantities consumed was obtained from five purposively selected licensed veterinary pharmaceutical sales/outlet establishments in the study area, based on keeping detailed sales records for the study period. Data analysis was done using IBM SPSS version 20. Animal population data were from FAO-Stat database used to extrapolate the quantity consumed in food animals to the entire population during the study period in Tanzania. The antimicrobials were analysed based on class, importance for human medicine and route of administration. The study revealed that 178.4 tonnes of antimicrobials (by weight of active ingredients) were consumed during the 3 years period, with an average of 59.5 ± 3.8 tonnes/year. The commonly consumed antimicrobials were tetracycline (44.4%), sulphonamides (20.3%), aminoglycosides (10.3%) and beta-lactams (7.4%). In relation to veterinary antimicrobial use importance to human medicine, 34.4% were of critically important antimicrobials; 4.1% reserve and 51% watch group according to AWaRe categorization of WHO. Most of the antimicrobials were administered orally. Overall, a mean of 7.44 ± 0.81 mg/PCU (population correction unit) was consumed by food-producing animals during the 3 years period. This finding can help improve monitoring and control of veterinary antimicrobial use in Dar es Salaam in particular and Tanzania in general by preserving the efficacy of antimicrobials for future animal and human generations.