Non-adherence to antimicrobial treatment guidelines results in more broad-spectrum but not more appropriate therapy

Abstract Background Limited antimicrobial resistance (AMR) data for Neisseria gonorrhoeae are available in Eastern Europe. We investigated AMR in N. gonorrhoeae isolates in the Republic of Belarus from 2009 to 2019, antimicrobial treatment recommended nationally, and treatment given to patients with gonorrhoea. Methods N. gonorrhoeae isolates (n = 522) cultured in three regions of Belarus in 2009–2019 were examined. Determination of minimum inhibitory concentrations (MICs) of eight antimicrobials was performed using Etest. Resistance breakpoints from the European Committee on Antimicrobial Susceptibility Testing were applied where available. A Nitrocefin test identified β-lactamase production. Gonorrhoea treatment for 1652 patients was also analysed. Statistical significance was determined by the Z-test, Fisher’s exact test, or Mann-Whitney U test with p-values of < 0.05 indicating significance. Results In total, 27.8% of the N. gonorrhoeae isolates were resistant to tetracycline, 24.7% to ciprofloxacin, 7.0% to benzylpenicillin, 2.7% to cefixime, and 0.8% to azithromycin. No isolates were resistant to ceftriaxone, spectinomycin, or gentamicin. However, 14 (2.7%) isolates had a ceftriaxone MIC of 0.125 mg/L, exactly at the resistance breakpoint (MIC > 0.125 mg/L). Only one (0.2%) isolate, from 2013, produced β-lactamase. From 2009 to 2019, the levels of resistance to ciprofloxacin and tetracycline were relatively high and stable. Resistance to cefixime was not identified before 2013 but peaked at 22.2% in 2017. Only sporadic isolates with resistance to azithromycin were found in 2009 (n = 1), 2012 (n = 1), and 2018–2019 (n = 2). Overall, 862 (52.2%) patients received first-line treatment according to national guidelines (ceftriaxone 1 g). However, 154 (9.3%) patients received a nationally recommended alternative treatment (cefixime 400 mg or ofloxacin 400 mg), and 636 (38.5%) were given non-recommended treatment. Conclusions The gonococcal resistance to ciprofloxacin and tetracycline was high, however, the resistance to azithromycin was low and no resistance to ceftriaxone was identified. Ceftriaxone 1 g can continuously be recommended as empiric first-line gonorrhoea therapy in Belarus. Fluoroquinolones should not be prescribed for treatment if susceptibility has not been confirmed by testing. Timely updating and high compliance with national evidence-based gonorrhoea treatment guidelines based on quality-assured AMR data are imperative. The need for continued, improved and enhanced surveillance of gonococcal AMR in Belarus is evident.

Download Full-text

High-dose steroid and heparin: a novel therapy for cerebral vasculitis associated with presumed group A Streptococcus meningitis

BMJ Case Reports ◽

10.1136/bcr-2020-239618 ◽

2021 ◽

Vol 14 (2) ◽

pp. e239618

Author(s):

Brian Alexander Hummel ◽

Julie Blackburn ◽

Anne Pham-Huy ◽

Katherine Muir

Keyword(s):

Treatment Guidelines ◽

Group A Streptococcus ◽

Oral Prednisone ◽

Acute Otitis Media ◽

Antimicrobial Treatment ◽

Cerebral Vasculitis ◽

High Dose ◽

Novel Therapy ◽

Intravenous Heparin ◽

Group A

Cerebral vasculitis is a serious complication of bacterial meningitis that can cause significant morbidity and mortality due to stroke. Currently, there are no treatment guidelines or safety and efficacy studies on the management of cerebral vasculitis in this context. Herein, we report a case of a previously well 11-year-old girl who presented with acute otitis media that progressed to mastoiditis and fulminant meningitis. Group A Streptococcus was found in blood and ear-fluid cultures (lumbar puncture was unsuccessful). Her decreased level of consciousness persisted despite appropriate antimicrobial treatment, and repeat MRI revealed extensive large vessel cerebral vasculitis. Based on expert opinion and a presumed inflammatory mechanism, her cerebral vasculitis was treated with 7 days of pulse intravenous methylprednisolone followed by oral prednisone taper. She was also treated with intravenous heparin. Following these therapies, she improved clinically and radiographically with no adverse events. She continues to undergo rehabilitation with improvement.

Download Full-text

Antimicrobial Treatment Guidelines for Acute Bacterial Rhinosinusitis

Clinical Pediatrics ◽

10.1177/000992280104000612 ◽

2001 ◽

Vol 40 (6) ◽

pp. 359-360

Author(s):

Christine Knoll

Keyword(s):

Treatment Guidelines ◽

Antimicrobial Treatment ◽

Acute Bacterial Rhinosinusitis

Download Full-text

Impact of a comprehensive antimicrobial stewardship program on antimicrobial utilization and clinical isolates distribution in ICUs

10.21203/rs.2.20643/v1 ◽

2020 ◽

Author(s):

Jiaojiao Song ◽

Rongsheng Zhu ◽

Leiqing Li ◽

Lingcheng Xu ◽

Quan Zhou ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Broad Spectrum ◽

Second Generation ◽

Antimicrobial Treatment ◽

Clinical Isolates ◽

Antimicrobial Use ◽

Antimicrobial Stewardship Program ◽

Stewardship Program ◽

Antimicrobial Utilization ◽

Lactamase Inhibitor

Abstract Objective This study aimed to evaluate the effect of a comprehensive antimicrobial stewardship program (ASP) and provide clinical evidence for the scientific stewardship of antimicrobials in intensive care units (ICUs) of a teaching hospital.Methods Between January 2013 and December 2018, we conducted a prospective study, based on an antimicrobial computerized clinical decision support system (aCDSS) deployed in 2015 in ICUs of a tertiary and teaching hospital. The primary outcomes included initial and overall use prevalence of antimicrobials. The second outcomes were the detection rate of common clinical isolates before and after therapeutic antimicrobial use, and the change in patterns of resistance of 5 common clinical isolates in the ICU.Results Various types of broad-spectrum antimicrobial use prevalence continued to increase from 2013 to 2015, since 2016, where initial use of carbapenems and glycopeptides were counterbalanced by an increase in use of the first/second-generation cephalosporins, β-lactam and β-lactamase inhibitor combinations and linezolid. From 2015 to 2018, the proportion of extended-broad spectrum antimicrobials alone, wide-coverage therapy and combination therapy decreased significantly (P<0.05). Similarly, where use of carbapenems, glycopeptides, third/fourth-generation cephalosporins and anti-fungi agents were counterbalanced by an increase in overall use of the first/second-generation cephalosporins and β-lactam and β-lactamase inhibitor combinations. A total of 21891 strains of bacteria and fungi were detected in ICUs from 2015 to 2018, of them, 6.5% (1426/21891) strains were detected before antimicrobial treatment. The detection proportion of Staphylococcus aureus , Escherichia coli , Klebsiella pneumoniae and fastidious bacteria were significantly higher before antimicrobial treatment (P<0.05), while Acinetobacter baumannii , Burkholderia cepacia , and Candida spp were significantly lower in all non-repetitive clinical isolates (P<0.05).Conclusions The implementation of a comprehensive ASP combining CDSS in ICUs seems to be effective to improve outcomes on antimicrobial utilization and clinical isolates distribution in critically ill patients.

Download Full-text

Assessment of antimicrobial use in private and government hospitals, a comparative study in central kerala, using who indicators

International Journal of Indigenous Herbs and Drugs ◽

10.46956/ijihd.v6i4.236 ◽

2021 ◽

pp. 88-92

Author(s):

Chinnu Roy ◽

Shaji George ◽

Aleena Issac ◽

Arya Ponnappan ◽

Dhanya Paul

Keyword(s):

Broad Spectrum ◽

Average Cost ◽

Private Hospital ◽

Antimicrobial Treatment ◽

Antimicrobial Use ◽

Government Hospital ◽

Prescribing Pattern ◽

Government Hospitals ◽

The Government ◽

Who Indicators

Background: Irrational use of antimicrobial can cause various unwanted and untoward events. It may diminish the quality of patient care, increase the cost of therapy, and involvement in various side effects. Thus, the appropriateness of antimicrobial use in hospitals plays a pivotal role in patient safety. Objective: To analyze and assess the prescribing pattern of antimicrobials in private and government hospitals as per the WHO indicators. Methodology: A prospective comparative observational study was carried out for 6 months, with the patient diagnosed with an infectious disease admitted to the medical ward of both the hospitals during the study period. The data obtained from the study sites were Compared and analyzed using WHO indicators described in WHO’s “How to Investigate Antimicrobial use in Hospitals: Selected Indicators, Feb 2012”. Results: The study involved 216 patients and the average number of antimicrobials prescribed was found to be 1.73 in a private hospital and 2.07 in the government hospital, average cost of antimicrobials was found to be 86.48 INR in private and 31.04 INR in the government hospital, average duration of antimicrobial treatment was 4.8 in private and 5.2 in the government hospital, and the percentage of antimicrobials prescribed in generic was 33.33% in private and 87.83% in the government hospital. Considering the spectrum of antibiotics, both private (94.7%) and government (88.8%) used broad-spectrum antimicrobials. In both hospitals, cephalosporins were the most frequently prescribed class of antimicrobials. Comparing the dosage of antimicrobials given, injection usage is at the highest in government (59.5%) as well as in the private hospital (68.4%). Conclusion: This study indicates that the average cost of antimicrobials was more in a private hospital than that in a government hospital and other indicators such as the number of antimicrobials per hospitalization, duration of antimicrobial treatment, and the percentage of generic antimicrobials prescribed were all found to be more in a government hospital. In both private and government hospitals broad-spectrum antimicrobials were widely used, with cephalosporin as the most prescribed class.

Download Full-text

Antibiotic resistance in the ICU

10.1093/med/9780199600830.003.0289 ◽

2016 ◽

Cited By ~ 1

Author(s):

Jonathan Edgeworth

Keyword(s):

Antimicrobial Stewardship ◽

Infection Prevention ◽

Antibiotic Use ◽

Antimicrobial Treatment ◽

Infection Prevention And Control ◽

Molecular Testing ◽

Local Selection ◽

Appropriate Therapy ◽

Therapeutic Decision Making ◽

And Control

The two objectives of ensuring early appropriate antimicrobial treatment for septic patients on the intensive care unit (ICU), and limiting emergence and spread of antimicrobial resistance are both complicated and potentially conflicting. Increasingly unpredictable resistance, particularly amongst Gram-negative bacteria, through both local selection and transmission, and importation of globally successful resistant clones encourages the use of broad-spectrum empiric antimicrobials for septic patients, including in combination. This may lead to a vicious cycle whereby increasing antibiotic use increases resistance, which in turn leads to higher levels of inappropriate therapy. In response, the multi-disciplinary ICU-team implements infection prevention and control, and antimicrobial stewardship programmes. Antimicrobial stewardship programmes provide interventions and guidance to optimize appropriate therapy,whilelimiting unnecessary use through a variety of measures. The development of rapid molecular testing for bacterial identification and antimicrobial susceptibility prediction could potentially bring useful microbiological information to the bedside at the time of therapeutic decision making.

Download Full-text

Present and Prospective Therapeutic Regimens for COPD

Clinical Medicine Insights Therapeutics ◽

10.4137/cmt.s2106 ◽

2012 ◽

Vol 4 ◽

pp. CMT.S2106

Author(s):

Teresa A. Schweiger

Keyword(s):

Combination Therapy ◽

Patient Outcomes ◽

Treatment Guidelines ◽

Chronic Obstructive ◽

Anticholinergic Agent ◽

Obstructive Pulmonary Disease ◽

Prevalent Disease ◽

Appropriate Therapy ◽

Long Acting ◽

General Step

Chronic Obstructive Pulmonary Disease is a prevalent disease throughout the world. Recently updated treatment guidelines were published and still endorse a general step-wise approach to therapy based on severity of disease. The heterogeneity of the disease makes it difficult to determine appropriate therapy based on the data available. Currently, combination therapy, specifically triple therapy with a long acting beta2 agonist, a long acting anticholinergic agent, and an inhaled corticosteroid appear to achieve the best patient outcomes. In addition, there is a desperate need for new therapy with a different mechanism of action than those already on the market. The recommendations concerning stable COPD treatment will be reviewed, as well as, efficacy data regarding combination therapy. In addition, a few new and prospective therapies will be evaluated.

Download Full-text

Antimicrobial prescribing behaviour in dogs and cats by Belgian veterinarians

Veterinary Record ◽

10.1136/vr.104316 ◽

2017 ◽

Vol 182 (11) ◽

pp. 324-324 ◽

Cited By ~ 13

Author(s):

Alexia Van Cleven ◽

Steven Sarrazin ◽

Hilde de Rooster ◽

Dominique Paepe ◽

Sofie Van der Meeren ◽

...

Keyword(s):

Primary Care ◽

Online Survey ◽

Treatment Guidelines ◽

Current Treatment ◽

Antimicrobial Treatment ◽

Fourth Generation ◽

National Guidelines ◽

First Line ◽

Clinical Scenarios ◽

Prescribing Behaviour

The objective of this study is to survey general prescribing behaviour by Belgian companion animal veterinarians and to assess agreement of these practices with current treatment guidelines. Therefore an online survey was administered with five realistic and frequently occurring first-line cases to primary-care veterinary practitioners. For each case a predefined pattern of questions were asked about whether or not they would prescribe antimicrobials, if they would prescribe a non-antimicrobial treatment and if they would perform additional diagnostic steps. The responses were compared with recommendations in national guidelines and recent literature. The overall most prescribed antimicrobials were potentiated amoxicillin (43.0 per cent), fluoroquinolones (14.7 per cent), third-generation and fourth-generation cephalosporins (10.9 per cent) and tetracyclines (10.9 per cent). Only 48.3 per cent of the veterinarians complied with the guidelines in nearly all of the clinical scenarios (ie, prescribing antimicrobials when indicated, not prescribing antimicrobials when it is not indicated). Moreover, when prescribing highest priority critically important antimicrobials, susceptibility testing on bacterial cultures was performed in only 12.4 per cent of the prescriptions. The results showed that the prescribing behaviour of antimicrobial compounds by primary-care veterinary practitioners in dogs and cats is often not in agreement with national guidelines. Focus in improvement of this prescribing behaviour should be on performing the appropriate diagnostic steps and decreasing the use of highest priority critically important antimicrobials.

Download Full-text

Beyond Susceptible and Resistant, Part I: Treatment of Infections Due to Gram-Negative Organisms With Inducible β-Lactamases

The Journal of Pediatric Pharmacology and Therapeutics ◽

10.5863/1551-6776-16.1.23 ◽

2011 ◽

Vol 16 (1) ◽

pp. 23-30 ◽

Cited By ~ 1

Author(s):

Conan MacDougall

Keyword(s):

Clinical Data ◽

Broad Spectrum ◽

Antimicrobial Treatment ◽

Antibiotic Exposure ◽

Common Mode ◽

Gram Negative ◽

Clinical Pathogens ◽

Gram Negative Organisms ◽

Emergence Of Resistance

ABSTRACT Inactivation of β-lactams by the action of β-lactamase enzymes is the most common mode of resistance to these drugs among Gram-negative organisms. The genomes of some key clinical pathogens such as Enterobacter and Pseudomonas encode AmpC, an inducible chromosomal β-lactamase. The potent activity of AmpC against broad-spectrum β-lactams complicates treatment of organisms with this gene. Antibiotic exposure can select for mutants expressing high levels of this enzyme, leading to the emergence of resistant isolates and failure of therapy, even when the initial isolate is fully susceptible. The risk of selecting for resistant organisms varies according to the particular β-lactam used for treatment. This article reviews the microbiology of these enzymes, summarizes clinical data on the frequency emergence of resistance, and discusses considerations for antimicrobial treatment of these organisms.

Download Full-text

Fourniers gangrene-A case report and literature review

Journal of College of Medical Sciences-Nepal ◽

10.3126/jcmsn.v7i3.6713 ◽

2012 ◽

Vol 7 (3) ◽

pp. 62-67

Author(s):

A Agarwal ◽

A Karmacharaya ◽

S Hirachan ◽

WK Belokar

Keyword(s):

Case Report ◽

Soft Tissue ◽

Broad Spectrum ◽

Skin Grafting ◽

Multiple Organ ◽

Medical Sciences ◽

Anaerobic Microorganisms ◽

Broad Spectrum Antibiotics ◽

Appropriate Therapy ◽

Aerobic And Anaerobic

Fournier’s gangrene(FG) is a rare, necrotising fasciitis of the genitals and perineum with occasional cranial extension to the abdominal wall caused by a mixture of aerobic and anaerobic microorganisms. The complications of this synergistic infection are multiple organ failure and death. Due to the aggressive nature of this condition, early diagnosis is crucial. Treatment involves extensive soft tissue debridement and broad-spectrum antibiotics. Despite appropriate therapy, mortality is high. We report a case of a gentleman who presented with gangrenous and necrotic penile, scrotal and perineal areas. Patient was successfully managed by extensive soft tissue debridement, broad spectrum antibiotics and skin grafting. DOI: http://dx.doi.org/10.3126/jcmsn.v7i3.6713 Journal of College of Medical Sciences-Nepal, 2011, Vol-7, No-3, 62-67

Download Full-text