Management of patients presenting with diarrhoea to a regional emergency department in KwaZulu-Natal:  Call for clearer, more relevant guidance

Background. HIV is prevalent throughout South Africa, and diarrhoea is a common presentation to the emergency department (ED) among both HIV-infected and -uninfected individuals. Method. We audited the management of diarrhoea against standard guidelines in the ED of a regional hospital in KwaZulu-Natal. Patients presenting with diarrhoea as their chief complaint were eligible and data were collected prospectively. Results. A total of 72 patients were included: 58 (81%) of patients were HIV-positive with an average CD4+ count of 180 cells/µl. A total of 34 stool samples were sent for standard microscopy and culture (M&C), among which 26 were positive (76%). Forty-three patients (60%) received antibiotics, 15 of whom had positive stool M&C. In all cases, the final diagnosis was listed as acute gastroenteritis without further specification, and antibiotic use according to guidelines appeared inconsistent. Conclusion. Based on this audit, we suggest that current guidelines are not clear concerning management of acute diarrhoea in HIV-infected individuals, and that the lack of clear management strategies is likely to affect patient safety and increase antibiotic resistance.

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Rotavirus serotypes and electropherotypes identified among hospitalised children in São Luís, Maranhão, Brazil

Revista do Instituto de Medicina Tropical de São Paulo ◽

10.1590/s0036-46652005000500009 ◽

2005 ◽

Vol 47 (5) ◽

pp. 287-293 ◽

Cited By ~ 13

Author(s):

Cláudia Regina N. E. Luz ◽

Joana D'Arc P. Mascarenhas ◽

Yvone B. Gabbay ◽

Ana Regina B. Motta ◽

Telma Vitorina Ribeiro Lima ◽

...

Keyword(s):

Acute Diarrhoea ◽

Incidence Rates ◽

Northeastern Brazil ◽

Rotavirus Infection ◽

First Semester ◽

Rotavirus Gastroenteritis ◽

Positive Stool ◽

Stool Samples ◽

Rotavirus Infections

During June 1997-June 1999 rotavirus infection was screened in infants aged up to 2 years and hospitalised with acute diarrhoea in São Luís, Northeastern Brazil. Altogether, 128 stool samples were collected from diarrhoeic patients and additional 122 faecal specimens from age- and- temporal matched inpatients without diarrhoea were obtained; rotavirus positivity rates for these groups were 32.0% (41/128) and 9.8% (12/122), respectively (p < 0.001). Both electropherotyping and serotyping could be performed in 42 (79.2%) of the 53 rotavirus-positive stool samples. Long and short electropherotypes were detected at similar rates - 38.1% and 40.5% of specimens, respectively. Overall, a G serotype could be assigned for 35 (83.3%) of specimens, the majority of them (66.7%) bearing G1-serotype specificity. Taking both electropherotypes and serotypes together, G1 rotavirus strains displaying long and short RNA patterns accounted for 30.9% and 19.0% of tested specimens, respectively; all G2 strains had short electropherotype. Rotavirus gastroenteritis was detected year-round and, in 1998, the incidence rates tended to be higher during the second semester than in the first semester: 45.2% and 26.1% (p = 0.13), respectively. Rotavirus infections peaked at the second semester of life with frequencies of 30.1% and 13.5% for diarrhoeic children and controls, respectively. While the six rotavirus strains bearing G2-type specificity were circulating throughout the whole study period, G1 serotypes (n = 27) emerged as from June 1998 onwards, 20 (74.1%) of which clustering in 1998. These data underscore the importance of rotaviruses in the aetiology of severe infantile gastroenteritis in Northeastern Brazil and sustain the concept that a future vaccine should confer protection against more than one serotype.

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Utility of echocardiography in patients with suspected acute myocardial infarction in the presence of left bundle-branch block

European Heart Journal ◽

10.1093/ehjci/ehaa946.1712 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

P.D Ratmann ◽

T Nestelberger ◽

L Cullen ◽

B Lindahl ◽

J Boeddinghaus ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Emergency Department ◽

Wall Motion ◽

Final Diagnosis ◽

Left Ventricular ◽

Funding Source ◽

Bundle Branch Block ◽

Current Guidelines ◽

Heart Foundation

Abstract Background Rapid identification of acute myocardial infarction (AMI) as life-threatening disorder by clinical assessment, cardiac troponin and the electrocardiogram (ECG) is important for the early initiation of highly effective, evidence-based therapy. Patients presenting with suspected AMI and left bundle branch block (LBBB) to the emergency department (ED) represent a unique diagnostic and therapeutic challenge, as altered ventricular depolarization masks changes in ventricular repolarization associated with myocardial ischemia. Current guidelines suggest, based on expert opinion, early echocardiography as a helpful tool in patients with suspected AMI and LBBB to identify new wall motion abnormalities, which guides further diagnostics strategies in these patients. Purpose To evaluate the diagnostic accuracy of echocardiography among patients with suspected AMI and LBBB in the recorded ECG at ED presentation. Methods We prospectively evaluated the diagnostic accuracy of echocardiography in patients with LBBB presenting with chest discomfort to 26 ED's in three international, prospective, diagnostic studies. Two independent cardiologists centrally adjudicated the final diagnosis in each study according to the universal definition of myocardial infarction. All patients underwent a clinical assessment that included standardized and detailed medical history including assessment of chest pain characteristics, vital signs, physical examination, 12-lead ECG, continuous ECG rhythm monitoring, pulse oximetry, standard blood test, and chest radiography and echocardiography if indicated. We compared echocardiographic findings in patients with LBBB who were diagnosed with an AMI to those without an AMI. Results Among 283 patients presenting with chest pain and LBBB to the ED, AMI was the final diagnosis in 36% (102 of 283 patients) of patients. An echocardiography had been performed in 100/283 patients (35%) in the emergency department. AMI was the final diagnosis in 41/100 (41%) of patients. A wall motion abnormality in any region was seen in 77 (77%) of patients with no difference between patients diagnosed with AMI (33 patients, 81%) versus without AMI (44 patients, 75%, p=0.49). Additionally, we found no differences for each wall region (Table 1). Most patients with LBBB had moderately reduced left ventricular ejection fraction (LVEF, median 40%), a dilated left atrium (67%) or left ventricular hypertrophy (55%) without any differences between the two groups (Table 1). Conclusions Early echocardiography in patients with suspected AMI and LBBB provided only limited utility to identify patients, which may benefit from immediate coronary angiography. Our findings scrutinize current guidelines and downgrades the utility of echocardiography in this setting. Funding Acknowledgement Type of funding source: Other. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation, the European Union, the Cardiovascular Research Foundation Basel, the University Hospital Basel, Queensland Emergency Medicine Research Foundation, Christchurch Heart Institute and Health Research Council and Heart Foundation of New Zealand, Christchurch Emergency Care Foundation

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Prospective observational study of point-of-care ultrasound for diagnosing pneumonia

Archives of Disease in Childhood ◽

10.1136/archdischild-2017-314496 ◽

2018 ◽

Vol 104 (1) ◽

pp. 12-18 ◽

Cited By ~ 24

Author(s):

Claire Lissaman ◽

Panida Kanjanauptom ◽

Cyril Ong ◽

Mark Tessaro ◽

Elliot Long ◽

...

Keyword(s):

Emergency Department ◽

Lung Ultrasound ◽

Point Of Care ◽

Antibiotic Use ◽

Final Diagnosis ◽

Point Of Care Ultrasound ◽

Antibiotic Overuse ◽

Paediatric Emergency Department ◽

Paediatric Emergency ◽

Registration Number

ObjectivesThe clinical diagnosis of pneumonia lacks specificity and may lead to antibiotic overuse, whereas radiological diagnoses can lack sensitivity. Point-of-care lung ultrasound is an emerging diagnostic tool. There are limited prospective data, however, on the accuracy of sonologists in the paediatric emergency department setting. We aimed to test the diagnostic accuracy of lung ultrasound for pneumonia using chest radiograph (CR) as the reference standard.MethodsThis prospective observational cohort study in a paediatric emergency department enrolled children aged 1 month to <18 years, who had a CR ordered for possible pneumonia. Lung ultrasounds were performed by two blinded sonologists with focused training. Sonographic pneumonia was defined as lung consolidation with air bronchograms. Radiograph and ultrasound results both required agreement between two readers, with final results determined by an arbiter in cases of disagreement. Patient management was decided by treating clinicians who were blinded to lung ultrasound results. Follow-up was performed by phone and medical record review to obtain final diagnosis and antibiotic use.ResultsOf 97 included patients, CR was positive for pneumonia in 44/97 (45%) and lung ultrasound was positive in 57/97 (59%). Ultrasound sensitivity was 91% (95% CI 78% to 98%) and specificity was 68% (95% CI 54% to 80%). Ultrasound results displayed greater consistency with CR and patient outcomes when sonographic consolidation exceeded 1 cm. Thirteen of 57 patients with sonographic consolidation improved without antibiotics.ConclusionLung ultrasound may have a role as first-line imaging in patients with possible pneumonia, with higher specificity for consolidations exceeding 1 cm.Trial registration numberACTRN12616000361404, http://www.ANZCTR.org.au/ACTRN12616000361404.aspx

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Molecular Detection of Group A Rotavirus in under Five Years Old Children with Acute Diarrhoea Admitted to Yangon Children’s Hospital

Myanmar Health Sciences Research Journal ◽

10.34299/mhsrj.00927 ◽

2019 ◽

Vol 31 (1) ◽

pp. 87-92

Keyword(s):

Acute Diarrhoea ◽

Enzyme Linked Immunosorbent Assay ◽

Viral Gastroenteritis ◽

Cross Sectional ◽

Under Five ◽

Group A Rotavirus ◽

Rotavirus Vaccination ◽

Group A ◽

Stool Samples ◽

Considerable Morbidity

Rotaviruses are regarded as the most common cause of viral gastroenteritis and are responsible for considerable morbidity and mortality among children especially under five years of age worldwide. In developing countries like Myanmar, where diarrhoea is in the priority childhood disease, rotavirus surveillance and detection of rotavirus genotypes are utmost important. A hospital-based, cross-sectional descriptive study was conducted at Yangon Children‟s Hospital among under five children admitted for acute diarrhoea from January to October 2016. This study includes detection of Group A rotavirus antigen by commercial enzyme-linked immunosorbent assay (ELISA) and genotyping by multiplex RT-PCR. From a total of 488 collected samples, rotavirus antigen was detected in 219 samples (45%). Rotavirus diarrhoea was most common among the age of 6-11 months (38.8%) followed by 12-23 months (37.9%). The results showed that boys were more commonly affected than girls. Detection of rotavirus positivity was peak in February (57.6 %). Out of 219 stool samples with positive ELISA result, 40 stool samples with high optical density value were proceeded for further determination of G and P genotypes. Regarding distribution of G genotypes, the most common G genotype was G9 which comprised 45%, and that of P genotype was P[8] which comprised 92.5%. Regarding combination of G and P genotypes, the most frequent combination is G9P[8], and it constituted 42.5%. Untypable genotypes were seen in 30% of G and 2.5% of P typing. As rotavirus infection can be prevented by vaccine, WHO recommended that rotavirus vaccination should be included in national immunization program especially in countries where prevalence of rotavirus is high. The distribution of G and P genotypes is important in consideration of appropriate vaccine in pre-vaccination and evaluation of effectiveness of vaccine in post-vaccination period. Therefore, the information on currently circulating genotypes of rotavirus in this study will serve as valuable data for vaccination programme.

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Epidemiology and outcomes from severe hypoglycemia in Kuwait: a prospective cohort study

BMC Emergency Medicine ◽

10.1186/s12873-021-00457-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Dalal Al Hasan ◽

Ameen Yaseen ◽

Mohammad Al Roudan ◽

Lee Wallis

Keyword(s):

Severe Hypoglycaemia ◽

Management Strategies ◽

Severe Hypoglycemia ◽

Inclusion Criteria ◽

Initial Management ◽

Scene Management ◽

Prehospital Management ◽

Improve Patient Management ◽

Current Guidelines ◽

Improve Patient

Abstract Background The objective of this study was to describe the epidemiology of severe hypoglycaemia in Kuwait, aiming to provide a preliminary background to update the current guidelines and improve patient management. Method This was a prospective analysis of severe hypoglycaemia cases retrieved from emergency medical services (EMS) archived data between 1 January and 30 June 2020. The severe hypoglycaemia cases were then sub-grouped based on EMS personal initial management and compared in terms of scene time, transportation rate, complications and outcomes. The primary outcomes were GCS within 10–30 min and normal random blood glucose (RBS) within 10–30 min. Results A total of 167 cases met the inclusion criteria. The incidence of severe hypoglycaemia in the national EMS was 11 per 100,000. Intramuscular glucagon was used on scene in 89% of the hypoglycaemic events. Most of the severe hypoglycaemia patients regained normal GCS on scene (76.5%). When we compared the two scene management strategies for severe hypoglycaemia cases, parenteral glucose administration prolonged the on-scene time (P = .002) but was associated with more favourable scene outcomes than intramuscular glucagon, with normal GCS within 10–30 min (P = .05) and normal RBS within 10–30 min (P = .006). Conclusion: Severe hypoglycaemia is not uncommon during EMS calls. Appropriate management by EMS personals is fruitful, resulting in favourable scene outcomes and reducing the hospital transportation rate. More research should be invested in improving and structuring the prehospital management of severe hypoglycaemia. One goal is to clarify the superiority of parenteral glucose over intramuscular glucagon in the prehospital setting.

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140. Symptoms and Situations Predispose Patients to Use Antibiotics Without Medical Advice

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.450 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S200-S200

Author(s):

Michael Hansen ◽

Barbara Trautner ◽

Roger Zoorob ◽

George Germanos ◽

Osvaldo Alquicira ◽

...

Keyword(s):

Primary Care ◽

Emergency Department ◽

Emergency Departments ◽

Primary Care Clinic ◽

Antibiotic Use ◽

Safety Net ◽

Care Clinic ◽

Primary Care Clinics ◽

Primary Care Patients ◽

Emergency Department Patients

Abstract Background Use of antibiotics without a prescription (non-prescription use) contributes to antimicrobial resistance. Non-prescription use includes obtaining and taking antibiotics without a prescription, taking another person’s antibiotics, or taking one’s own stored antibiotics. We conducted a quantitative survey focusing on the factors that impact patients’ decisions to use non-prescription antibiotics. Methods We surveyed patients visiting public safety net primary care clinics and private emergency departments in a racially/ethnically diverse urban area. Surveys were read aloud to patients in Spanish and English. Survey domains included patients’ perspectives on which syndromes require antibiotic treatment, their perceptions of health care, and their access to antibiotics without a prescription. Results We interviewed 190 patients, 122 from emergency departments (64%), and 68 from primary care clinics (36%). Overall, 44% reported non-prescription antibiotic use within the past 12 months. Non-prescription use was higher among primary care clinic patients (63%) than the emergency department patients (39%, p = 0.002). The majority felt that antibiotics would be needed for bronchitis (78%) while few felt antibiotics would be needed for diarrhea (30%) (Figure 1). The most common situation identified “in which respondents would consider taking antibiotics without contacting a healthcare provider was “got better by taking this antibiotic before” (Figure 2). Primary care patients were more likely to obtain antibiotics without prescription from another country than emergency department patients (27% vs. 13%, P=0.03). Also, primary care patients were more likely to report obstacles to seeking a doctor’s care, such as the inability to take time off from work or transportation difficulties, but these comparisons were not statistically significant. Figure 1. Patients’ agreement that antibiotics would be needed varied by symptom/syndrome. Figure 2. Situations that lead to non-prescription antibiotic use impacted the two clinical populations differently Conclusion Non-prescription antibiotic use is a widespread problem in the two very different healthcare systems we included in this study, although factors underlying this practice differ by patient population. Better understanding of the factors driving non-prescription antibiotic use is essential to designing patient-focused interventions to decrease this unsafe practice. Disclosures All Authors: No reported disclosures

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Social and Demographic Factors Associated with Postnatal Depression Symptoms among HIV-Positive Women in Primary Healthcare Facilities, South Africa

Healthcare ◽

10.3390/healthcare9010065 ◽

2021 ◽

Vol 9 (1) ◽

pp. 65

Author(s):

Kebogile Elizabeth Mokwena ◽

Nontokozo Lilian Mbatha

Keyword(s):

South Africa ◽

Primary Healthcare ◽

Postnatal Depression ◽

Hiv Positive ◽

P Value ◽

Depression Symptoms ◽

Healthcare Facilities ◽

Factors Associated ◽

Hiv Positive Women ◽

Kwazulu Natal

Background: Mothers living with HIV are at risk for mental health problems, which may have a negative impact on the management of their HIV condition and care of their children. Although South Africa has a high prevalence of HIV, there is a dearth of studies on sociodemographic predictors of postnatal depression (PND) among HIV-positive women in South Africa, even in KwaZulu Natal, a province with the highest prevalence of HIV in the country. Objective: The objective of the study was to determine sociodemographic factors associated with the prevalence of postnatal depression symptoms among a sample of HIV-positive women attending health services from primary healthcare facilities in Umhlathuze District, KwaZulu Natal. Methods: A quantitative cross-sectional survey was used to collect data from 386 HIV-positive women who had infants aged between 1 and 12 weeks. The Edinburgh Postnatal Depression Scale (EPNDS), to which sociodemographic questions were added, was used to collect data. Results: The prevalence of PND symptoms among this sample of 386 HIV-positive women was 42.5%. The age of the mothers ranged from 16 to 42 years, with a mean of 29 years. The majority of the mothers were single or never married (85.5%; n = 330), living in a rural setting (81.9%; n = 316%), with a household income of less than R 2000 (estimated 125 USD) per month (64.9%; n = 120). The government child support grant was the main source of income for most of the mothers (53%; n = 183). PND symptoms were significantly associated with the participant’s partner having other sexual partners (p-value < 0.001), adverse life events (p-value = 0.001), low monthly income (p-value = 0.015), and being financially dependent on others (p-value = 0.023). Conclusion: The prevalence of PND symptoms among the sample is high, with a number of social and demographic factors found to be significantly associated with PND. This requires the consideration of sociodemographic information in the overall management of both HIV and postnatal depression. Addressing the impact of these factors can positively influence the health outcomes of both the mother and the baby.

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Evaluation of Antibiotic Supply Decisions by Community Pharmacists in Thailand: A Vignette Study

Antibiotics ◽

10.3390/antibiotics10020154 ◽

2021 ◽

Vol 10 (2) ◽

pp. 154

Author(s):

Sisira Donsamak ◽

Marjorie C. Weiss ◽

Dai N. John

Keyword(s):

Respiratory Infections ◽

Acute Diarrhoea ◽

Community Pharmacists ◽

Antibiotic Use ◽

Educational Interventions ◽

Community Pharmacies ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Case Vignettes ◽

A Chain

In Thailand, antibiotics are available lawfully from community pharmacies without a prescription. Inappropriate supply of antibiotics from Thai community pharmacies to the public for common, self-limiting diseases has been reported. The study aimed to evaluate the appropriateness of antibiotics selected by community pharmacists in Thailand in response to vignettes. A cross-sectional survey of community pharmacists across Thailand was conducted using a self-administered questionnaire including nine case vignettes with three conditions, namely upper respiratory infections (URIs), acute diarrhoea and simple wounds. A total of 208 questionnaires were completed and analysed (20.8% response rate). In response to vignettes relating to URIs, 50.8% of pharmacist recommendations were not in accordance with antibiotic guidelines. Inappropriate recommendations for diarrhoea and wound cases were 20.8% and 16.7%, respectively. A higher proportion of younger pharmacists, those with less experience, Pharm. D. graduate pharmacists, employee pharmacists and those pharmacists who worked in a chain pharmacy were more likely to recommend appropriate antibiotic treatment in response to the vignettes (p < 0.05). These findings will be useful to promote educational interventions for community pharmacists regarding common infectious disease management in order to improve appropriate antibiotic use.

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Assessment of Testing and Treatment of Asymptomatic Bacteriuria Initiated in the Emergency Department

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa537 ◽

2020 ◽

Vol 7 (12) ◽

Author(s):

Lindsay A Petty ◽

Valerie M Vaughn ◽

Scott A Flanders ◽

Twisha Patel ◽

Anurag N Malani ◽

...

Keyword(s):

Emergency Department ◽

Antibiotic Treatment ◽

Asymptomatic Bacteriuria ◽

Antibiotic Use ◽

Altered Mental Status ◽

Estimating Equation ◽

Hospitalized Patients ◽

Clostridioides Difficile ◽

Cord Injury ◽

Clostridioides Difficile Infection

Abstract Background Reducing antibiotic use in patients with asymptomatic bacteriuria (ASB) has been inpatient focused. However, testing and treatment is often started in the emergency department (ED). Thus, for hospitalized patients with ASB, we sought to identify patterns of testing and treatment initiated by emergency medicine (EM) clinicians and the association of treatment with outcomes. Methods We conducted a 43-hospital, cohort study of adults admitted through the ED with ASB (February 2018–February 2020). Using generalized estimating equation models, we assessed for (1) factors associated with antibiotic treatment by EM clinicians and, after inverse probability of treatment weighting, (2) the effect of treatment on outcomes. Results Of 2461 patients with ASB, 74.4% (N = 1830) received antibiotics. The EM clinicians ordered urine cultures in 80.0% (N = 1970) of patients and initiated treatment in 68.5% (1253 of 1830). Predictors of EM clinician treatment of ASB versus no treatment included dementia, spinal cord injury, incontinence, urinary catheter, altered mental status, leukocytosis, and abnormal urinalysis. Once initiated by EM clinicians, 79% (993 of 1253) of patients remained on antibiotics for at least 3 days. Antibiotic treatment was associated with a longer length of hospitalization (mean 5.1 vs 4.2 days; relative risk = 1.16; 95% confidence interval, 1.08–1.23) and Clostridioides difficile infection (CDI) (0.9% [N = 11] vs 0% [N = 0]; P = .02). Conclusions Among hospitalized patients ultimately diagnosed with ASB, EM clinicians commonly initiated testing and treatment; most antibiotics were continued by inpatient clinicians. Antibiotic treatment was not associated with improved outcomes, whereas it was associated with prolonged hospitalization and CDI. For best impact, stewardship interventions must expand to the ED.

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Rapid Multiplex Testing for Upper Respiratory Pathogens in the Emergency Department: A Randomized Controlled Trial

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz481 ◽

2019 ◽

Cited By ~ 3

Author(s):

Larissa May ◽

Grant Tatro ◽

Eduard Poltavskiy ◽

Benjamin Mooso ◽

Simson Hon ◽

...

Keyword(s):

Emergency Department ◽

Length Of Stay ◽

Usual Care ◽

Controlled Trial ◽

Antibiotic Use ◽

Respiratory Pathogens ◽

Upper Respiratory Tract ◽

Upper Respiratory ◽

Tract Infections ◽

The Impact

Abstract Background Acute upper respiratory tract infections are a common cause of Emergency Department (ED) visits and often result in unnecessary antibiotic treatment. Methods We conducted a randomized clinical trial to evaluate the impact of a rapid, multi-pathogen respiratory panel (RP) test versus usual care (control). Patients were eligible if they were ≥12 months old, had symptoms of upper respiratory infection or influenza like illness, and were not on antibiotics. The primary outcome was antibiotic prescription; secondary outcomes included antiviral prescription, disposition, and length of stay (ClinicalTrials.gov# NCT02957136). Results Of 191 patients enrolled, 93 (49%) received RP testing; 98 (51%) received usual care. Fifty-three (57%) RP and 7 (7%) control patients had a virus detected and reported during the ED visit (p=0.0001). Twenty (22%) RP patients and 33 (34%) usual care patients received antibiotics during the ED visit (-12% [95% CI -25%, 0.4%]; p=0.06/0.08); 9 RP patients received antibiotics despite having a virus detected. The magnitude of antibiotic reduction was greater in children (-19%) versus adults (-9%; post-hoc analysis). There was no difference in antiviral use, length of stay, or disposition. Conclusions Rapid RP testing was associated with a trend towards decreased antibiotic use, suggesting a potential benefit from more rapid viral tests in the ED. Future studies should determine if specific groups are more likely to benefit from testing and evaluate relative cost and effectiveness of broad testing, focused testing, and a combined diagnostic and antimicrobial stewardship approach.

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