Antimicrobial Resistance: Is Health Technology Assessment Part of the Solution or Part of the Problem?

Antimicrobial resistance is a serious challenge to the success and sustainability of our healthcare systems. There has been increasing policy attention given to antimicrobial resistance in the last few years, and increased amounts of funding have been channeled into funding for research and development of antimicrobial agents. Nevertheless, manufacturers doubt whether there will be a market for new antimicrobial technologies sufficient to enable them to recoup their investment. Health technology assessment (HTA) has a critical role in creating confidence that if valuable technologies can be developed they will be reimbursed at a level that captures their true value. We identify 3 deficiencies of current HTA processes for appraising antimicrobial agents: a methods-centric approach rather than problem-centric approach for dealing with new challenges, a lack of tools for thinking about changing patterns of infection, and the absence of an approach to epidemiological risks. We argue that, to play their role more effectively, HTA agencies need to broaden their methodological tool kit, design and communicate their analysis to a wider set of users, and incorporate long-term policy goals, such as containing resistance, as part of their evaluation criteria alongside immediate health gains.     

我国常见细菌耐药趋势预测研究:基于灰色GM (1,1)模型

 目的 通过对耐甲氧西林金黄色葡萄球菌（MRSA）、耐碳青霉烯类铜绿假单胞菌（CRPA）、耐碳青霉烯类鲍曼不动杆菌（CRAB）、耐第三代头孢菌素的大肠埃希菌（3GCR-E.coli）、耐第三代头孢菌素的肺炎克雷伯菌（3GCR-KP）等细菌耐药数据构建灰色预测模型,分析细菌耐药特征的变化趋势,探讨灰色预测模型在细菌耐药领域的应用价值。方法 采用2014-2018年全国细菌耐药监测报告中MRSA、CRPA和CRAB、3GCR-E.coli、3GCR-KP等耐药率数据构建灰色预测GM （1,1）模型。用后验差比C值和小误差概率P值评估模型精度,用相对误差和级比偏差评估模型拟合效果,并用2019-2020年数据对模型预测效果进行验证。最终根据模型对2021-2023年的耐药率进行预测。结果 本研究构建的GM （1,1）模型对MRSA、CRPA、CRAB、3GCR-E.coli和3GCR-KP等细菌耐药率预测效果较好,根据该模型预测到2023年其耐药率分别可降低至23.9%、15.2%、50.2%、43.8%、26.1%。结论 全国针对细菌耐药情况采取的控制措施取得明显成效,GM （1,1）模型对细菌耐药率预测效果较好,可在细菌耐药管理领域推广应用。     

双—对二甲氨基苯甲醛缩二胺类希夫碱合成、表征及抗菌活性

目的：合成双－对二甲氨基苯甲醛缩二胺类希夫碱,并对其抗菌活性进行研究。方法：以对二甲氨基苯甲醛和二胺类为原料,经缩合反应,制得4种相应希夫碱。结果：结构经元素分析、红外光谱、核磁共振谱确定,4种化合物均未见文献报道,抗菌活性测试表明,它们具有一定抗菌活性。结论：乙酸是催化剂,对缩合反应有利,希夫碱化合物具有一定抗菌活性。     

13种抗生素对革兰阴性杆菌抗菌活性及耐药性分析

目的 :研究临床常用抗生素的体外抗菌活性 ,分析其耐药特点 ,为临床合理用药提供可靠依据。方法 :对本实验室分离的 316株革兰阴性杆菌进行了体外药敏分析 ,并测定其产 β 内酰胺酶及超广谱 β 内酰胺酶的百分率。结果 :头孢哌酮 /舒巴坦 (舒普深CFS)的MIC90 为 8mg/L ;依米配能 /西司他丁 (泰能IPM)的MIC90 为 4mg/L ,耐药率分别为 8%和 16 % ;而其他抗生素的MIC90 为 12 8mg/L或 2 5 6mg/L ,耐药率均大于 30 %。细菌 β 内酰胺酶总检出率为 5 4 1% ,超广谱 β 内酰胺酶 (ESBL)检出率为 12 1%。结论 :CFS和IPM对临床常见革兰阴性杆菌耐药率较低。由于持续高产量 β 内酰胺酶及超广谱β 内酰胺酶的产生 ,不仅使得三代头孢菌素的耐药率较高 ,也使得庆大霉素、阿米卡星和环丙沙星等抗生素出现较为严重的交叉耐药现象。建议临床医生在三代头孢菌素的使用上应参考实验室报告 ,合理选择 ,避免耐药菌株的产生。     

云南琵琶甲抗菌活性成分研究

目的：研究云南琵琶甲的抗菌活性成分。方法：通过溶剂提取、硅胶柱层析分离,应用光谱方法鉴定结构。结果：所分得的5个化合物分别鉴定为2－甲基－1,4苯二醇（2-methyl-1,4-benzenediol,Ⅰ）,对苯二酚（hydroquinone,Ⅱ）,三十二烷酸（dotriacontanoic acid),棕榈酸（palmitic acid,Ⅳ）,和三十烷醇（triacontanol,Ⅴ）,经抗菌活性实验,结果表明Ⅰ和Ⅱ具有抗菌活性。结论：以上5个化合物为首次从云南琵琶甲中分得。     

Trends of Prosthetic Joint Infection Organisms and Recurrence for a Single High-Volume Arthroplasty Surgeon Over 20 Years

BackgroundProsthetic joint infection (PJI) is a morbid complication following total joint arthroplasty (TJA). PJI diagnosis and treatment has changed over time, and patient co-management with a high-volume musculoskeletal infectious disease (MSK ID) specialist has been implemented at our institution in the last decade.MethodsWe retrospectively evaluated all consecutive TJA patients treated for PJI between 1995 and 2018 by a single high-volume revision TJA surgeon. Microbial identities, antibiotic resistance, prior PJI, and MSK ID consultation were investigated.ResultsIn total, 261 PJI patients (median age 66 years, interquartile range 57-75) were treated. One-year and 5-year reinfection rates were 15.8% (95% confidence interval [CI] 11.6-20.7) and 22.1% (95% CI 17.0-27.7), respectively. Microbial identities and antibiotic resistances did not change significantly over time. Despite seeing more prior PJI patients (53.3% vs 37.6%, P = .012), MSK ID-managed patients had similar infection rates as non-MSK ID-managed patients (hazard ratio [HR] 1.02, 95% CI 0.6-1.75, P = .93). Prior PJI was associated with higher reinfection risk (HR 2.39, 95% CI 1.39-4.12, P = .002) overall and in patients without MSK ID consultation, specifically (HR 2.78, 95% CI 1.37-5.65, P = .005). This risk was somewhat lower and did not reach significance in prior PJI patients with MSK ID consultation (HR 1.97, 95% CI 0.87-4.48, P = .106).ConclusionWe noted minimal differences in microbial/antibiotic resistances for PJI over 20 years in a single institution, suggesting current standards of PJI treatment remain encouragingly valid in most cases. MSK ID involvement was not associated with lower reinfection risk overall; however, in patients with prior PJI, the risk of reinfection appeared to be somewhat lower with MSK ID involvement.Level of EvidenceLevel IV–Case Series.     

Adult congenital heart disease

Continued advances in the understanding and management of congenital heart disease (CHD) mean that over 90% of children born with CHD now survive to adulthood. This in turn results in greater numbers of adult patients presenting for medical and surgical care at non-specialist centres. A simple classification of adult congenital heart disease (ACHD) according to complexity can help clinicians to understand the implications of the specific cardiac anomaly encountered. Issues relating to the conduct of anaesthesia in ACHD patient include careful attention to euvolaemia, the preservation of sinus rhythm and cardiac output, and in complex patients, manipulating the balance between systemic and pulmonary blood flows. Additionally, effective antibiotic prophylaxis and the prevention of either excessive bleeding or thromboembolism are vitally important. It should not be forgotten that although many patients with simple or repaired cardiac lesions may be very well managed in a non-specialist unit, those with Eisenmenger’s syndrome or severe pulmonary hypertension have an extremely high risk of death in the perioperative period, and in all but life-threatening situations should always be managed within specialist centres.     

Management of lung transplantation in the COVID-19 era—An international survey

It is unknown if solid organ transplant recipients are at higher risk for severe COVID-19. The management of a lung transplantation (LTx) program and the therapeutic strategies to adapt the immunosuppressive regimen and antiviral measures is a major issue in the COVID-19 era, but little is known about worldwide practice. We sent out to 180 LTx centers worldwide in June 2020 a survey with 63 questions, both regarding the management of a LTx program in the COVID-19 era and the therapeutic strategies to treat COVID-19 LTx recipients. We received a total of 78 responses from 15 countries. Among participants, 81% declared a reduction of the activity and 47% restricted LTx for urgent cases only. Sixteen centers observed deaths on waiting listed patients and eight centers performed LTx for COVID-19 disease. In 62% of the centers, COVID-19 was diagnosed in LTx recipients, most of them not severe cases. The most common immunosuppressive management included a decreased dose or pausing of the cell cycle inhibitors. Remdesivir, hydroxychloroquine, and azithromycin were the most proposed antiviral strategies. Most of the centers have been affected by the COVID-19 pandemic and proposed an active therapeutic strategy to treat LTx recipients with COVID-19.