Investigating the impact of COVID-19 on primary care antibiotic prescribing in North West London across two epidemic waves

ObjectivesWe investigated the impact of COVID-19 and national pandemic response on primary care antibiotic prescribing in London.MethodsIndividual prescribing records between 2015 and 2020 for 2 million residents in north west London were analysed. Prescribing records were linked to SARS-CoV-2 test results. Prescribing volumes, in total, and stratified by patient characteristics, antibiotic class and AWaRe classification, were investigated. Interrupted time series analysis was performed to detect measurable change in the trend of prescribing volume since the national lockdown in March 2020, immediately before the first COVID-19 peak in London.ResultsRecords covering 366 059 patients, 730 001 antibiotic items and 848 201 SARS-CoV-2 tests between January and November 2020 were analysed. Before March 2020, there was a background downward trend (decreasing by 584 items/month) in primary care antibiotic prescribing. This reduction rate accelerated to 3504 items/month from March 2020. This rate of decrease was sustained beyond the initial peak, continuing into winter and the second peak. Despite an overall reduction in prescribing volume, co-amoxiclav, a broad-spectrum “Access” antibiotic, prescribing rose by 70.1% in patients aged 50 and older from February to April. Commonly prescribed antibiotics within 14 days of a positive SARS-CoV-2 test were amoxicillin (863/2474, 34.9%) and doxycycline (678/2474, 27.4%). This aligned with national guidelines on management of community pneumonia of unclear cause. The proportion of “Watch” antibiotics used decreased during the peak in COVID-19.DiscussionA sustained reduction in community antibiotic prescribing has been observed since the first lockdown. Investigation of community-onset infectious diseases and potential unintended consequences of reduced prescribing is urgently needed.     

Antibiotic resistance associated with the COVID-19 pandemic: a systematic review and meta-analysis

BackgroundCOVID-19 and antimicrobial resistance (AMR) are two intersecting global public health crises.ObjectiveWe aimed to describe the impact of the COVID-19 pandemic on AMR across health care settings.Data sourceA search was conducted in December 2021 in WHO COVID-19 Research Database with forward citation searching up to June 2022.Study eligibilityStudies evaluating the impact of COVID-19 on AMR in any population were included and influencing factors were extracted. Reporting of enhanced infection prevention and control and/or antimicrobial stewardship programs was noted.MethodsPooling was done separately for Gram-negative and Gram-positive organisms. Random-effects meta-analysis was performed.ResultsOf 6036 studies screened, 28 were included and 23 provided sufficient data for meta-analysis. The majority of studies focused on hospital settings (n = 25, 89%). The COVID-19 pandemic was not associated with a change in the incidence density (incidence rate ratio 0.99, 95% CI: 0.67–1.47) or proportion (risk ratio 0.91, 95% CI: 0.55–1.49) of methicillin-resistant Staphylococcus aureus or vancomycin-resistant enterococci cases. A non-statistically significant increase was noted for resistant Gram-negative organisms (i.e. extended-spectrum beta-lactamase, carbapenem-resistant Enterobacterales, carbapenem or multi-drug resistant or carbapenem-resistant Pseudomonas aeruginosa or Acinetobacter baumannii, incidence rate ratio 1.64, 95% CI: 0.92–2.92; risk ratio 1.08, 95% CI: 0.91–1.29). The absence of reported enhanced infection prevention and control and/or antimicrobial stewardship programs initiatives was associated with an increase in gram-negative AMR (risk ratio 1.11, 95% CI: 1.03–1.20). However, a test for subgroup differences showed no statistically significant difference between the presence and absence of these initiatives (p 0.40).ConclusionThe COVID-19 pandemic may have hastened the emergence and transmission of AMR, particularly for Gram-negative organisms in hospital settings. But there is considerable heterogeneity in both the AMR metrics used and the rate of resistance reported across studies. These findings reinforce the need for strengthened infection prevention, antimicrobial stewardship, and AMR surveillance in the context of the COVID-19 pandemic.     

应急能力培训课程设置及模式在急诊科新护士培训中的研究

目的 为了提高急诊科新护士应急能力,在课程设置及模式方面进行尝试。方法 制定培训目标,采用理论讲授,结合实践操作训练,并采用多种教学模式相结合的培训方法。结果 对急诊科新护士建立“以岗位胜任力”为重要评价结果的考试考核评价体系,对综合培训形式的过程及结果等进行针对性评价。结论 让新护士从被动接受培训到主动参与,激发其学习的积极性,帮助其自觉完成培训计划,最终使其达到职业素养、专业知识、专科技能的全面提升。     

The effectiveness of information technology to improve antimicrobial prescribing in hospitals: A systematic review and meta-analysis

ObjectiveTo review evidence of the effectiveness of information technology (IT) interventions to improve antimicrobial prescribing in hospitals.MethodMEDLINE (1950-March 2015), EMBASE (1947-March 2015) and PubMED (1966-March 2015) were searched for studies where an IT intervention involving any device (e.g. computer, mobile phone) was evaluated in practice. All papers were assessed for quality using a 10-point rating scale.ResultsWe identified 45 articles that evaluated an IT intervention to improve antimicrobial prescribing in hospitals. IT interventions took four main forms: (1) stand-alone computerized decision support systems (CDSSs), (2) decision support embedded within a hospital’s electronic medical record (EMR) or computerized provider order entry (CPOE) system, (3) computerized antimicrobial approval systems (cAAS), and (4) surveillance systems (SSs). Results reported allowed us to perform meta-analyses for three outcome measures: appropriate use of antimicrobials, patient mortality and hospital length of stay (LOS). IT interventions increased appropriate use of antimicrobials (pooled RR: 1.49, 95%CI: 1.07–2.08); however no evidence of an effect was found when analysis included only studies with a quality score of five or above on the 10-point quality scale (pooled RR: 1.53, 95%CI: 0.96–2.44). There was little evidence of an effect of IT interventions on patient mortality or LOS. The range of study designs and outcome measures prevented meaningful comparisons between different IT intervention types to be made.ConclusionIT interventions can improve the appropriateness of antimicrobial prescribing. However, high quality, systematic multi-site comparative studies are critically needed to assist organizations in making informed decisions about the most effective IT interventions.     

Antimicrobial stewardship in the emergency department: characteristics and evidence for effectiveness of interventions

BackgroundEmergency departments (EDs) are the entrance gates for patients presenting with infectious diseases into the hospital, yet most antimicrobial stewardship programmes are primarily focused on inpatient management. With equally high rates of inappropriate antibiotic use, the ED is a frequently overlooked yet important unit for targeted antimicrobial stewardship (AMS) interventions.ObjectivesWe aimed to (a) describe the specific aspects of antimicrobial stewardship in the ED and (b) summarize the findings from improvement studies that have investigated the effectiveness of antimicrobial stewardship interventions in the ED setting.Sources: (a) a PubMed search for ‘antimicrobial stewardship’ and ‘emergency department’, and (b) published reviews on effectiveness combined with publications from the first source.Content: (a) An in depth analysis of selected publications provided four key antimicrobial use processes typically performed by front-line healthcare professionals in the ED: making a (tentative) clinical diagnosis, starting empirical therapy based on that diagnosis, performing microbiological tests before starting that therapy and following up patients who are discharged from the ED. (b) Further, we discuss the literature on improvement strategies in the ED focusing on guidelines and clinical pathways and multifaceted improvement strategies. We also summarize the evidence of microbiologic culture review.Implications: Based on our review of the literature, we describe four essential elements of antimicrobial use in the ED. Studying the various interventions targeting these care processes, we have found them to be of a variable degree of success. Nonetheless, while there is a paucity of AS studies specifically targeting the ED, there is a growing body of evidence that AS programmes in the ED are effective with modifications to the ED setting. We present key questions for future research.     

Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis

BackgroundThe proportion of patients infected with SARS-CoV-2 that are prescribed antibiotics is uncertain, and may contribute to patient harm and global antibiotic resistance.ObjectiveThe aim was to estimate the prevalence and associated factors of antibiotic prescribing in patients with COVID-19.Data SourcesWe searched MEDLINE, OVID Epub and EMBASE for published literature on human subjects in English up to June 9 2020.Study Eligibility CriteriaWe included randomized controlled trials; cohort studies; case series with ≥10 patients; and experimental or observational design that evaluated antibiotic prescribing.ParticipantsThe study participants were patients with laboratory-confirmed SARS-CoV-2 infection, across all healthcare settings (hospital and community) and age groups (paediatric and adult).MethodsThe main outcome of interest was proportion of COVID-19 patients prescribed an antibiotic, stratified by geographical region, severity of illness and age. We pooled proportion data using random effects meta-analysis.ResultsWe screened 7469 studies, from which 154 were included in the final analysis. Antibiotic data were available from 30 623 patients. The prevalence of antibiotic prescribing was 74.6% (95% CI 68.3–80.0%). On univariable meta-regression, antibiotic prescribing was lower in children (prescribing prevalence odds ratio (OR) 0.10, 95% CI 0.03–0.33) compared with adults. Antibiotic prescribing was higher with increasing patient age (OR 1.45 per 10 year increase, 95% CI 1.18–1.77) and higher with increasing proportion of patients requiring mechanical ventilation (OR 1.33 per 10% increase, 95% CI 1.15–1.54). Estimated bacterial co-infection was 8.6% (95% CI 4.7–15.2%) from 31 studies.ConclusionsThree-quarters of patients with COVID-19 receive antibiotics, prescribing is significantly higher than the estimated prevalence of bacterial co-infection. Unnecessary antibiotic use is likely to be high in patients with COVID-19.     

Antibiotic prescribing practices in three neonatology units in Kigali,Rwanda. – an observational study

IntroductionThere is limited published data on antibiotic use in neonatal units in resource-poor settings.ObjectivesThis study sought to describe antibiotic prescribing practices in three neonatology units in Kigali, Rwanda.MethodsA multi-center, cross-sectional study conducted in two tertiary and one urban district hospital in Kigali, Rwanda. Participants were neonates admitted in neonatology who received a course of antibiotics during their admission. Data collected included risk factors for neonatal sepsis, clinical signs, symptoms, investigations for neonatal sepsis, antibiotics prescribed, and the number of deaths in the included cohort.Results126 neonates were enrolled with 42 from each site. Prematurity (38%) followed by membrane rupture more than 18 hours (25%) were the main risk factors for neonatal sepsis. Ampicillin and Gentamicin (85%) were the most commonly used first-line antibiotics for suspected neonatal sepsis. Most neonates (87%) did not receive a second-line antibiotic. Cefotaxime (11%), was the most commonly used second-line antibiotic. The median duration of antibiotic use was four days in all surviving neonates (m=113). In neonates with negative blood culture and normal C-reactive protein (CRP), the median duration of antibiotics was 3.5 days; and for neonates, with positive blood cultures, the median duration was 11 days. Thirteen infants died (10%) at all three sites, with no significant difference between the sites.ConclusionThe median antibiotic duration for neonates with normal lab results exceeded the recommended duration mandated by the national neonatal protocol. We recommend the development of antibiotic stewardship programs in neonatal units in Rwanda to prevent the adverse effects which may be caused by inappropriate or excessive use of antibiotics.     

Analysis of the Impact of the Coronavirus Disease Epidemic on the Emergency Medical System in South Korea Using the Korean Triage and Acuity Scale

PurposeSevere acute respiratory syndrome coronavirus 2, which causes coronavirus disease 2019 (COVID-19), has spread worldwide. Global health systems, including emergency medical systems, are suffering from a lack of medical resources. Using a method for classifying patients visiting the emergency department (ED), we aimed to investigate trends in emergency medical system usage during the COVID-19 epidemic in Korea.Materials and MethodsThis retrospective observational study included patients who visited emergency medical institutions registered with the National Emergency Department Information System database from January 1, 2017 to May 31, 2020. The primary outcome was identification of changes in the distribution of patients visiting the ED according to the type of emergency medical institution. The secondary outcome was a detailed comparison of Korean Triage and Acuity Scale (KTAS) levels and patient distributions before and during the infectious disaster crisis period.ResultsSevere patients visited regional emergency centers (RECs) and local emergency centers (LECs) more frequently during the COVID-19 period, and disposition status warranting admission to the intensive care unit or resulting in death was more common in RECs and LECs during the COVID-19 period [RECs, before COVID-19: 300686 (6.3%), during COVID-19: 33548 (8.0%) (p<0.001); LECs, before COVID-19: 373593 (3.7%), during COVID-19: 38873 (4.5%) (p<0.001)].ConclusionDuring the COVID-19 period, severe patients were shifted to advanced emergency medical institutions, and the KTAS better reflected severe patients. Patient distribution according to the stage of emergency medical institution improved, and validation of the KTAS triage increased more in RECs.     

Profile of co-infections & secondary infections in COVID-19 patients at a dedicated COVID-19 facility of a tertiary care Indian hospital: Implication on antimicrobial resistance

BackgroundThe COVID-19 pandemic has raised concerns over secondary infections because it has limited treatment options and empiric antimicrobial treatment poses serious risks of aggravating antimicrobial resistance (AMR). Studies have shown that COVID-19 patients are predisposed to develop secondary infections. This study was conducted to ascertain the prevalence and profiles of co- & secondary infections in patients at the COVID-19 facility in North India.MethodsWe studied the profile of pathogens isolated from 290 clinical samples. Bacterial and fungal pathogens were identified, and antimicrobial susceptibility was determined by the Vitek2® system. Additionally, respiratory samples were tested for any viral/atypical bacterial co-infections and the presence of AMR genes by FilmArray test. The clinical and outcome data of these patients were also recorded for demographic and outcome measures analyses.ResultsA total of 151 (13%) patients had secondary infections, and most got infected within the first 14 days of hospital admission. Patients aged >50 years developed severe symptoms (p = 0.0004) and/or had a fatal outcome (p = 0.0005). In-hospital mortality was 33%.K.pneumoniae (33.3%) was the predominant pathogen, followed by A. baumannii (27.1%). The overall resistance was up to 84%.Majority of the organisms were multidrug-resistant (MDR) harbouring MDR genes.ConclusionA high rate of secondary infections with resistant pathogens in COVID-19 patients highlights the importance of antimicrobial stewardship programs focussing on supporting the optimal selection of empiric treatment and rapid-de-escalation, based on culture reports.     

A New Diagnostic Marker For Acute Pulmonary Embolism In Emergency Department: Mean Platelet Volume

Objective

To investigate the diagnostic importance of mean platelet volume (MPV) on acute pulmonary embolism (APE) in the emergency Department (ED).

Methods

Subjects were selected from patients admitted to ED with clinically suspected APE. Demographic, anthropometric and serologic data were collected for each patient.

Results

A total of 315 consecutive patients were analyzed, including 150 patients (53.44 ± 15.14 y; 92 men/58 women) in APE group and 165 patients (49.80 ±13.76y; 94 men/71 women) in the control group. MPV in the APE group was significantly higher than in the control group (9.42±1.22 fl vs. 8.04±0.89 fl, p<0.0001). The best cut-off values for MPV when predicting APE in patients with clinically suspected APE presenting at the ED were 8.55 fl (sensitivity 82.2%; specificity 52.3%).

Conclusions

MPV is a helpful parameter for the diagnosis of APE in ED, for the first time in the literature.     

Multidrug Resistance: The Growing Menace in PICU

How to cite this article: Kamath SR. Multidrug Resistance: The Growing Menace in PICU. Indian J Crit Care Med 2023;27(1):6–7.     

2014~2017年我院急诊科患者特点分析

目的 分析我院急诊患者分布特点,加强我院急诊科科学管理,为急诊患者提供高效及时的急诊诊疗服务。方法 将2014年1月~2017年12月来我院急诊就诊患者的数据进行整理,分析我院急诊患者就诊特点和规律。结果 急诊患者多在30~59岁;每年1、2月急诊患者较多;每天急诊患者就诊集中在18:00~20:59时段;急诊患者以循环系统疾病、神经系统疾病、呼吸系统疾病、消化系统疾病、外伤为主;急诊死亡以循环系统疾病、神经系统疾病为主。结论 根据急诊患者就诊时间分布,对医院急诊科医护人员及医疗药品设备进行合理的安排和利用,避免因医护人员不足或药品设备提供不及时而产生的差错事故,从而提高急诊科医疗服务质量。     

Antimicrobial consumption in intensive care unit patients at level 1 trauma centre in India

PurposeIncrease in the antimicrobial resistance causes a concern globally. To mitigate the rapidly rising antimicrobial resistance in the health system globally antimicrobial stewardship programs (AMSP) have been advocated. Therefore, we aim to measure aggregate antibiotic consumption by both Defined Daily Dosage (DDD) and Days of Therapy (DOT) methods.MethodsAs a part of Indian Council of Medical Research initiative to develop local AMSP, this prospective study of six months was conducted at a level ?1 Trauma Centre of AIIMS, New Delhi. In this, we have included all the patients of polytrauma and neurosurgical Intensive care units between April to October 2019. Consumption of antibiotics data were collected manually daily by infection control practitioners. Data were presented as Days of Therapy (DOT) and Defined Daily Dose (DDD).ResultsDuring the six months of study, antimicrobial consumption of ICU was compared with empirical therapy v/s culture-based therapy. Overall average antimicrobial consumption for the six months for both empirical therapy and culture-based therapy DDD/1000 patient days was 531.8 and 460.7 whereas DOT/1000 patient days 489.9 and 426.04 respectively.ConclusionsAntimicrobial Stewardship activities aim to ensure judicious consumption of antimicrobials. Such data will be of value in establishing, evaluating and monitoring the function of the AMSP in the healthcare settings.     

Seasonal Patterns of Asthma in Children and Adolescents Presenting at Emergency Departments in Korea

PurposeSeasonal variations in asthma-related hospitalizations and emergency department visits have long been recognized. This study aimed to investigate the seasonal patterns of asthma in children and adolescents who presented at emergency departments in Korea.MethodsWe analyzed the National Emergency Department Information System records from 117 emergency departments in Korea that comprised all of the patients with asthma who were aged 3-18 years and who presented at the emergency departments from 2007 to 2012. The children and adolescents were divided into 3 groups based on their ages, namely, 3-6 years, 7-12 years, and 13-18 years. The data were tabulated, and graphs were created to show the seasonal trends in the monthly numbers of emergency department visits as a consequence of asthma.ResultsA total of 41,128 subjects were identified, and the male-to-female ratio was 1:0.5. General ward admissions comprised 42.6% (n=17,524 patients) of the emergency department visits, and intensive care unit admissions comprised 0.8% (n=335 patients) of the emergency department visits. The monthly numbers of emergency department visits for asthma varied according to the season, with high peaks during fall, which was from September to November, and low levels in summer, which was from June to August.ConclusionsImportant differences in the seasonal patterns of emergency department visits for asthma were evident in children and adolescents. Identifying seasonal trends in asthma-related emergency department visits may help determine the causes and reduce the likelihood of asthma exacerbation.