Antibiotic audit in medicine intensive care unit of tertiary care centre: A must do exercise

PurposeAntimicrobial resistance (AMR) is a serious threat to the humanity now a days. To prevent it, the first step is to know about our antibiotic practices. Audit is the first step in continuous quality improvement which intend to go ahead. Antibiotic stewardship involves appropriate antibiotic (empirical or definitive) at correct time in correct doses and frequency for appropriate duration.MethodWe conducted a retrospective study in intensive care unit at our tertiary care center of Bihar, India. Our aim was to know about empirical antibiotic we are prescribing in suspected sepsis patients and their rationality too. National treatment guidelines for infectious disease released by National Centre for Disease Control (NCDC) was taken as standard of care. We recorded demographic profile, SOFA (Sequential Organ Failure Assessment), APACHE II (Acute Physiology and Chronic Health Evaluation), antibiotic prescribed, final etiology of infection, and outcome of the patient and total ICU stay.ResultWe found that combination of two antibiotics were given in majority of patients (53%) and the third generation cephalosporin was the most commonly prescribed antibiotic. In our audit, rational combinations according to the antibiotic policies were given in 73.7% of patients. Appropriate doses of antibiotics were given in 89.5% of patients.ConclusionAudit is a mandatory exercise to provide quality care in the health care system.     

Impact of time to antibiotic therapy on clinical outcome in patients with bacterial infections in the emergency department: implications for antimicrobial stewardship

BackgroundRapid initiation of antibiotic treatment is considered crucial in patients with severe infections such as septic shock and bacterial meningitis, but may not be as important for other infectious syndromes. A better understanding of which patients can tolerate a delay in start of therapy is important for antibiotic stewardship purposes.ObjectivesTo explore the existing evidence on the impact of time to antibiotics on clinical outcomes in patients presenting to the emergency department (ED) with bacterial infections of different severity of illness and source of infection.SourcesA literature search was performed in the PubMed/MEDLINE database using combined search terms for various infectious syndromes (sepsis/septic shock, bacterial meningitis, lower respiratory tract infections, urinary tract infections, intra-abdominal infections and skin and soft tissue infections), time to antibiotic treatment, and clinical outcome.ContentThe literature search generated 8828 hits. After screening titles and abstracts and assessing potentially relevant full-text papers, 60 original articles (four randomized controlled trials, 43 observational studies) were included. Most articles addressed sepsis/septic shock, while few studies evaluated early initiation of therapy in mild to moderate disease. The lack of randomized trials and the risk of confounding factors and biases in observational studies warrant caution in the interpretation of results. We conclude that the literature supports prompt administration of effective antibiotics for septic shock and bacterial meningitis, but there is no clear evidence showing that a delayed start of therapy is associated with worse outcome for less severe infectious syndromes.ImplicationsFor patients presenting with suspected bacterial infections, withholding antibiotic therapy until diagnostic results are available and a diagnosis has been established (e.g. by 4–8 h) seems acceptable in most cases unless septic shock or bacterial meningitis are suspected. This approach promotes the use of ecologically favourable antibiotics in the ED, reducing the risks of side effects and selection of resistance.     

Exposure to World Health Organization's AWaRe antibiotics and isolation of multidrug resistant bacteria: a systematic review and meta-analysis

BackgroundAntibiotic use drives antibiotic resistance.ObjectivesTo systematically review the literature and estimate associations between prior exposure to antibiotics across World Health Organization's (WHO) AWaRe categories (Access, Watch, Reserve) and isolation of critical and high-priority multidrug resistant organisms (MDROs) on the WHO priority pathogen list.Data SourcesEmbase, Ovid Medline, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov (from inception to 20/08/2020).Study eligibility criteriaCase-control, cohort, or experimental studies that assessed the risk of infection/colonization with MDROs.ParticipantsInpatients or outpatients of any age and sex.InterventionsPrior exposure to antibiotics that could be categorized into the AWaRe framework.Data analysisTailored design-specific checklists applied to each included study. For each antibiotic/class, crude odds ratios (ORs) were pooled through random-effects meta-analyses, both overall and by MDRO. Heterogeneity was examined.ResultsWe identified 349 eligible studies. All were observational, prone to bias due to design and lack of adjustment for confounding, and not primarily designed to compare associations across AWaRe categories. We found statistically significant associations between prior exposure to almost all antibiotics/classes across AWaRe categories and colonization/infection with any MDRO. We observed higher ORs for Watch and Reserve antibiotics than with Access antibiotics. First generation cephalosporins (Access) had the least association with any MDRO colonization/infection (58 studies; OR = 1.2 [95% CI: 1.0–1.4]), whereas strongest associations were estimated for linezolid (Reserve) (22 studies; OR = 2.6 [95% CI: 2.1–3.1]), followed by carbapenems (Watch) (237 studies; OR = 2.3 [95% CI: 2.1–2.5]). There was high heterogeneity for all antibiotic/MDRO associations.ConclusionsOptimising use of Access antibiotics is likely to reduce the selection of MDROs and global antibiotic resistance. Despite data limitations, our study offers a strong rationale for further adoption of AWaRe as an important tool to improve antibiotic use globally.     

Short-course antibiotics for common infections: what do we know and where do we go from here?

BackgroundOver the past 25 years, researchers have performed >120 randomized controlled trials (RCTs) illustrating short courses to be non-inferior to long courses of antibiotics for common bacterial infections.ObjectiveWe sought to determine whether clinical data from RCTs affirm the mantra of ‘shorter is better’ for antibiotic durations in 7 common infections: pneumonia, urinary tract infection, intra-abdominal infection, bacteraemia, skin and soft tissue infection, bone and joint infections, pharyngitis and sinusitis.SourcesPublished RCTs comparing short- versus long-course antibiotic durations were identified through searches of PubMed and clinical guideline documents.ContentShort-course antibiotic durations consistently result in similar treatment success rates as longer antibiotic courses among patients with community-acquired pneumonia, complicated urinary tract infections in women, gram-negative bacteraemia, and skin and soft tissue infections when the diagnosis is confirmed, appropriate antimicrobials are used, and patients show clinical signs of improvement. For patients with osteomyelitis, 6 weeks of antibiotics is adequate for the treatment of osteomyelitis in the absence of implanted foreign bodies and surgical debridement. Whether durations can be further shortened with debridement is unclear, although small studies are promising.ImplicationsWith few exceptions, short courses were non-inferior to long courses; future research should focus on appropriately defining the patient population, ensuring the correct choice and dose of antimicrobials and developing meaningful outcomes relevant for frontline clinicians.     

Appropriate antibiotic therapy is a predictor of outcome in patients with Stenotrophomonas maltophilia blood stream infection in the intensive care unit

Background/purposeThe study was to assess the relationship between antibiotic therapy and the outcome in intensive care unit (ICU) patients with Stenotrophomonas maltophilia bloodstream infection (BSI).MethodsICU patients with monomicrobial S. maltophilia BSI from January 2004 to December 2019 were included and divided into two groups—those with- and without appropriate antibiotic therapy after BSI—for comparison. The primary outcome was the relationship between appropriate antibiotic therapy and 14-day mortality. The secondary outcome was the influence of different antibiotic therapies: levofloxacin- and trimethoprim–sulfamethoxazole (TMP/SMX)-containing regimens, on 14-day mortality.ResultsA total of 214 ICU patients were included. Patients received appropriate antibiotic therapy (n = 133) after BSI had a lower 14-day mortality than those (n = 81) without appropriate antibiotic therapy (10.5% vs. 46.9%, p < 0.001). No difference on 14-day mortality between groups of patients by time of appropriate antibiotic therapy was observed (p > 0.05). After a propensity score matching, the results is consistent that 14-day mortality were lower in patients with appropriate antibiotic therapy than those without appropriate antibiotic therapy (11.5% vs. 39.3%, p < 0.001). Among patients with S. maltophilia BSI receiving appropriate antibiotic therapy, there was a trend levofloxacin-containing regimens is associated with lower mortality than TMP/SMX-containing regimens (HR 0.233, 95% CI 0.050–1.084, p = 0.063).ConclusionAppropriate antibiotic therapy was associated with decreased 14-day mortality in ICU patients with S. maltophilia BSI regardless of time. Levofloxacin-containing regimens may be better choice than TMP/SMX -containing regimens in treating ICU patients with S. maltophilia BSI.     

Effect of discontinuation of an antimicrobial stewardship programme on the antibiotic usage pattern

ObjectivesThis study aimed to analyse the effect of discontinuation of antimicrobial stewardship programme (ASP) activity on the usage pattern of antibiotics.MethodsAn interrupted time-series analysis assessing the trends in antibiotic use was conducted between September 2015 and August 2019 in an 859-bed university-affiliated hospital in Korea, where all ASP activities were discontinued in March 2018. The major activity of the ASP was a restrictive antibiotic programme.ResultsThe use of restrictive antibiotics increased immediately after the discontinuation of the ASP by 41.06 days of therapy (DOT)/1000 patient-days in the general ward (95% confidence interval (CI) 21.04–61.08) and by 391.04 DOT/1000 patient-days in the intensive care unit (ICU) (95%CI 207.56–574.51). In addition, there were positive changes in the slope for the use of restrictive antibiotics in the general ward (7.06 DOT/1000 patient-days per month, 95%CI 4.63–9.50) and ICU (35.95 DOT/1000 patient-days per month, 95%CI 18.70–53.19). The use of broad-spectrum antibiotics in the general ward significantly decreased (–87.54 DOT/1000 patient-days, 95%CI –149.29 to –25.79). For non-broad-spectrum antibiotics, there were positive changes in the slope in the general ward (16.54 DOT/1000 patient-days per month, 95%CI 12.99–20.09) and ICU (12.85 DOT/1000 patient-days per month, 95%CI 2.32–23.38).ConclusionsAfter discontinuation of the ASP, antibiotic usage patterns rapidly returned to the patterns prior to the implementation of the programme.     

Concurrent systemic antibiotics at catheter insertion and intravascular catheter-related infection in the ICU: a post hoc analysis using individual data from five large RCTs

ObjectivesData on the impact of systemic antibiotics at the time of catheter insertion are scarce. Therefore, we assessed the association between concurrent antibiotic administration at insertion and short-term catheter-related infections.MethodsWe used individual data gathered from five large, randomized, controlled ICU trials. We analysed adult patients who required arterial, short-term central venous or dialysis catheter insertion in the ICU. The effect of antibiotics at insertion on major catheter-related infection (MCRI), catheter-related bloodstream infection (CRBSI) and colonization was estimated using multivariate marginal Cox and propensity score models.ResultsWe included 10 269 patients and 18 743 catheters from 36 ICUs. Antibiotic use was ongoing at the time of 11 361 catheter insertions (60.6%). After adjusting for well-known risk factors for intravascular catheter infection, we observed a similar risk for MCRI (HR 0.83, 95%CI 0.62–1.10, p 0.19) and CRBSI (HR 0.85, 95%CI 0.60–1.22, p 0.38) between the antibiotic and no-antibiotic groups. A confirmatory analysis using propensity score showed consistent results. No specific antibiotic subclasses reduced the risk of MCRI. Non-fermenting Gram-negative bacilli were more frequently observed in the antibiotic group.ConclusionsOngoing antibiotic administration at the time of catheter insertion was not associated with a decrease risk of catheter-related infections and should not be carried out for preventing such infections. Our results bring new insights to antimicrobial stewardship in critically ill patients and may direct empirical antimicrobial therapy if an intravascular catheter infection is suspected.     

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.     

Predictors and microbiology of respiratory and bloodstream bacterial infection in patients with COVID-19: living rapid review update and meta-regression

BackgroundThe prevalence of bacterial infection in patients with COVID-19 is low, however, empiric antibiotic use is high. Risk stratification may be needed to minimize unnecessary empiric antibiotic use.ObjectiveTo identify risk factors and microbiology associated with respiratory and bloodstream bacterial infection in patients with COVID-19.Data sourcesWe searched MEDLINE, OVID Epub and EMBASE for published literature up to 5 February 2021.Study eligibility criteriaStudies including at least 50 patients with COVID-19 in any healthcare setting.MethodsWe used a validated ten-item risk of bias tool for disease prevalence. The main outcome of interest was the proportion of COVID-19 patients with bloodstream and/or respiratory bacterial co-infection and secondary infection. We performed meta-regression to identify study population factors associated with bacterial infection including healthcare setting, age, comorbidities and COVID-19 medication.ResultsOut of 33 345 studies screened, 171 were included in the final analysis. Bacterial infection data were available from 171 262 patients. The prevalence of co-infection was 5.1% (95% CI 3.6–7.1%) and secondary infection was 13.1% (95% CI 9.8–17.2%). There was a higher odds of bacterial infection in studies with a higher proportion of patients in the intensive care unit (ICU) (adjusted OR 18.8, 95% CI 6.5–54.8). Female sex was associated with a lower odds of secondary infection (adjusted OR 0.73, 95% CI 0.55–0.97) but not co-infection (adjusted OR 1.05, 95% CI 0.80–1.37). The most common organisms isolated included Staphylococcus aureus, coagulase-negative staphylococci and Klebsiella species.ConclusionsWhile the odds of respiratory and bloodstream bacterial infection are low in patients with COVID-19, meta-regression revealed potential risk factors for infection, including ICU setting and mechanical ventilation. The risk for secondary infection is substantially greater than the risk for co-infection in patients with COVID-19. Understanding predictors of co-infection and secondary infection may help to support improved antibiotic stewardship in patients with COVID-19.     

Ignorance of pre-ED healthcare setting is a factor leading to inappropriate initial antibiotic treatment of sepsis in ED and poor outcomes in ICU

ObjectivesAppropriate initial antibiotic therapy is critical for successfully treating sepsis. In the emergency department (ED), clinicians often rely on septic symptoms to guide empirical therapy. The aim of this study was to investigate whether history of contacting pre-ED healthcare setting is easy to be neglected and whether the patients received more inappropriate initial antibiotic therapy and developed poorer outcomes.MethodsSeptic patients (n = 453) admitted from ED to the intensive care unit (ICU) between 2014 and 2017 were retrospectively selected. Appropriate antibiotic treatment or not was determined by checking whether the selected antibiotics can effectively eradicate the bacteria identified. Various indexes were compared between patients with appropriate and inappropriate initial antibiotic treatments, including septic symptoms (qSOFA scores) in ED, septic-severity change in ICU (SOFA-score ratios), and septic outcomes (APACHE II scores, stay length, 30-day survival probability). These indexes were also compared between pre-ED healthcare and pre-ED community patients.ResultsIn comparison with pre-ED community patients, pre-ED healthcare patients received more inappropriate initial antibiotic treatment in ED, showing poorer outcomes in ICU, including septic severity, stay-lengths in ICU and 30-day survival probabilities. Pre-ED settings is more significant than qSOFA scores to predict the inappropriate initial antibiotic treatment.ConclusionsPre-ED healthcare settings, which are indexes for infection with antibiotic resistant pathogens, are easy to be neglected in the first hour in ED. We suggested that standard operating procedure for getting enough information of pre-ED settings should be incorporated to the 1 h bundle of sepsis guideline.     

What is the evidence base of used aggregated antibiotic resistance percentages to change empirical antibiotic treatment? A scoping review

ObjectivesAntibiotic resistance requires continuous monitoring by experts to decide whether empirical antibiotic therapies (EATs) should be replaced by alternative antibiotics. The exact moment and criteria for this change are unclear and generally based on consensus between experts. This scoping review aims to identify from the literature the resistance thresholds used for a change in EAT and the criteria on which they are based.MethodsScoping review for which a comprehensive structured literature search was conducted. Rayyan, software for systematic reviews, was used for the screening of abstracts and titles. Data sources were Pubmed and a hand-search of reference lists and grey literature. Papers were eligible if they concerned any type of bacterial infectious disease and mentioned or defined antibiotic resistance thresholds for decision-making purposes for EAT. The inclusion and analysis of articles was done by two researchers; any conflicts were resolved through discussion or by consulting a third reviewer.ResultsWe identified 3146 unique papers. Following title/abstract screening, 125 papers were comprehensively read, and 16 papers were included. The included papers gave thresholds for urinary tract infections, respiratory tract infections, meningitis, skin and soft tissue infections, gonorrhoea, and bone and joint infections. Six criteria were found that were commonly used to base the thresholds on. These were: disease severity, efficacy of treatment, adverse drug events, risk of Clostridioides difficile infection, costs, and increased resistance. The number of criteria used to define each threshold varied from one to six between papers.ConclusionsThe thresholds used for EATs are few, commonly based on expert opinion estimates, and can therefore have broad ranges. Used criteria underlying reported thresholds are heterogenous and require standardization. Considering the rising trend in resistance, there is a clear need for rigid tools to determine thresholds in order to support guideline development with the best and timely evidence.     

Utility of prior cultures in predicting antibiotic resistance of bloodstream infections due to Gram-negative pathogens: a multicentre observational cohort study

ObjectivesAppropriate empiric antibiotic therapy in patients with bloodstream infections due to Gram-negative pathogens can improve outcomes. We evaluated the utility of prior microbiologic results for guiding empiric treatment in Gram-negative bloodstream infections.MethodsWe conducted a multicentre observational cohort study in two large health systems in Canada and the United States, including 1832 hospitalized patients with Gram-negative bloodstream infection (community, hospital and intensive care unit acquired) from April 2010 to March 2015.ResultsAmong 1832 patients with Gram-negative bloodstream infection, 28% (n = 504) of patients had a documented prior Gram-negative organism from a nonscreening culture within the previous 12 months. A most recent prior Gram-negative organism resistant to a given antibiotic was strongly predictive of the current organism's resistance to the same antibiotic. The overall specificity was 0.92 (95% confidence interval (CI) 0.91–0.93), and positive predictive value was 0.66 (95% CI 0.61–0.70) for predicting antibiotic resistance. Specificities and positive predictive values ranged from 0.77 to 0.98 and 0.43 to 0.78, respectively, across different antibiotics, organisms and patient subgroups. Increasing time between cultures was associated with a decrease in positive predictive value but not specificity. An heuristic based on a prior resistant Gram-negative pathogen could have been applied to one in four patients and in these patients would have changed therapy in one in five.ConclusionsIn patients with a bloodstream infection with a Gram-negative organism, identification of a most recent prior Gram-negative organism resistant to a drug of interest (within the last 12 months) is highly specific for resistance and should preclude use of that antibiotic.     

Evaluation of antibiotic use in Pediatric Intensive Care Unit of a developing country

Background:Pediatric Intensive Care Unit (PICU) patients are often prescribed antibiotics with a low threshold in comparison to patients elsewhere. Irrational antibiotics use can lead to rapid emergence of drug resistance, so surveillance of their use is important.Objectives:To evaluate the use of antibiotics in relation to bacteriological findings in PICU of a Tertiary Hospital.Methods:Retrospective review of medical records of all children (age 1 month–16 years) admitted in our closed multidisciplinary-cardiothoracic PICU from January to June 2013 was performed, after approval from Ethical Review Committee. For each antibiotic, indication (prophylactic, empiric, therapeutic) and duration of use were recorded. All diagnoses of infections were recorded according to diagnostic criteria of IPSCC 2005. Results are presented as frequency and percentages and median with inter quartile range using SPSS version 19.Results:All of the total 240 patients admitted in PICU during the study period received antibiotics: 43% (n = 104) prophylactically, 42% (n = 102) empirically, and 15% (n = 15) therapeutically. Median number of antibiotic use per patient in PICU was 3, with range of 1–7. 25% received 1 antibiotic, 23% received 2 antibiotics, 29% received 3 antibiotics, and rest received ≥4 antibiotics. Most commonly used antibiotics were cefazolin, meropenem, vancomycin and ceftriaxone, and most frequently used combination was meropenem and vancomycin. In majority of the cases, (70%) empiric antibiotic combinations were stopped in 72 h.Conclusion:This is the first report of antibiotics use in PICU from our country, which shows that antibiotics are prescribed universally in our PICU. Strategies to assess the need for antibiotic use are needed.     

Microbiology of bile in extrahepatic biliary obstruction: A tropical experience

PurposeBile is considered sterile, but in obstructed biliary system, growth of micro-organisms results in bacteraemia and toxaemia. We analysed bacterial profile of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and evaluated antibiotic resistance patterns to formulate strategy for antibiotics in patients undergoing ERCP.Materials and methodsPatients with cholestasis who underwent ERCP were enrolled. Bile, collected aseptically, was cultured. Positive cultures were processed for isolate identification and antibiotic susceptibility.ResultsOne hundred and sixty-three patients (78 females; mean age – 55.1 ± 15.8 years) were enrolled and divided into two groups: Group I (n = 99) were naïve and Group II (n = 64) had undergone ERCP and stenting previously. Positive culture was seen in 68.1% (n = 111) with monomicrobial growth in 74.8% (n = 83) and poly-microbial growth in 25.2% (n = 28). Culture positivity was common in Group II vis-a-vis Group I (84.4% vs. 57.5%). Poly-microbial growth was significantly more common in Group II (35.2% vs. 15.8%, P = 0.028). Gram-negative bacilli were the predominant organisms isolated with Escherichia coli, Pseudomonas aeruginosa and Klebsiella pneumoniae comprising 70% of the isolates. The most sensitive antibiotics were piperacillin-tazobactam and imipenem. The sensitivity of vancomycin, against Enterococcus spp. was in the range of 60%–70%.ConclusionCholestasis leads to bacterial colonisation in most cases, regardless of the presence of a biliary stent. Biliary stent however predisposes to a polymicrobial growth. Most of the commonly used antibiotics continue to have significant sensitivity and may be used empirically. However, previously stented patients may have a higher incidence of infection with Enterococcus spp. and may require specific therapy.     

Antibiotics: easier to start than to stop? Predictors of antimicrobial stewardship recommendation acceptance

ObjectivesAcceptance of prospective audit and feedback antimicrobial stewardship programme (ASP) recommendations has been shown to vary, but the drivers of recommendation acceptance are not well understood. We sought to identify the factors associated with recommendation acceptance at a large community teaching hospital.MethodsData from an ASP recommendation registry were collected from 2010 to 2018. Variables included data about the infection, the prescriber, and the recommendation, categorized by whether they increase, decrease, or are neutral to antibiotic exposure. The primary outcome was acceptance of ASP recommendations. Adjusted odds ratios and 95% confidence intervals were estimated using logistic regression models with random intercepts in order to account for clustering by prescriber.ResultsOver the 8-year period, a total of 11 014 evaluable recommendations were made to 146 prescribers, and 9058 (82.2%) were accepted. The most common recommendations were: reduce duration (n = 2796; 25%), stop antibiotics (n = 2184; 20%), de-escalate (n = 1876; 17%) and increase duration (n = 1176; 11%). Acceptance by service ranged from 70% (n = 843/1196) (surgery) to 86% (n = 6378/7444) (general medicine). In the multivariable analysis, compared to recommendations that have a neutral impact on antibiotic exposure, recommendations to decrease antibiotic exposure had lower odds of acceptance (aOR 0.73; 95%CI 0.64–0.84) while recommendations to increase exposure were associated with greater acceptance (aOR 2.00; 95%CI 1.62–2.45). Other factors associated with increased acceptance included the presence of the ASP physician during rounds and making the recommendation verbally.ConclusionsRecommendations to decrease antibiotic exposure had lower odds of acceptance than those to increase antibiotic exposure. This study presents important considerations for ASPs with prospective audit and feedback programmes aiming to evaluate and increase the impact of their recommendations.     

A systematic review and meta-analysis on the antibiotic resistance of Neisseria meningitidis in the last 20 years in the world

BackgroundNeisseria meningitidis is one of the most important causes of meningitis and pathogens-associated deaths in developing and developed countries. Effective anti-microbial agents are pivotal to treat and control N. meningitidis infections. The aim of the present study was to systematically review published studies on the antibiotic resistance of N. meningitidis in the last 20 years (2000–2020) in the world.MethodsPublished researches were identified through a literature search using reputable databases including PubMed, Scopus, and Web of Science. Finally, 24 studies were included for a random-effects model meta-analysis.ResultsThe overall resistance to most commonly used antibiotics such as ceftriaxone, cefotaxime, ciprofloxacin and rifampin was low, ranging from 1 to 3.4%. However, non-sensitivity to penicillin, as the first-line antibiotic against N. meningitidis, was higher (27.2%). Altogether, the resistance to the first-line antibiotics (except penicillin) is still low indicating these drugs are effective against meningococcal meningitis. We also found a significant gap between MIC and disk diffusion for evaluating resistance to antibiotics in which disk diffusion overestimate the resistance rate.ConclusionsTo properly management and prevent the spread of N. miningitidis isolates resistant antibiotics, it is necessary to monitor the pattern of antibiotic susceptibility regionally and globally using the MIC methods.     

The effect of preoperative oral antibiotic use on the risk of periprosthetic joint infection after primary knee or hip replacement: a retrospective study with a 1-year follow-up

ObjectivesAntibiotics are used for various reasons before elective joint replacement surgery. The aim of this study was to investigate patients' use of oral antibiotics before joint replacement surgery and how this affects the risk for periprosthetic joint infection (PJI).MethodsPatients having a primary hip or knee replacement in a tertiary care hospital between September 2002 and December 2013 were identified (n = 23 171). Information on oral antibiotic courses purchased 90 days preoperatively and patients' chronic diseases was gathered. Patients with a PJI in a 1-year follow-up period were identified. The association between antibiotic use and PJI was examined using a multivariable logistic regression model and propensity score matching.ResultsOne hundred and fifty-eight (0.68%) cases of PJI were identified. In total, 4106 (18%) joint replacement operations were preceded by at least one course of antibiotics. The incidence of PJI for patients with preoperative use of oral antibiotics was 0.29% (12/4106), whereas for patients without antibiotic use it was 0.77% (146/19 065). A preoperative antibiotic course was associated with a reduced risk for subsequent PJI in the multivariable model (OR 0.40, 95% CI 0.22–0.73). Similar results were found in the propensity score matched material (OR 0.34, 95% CI 0.18–0.65).ConclusionsThe use of oral antibiotics before elective joint replacement surgery is common and has a potential effect on the subsequent risk for PJI. Nevertheless, indiscriminate use of antibiotics before elective joint replacement surgery cannot be recommended, even though treatment of active infections remains an important way to prevent surgical site infections.