Knowing when but not how!--mothers' perceptions and use of antibiotics in a rural area of Viet Nam

Given the world-wide focus on how to rationally use antibiotics, national drug policy programmes have been developed in many countries in order to minimize the environmental antibiotic pressure and thereby hopefully limit increasing bacterial resistance. This study investigated perceptions of antibiotics in a health system with weak drug regulation. The study was conducted in two rural communes in Viet Nam, with a drug market characterized by the increased accessibility and consumption of pharmaceuticals. The study focused on rural mothers' perceptions and use of antibiotics in the treatment of acute respiratory infections (ARI) in children 5 years and under. A combination of qualitative and quantitative methods were used including key informant interviews, focus group discussions, and interviews with mothers and drug vendors. The study demonstrated that using a combination of qualitative and quantitative methods gives a better understanding of the prevailing perceptions and use of antibiotics in communities. The results showed that the mothers recognized well the signs of severe ARI and that antibiotics were reserved for more severe illness episodes, where penicillin V and ampicillin were first drugs of choice. However, the mothers' perceptions and use of antibiotics reflects indigenization of antibiotics into traditional Vietnamese thinking and medical practice. This resulted in self-medication and a respect for antibiotics from the mothers' point of view. A first step towards the rational use of antibiotics is already taken where mothers, as the health decision-maker, know when to initiate antibiotic treatment and try to limit unnecessary use of antibiotics. The next step is to develop a well-functioning health education programme in order to promote the correct use of antibiotics for a successful clinical outcome. This requires acknowledgement of the mothers' culture based behaviour.     

鼠疫菌对抗生素的敏感性综合评价

目的 建立鼠疫菌对抗生素敏感性综合评价方法,并用该方法就鼠疫菌对6种抗生素的敏感性进行综合评价。方法 通过查阅文献,收集鼠疫菌对抗生素敏感性实验数据,以抗生素对强毒141菌株、弱毒EV76paris菌株和云南分离菌株的抑菌情况,即抑菌环直径作为评价指标,用层次分析法综合评价鼠疫菌对所选6种抗生素（头孢他啶、氨苄青霉素、头孢唑啉、环丙沙星、诺佛沙星、链霉素）的敏感性。结果 鼠疫菌对不同抗生素的敏感性存在差异,鼠疫菌对所选6种抗生素的敏感性由高到低依次为头孢他啶、氨苄青霉素、头孢唑啉、环丙沙星、诺佛沙星、链霉素,综合评分指数分别为1.730 77、1.631 77、1.581 95、1.567 80、1.449 48、0.999 99。结论 运用层次分析法评价鼠疫菌对不同抗生素的敏感性可以取得合理、客观和较为准确的评价结果,可以利用该方法及其评价结果为进一步筛选适宜的鼠疫治疗药物提供参考依据。     

Combination of oral non-absorbable and intravenous antibiotics versus intravenous antibiotics alone in the prevention of surgical site infections after colorectal surgery: a meta-analysis of randomized controlled trials

Background  

Oral non-absorbable antibiotics work by decreasing intraluminal bacterial content after mechanical bowel preparation. The advantage of adding oral non-absorbable antibiotics to intravenous antibiotics to decrease surgical site infection (SSI) after colorectal surgery is not well known. We conducted a meta-analysis of randomized controlled trials (RCT) comparing the effectiveness of combined oral non-absorbable and intravenous antibiotics versus intravenous antibiotics alone in reducing the incidence of SSI following colorectal surgery.     

Antibiotic prophylaxis for cardiac surgery: current United Kingdom practice.

A questionnaire was sent to 120 United Kingdom cardiac surgeons to ask for information on their use of prophylactic antibiotics in adult cardiac surgical patients. Data on type and duration of antibiotic were specifically sought. The response rate was 91%. All respondents used prophylactic antibiotics: 32% used single agents (second and third generation cephalosporins were the most commonly used) and 68% used either two (89%) or three (11%) antibiotics in combination. The total duration of prophylactic antibiotic treatment was less than 48 hours for 89% of respondents. Single dose antibiotics were used by only 6%. The use of prophylactic antibiotics has changed in the past few years, with a trend away from combinations of antibiotics to single agents. The duration of use of antibiotics has shortened and the use of single dose agents has increased.     

Overcoming Antibiotic Resistance: Playing the ‘Silver Nanobullet’ Card

Enhancing the antibacterial activity of old antibiotics by a multitarget approach, such as combining antibiotics with metal nanoparticles, is a valuable strategy to overcome antibacterial resistance. In this work, the synergistic antimicrobial effect of silver nanoparticles and antibiotics, immobilized on a solid support, was investigated. Nanometric layered double hydroxides (LDH) based on Zn(II) and Al(III) were prepared by the double microemulsion technique. The dual function of LDH as an anionic exchanger and support for metal nanoparticles was exploited to immobilize both silver and antibiotics. Cefazolin (CFZ), a β-lactam, and nalidixic acid (NAL), a quinolone, were selected and intercalated into LDH obtaining ZnAl-CFZ and ZnAl-NAL samples. These samples were used for the growth of silver nanoparticles with dimension ranging from 2.5 to 8 nm. Silver and antibiotics release profiles, from LDH loaded with antibiotics and Ag/antibiotics, were evaluated in two different media: water and phosphate buffer. Interestingly, the release profiles are affected by both the acceptor media and the presence of silver. The synergistic antibacterial activity of LDH containing both silver and antibiotics were investigated on gram-positives (Staphylococcus aureus and Streptococcus pneumoniae) and gram-negatives (Pseudomonas aeruginosa) and compared with the plain antimicrobials and LDH containing only antibiotics or silver.     

Analysis of emergency department management of suspected bacterial meningitis

Previous studies of emergency department management of bacterial meningitis have indicated that there are often long delays before initiation of antibiotics. The purpose of our study was to determine whether these delays were related to specific aspects of patient management. From 1981 through 1988, we retrospectively reviewed the medical records of 122 patients primarily evaluated in the ED and admitted for suspected bacterial meningitis at a university (55) and a community (67) hospital. The median time (interquartile range) from ED registration until initiation of antibiotics (time to antibiotics) was 3.0 hours (1.6 and 4.3 hours, respectively) (total range, 0.5 to 18 hours). The time to antibiotics was not significantly related to the time of ED registration. Ninety percent of the total time to antibiotics occurred after the initial physician encounter. Time to antibiotics was significantly (P less than .00005) longer for patients in whom computed tomography scan and/or laboratory analysis of cerebrospinal fluid preceded initiation of antibiotics compared with patients in whom antibiotic administration was not contingent on the results of these procedures (4.3 [3.2 and 6.0] versus 1.9 [1.2 and 3.4] hours, respectively). Also, time to antibiotics was significantly (P less than .00005) longer for patients in whom antibiotics were initiated on the ward as compared with in the ED (4.5 [3.5 and 6.8] versus 2.2 [1.4 and 3.5] hours, respectively). We conclude that long delays exist in the ED before initiation of antibiotics for cases of suspected bacterial meningitis, and that in general these delays appear to be physician generated and to a great extent potentially avoidable.     

Availability of antibiotics as over-the-counter drugs in pharmacies: a threat to public health in Vietnam

A survey on the use of antibiotics purchased through retail pharmacies was conducted in the Badinh district of Hanoi, Vietnam. The survey found that purchasers visit a pharmacy when they or those who felt they needed antibiotics had minor symptoms such as cough (34.1%), sore throat (32.5%), stomach upsets (10.0%) and diarrhoea (8.8%). The most often purchased antibiotics were ampicillin (31.1%), amoxyllin (16.7%), cotrimoxazol (11.6%), tetracycline (5.2%) and cephalexin (4.8%). The median of the purchased quantity was to tablets, the mean 11.34 tablets (95% CI 9.65–12.97). About 30% of the purchasers intended to take antibiotics for three days or less. The mean cost of a antibiotic purchase was US$1.27 (95%CI 1.06–1.39). The main reason for not taking a full course of antibiotics was not economic constraint, but the purchasers poor knowledge about antibiotics. Logistic regression analysis indicates that age of purchasers, length of symptoms and kinds of treatment used before visiting a pharmacy could be used as predictive variables for the decision to buy antibiotics in preference to alternative drugs. Antibiotics are used when illness lasts longer than one week and antibiotics have not yet been taken. Antibiotics are-also purchased by young rather than old people. The study documents the need for better health education about the rational use of antibiotics in the general public.     

Desire for antibiotics and antibiotic prescribing for adults with upper respiratory tract infections

OBJECTIVE: Prior studies have shown that 60% to 75% of adults with upper respiratory tract infections want antibiotics. More recent research indicates declines in antibiotic prescribing for upper respiratory tract infections. To investigate whether there has been a comparable decrease in patients' desire for antibiotics, we measured the proportion of adults with upper respiratory tract infections who wanted antibiotics in the winter of 2001-2002. We also sought to identify factors independently associated with wanting antibiotics and antibiotic prescribing. DESIGN: Prospective survey of adults with upper respiratory tract infections prior to visiting an acute care clinic from November 2001 to February 2002. MEASUREMENTS AND MAIN RESULTS: Thirty-nine percent of 310 patients wanted antibiotics. Many patients wanted relief from symptoms (43%) or pain (24%) and many patients expected to receive a diagnosis (49%) or reassurance during the visit (13%). In multivariable modeling, independent predictors of wanting antibiotics were prior antibiotic use (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.3 to 4.7) and current smoking (OR, 3.1; 95% CI, 1.3 to 7.3). Physicians prescribed antibiotics to 46% of patients who wanted antibiotics and 29% of patients who did not want antibiotics (P=.01). In multivariable modeling, wanting antibiotics was an independent predictor of antibiotic prescribing (OR, 2.1; 95% CI, 1.1 to 4.4). CONCLUSIONS: Only 39% of adults seeking care for upper respiratory tract infections wanted antibiotics, less than in previous studies. In continuing efforts to break the cycle of inappropriate antibiotic use, physicians should not assume that most patients with upper respiratory tract infections want antibiotics.     

Role of antibiotics in the management of hepatic encephalopathy

This article explores the rationale for use of antibiotics in the treatment of hepatic encephalopathy, discusses the role of antibiotics relative to other therapeutic approaches, and considers the reasons that limit the use of the antibiotics most commonly prescribed for the management of hepatic encephalopathy in the United States. Although the scientific rationale for the use of antibiotics in hepatic encephalopathy is well founded, the clinical evidence for their benefits is rather limited. There is no doubt that many antibiotics cause a decrease in intraluminal production of ammonia. However, the commonly prescribed antibiotics are also associated with a variety of adverse effects. None of the antibiotics typically used for hepatic encephalopathy is adequately tolerated in the target patient population. The clinical evidence to date does not support the first-line use of currently available antibiotics in the treatment of hepatic encephalopathy. To improve upon current antibiotic offerings for hepatic encephalopathy, an antibiotic should provide broad-spectrum coverage against both aerobic and anaerobic bacteria, effectively control neuropsychiatric signs and symptoms, and be extremely well tolerated in the target population. An antibiotic fulfilling these criteria would constitute an advance in therapy for hepatic encephalopathy.     

A continuous quality improvement initiative reduces inappropriate prescribing of prophylactic antibiotics for endoscopic procedures

OBJECTIVE: Despite the availability of guidelines, most gastroenterologists do not administer prophylactic antibiotics appropriately to patients having endoscopic procedures. In 1994 we recognized that in our endoscopy unit, many patients were receiving antibiotics without proper indication. We devised a continuous quality improvement initiative to analyze and improve this problem. METHODS: Divisional guidelines for the appropriate administration of prophylactic antibiotics for endoscopy were drawn up in 1995. By retrospective analysis of our comprehensive endoscopy database we compared the rate of prophylactic antibiotic administration, and the proportion of antibiotics that were indicated before and after adoption of the divisional guidelines. RESULTS: A total of 1427 endoscopic procedures were done during a 6-month period in 1994 (before adoption of guidelines). Of these, 55 (3.85%) received antibiotics. In a 6-month period in 1996 after adoption of guidelines, 1452 procedures were performed and 29 of these (1.99%) received antibiotics. The odds ratio for receiving antibiotics appropriately in 1996, compared with 1994, was 3.4 (chi2 p = 0.016). Given an annual volume of 2900 procedures in our endoscopy unit, approximately 54 patients will avoid unnecessary antibiotics, yielding a cost saving of $1128 per year. CONCLUSIONS: A divisional continuous quality improvement initiative on antibiotic prophylaxis for endoscopy significantly reduced the proportion of patients receiving antibiotics unnecessarily. This quality improvement initiative enhanced the quality of care for patients having endoscopy and yielded a small cost saving. These improvements were achieved with minimal effort and cost to the division.     

Conservative treatment of acute colonic diverticulitis: are antibiotics always mandatory?

OBJECTIVE: Most patients admitted for acute colonic diverticulitis (AD) are managed conservatively and receive antibiotics, although it is uncertain whether all patients with AD benefit from this treatment. The aim of this study was to evaluate the influence of antibiotic treatment on outcome in the conservative management of patients with mild AD. MATERIAL AND METHODS: A retrospective audit of 311 patients (64% F, mean age 60 years) hospitalized for AD was carried out. All patients were initially treated conservatively with observation and restriction of oral intake. Patients receiving antibiotics (n=118) were compared with patients treated with observation and restriction of oral intake only (n=193). Mean follow-up time (FU) was 30 months. RESULTS: Inflammation in patients treated with antibiotics was more pronounced (laboratory parameters (C-reactive protein, white blood cell count) were higher (p<0.01), fever was more common (p<0.01) and CT grading of inflammation was classified as severe in a higher proportion (p<0.01)) compared with patients treated without antibiotics. When initially treated with antibiotics, 3 patients (3%) failed to respond to treatment and had to undergo surgery. There were 7 (4%) failures in patients initially treated without antibiotics, and antibiotics were then added. During FU, 29% of patients treated with antibiotics had further events (recurrent AD and/or subsequent surgery) compared with 28% (NS) among those treated without antibiotics. In a multivariate analysis, the risk of a further event was not influenced by antibiotic treatment (OR 1.03, CI 95% 0.61-1.74). CONCLUSIONS: Our results indicate that antibiotics are not mandatory in mild AD. Treatment without antibiotics appears to be safe and seems not to change the rate of further events. These results warrant further randomized prospective studies.     

Sulfonamide allergy and cross-reactivity

Concerns about cross-allergenicity between sulfonamide antibiotics and nonantibiotic sulfonamide-containing drugs continue to complicate pharmacotherapy. Several elegant investigations have demonstrated unequivocal lack of interaction between the sulfonamide group and either cellular or humoral immunity. The immunologic determinant of type I immunologic responses to sulfonamide antibiotics is the N1 heterocyclic ring, and nonantibiotic sulfonamides lack this structural feature. Many non-type I hypersensitivity responses to sulfonamide antibiotics are attributable to reactive metabolites that cause either direct cytotoxicity or humoral or cellular responses. Metabolite formation is stereospecific to the N4 amino nitrogen of the sulfonamide antibiotics, a structure not found on any nonantibiotic sulfonamide drugs. Cellular immune responses to sulfonamide antibiotics are responsible for many non-immunoglobulin E-mediated dermatologic reactions; however, the stereospecificity of T-cell response renders cross-reactivity between sulfonamide antibiotics and nonantibiotics highly unlikely. Apparent cross-reactivity responses to sulfonamide-containing drugs likely represent multiple concurrent, rather than linked, drug hypersensitivities.     

Forgotten antibiotics: an inventory in Europe, the United States, Canada, and Australia

In view of the alarming spread of antimicrobial resistance in the absence of new antibiotics, this study aimed at assessing the availability of potentially useful older antibiotics. A survey was performed in 38 countries among experts including hospital pharmacists, microbiologists, and infectious disease specialists in Europe, the United States, Canada, and Australia. An international expert panel selected systemic antibacterial drugs for their potential to treat infections caused by resistant bacteria or their unique value for specific criteria. Twenty-two of the 33 selected antibiotics were available in fewer than 20 of 38 countries. Economic motives were the major cause for discontinuation of marketing of these antibiotics. Fourteen of 33 antibiotics are potentially active against either resistant Gram-positive or Gram-negative bacteria. Urgent measures are then needed to ensure better availability of these antibiotics on a global scale.     

Case of severe eosinophilic pneumonia, induced by several antibiotics, requiring mechanical ventilation]

We report a case of severe eosinophilic pneumonia induced by several antibiotics, requiring mechanical ventilation. A 44-year-old man had been admitted previously to a different hospital because of a high fever and dry cough continuing for a week. Although bacterial pneumonia was diagnosed and he had been treated with several antibiotics, his respiratory state worsened gradually and he was refered to our hospital with severe hypoxia. He needed mechanical ventilation on the fifth hospital day. TBLB identified eosinophilic pneumonia. Although we discontinued all antibiotics and started steroid therapy, he became feverish and his leukocyte count, which was neutrophil dominant, elevated again. We suspected bacterial pneumonia and administered antibiotics that he had never received before. However we had to discontinue these antibiotics soon because of a further inflammatory response. His condition then improved gradually and he was weaned from mechanical ventilation. It is rare for drug-induced eosinophilic pneumonia to become so severe that mechanical ventilation is necessary. We thought that an allergic reaction may have been induced by the series of several antibiotics, inducing severe pneumonia.     

Duration of effect of intravenous antibiotics on spirometry and sputum cytokines in children with cystic fibrosis

Intravenous (IV) antibiotics are a mainstay of therapy in children with cystic fibrosis. It is unclear, however, over what period associated improvements in pulmonary function are maintained, and to what extent the underlying inflammatory process is impeded in children admitted for a course of IV antibiotics. This was a prospective, interventional study of 14 children (median age, 14 years; interquartile range, 10-14) with cystic fibrosis who were regular sputum producers and who required admission for a 2-week course of IV antibiotics. Children performed spirometry and provided a sputum sample prior to starting IV antibiotics and then weekly for 6 weeks, the first 2 weeks of which IV antibiotics were given. Sputum IL-8, TNF-alpha, IL-6, IL-10, MIP1-alpha, and elastase were measured. Seven children were asked to repeat the protocol in a subsequent exacerbation to assess similarities in response to therapy. Significant improvements were seen in forced expired volume in 1 sec (FEV(1)) in association with IV antibiotics (27% relative improvement in predicted from baseline to end of week 1, median FEV(1) 41.3% increasing to 52.2%), but this continued only 1 week following cessation of antibiotics. Although IL-8 demonstrated a trend for reduction in association with antibiotics, no significant profile was demonstrated for any of the cytokines assessed. IL-10 was detectable in 64% of samples (all <100 pg/ml). In children with two episodes assessed, although there was a close correlation of FEV(1) and FVC between exacerbations (before antibiotics), no significant correlation was seen for IL-8, TNF-alpha, or IL-10 measured in both sets of samples at any sample point (indeed, a discordant response was seen between sample points in the two exacerbations). Although FEV(1) temporarily improves in response to admission for IV antibiotics, no such response is seen in sputum cytokine values. In addition, assessment of cytokines in subsequent exacerbations does not show a similar pattern of response to treatment.     

Antibiotic therapy for Crohn's disease: a review.

Increasing evidence suggests that gut bacteria play a pathogenic role in Crohn's disease (CD), providing a rationale for the use of antibiotics in the primary treatment of the disease. While there are data to suggest that antibiotics may be effective in treating active luminal, particularly colonic, and/or perianal CD, evidence for their use in these settings is hampered by the lack of well-designed, adequately powered, placebo-controlled trials. Furthermore, although nitroimidazole antibiotics have been shown to reduce postoperative recurrence following ileocolonic resection, their use is limited by side effects. There is a current need for rigorous multicentre studies looking into the role of antibiotics in treating perianal and luminal CD, as well as a need for the large-scale assessment of novel antibiotics, with low systemic absorption, which may improve patient tolerance.     

Public beliefs and use of antibiotics for acute respiratory illness

OBJECTIVE: To better understand public beliefs and use of antibiotics for acute respiratory illnesses. DESIGN: Cross-sectional telephone survey. PARTICIPANTS: Three hundred eighty-six adult members (aged 18 years or older) of a group-model HMO in the Denver metropolitan area. MEASUREMENTS AND MAIN RESULTS: Two hundred seventy-three (70%) of the respondents reported that antibiotics were beneficial for bacterial respiratory illnesses, 211 (55%) reported that antibiotics were beneficial for viral respiratory illnesses, and 82 (21%) reported that antibiotics were beneficial for bacterial but not for viral illness. Multivariate regression analysis identified consulting an advice nurse (odds ratio [OR] 2.9; 95% confidence interval [CI] 1.7, 5.3), ever being told by a provider that antibiotics were not needed for a respiratory illness episode (OR 2.0; 95% CI 1.2, 3.6), having a chronic medical condition (OR 2.0; 95% CI 1.0, 3.9), and believing antibiotics to be helpful for viral (OR 2.5; 95% CI 1.3, 4.7) or bacterial (OR 2.6; 95% CI 1.2, 6.7) respiratory illnesses to be independently associated with antibiotic use for respiratory illnesses during the previous year. There was a trend toward lower previous antibiotic use among those believing antibiotics to be helpful for bacterial illness but not for viral illness. CONCLUSIONS: A lack of understanding about antibiotic effectiveness exists in the community. Increased previous antibiotic use among those believing antibiotics to be effective for viral illnesses suggests that improvements are needed in communications to patients and the public about antibiotic appropriateness.     

Can antibacterial therapy be discontinued in persistently febrile granulocytopenic cancer patients?

It has been suggested that empiric broad-spectrum antibiotics, instituted for fever in the presence of granulocytopenia, should continue to be administered, even when infection is not demonstrable, to those patients who remain persistently febrile and granulocytopenic. Therefore, the consequences of discontinuing antibiotics when the presence of infection is doubted in this setting were evaluated. In 16 (3.7 percent) of 429 episodes of fever and granulocytopenia for which empiric antibiotic therapy was instituted, after approximately four days, persistence of both fever and granulocytopenia was found, and yet infection was prospectively classified at that time as "doubtful." The initial empiric antibiotic regimen was therefore discontinued after a mean of 4.8 (median 5.0) days. Discontinuation of antibiotics proved appropriate for half of the patients; eight patients received no systemic therapeutic antibiotics with no evidence of infection during a period of at least two weeks. The other eight patients had antibacterial antibiotics reinstituted within a mean of 2.4 days; six infections were subsequently demonstrable. Six of these eight patients also required or were believed to require antifungal therapy with intravenous amphotericin B for presumed fungal infections. Patients with relapsed leukemia or lymphoma and those with a likelihood of continued profound granulocytopenia (counts below 100/microliters) or both were the ones who tended to require reinstitution of antibiotics. Discontinuation of antibiotics when infection was considered doubtful despite persistence of both fever and granulocytopenia was, therefore, successful in eight of 16 patients. Reinstitution of antibiotics was required in the eight remaining patients. No definite rule appears to be applicable to all patients.