JAC-Antimicrobial Resistance最新文献

Background: Reducing antibiotic duration is a key stewardship intervention to mitigate antimicrobial resistance (AMR). We examined current evidence informing antibiotic duration for common bacterial infections to identify any gaps in terms of settings, patient populations and infectious conditions. Trial methodologies were assessed to identify areas for improvement.

Methods: MEDLINE and Embase were searched up to July 2024 for randomized trials comparing antibiotic durations in hospital and community settings (PROSPERO 2021, CRD42021276209). A narrative synthesis of the results was performed with a review on the major guidelines published by IDSA, NICE, WHO and other international societies to assess the impact of these trials on practice guidance.

Results: Out of 315 studies, 85% concluded equivalence or non-inferiority of shorter courses. Adult bacterial sinusitis, community-acquired pneumonia, female cystitis/pyelonephritis, uncomplicated cellulitis and intra-abdominal infection with adequate source control and perioperative prophylaxis had robust evidence supporting shorter durations. Few trials studied severe infections, such as bloodstream infections and ventilator-associated pneumonia. Twenty-three (7%) of the trials were conducted in intensive care settings and only 43 trials (14%) enrolled patients from low-to-middle- or low-income countries. Only 15% of studies were at low risk for bias.

Conclusions: Reducing antibiotic duration likely remains an important strategy for antibiotic stewardship, and an area of active research. While shorter antibiotic courses may be suitable for many bacterial infections, more evidence is needed for severe infections and in low- and middle-income settings.

Objectives: In this study, bacteria isolated from companion animals in China were taxonomically identified and assessed for antimicrobial susceptibility to evaluate the prevalence of antimicrobial resistance (AMR) in pets.

Methods: From October 2022 to October 2023, 5468 samples were collected from pets, predominantly from cats and dogs, in China, of which 5253 bacterial strains were identified (>98%). Antimicrobial susceptibility was assessed using the VITEK 2 COMPACT system and the Kirby-Bauer disc diffusion method.

Results: The most common bacterial species were Escherichia coli (14.5%) and Staphylococcus pseudintermedius (13.6%). E. coli exhibited high resistance to ampicillin and cefpodoxime (56.8%-73.2%) but moderate resistance to doxycycline, trimethoprim-sulfamethoxazole, enrofloxacin, gentamicin, and amoxicillin-clavulanate (18.1%-38.5%). Klebsiella spp. and Enterobacter spp. were resistance to several antimicrobials (32.2%-57.7%). High susceptibility to imipenem was noted in Proteus spp., Pseudomonas spp., and Acinetobacter spp. (91.7%-94.1%). Coagulase-positive Staphylococcus spp. demonstrated higher resistance than coagulase-negative strains. Enterococcus faecium showed greater resistance to some antimicrobials compared with E. faecalis. Streptococcus spp. exhibited low resistance to enrofloxacin (1.6%) and penicillin (1.1%).

Conclusions: The study demonstrates that AMR is widespread in companion animals in China, emphasizing the need for continuous surveillance. The accumulation of commercial antimicrobial susceptibility data can improve understanding of AMR and promote more effective antimicrobial stewardship and clinical practices in veterinary medicine.

Background: Research on the contextual drivers of antimicrobial stewardship (AMS) programme interventions in neonatal units is limited.

Methods: As part of a prospective mixed-methods multidisciplinary neonatal AMS (NeoAMS) interventional study in 14 South African hospitals, we applied a three-phased process to assess implementation barriers and contextual drivers experienced by participating health professionals. The study included: (Phase one; P1) a survey of pre-intervention barriers and enablers; (P2) written feedback during the study intervention phase; and (P3) semi-structured exit interviews.

Results: Respondents to the P1 survey (n = 100) identified 15 barriers, 9 in the domain of personnel resources, including staffing, time and workload constraints. Other barriers related to limited access to antimicrobial use and surveillance trends, complexity of neonatal care, absence of multidisciplinary team (MDT) AMS and change resistance. For P2, written feedback during implementation (n = 42) confirmed that the MDT approach facilitated systems changes, including policy adaptations, process improvements, strengthened infection control practices, and expansion of AMS MDT roles. MDT benefits were described as aligned team purpose, improved communication, and knowledge sharing. Reported challenges included time to meet and building trust. In P3 interviews (n = 42), improved interpersonal communication, trust, personal growth and confidence building were cited as highlights of working in multidisciplinary AMS teams. Extending the MDT approach to other hospitals, training more health professionals in AMS and increasing management involvement were identified as priorities going forward.

Conclusions: Understanding the organizational and interprofessional context for NeoAMS implementation enabled an MDT approach to develop and optimize neonatal AMS with potential for adoption in similar resource-constrained settings.

Background: There is a pressing need for global surveillance of ESBL-producing Escherichia coli due to its health impacts, travel and increased antibiotic use during the COVID-19 pandemic. This systematic review and meta-analysis aimed to summarize evidence investigating the global prevalence of ESBL E. coli.

Methods: Four databases, including Embase, MEDLINE, PubMed and Web of Science, were searched for quantitative studies that reported prevalence data of faecal carriage of ESBL-producing E. coli published between 23 April 2021 and 22 April 2024. Meta-analysis was performed using the inverse variance heterogeneity model.

Results: Of the 25 studies (13 901 unique participants) included for final analysis, the overall pooled prevalence of ESBL E. coli was 25.4% (95% CI, 19.7%-31.2%). The pooled prevalences of ESBL E. coli in healthy individuals in community settings and inpatients in healthcare settings were 23.4% (95% CI, 14.7%-32.2%) and 27.7% (95% CI, 18.8%-36.7%), respectively. Nearly one-third of the included studies (32%) were from the Western Pacific Region. There was a significant between-group difference for studies with different WHO regions and healthcare contact.

Conclusions: The pooled prevalence of ESBL E. coli remains high and there was a significant between-group difference for different WHO regions, with the highest being in Asian regions. Standardized surveillance of antimicrobial resistance and antibiotic stewardship especially in these regions are needed to enhance the control of this global emergency.

Background: The role of oral switch antibiotic therapy in uncomplicated Enterococcus faecalis bloodstream infection (BSI) remains unclear. This retrospective cohort study examines the effectiveness of oral switch compared with standard intravenous antibiotic therapy in uncomplicated E. faecalis BSI.

Methods: Adults with first episodes of uncomplicated monomicrobial E. faecalis BSI were admitted to 10 Prisma Health hospitals in South Carolina from January 2021 to June 2023 were included. Deaths within 7 days were excluded to mitigate immortal time bias. Multivariate Cox proportional hazards regression examined the risk of treatment failure (all-cause mortality or recurrence) within 90 days after adjustment for the propensity of transitioning to oral switch therapy.

Results: Of 476 screened patients, 131 with uncomplicated E. faecalis BSI were included in the analysis. The median age was 70 years, 84 (64%) were men, and 46 (35%) had a urinary source of infection. Eighty-seven patients (66%) received standard intravenous therapy and 44 (34%) were transitioned to oral switch therapy. Aminopenicillins were the most commonly used antibiotics for oral switch therapy (33/44; 75%). There was no increased risk of treatment failure with oral switch therapy compared with standard intravenous therapy (hazard ratio 0.77, 95% CIs 0.23-2.57, P = 0.67). Hospital length of stay (HLOS) was 7 and 11 days in the oral switch and standard intravenous groups, respectively (P < 0.001).

Conclusions: Transitioning patients with uncomplicated E. faecalis BSI from intravenous to oral switch antibiotic therapy appears to be a promising strategy with shorter HLOS and no significant increase in the risk of treatment failure.

Objectives: To characterize resistance rates in urinary tract infections caused by Enterobacterales to first- and second-line antibiotics.

Methods: Positive urine cultures examined by the Eastern Pathology Alliance network from September 2018 to September 2023 were retrospectively analysed. Enterobacterales from non-pregnant adults were included. Resistance to cefalexin, nitrofurantoin, trimethoprim, pivmecillinam and fosfomycin was investigated.

Results: A total of 193 137 samples from 99 635 patients met inclusion criteria. The mean number of episodes per patient was 1.94, with a range of 1-55 episodes over the 5 year period. Patients were predominantly of female sex (76.6%) and of an older age (mean age 66.4 ± 19.5 SD). Escherichia coli was the commonest organism isolated (73%) followed by undifferentiated coliforms (16%), Proteus spp. (6%) and Klebsiella pneumoniae (2%). Across all samples, trimethoprim resistance was high at 27%, with lower cefalexin (8.3%) and nitrofurantoin (8.8%) resistance. Resistance to two or three of the first-line antibiotics-trimethoprim, cefalexin and nitrofurantoin-was 5.5% and 0.6%, respectively. In E. coli there was low fosfomycin resistance at 3.1%. In resistant isolates subject to extended sensitivity testing, moderate pivmecillinam (21%) resistance was demonstrated. Organisms demonstrating AmpC and ESBL resistance were detected in 3.2% and 3.5% of isolates. Trimethoprim resistance was highest at James Paget University Hospital (37%) and surrounding general practices (30%).

Conclusions: This study illustrates resistance rates to commonly prescribed antibiotics for urinary tract infections in Norfolk and Waveney. Adjustments to local empirical antibiotic guidelines have been shaped by the resistance rates demonstrated herein.

Background: Local production of antibiotics is essential for improving access to treatment of clinical infection and avoiding vulnerability to expensive drug imports.

Objectives: To describe the country of origin and cost of antibiotics in Vietnam.

Methods: This was an observational study. Antibiotic procurement in 372 healthcare facilities in Vietnam between 2018 and 2022 were included in this analysis. Antibiotics were classified using the Anatomical Therapeutic Chemical Index and the 2021 WHO Access, Watch and Reserve groups. The country of origin of antibiotics was determined by the place where the final products were manufactured. Antibiotic costs were estimated in US dollars per DDD and adjusted by annual inflation.

Results: This study included 2.54 billion antibiotic DDDs, totalling 3.13 billion US dollars. Local production accounted for 80.2% of the number of DDDs and 43.4% of the total expenditure. The antibiotics from other countries were driven by imports from high-income countries, which accounted for 75.5% of DDDs and 89.6% of the expenditure on imported antibiotics. Availability of Reserve group antibiotics was more dependent on imports from high-income countries (36.6% of DDDs) than those of Access (15.7% of DDDs) and Watch group antibiotics (14.2% of DDDs).

Conclusions: A comprehensive policy approach is needed to ensure the affordability and to reduce dependency on imported Reserve group antibiotics.

Background: Antibiotic resistance in nursing homes (NHs) is inconsistently tackled by antimicrobial stewardship programmes. The literature on individual determinants of antibiotic prescriptions (APs) in NHs is extensive. However, less is known about the structural determinants of AP in NHs.

Objectives: To examine how different organizational contexts influenced interprofessional collaboration in the diagnosis and treatment of infections in NHs.

Methods: We conducted multiple case study observational research through field notes and sketches from pictures of NH layouts.

Results: We observed three NHs for 10 days (i.e. 82 h). We inductively identified four successive steps: (i) trigger by an assistant nurse, (ii) internal decision-making, (iii) calling on an external general practitioner (GP) and (iv) GP intervention. Diagnosis and treatment of infections involved various degrees of interprofessional collaboration within NHs, resulting in a range of actions, more or less directly involving AP by external GPs. In the case of onsite AP, external GPs barely relied on information about residents provided by NH professionals and did not provide any feedback regarding their decision, resulting in limited interprofessional collaboration. In contrast, remote AP (through phone calls) relied on interprofessional collaboration through mandatory exchanges between external GPs and NH nurses about the resident's symptoms and signs.

Conclusions: Diagnosis and treatment of infections through AP involved two distinct organization types (institutional versus private practices) and often lacked interprofessional collaboration. Future antimicrobial stewardship in NHs should consider (i) improving the connection between these two organizations and (ii) developing tools to support remote interprofessional collaboration to sustain prescription.

Background: Antimicrobial stewardship promotes the appropriate use of antibiotics to prevent the emergence and spread of antimicrobial resistance. This study evaluated the use of antibiotics using a point prevalence survey at the Centre Hospitalier Universitaire de Zone d'Abomey Calavi/Sô-Ava (CHUZ/AS) in Benin.

Methods: This cross-sectional study utilized the WHO point prevalence survey methodology for monitoring antibiotic use among inpatients in hospitals. The survey was conducted from 11 January 2022 to 19 January 2022 among hospitalized patients before 8:00 a.m. on the day of the survey.

Results: Of the 111 inpatient medical files reviewed, the prevalence of antibiotic use was 82.9%. The number of antibiotics received per patient ranged from 1 to 5, with a mean of 2.45 ± 1.11 and a median of 2. The most commonly prescribed class of antibiotics was beta-lactams (46.7%), aminoglycosides (20.6%) and nitroimidazoles (19.7%). According to the WHO AWaRe classification, 30.4% of inpatients received the Access group of antibiotics and 44% received a combination of Access and Watch group antibiotics; treatment was empiric in 94.5% of encounters. Only 22.7% of patients were treated based on microbiological examination/culture and sensitivity testing.

Conclusions: This study found a high prevalence of antibiotic use among inpatients at the CHUZ/AS Tertiary Care Hospital in Benin. The most prescribed antibiotics were ampicillin, metronidazole and ceftriaxone. Consequently, the study found a low use of culture and sensitivity testing to guide treatment, particularly in the paediatric and surgical population, and the preference for broad-spectrum antibiotics suggests that antibiotic use at the CHUZ/AS Tertiary Care is not optimal. Therefore, antimicrobial stewardship programmes, policies and guidelines must be instigated and strengthened to address these gaps and promote rational use of antibiotics.

Background: TB is a leading infectious disease globally, with war and displacement significantly increasing its burden. In Ethiopia, ongoing conflict and displacement have worsened health conditions, yet data on TB prevalence and resistance remain scarce. This study aimed to determine the prevalence of TB, rifampicin-resistant TB (RR-TB), and associated factors among presumptive TB patients in hospitals during the ongoing crisis.

Methods: A cross-sectional study was conducted with 273 presumptive TB participants, recruited via convenience sampling. Data on socio-demographic and behavioural factors were collected through interviews using a pre-tested structured questionnaire. Sputum samples were examined using the Xpert MTB/RIF molecular assay. Binary logistic regression was used to analyse the association between independent variables and TB. Variables with a P value  ≤0.25 in the univariate analysis were included in the multivariable regression to identify independent predictors, with a P value ≤0.05 considered statistically significant.

Results: Among the 273 study participants, 47 were confirmed to have Mycobacterium tuberculosis, resulting in a prevalence of 17.2%. Of the 47 patients diagnosed with M. tuberculosis, 17 (36.2%) were found to have rifampicin-resistant strains. Previous contact with displaced persons [adjusted odds ratio (AOR): 4.237; 95% CI: 1.67-10.762; P value: 0.002), contact with TB-infected individuals (AOR: 5.644; 95% CI: 2.46-12.96; P value: <0.01) and being HIV positive (AOR: 3.074; 95% CI: 1.26-7.50; P value: 0.014) were the significant predictors for TB.

Conclusions: Our study revealed a troubling prevalence of RR-TB, underscoring the adverse effects of war and displacement on healthcare services. Significant associations with predictors like HIV infection and close contact with TB-infected individuals necessitate targeted interventions.