JAC-Antimicrobial Resistance最新文献

Background: Increasing resistance to broad-spectrum beta-lactams and carbapenems is a significant concern in healthcare settings. This study aimed to determine the prevalence of intestinal carriage of extended-spectrum β-lactamase (ESBL)-producing and carbapenem-resistant Enterobacterales (CRE) in a tertiary care hospital and to evaluate the utility of long-read sequencing for carbapenem resistance surveillance.

Methods: In 2021, stool samples (n = 538) and rectal swabs (n = 256) from hospitalized patients were cultured after enrichment on selective chromogenic medium to detect ESBL and CRE carriage. CRE isolates were characterized by antimicrobial susceptibility testing and whole-genome sequencing.

Results: Among 794 patient samples, 239 (30%) Enterobacterales isolates grew on ESBL media. On CRE agar, 28 Enterobacterales were cultured, 27 confirmed carbapenem-resistant and identified as Klebsiella pneumoniae (n = 25), Escherichia coli (n = 1), and Enterobacter cloacae (n = 1). In CRE, 29.6% (8/27) were carbapenemase-producing Enterobacterales (CPE), carrying the bla _OXA-48 (n = 7) or bla _NDM-1 (n = 1) genes. The remaining 70.4% (19/27) were non-carbapenemase-producing CRE isolates (non-CP-CRE). The bla _OXA-48 gene was localized on identical IncL plasmids with an inverted Tn1999.2 transposon in non-clonally related isolates. CPE isolates exhibited distinct resistance patterns to carbapenems, β-lactam/β-lactamase inhibitor combinations, with 87.5% resistant to cefiderocol. All non-CP-CRE isolates remained susceptible to imipenem; two were resistant to meropenem and carried either five or six copies of the bla _CTX-M-15 gene along with mutations in porin genes.

Conclusions: A 30% prevalence of intestinal carriage of ESBL-producing Enterobacterales and a 3.4% carriage prevalence of CRE were found. Long-read sequencing revealed IncL plasmid-mediated dissemination of OXA-48 β-lactamase and bla _CTX-M-15 gene amplification, demonstrating its added value for antimicrobial resistance monitoring.

Background: Shared decision making (SDM) is a collaborative process between patients and prescribers and identified as a strategy to support antimicrobial stewardship. SDM can improve patient and clinician satisfaction and reduce antibiotic prescribing. However, little is known about how to implement antibiotic SDM in secondary care.

Objectives: Identify opportunities for antibiotic SDM between patients and clinicians in secondary care.

Methods: Semi-structured interviews were conducted with senior decision makers (registrar or consultant grade) and adult patients who had received antibiotics during their medical or surgical admission, recruited from three secondary care Trusts in England. Interviews explored participants' views on opportunities for SDM when prescribing antibiotics in secondary care, guided by the 'Start Smart, Then Focus' framework. Interviews were audio recorded, transcribed verbatim and analysed thematically.

Results: 18 clinicians and 20 patients were interviewed. Two themes were identified. In 'Pushing back against SDM', participants challenged the amenability and prioritization of SDM for antibiotics in inpatient settings, related to clinicians being seen as main decision makers, with patients not seeking further involvement. This was reinforced by the perceived urgency of treatment, the fast-paced hospital environment, and the view that antibiotic decisions were either too complex or too straightforward to invite shared input. In 'If not SDM, then what?', participants endorsed bi-directional communication and information provision as alternative priorities, highlighting its value.

Conclusions: SDM was not well understood or endorsed for antibiotic prescribing decision making in secondary care. Further work is warranted to educate and upskill clinicians in SDM as a concept within secondary care.

Background: Acute bacterial prostatitis (ABP) is a complicated urinary tract infection (UTI) requiring timely and appropriate antibiotic therapy. Because of growing concern over fluoroquinolone resistance, second-generation cephalosporins such as cefuroxime may offer a viable alternative.

Objectives: This study evaluates the use of cefuroxime as an empirical first-line intravenous treatment in hospitalized patients with ABP and compares outcomes following various oral antibiotic step-down regimens.

Methods: We conducted a single-centre retrospective cohort study at Clinique Saint-Pierre Ottignies, Belgium, including male patients ≥18 years diagnosed with ABP and treated empirically with intravenous cefuroxime between January 2019 and December 2023. Patients were grouped based on their oral antibiotic step-down therapy (cefuroxime, ciprofloxacin, trimethoprim-sulfamethoxazole or amoxicillin). The primary outcomes were bacterial failure and clinical recurrence within 6 months.

Results: Of 148 patients screened, 88 met inclusion criteria. No relapses were reported. Escherichia coli was the predominant pathogen (49/88); 100% were cefuroxime-susceptible, while four were fluoroquinolone-resistant. Among non-E. coli isolates, resistance to cefuroxime was significantly higher (OR 8.5, P = 0.003).

Conclusions: Empirical intravenous cefuroxime followed by oral step-down appears safe and effective for ABP, especially in the absence of known risk factors for resistant pathogens. These findings support fluoroquinolone-sparing approaches in empiric UTI management, tailored to local microbiological profiles and individual comorbidities.

Objectives: One of the biggest challenges for healthcare providers is the difficulty with screening for carbapenemase-producing, carbapenem-resistant Pseudomonas aeruginosa (CP-CRPa; P. aeruginosa), given the variety of mechanisms that can mediate carbapenem resistance in P. aeruginosa. We sought to develop an improved algorithm to screen for carbapenemase activity in P. aeruginosa using routine antimicrobial susceptibility testing readily available in most clinical microbiology laboratories.

Methods: Antibiograms of a reference set of P. aeruginosa (n = 100) with diverse phenotypic and genotypic profiles were compared to determine which antibiotics optimally screen for and differentiate CP-CRPa from CRPa and non-CRPa. The developed algorithm was then applied to 1482 clinical P. aeruginosa isolates. Carbapenemase PCR and the modified carbapenem inactivation method were performed on all meropenem-resistant P. aeruginosa isolates.

Results: The CP-CRPa screening algorithm developed here uses meropenem, ceftazidime and tobramycin. Carbapenem resistance was identified in 85 (5.7%) isolates, of which 26 (1.8%) were confirmed as CP-CRPa. bla _GES (57.7%) was the predominant carbapenemase detected, whilst bla _NDM, bla _VIM, bla _IMP and bla _KPC carbapenemases were also detected. The CP-CRPa screening algorithm was 100% sensitive (CI_95% 84.0%-100%) and 96.6% specific (CI_95% 87.3%-99.4%).

Conclusions: We present an antimicrobial susceptibility testing-based screening algorithm that uses meropenem, ceftazidime, and tobramycin to screen for CP-CRPa. When appropriate screening criteria are utilized, confirmatory testing can be significantly reduced, resulting in substantial time and resource savings, without compromising sensitivity, particularly in settings with varying carbapenemase epidemiology.

Background and objective: Antimicrobial resistance (AMR) is a global health challenge driven by inappropriate prescribing. Antimicrobial stewardship (AMS) education during undergraduate training is important to prepare future healthcare professionals for responsible prescribing, yet provision remains inconsistent across disciplines. To systematically review AMS educational interventions for undergraduate medical, pharmacy, nursing, dental, veterinary and midwifery students, and evaluate the behavioural coverage using the COM-B framework.

Methods: A protocol was registered on PROSPERO (CRD420250655653). Six databases were searched on 4 February 2025. Eligible studies evaluated AMS educational interventions for undergraduate students. Data were independently extracted in duplicate, methodological quality appraised using Medical Education Research Study Quality Instrument (MERSQI) and findings were synthesized narratively using COM-B.

Results: Of 7771 records screened, 42 studies were included, involving 8567 students across six continents. Most were single-group pre-/post-designs, with two randomized controlled trials. All studies addressed psychological capability, mainly by increasing knowledge and reasoning, while reflective motivation was supported in 25/42. Physical opportunity (20/42) and social opportunity (18/42) were less frequent, typically via structured cases or teamwork. Physical capability (9/42) and automatic motivation (2/42) were least represented, usually through simulation, supervised practice or affective engagement. MERSQI scores indicated moderate methodological quality overall.

Conclusions: Undergraduate AMS education is widespread but uneven in its coverage, with emphasis on knowledge and limited attention to skills, opportunities and motivation. Applying COM-B highlights the need for curricula to combine knowledge with rehearsal, authentic resources, teamwork, identity development and positive engagement to prepare graduates for stewardship practice.

Aim: This systematic review examined the practices and challenges of implementing antimicrobial stewardship (AMS) in sub-Sahara Africa (SSA) regulated retail medicine settings.

Methods: We searched studies published between January 1, 2010, and July 30, 2024, from PubMed, Web of Science, ProQuest Central, Google Scholar, African Journals Online, and Wiley Online Library. We also reviewed reference lists of studies included in the review. The included studies were quality-assessed using the Mixed Method Appraisal Tool, with data analysed thematically. The protocol was registered in the International Prospective Register for Systematic Reviews (PROSPERO), registration number CRD42023381320.

Results: Of the 2555 screened studies, 26 met the inclusion criteria; eight qualitative, 16 quantitative and two mixed methods. Community pharmacists, accredited drug dispensers, and patent medicine vendors were reported to be aware of antimicrobial resistance (AMR) and AMS. Across studies with extractable numeric data (n = 10), the median prevalence of non-prescription antibiotic dispensing was 67.5% (IQR: 52.5%-84.9%), indicating that the practice is widespread in sub-Saharan Africa. However, few studies documented AMS activities that have taken place. Reported barriers to AMS included non-prescription antibiotic dispensing, weak regulation, and economic pressures despite knowledge of antibiotics, antibiotic resistance and the importance of AMS.

Conclusion: Our study revealed limited data on AMS implementation in SSA-regulated retail medicine settings. Despite self-reported awareness of AMR, AMS efforts are hindered by systemic challenges such as economic constraints, weak regulatory enforcement, and systemic barriers. Strengthening regulations, public awareness, and multi-stakeholder collaboration is critical to improving AMS in SSA retail medicine settings.

Background: Urinary tract infections (UTIs) are one of the most common bacterial infections affecting women. The COVID-19 pandemic altered how healthcare was accessed and resulted in the rapid adoption of remote technologies. This study explored patients' experiences of consultations for UTIs in general practice during the pandemic.

Methods: Women included in this study were ≥16 years, recruited via Ipsos's online panels in England, reporting at least one episode of UTI symptoms in the previous year, and had sought a consultation with a healthcare professional. We analysed 799 responses to a free-text questions, using inductive thematic analysis, regarding their experiences.

Results: We identified key themes related to (i) the consultation mode and healthcare professional consulted, (ii) UTI assessment and management, (iii) validation of UTI symptoms and experience and (iv) concerns due to the COVID-19 pandemic. Positive aspects of care related to prompt and thorough assessment and treatment, consulting a healthcare professional (HCP) who validated their experience, while encouraging discussions about prevention and self-care. Negative aspects of care were related to long appointment waiting times, a lack of in-person consultation if desired and patients feeling uninformed and unvalidated about their UTIs.

Conclusion: This study presents evidence that positive patient experience on UTI assessment and management is determined by the HCP involved, the mode of consultation and the application of shared decision-making to determine treatment. To improve satisfaction, systems and consultations should account for these patient preferences with shared decision-making approaches, adapted for remote consultations, to support discussions around UTI investigation and management.

Background: The UK Antimicrobial Registry (UKAR) was developed to capture data on real-world usage of recently launched antimicrobial agents.

Methods: UKAR is an ongoing prospective registry of adult inpatients prescribed 11 eligible study drugs (cefiderocol, ceftaroline, ceftazidime/avibactam, ceftobiprole, ceftolozane/tazobactam, dalbavancin, delafloxacin, eravacycline, imipenem/cilastatin/relebactam, meropenem/vaborbactam and oritavancin). Data collected from participants' medical records include demographics, infection site, comorbidities, microbiology isolates and susceptibility, treatment regimen and outcomes. Primary outcome is clinical resolution of infection measured 28 days post cessation of study drug.

Results: In the first 20 months, 631 participants were recruited, 56% male, with a median age of 60 years. Overall, 44.8% of patients were treated for lower respiratory tract infection, 18.0% for systemic infections including sepsis and 11.1% for urinary tract infection. Comorbidities were common (>90%), 81% of participants had a documented history of resistant organism colonization and only a small proportion of patients received an eligible study drug while in critical care. For Gram-negative agents ceftazidime/avibactam, cefiderocol and ceftolozane/tazobactam predominated, and for Gram-positive agents 94% received dalbavancin. Empirical use was seen in 4.9% of Gram-negative and 66.2% of Gram-positive prescriptions. Where patient outcome was evaluable, infection resolution was seen in 69% and 64% of Gram-negative and Gram-positive participants, respectively.

Conclusions: The UKAR provides real-world data on the use of novel antimicrobials confirming they are sometimes used empirically as well as for directed therapy to treat both complex and common infections, and often for multiresistant pathogens. The study is a novel and important resource to support the judicious use of these drugs.

Background: Although adjunctive rifampicin and/or gentamicin have been recommended for Staphylococcus aureus prosthetic valve endocarditis, evidence regarding the evaluation of their clinical effectiveness is limited.

Objectives: To compare the clinical impact of adjunctive rifampicin without gentamicin, and adjunctive gentamicin without rifampicin therapies for S. aureus prosthetic valve endocarditis.

Methods: This retrospective study used TriNetX to evaluate multicentre electronic medical records of patients aged 18 years or older in the USA between 2016 and 2024. After propensity score matching, HRs were estimated with 95% CIs. Covariates included age, sex, ethnicity and medical comorbidities.

Results: A total of 353 and 369 patients were identified in the rifampicin and gentamicin groups, respectively. One-year all-cause mortality was observed in 87 (31.3%) and 111 (39.9%) patients in the rifampicin and gentamicin groups after propensity score matching, respectively, leading to an HR of 0.71 (95% CI, 0.54-0.94; P = 0.016). The HRs were not statistically significant for ICU admission (HR 0.93; 95% CI, 0.74-1.18; P = 0.540), recurrent endocarditis (HR 0.76; 95% CI, 0.42-1.40; P = 0.381), kidney failure (HR 0.93; 95% CI, 0.74-1.18; P = 0.540) or hepatic failure (HR 0.96; 95% CI, 0.66-1.39; P = 0.822).

Conclusions: The rifampicin-containing regimen without gentamicin was associated with reduced 1 year mortality compared with the gentamicin-containing regimen without rifampicin. Although the results should be interpreted with caution because of potential residual unmeasured confounders, including duration of antimicrobial treatment and biases, our findings provide further evidence that adjunctive gentamicin may not be routinely needed for S. aureus prosthetic valve endocarditis.

Background: Optimizing antibiotic use is a UK Government priority. This study aimed to identify which combinations of interventions are associated with meeting primary care antibiotic prescribing targets in England's National Health Service, going beyond typical evaluations of individual interventions.

Methods: Data on interventions implemented by Integrated Care Boards (ICBs) in England were collected via an online survey (October 2023 to January 2024). The survey gathered information about 61 interventions covering data monitoring, incentives, governance, staff training, guidance, diagnostics, decision support tools and public awareness-raising activities.The survey data were linked to ICB-level antibiotic prescribing data, analysed descriptively and through a set-theoretic approach (fuzzy-set Qualitative Comparative Analysis, fsQCA). Clusters of ICBs that used a common set of interventions and met prescribing targets were identified. The average prescribing rates were calculated for each cluster and compared with ICBs that did not implement those interventions.

Results: Fifty-four responses were received from staff at 29 out of 42 ICBs (69%). Locally adapted prescribing guidance was used by all ICBs meeting targets. ICBs that monitored data and used incentives, guidance and/or challenged prescribers on their behaviour had the lowest prescribing. Implementing diagnostics, staff training or public awareness-raising interventions was not associated with lower prescribing.

Conclusions: In a country that has been reducing antibiotic prescribing and implementing numerous antimicrobial stewardship interventions over the last decade, commissioning organizations that met policy targets were using combinations of a limited number of interventions by 2024. National and local efforts could therefore start prioritizing fewer interventions to further reduce prescribing.