Stewardship antibióticos

Indications and classes of outpatient antibiotic prescriptions in Japan: A descriptive study using the national database of electronic health insurance claims, 2012-2015.

Int J Infect Dis. 2019 Nov 12;:

Authors: Hashimoto H, Saito M, Sato J, Goda K, Mitsutake N, Kitsuregawa M, Nagai R, Hatakeyama S

Abstract
OBJECTIVES: To evaluate condition-specific antibiotic prescription rates and the appropriateness of antibiotic use in outpatient settings in Japan.
METHODS: Using Japan's national administrative claims database, all outpatient visits with infectious disease diagnoses were linked to reimbursed oral antibiotic prescriptions. Prescription rates stratified by age, sex, prefecture, and antibiotic category were determined for each infectious disease diagnosis. The proportions of any antibiotic prescription to all infectious disease visits and the proportions of first-line antibiotic prescriptions to all antibiotic prescriptions were calculated for each infectious disease diagnosis.
RESULTS: Of the 659 million infectious disease visits between April 2012 and March 2015, antibiotics were prescribed in 266 million visits (704 prescriptions per 1000 population per year). Third-generation cephalosporins, macrolides, and quinolones accounted for 85.9% of all antibiotic prescriptions. Fifty-six percent of antibiotic prescriptions were directed toward infections for which antibiotics are generally not indicated. The diagnoses with frequent antibiotic prescription were bronchitis (184 prescriptions per 1000 population per year), viral upper respiratory infections (166), pharyngitis (104), sinusitis (52), and gastrointestinal infection (41), for which 58.3%, 40.6%, 58.9%, 53.9%, and 26.1% of visits antibiotics were prescribed, respectively. First-line antibiotics were rarely prescribed for pharyngitis (8.8%) and sinusitis (9.8%). More antibiotics were prescribed for children aged 0-9 years, adult women, and patients living in western Japan.
CONCLUSIONS: Antibiotic prescription rates are high in Japan. Acute respiratory or gastrointestinal infections, which received the majority of the antibiotics generally not indicated, should be the main targets of antimicrobial stewardship intervention.

PMID: 31730926 [PubMed - as supplied by publisher]

Molecular mechanism of azithromycin resistance among typhoidal Salmonella stains in Bangladesh identified through passive pediatric surveillance.

PLoS Negl Trop Dis. 2019 Nov 15;13(11):e0007868

Authors: Hooda Y, Sajib MSI, Rahman H, Luby SP, Bondy-Denomy J, Santosham M, Andrews JR, Saha SK, Saha S

Abstract
BACKGROUND: With the rise in fluoroquinolone-resistant Salmonella Typhi and the recent emergence of ceftriaxone resistance, azithromycin is one of the last oral drugs available against typhoid for which resistance is uncommon. Its increasing use, specifically in light of the ongoing outbreak of extensively drug-resistant (XDR) Salmonella Typhi (resistant to chloramphenicol, ampicillin, cotrimoxazole, streptomycin, fluoroquinolones and third-generation cephalosporins) in Pakistan, places selective pressure for the emergence and spread of azithromycin-resistant isolates. However, little is known about azithromycin resistance in Salmonella, and no molecular data are available on its mechanism.
METHODS AND FINDINGS: We conducted typhoid surveillance in the two largest pediatric hospitals of Bangladesh from 2009-2016. All typhoidal Salmonella strains were screened for azithromycin resistance using disc diffusion and resistance was confirmed using E-tests. In total, we identified 1,082 Salmonella Typhi and Paratyphi A strains; among these, 13 strains (12 Typhi, 1 Paratyphi A) were azithromycin-resistant (MIC range: 32-64 μg/ml) with the first case observed in 2013. We sequenced the resistant strains, but no molecular basis of macrolide resistance was identified by the currently available antimicrobial resistance prediction tools. A whole genome SNP tree, made using RAxML, showed that the 12 Typhi resistant strains clustered together within the 4.3.1.1 sub-clade (H58 lineage 1). We found a non-synonymous single-point mutation exclusively in these 12 strains in the gene encoding AcrB, an efflux pump that removes small molecules from bacterial cells. The mutation changed the conserved amino acid arginine (R) at position 717 to a glutamine (Q). To test the role of R717Q present in azithromycin-resistant strains, we cloned acrB from azithromycin-resistant and sensitive strains, expressed them in E. coli, Typhi and Paratyphi A strains and tested their azithromycin susceptibility. Expression of AcrB-R717Q in E. coli and Typhi strains increased the minimum inhibitory concentration (MIC) for azithromycin by 11- and 3-fold respectively. The azithromycin-resistant Paratyphi A strain also contained a mutation at R717 (R717L), whose introduction in E. coli and Paratyphi A strains increased MIC by 7- and 3-fold respectively, confirming the role of R717 mutations in conferring azithromycin resistance.
CONCLUSIONS: This report confirms 12 azithromycin-resistant Salmonella Typhi strains and one Paratyphi A strain. The molecular basis of this resistance is one mutation in the AcrB protein at position 717. This is the first report demonstrating the impact of this non-synonymous mutation in conferring macrolide resistance in a clinical setting. With increasing azithromycin use, strains with R717 mutations may spread and be acquired by XDR strains. An azithromycin-resistant XDR strain would shift enteric fever treatment from outpatient departments, where patients are currently treated with oral azithromycin, to inpatient departments to be treated with injectable antibiotics like carbapenems, thereby further burdening already struggling health systems in endemic regions. Moreover, with the dearth of novel antimicrobials in the horizon, we risk losing our primary defense against widespread mortality from typhoid. In addition to rolling out the WHO prequalified typhoid conjugate vaccine in endemic areas to decrease the risk of pan-resistant Salmonella Typhi strains, it is also imperative to implement antimicrobial stewardship and water sanitation and hygiene intervention to decrease the overall burden of enteric fever.

PMID: 31730615 [PubMed - as supplied by publisher]

Early Steps Toward Ambulatory Antimicrobial Stewardship: Dental and Orthopedic Focus.

Clin Infect Dis. 2019 Nov 15;:

Authors: File TM, Bleasdale SC

PMID: 31728516 [PubMed - as supplied by publisher]

Review of Guidelines for Dental Antibiotic Prophylaxis for Prevention of Endocarditis and Prosthetic Joint Infections and Need for Dental Stewardship.

Clin Infect Dis. 2019 Nov 15;:

Authors: Goff DA, Mangino JE, Glassman AH, Goff D, Larsen P, Scheetz R

Abstract
Dentists prescribe 10% of all outpatient antibiotic prescriptions, writing more than 25.7 million prescriptions per year. Many are for prophylaxis in patients with prosthetic joint replacements; the American Dental Society states "in general" prophylactic antibiotics are not recommended to prevent prosthetic joint infections. Orthopedic surgeons are concerned with the risk of implant infections following a dental procedure and therefore see high value and low risk in recommending prophylaxis. Patients' are "stuck in the middle" with conflicting recommendations from OS and dentists. Unnecessary prophylaxis and fear of lawsuits amongst private practice dentists and OS has not been addressed. We review The American Heart Association/American College of Cardiology, American Dental Association, and American Association of Orthopedic Surgeons' guidelines on dental antibiotic prophylaxis for prevention of endocarditis and prosthetic joint infections. We provide experience on how to engage private practice dentists and OS in dental stewardship using a community-based program.

PMID: 31728507 [PubMed - as supplied by publisher]

Antibiotic Utilization in Iran 2000-2016: Pattern Analysis and Benchmarking with Organization for Economic Co-operation and Development Countries.

J Res Pharm Pract. 2019 Jul-Sep;8(3):162-167

Authors: Abbasian H, Hajimolaali M, Yektadoost A, Zartab S

Abstract
Objectives: Antibiotic resistance is the main threat to health all over the world. The consumption of antibiotics is one of the factors causing the emergence of multidrug resistance. The purpose of this study was to recognize the patterns, trends, and changes of consumption in Iran and to compare them with those of Organization for Economic Co-operation and Development (OECD) countries.
Methods: The data were collected from a national pharmaceutical wholesale data bank. Defined daily dose (DDD) or DDDs per 1000 inhabitants per day (DID) was calculated as a standard indicator for the consumption over 17 years.
Results: Were benchmarked with the consumption of OECD countries. Drug utilization 90% (DU90%) method was used to assess the drug consumption pattern.
Findings: The antibiotic consumption jumped up from 33.6 DID to 60 DID from 2000 to 2016. Compared to the average consumption of OECD countries, Iran has consumed antibiotics almost triple times. There were 9-11 chemical substances in the DU90% list during these years. Changes in DU90% list occurred within antibiotics classes during the study period. Although the total consumption growth was equal to 79% during these years, consumption of some pharmacological subgroups such as sulfonamide and aminoglycosides has decreased.
Conclusion: Albeit the existence of surveillance system for health-related infectious diseases, the consumption of antibiotics has increased drastically, which illustrates the necessity of comprehensive and effective national antibiotic stewardship.

PMID: 31728348 [PubMed]

Antimicrobial stewardship staffing: How much is enough?

Infect Control Hosp Epidemiol. 2019 Nov 15;:1-11

Authors: Greene MH, Nesbitt WJ, Nelson GE

Abstract
Antimicrobial stewardship improves patient care and reduces antimicrobial resistance, inappropriate use, and adverse outcomes. Despite high-profile mandates for antimicrobial stewardship programs across the healthcare continuum, descriptive data, and recommendations for dedicated resources, including appropriate physician, pharmacist, data analytics, and administrative staffing support, are not robust. This review summarizes the current literature on antimicrobial stewardship staffing and calls for the development of minimum staffing recommendations.

PMID: 31727195 [PubMed - as supplied by publisher]