Point prevalence survey of antibiotic use in hospitals in Latin American countries.

BACKGROUND: Point prevalence surveys (PPSs) on antibiotic use are useful for understanding different aspects related to prescription patterns in hospitals. METHODS: An adaptation of the WHO methodology for a PPS on antibiotic use was applied. Hospital wards were divided into medical (MED), surgical (SUR), ICUs, gynaecology and obstetrics (GO), high-risk (HR) and mixed wards (MIX). A web application (RedCap©) through a mobile device was used for data collection. RESULTS: Between December 2018 and August 2019, 5444 patients in 33 hospitals in five countries were included (10 hospitals in Cuba, 7 in Paraguay, 6 in El Salvador, 5 in Mexico and 5 in Peru). Of these patients, 54.6% received at least one antibiotic, with variations between and within hospitals and countries. Antibiotics were more frequently used in ICUs (67.2%), SUR (64.5%) and MED wards (54.2%), with 51.2% of antibiotics prescribed for community-acquired infections (CAIs), 22.9% for healthcare-associated infections (HAIs), 11.1% for surgical prophylaxis and 6.1% for unknown reasons. Adherence to guidelines was observed in 68.6% of cases (72.8% for CAIs, 72.4% for HAIs and 44.3% for prophylaxis). Third-generation cephalosporins were the class of antibiotics most frequently used (26.8%), followed by carbapenems (10.3%) and fluoroquinolones (8%). Targeted treatments were achieved in 17.3% of cases. CONCLUSIONS: Antibiotic use was generally higher than that published in other studies. There is an urgent need to promote and strengthen the antimicrobial stewardship programmes in Latin America.

Budget impact analysis of using procalcitonin to optimize antimicrobial treatment for patients with suspected sepsis in the intensive care unit and hospitalized lower respiratory tract infections in Argentina.

BACKGROUND: Inappropriate antibiotic use represents a major global threat. Sepsis and bacterial lower respiratory tract infections (LRTIs) have been linked to antimicrobial resistance, carrying important consequences for patients and health systems. Procalcitonin-guided algorithms may represent helpful tools to reduce antibiotic overuse but the financial burden is unclear. The aim of this study was to estimate the healthcare and budget impact in Argentina of using procalcitonin-guided algorithms to guide antibiotic prescription. METHODS: A decision tree was used to model health and cost outcomes for the Argentinean health system, over a one-year duration. Patients with suspected sepsis in the intensive care unit and hospitalized patients with LRTI were included. Model parameters were obtained from a focused, non-systematic, local and international bibliographic search, and validated by a panel of local experts. Deterministic and probabilistic sensitivity analyses were performed to analyze the uncertainty of parameters. RESULTS: The model predicted that using procalcitonin-guided algorithms would result in 734.5 [95% confidence interval (CI): 1,105.2;438.8] thousand fewer antibiotic treatment days, 7.9 [95% CI: 18.5;8.5] thousand antibiotic-resistant cases avoided, and 5.1 [95% CI: 6.7;4.2] thousand fewer Clostridioides difficile cases. In total, this would save $422.4 US dollars (USD) [95% CI: $935;$267] per patient per year, meaning cost savings of $83.0 [95% CI: $183.6;$57.7] million USD for the entire health system and $0.4 [95% CI: $0.9;$0.3] million USD for a healthcare provider with 1,000 cases per year of sepsis and LRTI patients. The sensitivity analysis showed that the probability of cost-saving for the sepsis patient group was lower than for the LRTI patient group (85% vs. 100%). CONCLUSIONS: Healthcare and financial benefits can be obtained by implementing procalcitonin-guided algorithms in Argentina. Although we found results to be robust on an aggregate level, some caution must be used when focusing only on sepsis patients in the intensive care unit.

Update on the epidemiology of carbapenemases in Latin America and the Caribbean.

INTRODUCTION: Carbapenemases are ß-lactamases able to hydrolyze a wide range of ß-lactam antibiotics, including carbapenems. Carbapenemase production in Enterobacterales, Pseudomonas aeruginosa, and Acinetobacter spp., with and without the co-expression of other ß-lactamases is a serious public health threat. Carbapenemases belong to three main classes according to the Ambler classification: class A, class B, and class D. AREAS COVERED: Carbapenemase-bearing pathogens are endemic in Latin America. In this review, we update the status of carbapenemases in Latin America and the Caribbean. EXPERT OPINION: Understanding the current epidemiology of carbapenemases in Latin America and the Caribbean is of critical importance to improve infection control policies limiting the dissemination of multi-drug-resistant pathogens and in implementing appropriate antimicrobial therapy.

Antimicrobial stewardship in hospitals in Latin America and the Caribbean: a scoping review.

OBJECTIVES: To examine published antimicrobial stewardship (AMS) initiatives in hospitals in Latin America and the Caribbean (LAC) in order to characterize AMS terminology usage, geotemporality, and elements of structure (human resources), process (interventions), and outcomes, and to set priority areas for improving AMS reporting. METHODS: This was a scoping review that searched PubMed, LILACS, EMBASE, and 12 other databases, along with a manual search for academic and grey literature to identify documents on AMS initiatives in hospitals in 33 countries of LAC, up to August 2019. Keywords included 'antibiotic' or 'antimicrobial' AND 'stewardship, policy, strategies, management, control, rational use, appropriate use, surveillance, or interventions' and 33 country names. RESULTS: Selected articles totalled 147 studies published in 1985 - 2019; of those, 22% used 'antimicrobial stewardship' in the title. Eighteen countries published AMS hospital initiatives, one-half of which were implemented in capital cities. Brazil, Argentina, Colombia, Cuba, Mexico, and Chile, in descending frequency, made up > 59% of published initiatives. Educational interventions were the most frequently reported, followed by persuasive and restrictive strategies. Antimicrobial consumption was the most common outcome measure reported. About one-third of the studies (35%) referred to baseline measures-only in preparation for AMS interventions. Fifty-nine studies from 6 countries reported AMS comprehensively, using structure, process, and outcome (SPO) elements. CONCLUSIONS: Published hospital AMS initiatives have increased over time and have expanded across LAC. However, more programs need to be developed. Complete reporting of SPO elements is imperative to evaluating and replicating AMS actions.

Antimicrobial stewardship in hospitals in Latin America and the Caribbean: a scoping review

[ABSTRACT]. Objectives. To examine published antimicrobial stewardship (AMS) initiatives in hospitals in Latin America and the Caribbean (LAC) in order to characterize AMS terminology usage, geotemporality, and elements of structure (human resources), process (interventions), and outcomes, and to set priority areas for improving AMS reporting. Methods. This was a scoping review that searched PubMed, LILACS, EMBASE, and 12 other databases, along with a manual search for academic and grey literature to identify documents on AMS initiatives in hospitals in 33 countries of LAC, up to August 2019. Keywords included ‘antibiotic’ or ‘antimicrobial’ AND ‘stewardship, policy, strategies, management, control, rational use, appropriate use, surveillance, or interventions’ and 33 country names. Results. Selected articles totalled 147 studies published in 1985 – 2019; of those, 22% used ‘antimicrobial stewardship’ in the title. Eighteen countries published AMS hospital initiatives, one-half of which were implemented in capital cities. Brazil, Argentina, Colombia, Cuba, Mexico, and Chile, in descending frequency, made up > 59% of published initiatives. Educational interventions were the most frequently reported, followed by persuasive and restrictive strategies. Antimicrobial consumption was the most common outcome measure reported. About one-third of the studies (35%) referred to baseline measures-only in preparation for AMS interventions. Fifty-nine studies from 6 countries reported AMS comprehensively, using structure, process, and outcome (SPO) elements. Conclusions. Published hospital AMS initiatives have increased over time and have expanded across LAC. However, more programs need to be developed. Complete reporting of SPO elements is imperative to evaluating and replicating AMS actions.

[RESUMEN]. Objetivos. Examinar las iniciativas publicadas sobre optimización del uso de antimicrobianos (OUA) en hospitales de América Latina y el Caribe para caracterizar el uso de la terminología, la geotemporalidad y algunos elementos de la estructura (recursos humanos), el proceso (intervenciones) y los resultados, así como para establecer las áreas prioritarias para mejorar la información sobre este tema. Métodos. En esta revisión exploratoria se realizaron búsquedas en PubMed, LILACS, Embase y otras doce bases de datos, además de una búsqueda manual de la bibliografía académica y gris, con el fin de encontrar documentos acerca de las iniciativas de optimización del uso de antimicrobianos en hospitales de 33 países de América Latina y el Caribe hasta agosto del 2019. Algunas de las palabras clave fueron “antibiótico” o “antimicrobiano” Y “rectoría”, “política”, “estrategias”, “gestión”, “control”, “uso racional”, “uso apropiado”, “vigilancia” o “intervenciones”, además de los nombres de los 33 países. Resultados. Los artículos seleccionados sumaron 147 estudios publicados entre 1985 y el 2019, de los que en un 22 % se mencionó la optimización del uso de antimicrobianos (‘antimicrobial stewardship’) en su título. Dieciocho países publicaron iniciativas de optimización del uso de antimicrobianos para hospitales, la mitad de las cuales se ejecutaron en sus ciudades capitales. Brasil, Argentina, Colombia, Cuba, México y Chile, en orden descendente según la frecuencia, constituyeron más del 59% de las iniciativas publicadas. Las intervenciones educativas fueron las que se informaron con mayor frecuencia, seguidas por las estrategias persuasivas y restrictivas. La medida de resultado notificada más comúnmente fue el consumo de antimicrobianos. Cerca de un tercio de los estudios (35%) se refirió únicamente a las mediciones de base en preparación para las intervenciones de optimización del uso de antimicrobianos. Cincuenta y nueve estudios de seis países informaron exhaustivamente sobre las iniciativas de optimización del uso de antimicrobianos mediante elementos relativos a la estructura, el proceso y los resultados (EPR). Conclusiones. Las iniciativas publicadas sobre la optimización del uso de antimicrobianos en los hospitales han aumentado con el transcurso del tiempo y se han ampliado en América Latina y el Caribe. Sin embargo, se necesitan más programas. Es esencial suministrar información completa de los elementos relativos a la EPR para evaluar y replicar las medidas de optimización del uso de antimicrobianos.

[RESUMO]. Objetivos. Examinar iniciativas publicadas sobre a otimização do uso de antimicrobianos em hospitais da América Latina e Caribe (ALC), caracterizar o uso da terminologia sobre iniciativas de otimização do uso de antimicrobianos, geotemporalidade e elementos das estruturas (recursos humanos), processos (intervenções) e resultados, bem como estabelecer áreas prioritárias para melhorar a publicação de estudos sobre iniciativas de otimização do uso de antimicrobianos. Métodos. Realizamos uma revisão exploratória pesquisando as bases de dados PubMed, LILACS, EMBASE e outras 12, juntamente com uma pesquisa manual da literatura acadêmica e cinzenta para identificar artigos sobre iniciativas de otimização do uso de antimicrobianos em hospitais de 33 países da ALC, até agosto de 2019. Os termos de busca foram ‘antibiótico’ ou ‘antimicrobiano’ E ‘gestão, políticas, estratégias, gerenciamento, controle, uso racional, uso apropriado, vigilância ou intervenções’, bem como os nomes de 33 países. Resultados. Os artigos selecionados totalizaram 147 estudos publicados entre 1985 e 2019; desses, 22% utilizaram a expressão ‘iniciativas de otimização do uso de antimicrobianos’ (‘antimicrobial stewardship’) no título. Ao todo, 18 países publicaram iniciativas hospitalares sobre otimização do uso de antimicrobianos, das quais a metade foi implementada nas capitais. Brasil, Argentina, Colômbia, Cuba, México e Chile, em frequência decrescente, constituíram >59% das iniciativas publicadas. A maior parte dos estudos descreveu intervenções educacionais, seguidas de estratégias persuasivas e restritivas. O consumo de antimicrobianos foi o desfecho relatado com mais frequência. Cerca de um terço dos estudos (35%) mencionou apenas medidas feitas na linha de base em preparação para as intervenções de otimização do uso de antimicrobianos. Ao todo, 59 estudos de 6 países descreveram as iniciativas de otimização do uso de antimicrobianos de forma abrangente, relatando elementos de estruturas, processos e resultados (EPR). Conclusões. As iniciativas publicadas sobre a otimização do uso de antimicrobianos em hospitais têm aumentado ao longo do tempo, expandindo-se em toda a ALC. No entanto, é preciso desenvolver mais programas. A descrição completa de elementos de EPR é fundamental para avaliar e reproduzir as ações de otimização do uso de antimicrobianos.

Detection, treatment, and prevention of carbapenemase-producing Enterobacteriaceae: recommendations from an International Working Group.

The prevalence of carbapenemase-producing Enterobacteriaceae (CPE) has increased during the past 10 years. Its detection is frequently difficult, because they do not always show a minimum inhibitory concentration (MIC) value for carbapenems in the resistance range. Both broth microdilution and agar dilution methods are more sensitive than disk diffusion method, Etest and automated systems. Studies on antimicrobial treatment are based on a limited number of patients; therefore, the optimal treatment is not well established. Combination therapy with two active drugs appears to be more effective than monotherapy. Combination of a carbapenem with another active agent--preferentially an aminoglycoside or colistin--could lower mortality provided that the MIC is ≤4 mg/l and probably ≤8 mg/l, and is administered in a higher-dose/prolonged-infusion regimen. An aggressive infection control and prevention strategy is recommended, including reinforcement of hand hygiene, using contact precautions and early detection of CPE through use of targeted surveillance.

[Inter-society consensus for the management of respiratory infections: acute bronchitis and chronic obstructive pulmonary disease]. / Consenso Intersociedades para el manejo de infecciones respiratorias: bronquitis aguda y enfermedad pulmonar obstructiva crónica.

The Argentine Society for Infectious Diseases and other national societies issued updated practical guidelines for the management of acute bronchitis (AB) and reactivations of chronic obstructive pulmonary disease (COPD) with the aim of promoting rational use of diagnostic and therapeutic resources. AB is a condition characterized by inflammation of the bronchial airways which affects adults and children without underlying pulmonary disease. It is usually caused by a virus. The diagnosis is based on clinical findings after community acquired pneumonia has been ruled out. Treatment of AB is mainly symptomatic. Antibiotics should be used in immune-compromised hosts, patients with chronic respiratory or cardiac diseases and in the elderly with co-morbidities. Reactivation of COPD is defined as an acute change in the patient's baseline clinical situation beyond normal day to day variations, with an increase in dyspnea, sputum production and/or sputum purulence, warranting a change in medication. An increase in one symptom is considered a mild exacerbation, two as moderate, and the presence of three symptoms is considered a severe exacerbation. An infectious agent can be isolated in sputum in 50 to 75% of COPD reactivations. Moderate and severe episodes must be treated with antibiotics, amoxicillin/ beta-lactamase inhibitor, macrolides and fluoroquinolones are first choice drugs.

Consenso Intersociedades para el manejo de infecciones respiratorias: bronquitis aguda y enfermedad pulmonar obstructiva crónica / [Inter-society consensus for the management of respiratory infections: acute bronchitis and chronic obstructive pulmonary disease].

The Argentine Society for Infectious Diseases and other national societies issued updated practical guidelines for the management of acute bronchitis (AB) and reactivations of chronic obstructive pulmonary disease (COPD) with the aim of promoting rational use of diagnostic and therapeutic resources. AB is a condition characterized by inflammation of the bronchial airways which affects adults and children without underlying pulmonary disease. It is usually caused by a virus. The diagnosis is based on clinical findings after community acquired pneumonia has been ruled out. Treatment of AB is mainly symptomatic. Antibiotics should be used in immune-compromised hosts, patients with chronic respiratory or cardiac diseases and in the elderly with co-morbidities. Reactivation of COPD is defined as an acute change in the patient’s baseline clinical situation beyond normal day to day variations, with an increase in dyspnea, sputum production and/or sputum purulence, warranting a change in medication. An increase in one symptom is considered a mild exacerbation, two as moderate, and the presence of three symptoms is considered a severe exacerbation. An infectious agent can be isolated in sputum in 50 to 75

of COPD reactivations. Moderate and severe episodes must be treated with antibiotics, amoxicillin/ beta-lactamase inhibitor, macrolides and fluoroquinolones are first choice drugs.

Consenso Intersociedades para el manejo de infecciones respiratorias: bronquitis aguda y enfermedad pulmonar obstructiva crónica. / [Inter-society consensus for the management of respiratory infections: acute bronchitis and chronic obstructive pulmonary disease].

The Argentine Society for Infectious Diseases and other national societies issued updated practical guidelines for the management of acute bronchitis (AB) and reactivations of chronic obstructive pulmonary disease (COPD) with the aim of promoting rational use of diagnostic and therapeutic resources. AB is a condition characterized by inflammation of the bronchial airways which affects adults and children without underlying pulmonary disease. It is usually caused by a virus. The diagnosis is based on clinical findings after community acquired pneumonia has been ruled out. Treatment of AB is mainly symptomatic. Antibiotics should be used in immune-compromised hosts, patients with chronic respiratory or cardiac diseases and in the elderly with co-morbidities. Reactivation of COPD is defined as an acute change in the patients baseline clinical situation beyond normal day to day variations, with an increase in dyspnea, sputum production and/or sputum purulence, warranting a change in medication. An increase in one symptom is considered a mild exacerbation, two as moderate, and the presence of three symptoms is considered a severe exacerbation. An infectious agent can be isolated in sputum in 50 to 75

of COPD reactivations. Moderate and severe episodes must be treated with antibiotics, amoxicillin/ beta-lactamase inhibitor, macrolides and fluoroquinolones are first choice drugs.

[Consensus guidelines for the management of upper respiratory tract infections]. / Consenso sobre diagnóstico y tratamiento de infecciones de vías respiratorias altas.

Upper respiratory tract infections are the most common source of antibiotic prescriptions. Acute pharyngitis is caused mainly by viruses, viral cases can be distinguished from acute streptococcal pharyngitis using Centor clinical epidemiological criteria, by rapid antigen tests or throat culture. Treatment of choice for streptococcal infection is penicillin V given in two daily doses. In children, acute otitis media (AOM) is the infection for which antibiotics are most often prescribed. Predominant causative pathogens include Streptococcus pneumoniae, Haemophilus influenzae non-type b and Moraxella catarrhalis. Diagnosis is based on history, physical examination and otoscopic exam. Antibiotic treatment should be initiated promptly in all children<2 years of age, and in older children presenting bilateral AOM, otorrhoea, co-morbidities or severe illness. In Argentina, amoxicillin is the drug of choice given the low penicillin resistance rates for S. pneumoniae. In children who fail amoxicillin therapy, amoxicillin/clavulanate provides better coverage against beta-lactamase producing H. influenzae and M. catarrhalis. Rhinosinusitis is caused mainly by viruses, secondary bacterial complication occurs in less than 5% of cases. Diagnosis is based on physical examination and additional studies are not usually required. Acute bacterial sinusitis is caused by the same pathogens that cause AOM and amoxicillin is the drug of choice.

Consenso sobre diagnóstico y tratamiento de infecciones de vías respiratorias altas / Consensus guidelines for the management of upper respiratory tract infections

Las infecciones respiratorias altas son la primera causa de prescripción de antibióticos. La faringitis aguda es de origen viral en la mayoría de los casos; los episodios virales pueden diferenciarse de los de origen bacteriano producidos por Streptococcus pyogenes por criterios clínico-epidemiológicos (criterios de Centor), por pruebas diagnósticas rápidas o por el cultivo de fauces. Cuando la etiología es estreptocócica, la droga de elección es penicilina V (cada 12 horas). La otitis media aguda (OMA) es una de las causas más frecuentes de prescripción de antibióticos en niños. Los patógenos principales son Streptococcus pneumoniae, Haemophilus influenzae no tipable y Moraxella catarrhalis. Los antecedentes, la evaluación clínica junto con la otoscopía permiten establecer el diagnóstico. En niños menores de 2 años se recomienda tratamiento antibiótico precoz al igual que en niños mayores de 2 años con otitis bilateral, otorrea, presencia de comorbilidad o cuadro clínico grave. En la Argentina, debido a los bajos niveles de resistencia de S. pneumoniae a penicilina la droga de elección es amoxicilina; ante falta de respuesta al tratamiento puede utilizarse amoxicilina/clavulánico para cubrir cepas de H. influenzae y de M. catarrhalis productoras de betalactamasas. Las rinosinusitis son virales en la mayoría de los casos y menos del 5% se complican con sinusitis bacteriana. El diagnóstico es clínico y en general no se requieren estudios complementarios. Los patógenos bacterianos implicados son los mismos que causan OMA, por esta razón también se recomienda la amoxicilina como droga de elección.

Upper respiratory tract infections are the most common source of antibiotic prescriptions. Acute pharyngitis is caused mainly by viruses, viral cases can be distinguished from acute streptococcal pharyngitis using Centor clinical epidemiological criteria, by rapid antigen tests or throat culture. Treatment of choice for streptococcal infection is penicillin V given in two daily doses. In children, acute otitis media (AOM) is the infection for which antibiotics are most often prescribed. Predominant causative pathogens include Streptococcus pneumoniae, Haemophilus influenzae non-type b and Moraxella catarrhalis. Diagnosis is based on history, physical examination and otoscopic exam. Antibiotic treatment should be initiated promptly in all children < 2 years of age, and in older children presenting bilateral AOM, otorrhoea, co-morbidities or severe illness. In Argentina, amoxicillin is the drug of choice given the low penicillin resistance rates for S. pneumoniae. In children who fail amoxicillin therapy, amoxicillin/clavulanate provides better coverage against beta-lactamase producing H. influenzae and M. catarrhalis. Rhinosinusitis is caused mainly by viruses, secondary bacterial complication occurs in less than 5% of cases. Diagnosis is based on physical examination and additional studies are not usually required. Acute bacterial sinusitis is caused by the same pathogens that cause AOM and amoxicillin is the drug of choice.

Consenso sobre diagnóstico y tratamiento de infecciones de vías respiratorias altas / Consensus guidelines for the management of upper respiratory tract infections

Las infecciones respiratorias altas son la primera causa de prescripción de antibióticos. La faringitis aguda es de origen viral en la mayoría de los casos; los episodios virales pueden diferenciarse de los de origen bacteriano producidos por Streptococcus pyogenes por criterios clínico-epidemiológicos (criterios de Centor), por pruebas diagnósticas rápidas o por el cultivo de fauces. Cuando la etiología es estreptocócica, la droga de elección es penicilina V (cada 12 horas). La otitis media aguda (OMA) es una de las causas más frecuentes de prescripción de antibióticos en niños. Los patógenos principales son Streptococcus pneumoniae, Haemophilus influenzae no tipable y Moraxella catarrhalis. Los antecedentes, la evaluación clínica junto con la otoscopía permiten establecer el diagnóstico. En niños menores de 2 años se recomienda tratamiento antibiótico precoz al igual que en niños mayores de 2 años con otitis bilateral, otorrea, presencia de comorbilidad o cuadro clínico grave. En la Argentina, debido a los bajos niveles de resistencia de S. pneumoniae a penicilina la droga de elección es amoxicilina; ante falta de respuesta al tratamiento puede utilizarse amoxicilina/clavulánico para cubrir cepas de H. influenzae y de M. catarrhalis productoras de betalactamasas. Las rinosinusitis son virales en la mayoría de los casos y menos del 5% se complican con sinusitis bacteriana. El diagnóstico es clínico y en general no se requieren estudios complementarios. Los patógenos bacterianos implicados son los mismos que causan OMA, por esta razón también se recomienda la amoxicilina como droga de elección.(AU)

Upper respiratory tract infections are the most common source of antibiotic prescriptions. Acute pharyngitis is caused mainly by viruses, viral cases can be distinguished from acute streptococcal pharyngitis using Centor clinical epidemiological criteria, by rapid antigen tests or throat culture. Treatment of choice for streptococcal infection is penicillin V given in two daily doses. In children, acute otitis media (AOM) is the infection for which antibiotics are most often prescribed. Predominant causative pathogens include Streptococcus pneumoniae, Haemophilus influenzae non-type b and Moraxella catarrhalis. Diagnosis is based on history, physical examination and otoscopic exam. Antibiotic treatment should be initiated promptly in all children < 2 years of age, and in older children presenting bilateral AOM, otorrhoea, co-morbidities or severe illness. In Argentina, amoxicillin is the drug of choice given the low penicillin resistance rates for S. pneumoniae. In children who fail amoxicillin therapy, amoxicillin/clavulanate provides better coverage against beta-lactamase producing H. influenzae and M. catarrhalis. Rhinosinusitis is caused mainly by viruses, secondary bacterial complication occurs in less than 5% of cases. Diagnosis is based on physical examination and additional studies are not usually required. Acute bacterial sinusitis is caused by the same pathogens that cause AOM and amoxicillin is the drug of choice.(AU)

"Ten Commandments" for the Appropriate use of Antibiotics by the Practicing Physician in an Outpatient Setting.

A multi-national working group on antibiotic stewardship, from the International Society of Chemotherapy, put together ten recommendations to physicians prescribing antibiotics to outpatients. These recommendations are: (1) use antibiotics only when needed; teach the patient how to manage symptoms of non-bacterial infections; (2) select the adequate ATB; precise targeting is better than shotgun therapy; (3) consider pharmacokinetics and pharmacodynamics when selecting an ATB; use the shortest ATB course that has proven clinical efficacy; (4) encourage patients' compliance; (5) use antibiotic combinations only in specific situations; (6) avoid low quality and sub-standard drugs; prevent prescription changes at the drugstore; (7) discourage self-prescription; (8) follow only evidence-based guidelines; beware those sponsored by drug companies; (9) rely (rationally) upon the clinical microbiology lab; and (10) prescribe ATB empirically - but intelligently; know local susceptibility trends, and also surveillance limitations.