Antimicrobial guidelines in clinical practice: incorporating the ethical perspective.

INTRODUCTION: Guidelines on antimicrobial therapy are subject to periodic revision to anticipate changes in the epidemiology of antimicrobial resistance and new scientific knowledge. Changing a policy to a broader spectrum has important consequences on both the individual patient level (e.g. effectiveness, toxicity) and population level (e.g. emerging resistance, costs). By combining both clinical data evaluation and an ethical analysis, we aim to propose a comprehensive framework to guide antibiotic policy dilemmas. METHODS: A preliminary framework for decision-making on antimicrobial policy was constructed based on existing literature and panel discussions. Antibiotic policy themes were translated into specific elements that were fitted into this framework. The adapted framework was evaluated in two moral deliberation groups. The moral deliberation sessions were analysed using ATLAS.ti statistical software to categorize arguments and evaluate completeness of the final framework. RESULTS: The final framework outlines the process of data evaluation, ethical deliberation and decision-making. The first phase is a factual data exploration. In the second phase, perspectives are weighed and the policy of moral preference is formulated. Judgments are made on three levels: the individual patient, the patient population and society. In the final phase, feasibility, implementation and re-evaluation are addressed. CONCLUSIONS: The proposed framework facilitates decision-making on antibiotic policy by structuring existing data, identifying knowledge gaps, explicating ethical considerations and balancing interests of the individual and current and future generations.

Infection control measures in times of antimicrobial resistance: a matter of solidarity.

Control measures directed at carriers of multidrug-resistant organisms are traditionally approached as a trade-off between public interests on the one hand and individual autonomy on the other. We propose to reframe the ethical issue and consider control measures directed at carriers an issue of solidarity. Rather than asking "whether it is justified to impose strict measures", we propose asking "how to best care for a person's carriership and well-being in ways that do not imply an unacceptable risk for others?". A solidarity approach could include elevating baseline levels of precaution measures and accepting certain risks in cases where there is exceptionally much at stake. A generous national compensation policy that also covers for costs related to dedicated care is essential in a solidarity approach. An additional benefit of reframing the questions is that it helps to better acknowledge that being subjected to control measures is a highly personal matter.

Ethics of Infection Control Measures for Carriers of Antimicrobial Drug-Resistant Organisms.

Many countries have implemented infection control measures directed at carriers of multidrug-resistant organisms. To explore the ethical implications of these measures, we analyzed 227 consultations about multidrug resistance and compared them with the literature on communicable disease in general. We found that control measures aimed at carriers have a range of negative implications. Although moral dilemmas seem similar to those encountered while implementing control measures for other infectious diseases, 4 distinct features stand out for carriage of multidrug-resistant organisms: carriage presents itself as a state of being; carriage has limited relevance for the health of the carrier; carriage has little relevance outside healthcare settings; and antimicrobial resistance is a slowly evolving threat on which individual carriers have limited effect. These features are of ethical relevance because they influence the way we traditionally think about infectious disease control and urge us to pay more attention to the personal experience of the individual carrier.

[Pre-exposure prophylaxis for the prevention of sexual HIV transmission; new preventative strategy using tenofovir/emtricitabine]. / Pre-expositieprofylaxe van seksuele hiv-transmissie; nieuwe preventiestrategie met tenofovir/emtricitabine.

The Netherlands has approximately 20,000 registered HIV-infected patients. The current HIV prevention policy consisting of condom use and active HIV testing does not effectively mitigate the HIV epidemic in all risk groups. In July of 2012, tenofovir/emtricitabine (TDF/FTC) was approved by the American Food and Drug Administration (FDA) for pre-exposure prophylaxis (PrEP) for long-term use in persons who exhibit frequent risky and unsafe sexual behaviour. With once-daily use and good therapy compliance, TDF/FTC has proved to be effective as PrEP, and few side effects are reported. Drawbacks in the use of TDF/FTC as PrEP are the potential risk of viral resistance and reduced condom use, the relatively high cost and the intensive counselling required. In special cases, long-term PrEP could enhance the current Dutch preventive policy. Further research is needed into the practical feasibility and protective efficacy of the ad hoc use of TDF/FTC as PrEP before a high-risk contact occurs.

Parasitic skin diseases: health care-seeking in a slum in north-east Brazil.

Ectoparasitic diseases are endemic in many poor communities in north-east Brazil, and heavy infestation is frequent. We conducted two studies to assess disease perception and health care seeking behaviour in relation to parasitic skin diseases and to determine their public health importance. The first study comprised a representative cross-sectional survey of the population of a slum in north-east Brazil. Inhabitants were examined for the presence of scabies, tungiasis, pediculosis and cutaneous larva migrans (CLM). The second study assessed health care seeking behaviour related to these ectoparasitic diseases of patients attending a Primary Health Care Centre (PHCC) adjacent to the slum. Point prevalence rates in the community were: head lice 43.3% (95% CI: 40.5-46.3), tungiasis 33.6% (95% CI: 30.9-36.4), scabies 8.8% (95% CI: 7.3-10.6) and CLM 3.1% (95% CI: 2.2-4.3). Point prevalence rates of patients attending the PHCC were: head lice 38.2% (95% CI: 32.6-44.1), tungiasis 19.1% (95% CI: 14.7-24.1), scabies 18.8% (95% CI: 14.4-23.7) and CLM 2.1% (95% CI: 0.8-4.5). Only 28 of 54 patients with scabies, three of 55 patients with tungiasis, four of six patients with CLM and zero of 110 patients with head lice sought medical assistance. The physicians of the PHCC only diagnosed a parasitic skin disease when it was pointed out by the patient himself. In all cases patients were correctly informed about the ectoparasites they carried. The results show that tungiasis and pediculosis, and to a lesser extent scabies and CLM, are hyperendemic but neglected by both population and physicians, and that prevalence rates of tungiasis and scabies at the PHCC do not reflect the true prevalence of these diseases in the community.