Does selective digestive decontamination (SDD) increase antibiotic resistance? Long-term comparison of two intensive care units (with and without SDD) of the same tertiary hospital.

PURPOSE: The aim of this study was to to compare the antimicrobial resistance rate and its relationship with the antibiotic consumption in two separate Intensive Care Units (ICUs) of the same hospital, one with and other without selective decontamination of the digestive tract (SDD). METHODS: We performed a retrospective study in the two ICUs of the Araba University Hospital. Trauma and neurosurgical patients are admitted to the SDD-ICU, and general digestive surgery patients go to the no SDD-ICU. From 2014 to 2018 we analyzed the number of isolates, and the bacterial resistance trends of 47 antimicrobial-microorganism combinations. Additionally, antimicrobial consumption was estimated in both ICUs. Resistance rates were also compared with those reported in ENVIN-HELICS Spanish national registry. RESULTS: In the ICU with SDD protocol, there was a significant decrease in the resistance of E. coli to amoxicillin/clavulanic acid and in the resistance of E. faecalis to high concentration of gentamycin and high concentration of streptomycin. A significant increase of resistance of Staphylococcus coagulasa negative (CoNS) to linezolid in the no SDD-ICU was also detected. Overall, the level of resistance in the SDD-ICU was lower or of the same order than in the ICU without SDD and that reported in the Spanish national registry. CONCLUSIONS: SDD had neither a clinically relevant impact on emergence and spread of resistance, nor in the overall systemic antimicrobial use. The patient type rather than the SDD protocol showed to condition the ecology and therefore, the resistance rate in the ICUs.

Trends in inpatient antimicrobial consumption using days of therapy and days of antibiotic spectrum coverage: A nationwide claims database study in Japan.

INTRODUCTION: Days of antibiotic spectrum coverage (DASC), a novel metric for both antimicrobial volume and spectrum, was proposed to measure inpatient antimicrobial consumption in 2022. The DASC may better reflect efforts toward antimicrobial stewardship; however, no previous study has described the distribution of trends in DASC in hospitals or the association between the trend in DASC and days of therapy (DOT). This study assessed trends in antimicrobial consumption for inpatients at acute care hospitals in Japan using the DOT and DASC. METHODS: This retrospective observational study used the nationwide administrative inpatient claims database of Japanese acute care hospitals between 2014 and 2018. The prescriptions of all antibiotics were identified to calculate DOT/1000 patient-days, DASC/1000 patient-days, and DASC/DOT. We described the five-year trend in these metrics and examined the association between the trends in DOT and DASC. RESULTS: In total, 26,301,685 admissions from 634 hospitals were included. The DOT/1000 patient-days and DASC/1000 patient-days increased significantly by 6.1% and 5.6%, respectively. The DASC/DOT ratio did not change significantly (P = 0.35). Moreover, there was little correlation between DOT/1000 patient-days and DASC/DOT (R2 = 0.01). There was also little correlation between the five-year changes in DOT/1000 patient-days and those in DASC/DOT (R2 = 0.02). CONCLUSIONS: It may be difficult to assess trends in the antibiotic spectrum using DASC alone. However, the combination of DOT as a quantity indicator and DASC/DOT as a spectrum indicator may allow for a more appropriate evaluation of stewardship efforts.

Prescriber-level surveillance of outpatient antimicrobial consumption to enable targeted antimicrobial stewardship: a nationwide observational study, Switzerland, 2015 to 2022.

BackgroundIn Europe and other high-income countries, antibiotics are mainly prescribed in the outpatient setting, which consists of primary, specialist and hospital-affiliated outpatient care. Established surveillance platforms report antimicrobial consumption (AMC) on aggregated levels and the contribution of the different prescriber groups is unknown.AimTo determine the contribution of different prescribers to the overall outpatient AMC in Switzerland.MethodsWe conducted a retrospective observational study using claims data from one large Swiss health insurance company, covering the period from 2015 to 2022. We analysed antibiotic prescriptions (ATC code J01) prescribed in the Swiss outpatient setting. Results were reported as defined daily doses per 1,000 inhabitants per day (DID) and weighted according to the total population of Switzerland based on census data.ResultsWe analysed 3,663,590 antibiotic prescriptions from 49 prescriber groups. Overall, AMC ranged from 9.12 DID (2015) to 7.99 DID (2022). General internal medicine (40.1% of all prescribed DID in 2022), hospital-affiliated outpatient care (20.6%), group practices (17.3%), paediatrics (5.4%) and gynaecology (3.7%) were the largest prescriber groups. Primary care accounted for two-thirds of the prescribed DID. Quantity and type of antibiotics prescribed varied between the prescriber groups. Broad-spectrum penicillins, tetracyclines and macrolides were the most prescribed antibiotic classes.ConclusionPrimary care contributed considerably less to AMC than anticipated, and hospital-affiliated outpatient care emerged as an important prescriber. Surveillance at the prescriber level enables the identification of prescribing patterns within all prescriber groups, offering unprecedented visibility and allowing a more targeted antibiotic stewardship according to prescriber groups.

The impact of the COVID-19 pandemic on antibiotic consumption and prevalence of pathogens in primary and secondary healthcare settings in Northern Ireland.

AIM: To evaluate the impact of the COVID-19 pandemic on the patterns of antimicrobial use and the incidence of pathogens in primary and secondary healthcare settings in Northern Ireland. METHODS: Data were collected on antibiotic use and Gram-positive and Gram-negative pathogens from primary and secondary healthcare settings in Northern Ireland for the period before (January 2015-March 2020) and during (April 2020-December 2021) the pandemic. Time series intervention analysis methods were utilized. RESULTS: In the hospital setting, the mean total hospital antibiotic consumption during the pandemic was 1864.5 defined daily doses (DDDs) per 1000 occupied-bed days (OBD), showing no significant change from pre-pandemic (P = .7365). During the pandemic, the use of second-generation cephalosporins, third-generation cephalosporins, co-amoxiclav and levofloxacin increased, there was a decrease in the percentage use of the hospital Access group (P = .0083) and an increase in the percentage use of Watch group (P = .0040), and the number of hospital Klebsiella oxytoca and methicillin-susceptible Staphylococcus aureus cases increased. In primary care, the mean total antibiotic consumption during the COVID-19 pandemic was 20.53 DDDs per 1000 inhabitants per day (DID), compared to 25.56 DID before the COVID-19 pandemic (P = .0071). During the pandemic, there was a decrease in the use of several antibiotic classes, an increase in the percentage use of the Reserve group (P = .0032) and an increase in the number of community-onset Pseudomonas aeruginosa cases. CONCLUSION: This study provides details of both changes in antibiotic consumption and the prevalence of infections in hospitals and primary care before and during the COVID-19 pandemic that emphasize the importance of antimicrobial stewardship in pandemic situations.

Trends of Antimicrobial Consumption in Hospital: Tackling the Hidden Part of the Iceberg with an Electronic Personalised Prescription Software for Antimicrobial Stewardship.

BACKGROUND: The monitoring of antibiotic prescriptions is of fundamental importance in the hospital setting. Inappropriate prescriptions could cause an unjustified exposure of patients to the risk of ADR (adverse drug reactions) and increase the risk of spreading the ecological resistance of hospital microorganisms. The use of IT media is essential in antimicrobial stewardship programs. OBJECTIVE: The purpose of this work was to evaluate the variation in the exposure index to antibiotics following the adoption of electronic pharmacist-controlled prescriptions in 2015. METHODS: Electronic Personalised Prescription Software (EPPS) was introduced in our University Hospital in 2015. The exposure index to antibiotics was expressed per WHO methodology in DDD (defined daily dose)/100 patient days (DPD). The changes in DPDs over the 2015-2020 period were calculated as percentages and through linear regressions. The analysis was performed using SPSS® (IBM). RESULTS: Following the introduction of EPPS, there was a progressive decline in DPDs during the 2015-2020 period from 98.9 to 65.1 (R2 = 0.687, p = 0.041). This could mainly be linked to the decreased use of ATC class J01CR - penicillin association, including beta-lactamase inhibitors (DPD 2015 39.9; DPD 2020 11.5; variation -71.1%). Expenditure progressively decreased from € 427,000 in 2015 to € 269,000 in 2020. CONCLUSION: The use of EPPS was shown to be useful for pharmacists in implementing proper antibiotic dispensing practices; the avoidance of inappropriate prescriptions leads to a better monitoring of DPDs and the related expenditure which is the main goal of antibiotic stewardship programs.

Rebound in community antibiotic consumption after the observed decrease during the COVID-19 pandemic, EU/EEA, 2022.

We observed a rebound in consumption of antibacterials for systemic use (ATC J01) in the community sector in the European Union/European Economic Area during 2021 and 2022, after an observed decrease between 2019 and 2020. The rates in 2022 returned to pre-COVID-19-pandemic levels and were exceeded in 13 countries. Although these patterns could partly be a result of changes in disease transmission during the study period, it could also reflect a lost opportunity to strengthen and reinforce prudent antibiotic use.

Impact of an electronic alert on prescription patterns of meropenem, voriconazole and caspofungin.

BACKGROUND: Antimicrobial stewardship programs promote the appropriate use of antimicrobial substances through the implementation of evidence-based, active and passive interventions. We analyzed the effect of a computer-assisted intervention on antimicrobial use in a tertiary care hospital. METHODS: Between 2011 and 2016 we introduced an electronic alert for patients being prescribed meropenem, voriconazole and caspofungin. At prescription and at day 3 of treatment, physicians were informed about the risk related to these antimicrobial substances by an electronic alert in the medical records. Physicians were invited to revoke or confirm the prescription and to contact the infectious disease (ID) team. Using interrupted time series regression, the days of therapy (DOTs) and the number of prescriptions before and after the intervention were compared. RESULTS: We counted 64,281 DOTs for 5549 prescriptions during 4100 hospital stays. Overall, the DOTs decreased continuously over time. An additional benefit of the alert could not be observed. Similarly, the number of prescriptions decreased over time, without significant effect of the intervention. When considering the three drugs separately, the alert impacted the duration (change in slope of DOTs/1000 bed days; P = 0.0017) as well as the number of prescriptions (change in slope of prescriptions/1000 bed days; P < 0.001) of voriconazole only. CONCLUSIONS: The introduction of the alert lowered prescriptions of voriconazole only. Thus, self-stewardship alone seems to have a limited impact on electronic prescriptions of anti-infective substances. Additional measures such as face-to-face prompting with ID physicians or audit and feedback are indispensable to optimize antimicrobial use.

Population-Level Antimicrobial Consumption Is Associated With Decreased Antimicrobial Susceptibility in Neisseria gonorrhoeae in 24 European Countries: An Ecological Analysis.

OBJECTIVES: There are substantial variations between different populations in the susceptibility of Neisseria gonorrhoeae to antimicrobials, and the reasons for this are largely unexplored. We aimed to assess whether the population-level consumption of antimicrobials is a contributory factor. METHODS: Using antimicrobial susceptibility data from 24 countries in the European Gonococcal Antimicrobial Surveillance Programme and antimicrobial consumption data from the IQVIA MIDAS database, we built mixed-effects linear/logistic regression models with country-level cephalosporin, fluoroquinolone, and macrolide consumption (standard doses/1000 population/year) as the explanatory variables (from 2009 to 2015) and 1-year-lagged ceftriaxone, cefixime, azithromycin, and ciprofloxacin geometric mean minimum inhibitory concentrations (MICs) as the outcome variables (from 2010 to 2016). RESULTS: Positive correlations were found between the consumption of cephalosporins and the geometric mean MICs of ceftriaxone and cefixime (P < .05 for both comparisons). Fluoroquinolone consumption was positively associated with the prevalence of resistance to ciprofloxacin (P < .05). CONCLUSIONS: Differences in the population-level consumption of particular antimicrobials may contribute to variations in the level of antimicrobial resistance in N. gonorrhoeae in different settings. Further interventions to reduce misuse and overuse of antimicrobials in high-consumption populations and core groups are required.

Reversing the Trend of Antimicrobial Resistance in ICU: Role of Antimicrobial and Diagnostic Stewardship.

BACKGROUND: Increasing antimicrobial resistance (AMR) among common bacteria combined with the slow development of new antibiotics has posed a challenge to clinicians. AIM AND OBJECTIVE: To demonstrate whether antimicrobial and diagnostic stewardship program (ASP and DSP)-related interventions improve antibiotic susceptibilities among common bacteria causing bloodstream infections (BSI) in patients admitted to the intensive care unit (ICU) and whether these resulted in changes in the volume of antimicrobial consumption. MATERIALS AND METHODS: We compared the susceptibility patterns of gram-negative bacteria (GNB) and gram-positive cocci (GPC) causing BSI and changes in the volume of antibiotics prescribed for the same before and after 2017 by a retrospective analysis. RESULTS: Postintervention, there was increased susceptibility of all GNBs to aminoglycosides; Escherichia coli and Klebsiella spp. to beta-lactambeta-lactamase inhibitors (BLBLI) combinations; and Klebsiella spp. and Pseudomonas spp. to carbapenems. Acinetobacter spp., Klebsiella spp., and Pseudomonas spp. showed improved susceptibility to doxycycline, whereas E. coli and Klebsiella spp. showed significantly improved susceptibility to fluoroquinolones. Among GPCs, there was increased susceptibility of Staphylococcus aureus (levofloxacin, clindamycin, and aminoglycoside), coagulase-negative S. aureus (CoNS) (chloramphenicol, levofloxacin, clindamycin, and aminoglycoside), and enterococci (chloramphenicol, levofloxacin, and clindamycin). There was a significant reduction in usage of antimicrobials for the treatment of GPCs (linezolid, doxycycline, chloramphenicol, levofloxacin, BLBLI, macrolide, and cephalosporin) and GNBs (levofloxacin, cephalosporin, carbapenem, and colistin), which caused BSI. CONCLUSION: The present study illustrated that combined ASP and DSP interventions successfully reversed the resistance pattern of organisms causing BSI and resulted in a reduction in antibiotic utilization. HOW TO CITE THIS ARTICLE: Agarwal J, Singh V, Das A, Nath SS, Kumar R, Sen M. Reversing the Trend of Antimicrobial Resistance in ICU: Role of Antimicrobial and Diagnostic Stewardship. Indian J Crit Care Med 2021;25(6):635-641.

Patterns of antimicrobial consumption in neonatal and pediatric intensive care units in Germany and Brazil.

Antibiotic consumption (AC) is a key component of antimicrobial stewardship programs to recognize local patterns of antibiotic use. Our aim was to measure AC in neonatal units, including neonatal (NICU)/paediatric (PICU) intensive care units in different countries. We conducted a multicenter, retrospective, cohort study in three NICUs, one neonatal ward, and three PICUs with a total of 84 beds. Global and individual AC in days of therapy (DOT) and DOT per 1000 patient-days were assessed. During the study period, 2567 patients were admitted, corresponding to 4961 patient-days in neonatal units and 9243 patient-days in PICUs. Multidrug-resistant Gram-negative bacteria and methicillin-resistant Staphylococcus aureus were more frequent in Brazil than in Germany. Average AC was 386.5 and 1335.5 DOT/1000PD in German and Brazilian neonatal units, respectively. Aminopenicillins plus 3rd generation cephalosporins were the most commonly prescribed antibiotics in German neonatal units, while aminopenicillins plus aminoglycosides were the class most commonly used in Brazilian NICU. Average AC was 888.1 and 1440.7 DOT/1000PD in German and Brazilian PICUs, respectively. Antipseudomonal penicillins were most commonly used in the German PICU, and glycopeptides were the most frequently prescribed in Brazilian PICUs. Carbapenems represented 2.3-14% of total DOTs in German neonatal units and 4% in the Brazilian NICU and 13.0% in the German PICU and 6-12.2% in Brazilian PICUs. We concluded that different patterns of most commonly prescribed antibiotics were observed in neonatal units and PICUs in these two countries, probably related to different local patterns of antibiotic resistance, with a higher antibiotic consumption in Brazilian study units.

Development of the predicted and standardized carbapenem usage metric: Analysis of the Japanese Diagnosis Procedure Combination payment system data.

This study aimed to develop a metric for standardized and predicted carbapenem consumption using the Diagnosis Procedure Combination payment system database and patients' characteristics. Based on Diagnosis Procedure Combination data analysis, the developed metric will provide useful benchmarks that stewardship programs can use to help drive improvements.

Cost of inappropriate antimicrobial use for upper respiratory infection in Japan.

BACKGROUND: Antibiotics are often prescribed inappropriately to patients with upper respiratory infection (URI) in ambulatory care settings; however, the economic burden of such prescription has not been quantitatively assessed. Here, we aimed to evaluate the additional cost of antimicrobial prescription for URI at the population level in Japan. METHODS: We conducted a retrospective observational survey using longitudinal claims data between 2013 and 2016 obtained from JMDC Claims Database, which contains data from 5·1 million corporate employees and family members under the age of 65 years. Appropriateness of antibiotic prescription was assessed by a panel of six infectious disease physicians according to ICD-10 code in JMDC Claims Database. Total additional cost of antibiotic prescription for URI at the national level was estimated by weighting of age-structured population data. RESULTS: The annual additional cost of inappropriate antibiotic prescription for URI was estimated at 423·6 (95% CI: 416·8-430·5) million USD in 2013, 340·9 (95% CI: 335·7-346·2) million USD in 2014, 349·9 (95% CI: 344·5-355·3) million USD in 2015, and 297·1 (95% CI: 292·4-301·9) million USD in 2016. Three classes of broad-spectrum oral antibiotics (third-generation cephalosporins, macrolides, and fluoroquinolones) accounted for > 90% of the total additional cost. CONCLUSIONS: Although a decreasing trend was observed, annual additional costs of inappropriate antibiotic prescriptions for URI could be a substantial economic burden in Japan. Appropriately prescribing broad-spectrum oral antibiotics might be an important issue to reduce unnecessary medical costs in Japanese ambulatory care.

Correlation between antimicrobial consumption and the prevalence of carbapenem-resistant Escherichia coli and carbapenem-resistant Klebsiella pneumoniae at a university hospital in Thailand.

WHAT IS KNOWN AND OBJECTIVE: Carbapenem-resistant Enterobacteriaceae (CRE) are virulent gram-negative bacilli and cause urgent healthcare problems worldwide. One of the main factors leading to the emergence of CRE is antimicrobial consumption. The objective of this study was to assess how closely the rate of antimicrobial consumption and the prevalences of carbapenem-resistant Escherichia coli (CR-EC) and carbapenem-resistant Klebsiella pneumoniae (CR-KP) are correlated. METHODS: A retrospective study was performed at a university hospital in Thailand from January 2013 to September 2016. The prevalence of E coli and K pneumoniae was represented as percentages per species per quarter. The antimicrobial consumption rate per quarter was expressed as the defined daily dose (DDD)/1000 patient-days. Evaluation of the relationships between the rate of antimicrobial consumption and the prevalences of CR-EC and CR-KP was conducted via Pearson's or Spearman's correlation analyses. RESULTS AND DISCUSSION: During the study period, the prevalence of CR-EC and CR-KP was less than 6%; however, significantly increasing prevalences were reported for both CR-EC (r = 0.55, P = 0.03) and CR-KP (r = 0.87, P < 0.01). There was a significant increasing trend in the consumption of meropenem (r = 0.65, P = 0.01), levofloxacin (r = 0.63, P = 0.01), ceftriaxone (r = 0.55, P = 0.03), ertapenem (r = 0.52, P = 0.05) and the carbapenem group (r = 0.64, P = 0.01). A significant correlation was observed between CR-KP prevalence and total carbapenem consumption (r = 0.55, P = 0.04). Moreover, levofloxacin consumption had a significant positive relationship with the prevalence of CR-KP (r = 0.65, P = 0.01). No positive correlation was found with the prevalence of CR-EC. WHAT IS NEW AND CONCLUSION: The rate of consumption of levofloxacin and carbapenems was the important key factor correlated with the rate of emergence of CR-KP. This is the first report demonstrating the correlation between levofloxacin consumption and CR-KP prevalence.

The effect of mastitis management input and implementation of mastitis management on udder health, milk quality, and antimicrobial consumption in dairy herds.

The main objective of this study was to evaluate evolutions in herd-level antimicrobial consumption (AMC) and in udder health and milk quality parameters between herds that received mastitis management input on a regular basis (actively advised by the first author; referred to as intervention herds) and herds that did not (referred to as control herds). Strikingly, herds in the intervention group had a significantly higher prevalence of new intramammary infections compared with those in the control group. No significant differences were observed in the percentage of chronically infected cows, the bulk milk somatic cell count, and the bacterial and coliform count between the intervention and control herds, nor did the herd-level AMC differ between them. Furthermore, the level of mastitis management applied in each herd was assessed and scored [mastitis management score (MMS); higher is better], as was the level of implementation of different recommended mastitis management practices over time, expressed as the mastitis management implementation score (MMIS; higher is better). A large variation was observed in MMS and MMIS in the intervention herds (median = 16 and range = 12 to 22; median = 13 and range = -5 to 31, respectively) and the control herds (median = 16 and range = 9 to 22; median = 9 and range = -13 to 22, respectively). Also, intervention herds in which the herd veterinarian attended each herd visit executed by the first author had a higher MMS and MMIS (median = 20 and 24, respectively) compared with herds in which the veterinarian sometimes (median = 16 and 17, respectively) or never (median = 16.5 and 7.5, respectively) attended the herd visits. Further, the association between MMS or MMIS on one hand and udder health, milk quality, and the herd-level AMC over time on the other was studied using the data of both groups of herds. Better mastitis management was associated with a reduction in the consumption of antimicrobials that are critically important for human health over time and with lower bacterial counts and bulk milk somatic cell count. Better mastitis management can be helpful in obtaining better milk quality and more responsible use of critically important antimicrobials on dairy farms.

Antimicrobial use in acute care hospitals: national point prevalence survey on healthcare-associated infections and antimicrobial use, Switzerland, 2017.

BackgroundA point prevalence survey (PPS) on healthcare-associated infections (HAI) and antimicrobial use was conducted in Swiss acute care hospitals in 2017.AimOur objective was to assess antimicrobial use in Swiss acute care hospitals.MethodsAll patients hospitalised in any acute care hospital in Switzerland were eligible. We used the most recent version of the PPS protocol of the European Centre for Disease Prevention and Control.ResultsData from 12,931 patients of 96 hospitals were collected. Of these, 4,265 (33%; 95% confidence interval (CI): 32.2-33.8) were on 5,354 antimicrobials for 4,487 indications. Most of the 2,808 therapeutic indications addressed 1,886 community-acquired infections (67.2%; 95% CI: 65.4-68.9). Of the 1,176 surgical prophylaxes, 350 (29.8%; 95% CI: 27.1-32.4) exceeded the duration of 1 day. Of the 1,090 antimicrobial regimens that were changed, 309 (28.3%; 95% CI: 25.7-31.0) were escalated and 337 (30.9%; 95% CI: 28.2-33.7) were de-escalated. Amoxicillin/clavulanic acid was the most frequent antimicrobial (18.8%; 95% CI: 17.7-19.8), prescribed mainly for therapeutic indications (76.0%; 95% CI: 73.3-78.7). A total of 1,931 (37.4%; 95% CI: 36.1-38.8) of the 5,158 antimicrobials for systemic use were broad-spectrum antibiotics, most frequently third- and fourth-generation cephalosporins (35.9%; 95% CI: 33.8-38.1).ConclusionsAntimicrobial consumption was at European average, the use of broad-spectrum antibiotics in the lower third. Swiss acute care hospitals should invest in antimicrobial stewardship, particularly in reducing the use of broad-spectrum antibiotics.

Decreasing and stabilising trends of antimicrobial consumption and resistance in Escherichia coli and Klebsiella pneumoniae in segmented regression analysis, European Union/European Economic Area, 2001 to 2018.

Investments to reduce the spread of antimicrobial resistance (AMR) in the European Union have been made, including efforts to strengthen prudent antimicrobial use. Using segmented regression, we report decreasing and stabilising trends in data reported to the European Surveillance of Antimicrobial Consumption Network and stabilising trends in data reported to the European Antimicrobial Resistance Surveillance Network. Our results could be an early indication of the effect of prioritising AMR on the public health agenda.

Immediate and later impacts of antimicrobial consumption on carbapenem-resistant Acinetobacter spp., Pseudomonas aeruginosa, and Klebsiella spp. in a teaching hospital in Brazil: a 10-year trend study.

To evaluate trends and the immediate and late impact of antimicrobial consumption on carbapenem-resistant Acinetobacter spp. (CRAs), carbapenem-resistant Pseudomonas aeruginosa (CRPA), and carbapenem-resistant Klebsiella spp. (CRKs) over a 10-year period. An ecological study was conducted at the teaching hospital in São Paulo, Brazil, from 2007 to 2016. Consumption and resistance data were collected from the supply sector and central laboratory of the institution, respectively. Associations between consumption and resistance were analyzed in the same year, 1 year later, and 2 years later by linear regression of mixed effects. A total of 22,041 isolates were analyzed. Among these, 9988 corresponded to the gram-negatives in this study [3682 (36.9%) were Klebsiella spp., 3169 (31.7%) were P. aeruginosa, and 3137 (31.4%) were Acinetobacter spp.]. An increasing trend of consumption was observed, except for fourth-generation cephalosporins. Carbapenems were the most used antimicrobial class; CRKs presented a substantial increase over this period (from 1.4 to 67.0%; p = 0.001). Increased consumption of third-generation cephalosporins reduced CRAs [- 2.43%, 95% confidence interval (CI), - 3.30 to - 1.57; p < 0.001] and increased CRPA [26.67%, 95% CI, 2.99 to 50.35; p = 0.034] in the same year. Increased consumption of ß-lactam/ß-lactamase inhibitors increased CRKs with a 1-year delay [5.13%, 95% CI, 2.40 to 7.86; p = 0.001]. Our study demonstrated high antimicrobial consumption and growing carbapenem-resistance rates among gram-negative bacteria, especially Klebsiella spp., and the immediate and later effects of consumption of multiple antimicrobials on carbapenem resistance.

Longitudinal point prevalence survey of antibacterial use in Northern Ireland using the European Surveillance of Antimicrobial Consumption (ESAC) PPS and Global-PPS tool.

Antimicrobial resistance is a limiting factor for the success of the treatment of infectious diseases and is associated with increased morbidity and cost. The present study aims to evaluate prescribing patterns of antimicrobials and quantify progress in relation to targets for quality improvement in the prescription of antimicrobials in Northern Ireland's secondary care sector using three repetitive point prevalence surveys (PPS) over a 6-year period: the European Surveillance of Antimicrobial Consumption (ESAC-PPS) in 2009 and 2011 and the Global-PPS on Antimicrobial Consumption and Resistance in 2015. Out of 3605 patients surveyed over the three time points, 1239 (34.4%) were treated with an antibiotic, the most frequently prescribed antibiotic groups were a combination of penicillins, including ß-lactamase inhibitors. Compliance with hospital antibiotic policies in 2009, 2011 and 2015 were 54.5%, 71.5% and 79.9%, respectively. Likewise, an indication for treatment was recorded in patient notes 88.5%, 87.7% and 90.6% in 2009, 2011 and 2015, respectively, and surgical prophylactic antibiotic prescriptions for >24 h was 3.9%, 3.2% and 0.7% in 2009, 2011 and 2015, respectively. Treatment based on biomarker data was used in 61.5% of cases. In conclusion, a general trend in the improvement of key antimicrobial-related quality indicators was noted. The PPS tool provided a convenient, inexpensive surveillance system of antimicrobial consumption and should be considered an essential component to establish and maintain informed antibiotic stewardship in hospitals.

Trends and patterns of national antimicrobial consumption in Japan from 2004 to 2016.

Frequent use of broad-spectrum antimicrobial classes has been reported in Japan; however, little is known about the long-term trend of national antimicrobial consumption, and that of individual agents. This study analyzed the national sales data of systemic antimicrobials from 2004 to 2016, derived from the IMS Japan Pharmaceutical Market database, to assess the consumption patterns of antimicrobial classes and agents in Japan. The number of defined daily doses per 1000 inhabitants per day (DID) was calculated for each antimicrobial agent. During the last 13 years, total antimicrobial consumption fluctuated by only 5% around the average of 14.41 DID. In 2016, the most used class was macrolides (32%), followed by cephalosporins (28%) and fluoroquinolones (19%). Oral agents comprised a large proportion (93%) of antimicrobial consumption. The most used agent, clarithromycin, accounted for 25% of all oral compounds used in 2016. The consumption of oral agents with high bioavailability, such as fluoroquinolones, amoxicillin, and sulfamethoxazole/trimethoprim increased, whereas that of cephalosporins decreased. In 2016, ceftriaxone was the most consumed parenteral agent, followed by cefazolin. The consumption of parenteral agents increased after 2009 when high-dose regimens of piperacillin/tazobactam, meropenem, and ampicillin/sulbactam were approved by the health insurance system. National antimicrobial consumption has been stable over the last 13 years. Moreover, shifts in the use of agents with high bioavailability and those approved for high-dose regimens were observed. However, the increased use of broad-spectrum agents is worrisome. A multifaceted approach is required to reduce overall antimicrobial consumption.

Antimicrobial consumption on dairy herds and its association with antimicrobial inhibition zone diameters of non-aureus staphylococci and Staphylococcus aureus isolated from subclinical mastitis.

The main objectives of this study were to quantify the consumption of antimicrobials on a convenience sample of dairy herds and to determine the association between herd-level antimicrobial consumption and inhibition zone diameters (IZD) of non-aureus staphylococci and Staphylococcus aureus isolates from subclinical mastitis cases. Also, the association between the IZD of non-aureus staphylococci and Staph. aureus isolates within a herd was studied. Antimicrobial consumption data on 56 Flemish dairy farms were obtained between 2013 and 2014 by so-called garbage can audits and expressed as antimicrobial treatment incidence (ATI), with the unit of ATI being the number of defined daily doses animal (DDDA) used per 1,000 cow-days. The average total ATI in adult dairy cattle for all active substances was 18.73 DDDA per 1,000 cow-days and ranged from 6.28 to 42.13 DDDA between herds. The ATI of critically important (for human health) antimicrobials was 6.91 DDDA per 1,000 cow-days; that is, 37% of total antimicrobial consumption. The average ATI for intramammary therapy of (sub)clinical mastitis, intramammary dry-cow therapy, and systemically administered therapy was 5.20, 6.70, and 6.73 DDDA, respectively. The IZD of 239 non-aureus staphylococci and 88 Staph. aureus isolates originating from milk samples from cows with subclinical mastitis collected on selected dairy herds were determined using Kirby-Bauer disk diffusion and ranged between 6 and 42 mm. Because only a limited number of clinical breakpoints (Clinical and Laboratory Standards Institute) and epidemiological cut-off values (European Committee on Antimicrobial Susceptibility Testing) are available for mastitis-causing bacteria in bovine, IZD were used as a proxy for antimicrobial resistance. Inhibition zone diameters of non-aureus staphylococci for cefquinome, a critically important ß-lactam antibiotic, were negatively associated with the ATI of critically important ß-lactam for systemically administered therapy and positively with the ATI for intramammary therapy of (sub)clinical mastitis of critically important ß-lactam antimicrobials. Only for neomycin was a positive association between the IZD of non-aureus staphylococci and Staph. aureus isolates within the same herd observed.