Infections in Critically Ill Children

Health care–associated infections (HAI) directly influence the survival of children in pediatric intensive care units (PICU), the most common being central line–associated bloodstream infection (CLABSI) 25–30%, followed by ventilator-associated pneumonia (VAP) 20–25%, and others such as catheter-associated urinary tract infection (CAUTI) 15%, surgical site infection (SSI) 11%. HAIs complicate the course of the disease, especially the critical one, thereby increasing the mortality, morbidity, length of hospital stay, and cost. The incidence of HAI in Western countries is 6.1–15.1% and in India, it is 10.5 to 19.5%. The advances in healthcare practices have reduced the incidence of HAIs in the recent years which is possible due to strict asepsis, hand hygiene practices, surveillance of infections, antibiotic stewardship, and adherence to bundled care. The burden of drug resistance and emerging infections are increasing with limited antibiotics in hand, is still a dreadful threat. The most common manifestation of HAIs is fever in PICU, hence the appropriate targeted search to identify the cause of fever should be done. Proper isolation practices, judicious handling of devices, regular microbiologic audit, local spectrum of organisms, identification of barriers in compliance of hand hygiene practices, appropriate education and training, all put together in an efficient and sustained system improves patient outcome.

Clinical and Bacteriological Profile of Neonatal Sepsis- A Retrospective Study

Background: Neonatal sepsis is a major cause of mortality and morbidity in newborn in developing countries. The spectrum of bacteria which causes neonatal sepsis varies in different parts of the world. Surveillance of causative organisms and their antibiotic sensitivity pattern promotes rational use of antibiotics and antibiotic stewardship. Objective: To assess the clinical and bacteriological profile of neonatal sepsis.Material & Methods:A retrospective study was conducted at Department of Pediatrics, Rajshahi Medical College Hospital, Rajshahi, Bangladesh from January to June 2019. Of the 207 neonates with clinical suspicion of sepsis, 55 neonates included. Culture positive sepsis was defined as isolation of bacterial pathogen from blood in neonates with clinical suspicion of sepsis.Results:Of the 207 neonates with clinical suspicion of sepsis, 55 neonates had blood culture positive sepsis. Sepsis was predominant in males (64.5%). Low birth weight (47.2%) and prematurity (40.9%) were important neonatal risk factors for sepsis. Early onset sepsis occurred in 58.1% of the cases and late onset sepsis in 41.9% of the neonates. Gram-positive cocci constituted 67.52% of all isolates and gram negative 30.76%. The most frequently isolated organism in blood was methicillin resistant coagulase negative staphylococcus (MRCONS) (32.47%). Gram positive organisms included MRCONS, methicillin resistant Staphylococci aureus (MRSA), group B Streptococci (GBS), Staphylococcus aureus and Enterococci. Among Gram-negative organisms, Acinetobacter was most frequently isolated followed by Klebsiella, Escherichia coli, Pseudomonas, Citrobacter and Burkholderia species. The mortality in the study group was 13.5%. Gram negative organisms were most resistant to ampicillin and cephalosporins. Gram positive isolates were least resistant to vancomycin and linezolid.Conclusion:In conclusion, gram positive sepsis was found to be common in present study, although mortality was high in gram negative sepsis. Careful measures have to be taken to overcome the change in trend of organisms causing sepsis, and selection of antibiotics should be prudent.

Report of two events of nosocomial outbreak and pseudo-outbreak due to contamination with Achromobacter spp / Comunicación de 2 eventos de brote y seudobrote nosocomial debido a contaminación con Achromobacter spp

Abstract Achromobacter spp. are increasingly recognized as emerging pathogens in immunocompromised patients or suffering cystic fibrosis, but unusual in immunocompetent hosts or individuals that underwent surgery. In this study we describe two simultaneous events attributable to two different Achromobacter spp. contaminated sources. One event was related to an episode of pseudo-bacteremia due to sodium citrate blood collection tubes contaminated with Achromobacter insuavis and the other to Achromobacter genogroup 20 infection and colonization caused by an intrinsically contaminated chlorhexidine soap solution. Both threatened the appropriate use of antimicrobials. Molecular approaches were critical to achieving the accurate species identification and to assess the clonal relationship, strengthening the need for dedicated, multidisciplinary and collaborative work of microbiologists, specialists in infectious diseases, epidemiologists and nurses in the control of infections to clarify these epidemiological situations.

Resumen Achromobacter spp. son reconocidas con mayor frecuencia como patógenos emergentes en pacientes con fibrosis quística e inmunodeprimidos, pero son inusuales en hospedadores inmunocompetentes o quirúrgicos. En este estudio describimos 2 eventos simultáneos atribuibles a 2 fuentes contaminadas con Achromobacter spp. Uno correspondió a un episodio de seudobacteriemia por tubos de citrato de sodio contaminados con Achromobacter insuavis y el otro a infecciones y colonizaciones debidas al uso de solución jabonosa de clorhexidina intrínsecamente contaminada con Achromobacter genogrupo 20. Ambos episodios pusieron en peligro el uso apropiado de antimicrobianos. Los enfoques moleculares fueron fundamentales para lograr la identificación precisa de las especies y evaluar la relación clonal de los aislamientos, lo que refuerza la necesidad del trabajo perseverante y multidisciplinario de microbiólogos, especialistas en enfermedades infecciosas, epidemiólogos y enfermeras en el control de infecciones para el esclarecimiento de estas situaciones epidemiológicas.

Evaluación de la administración de medicamentos veterinarios en hatos lecheros de quince municipios de Cundinamarca, Colombia

Objetivo Evaluar el conocimiento en el uso de Medicamentos de Uso Veterinario (MUV) de los productores ganaderos y personal involucrado en Bogotá y municipios aledaños. Métodos Se realizó un estudio de corte transversal a través de entrevistas a operarios y productores ganaderos de una muestra de 30 hatos lecheros localizados en 15 municipios cerca de Bogotá, Cundinamarca. Resultados Se identificó la implementación de prácticas para la administración de MUV, incluyendo parámetros que influencian su administración y conocimientos en las personas que los prescriben y administran. Se encontró que los medicamentos de mayor frecuencia fueron los antimicrobianos con 60,7%, entre los cuales se destaca el uso de penicilina y oxitetraciclina. Los MUV inyectables (parenterales) fueron las formas más frecuentes de aplicación con un 64,7%. Se identificaron 251 MUV en los hatos lecheros, de los cuales el 81,3% están compuestos por principios activos que requieren tiempo de retiro en leche y carne. Se destaca el rol del mayordomo en el cuidado animal a nivel diagnóstico y administración del tratamiento. Conclusión El presente estudio sugiere que el uso de MUV es implementado empíricamente en producciones lecheras y podría contribuir a mediano y largo plazo a la emergencia de cepas con resistencia a MUV.

Objective To evaluate the knowledge in the antibiotic stewardship practices in livestock producers and associated staff from Bogotá and neighboring municipalities. Methods A cross-sectional study was performed through interviews for livestock producers and staff in a sample of 30 dairy farms located in 15 municipalities near Bogota, Cundinamarca. We evaluated practice administration of veterinary drugs and knowledge in antibiotic stewardship by farm livestock managers in charge who prescribe and administer veterinary drugs. Results The most common veterinary drugs were antimicrobials with 60.7% such as penicillin and oxytetracycline. The injectable veterinary drugs (parenteral) were the most frequently used with 64.7%. We identified 251 veterinary drugs in the dairy farms where 81.3% of active compounds require withdrawal time in the milk and meat. The butler role in animal care was highlighted at diagnostic level and treatment compliance. Conclusion This study suggests that recommendations for veterinary drug stewardship remain empirically implemented in dairy farms which might lead to the future emergence of multidrug-resistant strains in the long and middle term.

Antimicrobial prescribing pattern in a tertiary care teaching hospital: a pilot study

Background: The emergence of antimicrobial resistance is a worldwide challenge threatening to negate the gains made by discovery of antimicrobial agents (AMAs). Antimicrobial Stewardship Program (ASP) is an important strategy for ensuring appropriate use of AMAs and controlling emergence of antibiotic resistance. Implementation of ASP must start with assessment of the current state of antimicrobial use. This study was therefore conducted to assess the prevalent prescribing patterns in a tertiary care hospital and identify gaps which warrant corrective intervention.Methods: This prospective pilot study presents analysis of the first 30 Patients from the medicine ward prescribed at least one antimicrobial agent during the two months of study period. Relevant data was collected in AMA record form. Appropriateness of AMAs was analyzed regarding selection as well as administration protocol as per the hospital antibiotic policy.Results: Out of the 60 AMAs prescribed to these patients, most commonly prescribed were cephalosporins (63.3%), anti-amoebics (26.6%) and macrolides (23.3%). Common diseases involved were urinary tract infection, acute gastroenteritis, sepsis and lower respiratory tract infections. Use of AMAs was found to be appropriate for the indication in 42 %, dose in 97%, duration 60 %, route 93% and frequency 90 %.Conclusions: This gap between the appropriate and the actual practice use of AMAs indicates an urgent need of rigorous implementation of ASP in order to avoid emergence of resistance and to conserve the sensitivity to the available AMAs.

The Increasing Interest in Antibiotic Stewardship Programs

Background:The inappropriate use of antibiotics leads to many adverse effects and also leads to bacterial resistance. A hospital-based program, commonly referred to as antibiotic stewardship programs, is usedto improve the usage of antibiotics. This study aims to explore the increasing interest of the public in antibiotic stewardship programs by using data from Google Trends and Twitter.Methodology:A search trends feature that shows how frequently a given search term is entered into Google’s search engine (Google Trends) and a social network site (Twitter) were used.Results:The public and the health care professionals are now more interested in antibiotic use and antibiotic resistance due to the development of more severe infections that were caused by bacteria resisted to many antibiotics which lead to high morbidity and mortality rates.Conclusion:There is a high prevalence of infections caused by multi-drug resistant organism that could lead to more mortality and morbidity rates, as a result the interest in antimicrobial stewardship programs in internet is increased. So it is important to increase the knowledge of health care professionals regarding the appropriate antibiotic use and to encourage them tochange their unsuitable prescribing patterns

Study of resistance pattern of isolated micro-organisms towards commonly used anti-microbial agents in medical intensive care unit of a tertiary care teaching hospital

Background: The objective of the study was to find out different types of biological samples from admitted patients tested for culture and sensitivity (C&S), prevalence of different types of organisms isolated from those samples, and to analyze the resistance pattern of those isolated organisms against commonly used or tested anti-microbial agents (AMAs).Methods: Following institutional ethics committee approval and written informed consent, adult patients of both genders, receiving AMAs were enrolled from June 2014 to July 2015 and followed up daily till they were in medical intensive care unit (MICU). Demographic data, diagnosis, culture-sensitivity (antibiogram) and other investigation reports and treatment details were recorded. Descriptive statistical analysis of collected data was done.Results: Of the 514 samples (from 600 patients enrolled) sent for C&S testing, 143 were reported as sterile while from the rest 371 samples, 504 organisms were isolated; commonly isolated organisms were Pseudomonas aeruginosa (30%), Acinetobacter baumannii (23%), Klebsiella pneumoniae (16%), Providencia sp. (7.1%), Escherichia coli (5.7%), and Enterobacter sp. (4.2%). Samples were sent in 63% of enrolled patients, the commonest being broncho-alveolar lavage (48% of total). Microbial resistance was high for cephalosporins (ceftriaxone, cefepime, ceftazidime), carbapenems (meropenem, imipenem), penicillins (piperacillin), quinolones (ciprofloxacin, levofloxacin), aminoglycosides (gentamicin, netilmicin, amikacin) and cotrimoxazole. Most organisms were sensitive to colistin (100%), polymyxin B (92%) and tigecycline (69%).Conclusions: The information regarding commonly isolated organisms and their resistant pattern would aid in rational selection of AMAs and thus the present study is useful to clinicians managing MICU and the hospital infection committee to plan future policies regarding AMA use in MICU.

A cross-sectional observational study on knowledge, attitude and practices about indiscriminate use of antibiotics and antibiotic resistance among medical doctors at Sapthagiri Hospital, Bangalore

Background: WHO defines Antimicrobial resistance (AMR) as “the ability of a microorganism to stop an antimicrobial from working against it”. The Global burden includes increased morbidity, prolonged illness and a higher mortality rate, along with economic burden. The cause can be tracked down to irrational usage of antibiotics and lack of awareness of rational prescribing practices.Methodology: A cross-sectional questionnaire-based observational study was carried out using a standard pre-validated questionnaire, which was administered to all the medical doctors present in their respective departments during the study period, exploring their knowledge regarding rational antibiotic usage, their attitudes and awareness towards AMR. Informed consent from the participants was obtained verbally, and confidentiality assured. The collected data was analyzed as per descriptive statistics.Results: Majority of doctors (91.3%) have a good knowledge and agree that indiscriminate use of antibiotics leads to antimicrobial resistance. 96.12% of doctors identify it as a global issue but only 85.5% consider it a problem in their hospital. Doctors (78%) have a positive attitude and do not prefer to prescribe an antibiotic for minor illnesses, but only 40% think it might contribute to antimicrobial resistance.Conclusion: Our study has demonstrated that doctors have a good knowledge about the emerging problem of antimicrobial resistance, however a minor percentage of doctors fail to acknowledge this at the level of their own hospital. Regular updates on the local antimicrobial resistance rates & antibiotic stewardship might help to control the global issue of AMR.

Análisis crítico de un antimicrobiano sub-óptimo, de frecuente sobre-utilización e inadecuada dosificación: vancomicina / Critical review of a suboptimal antibiotic, frequently overused and inappropriately dosed: vancomycin

Resumen Introducción: Vancomicina, terapia estándar para enterococos y estafilococos resistentes a β-lactámicos tradicionales (Staphylococcus aureus [SARM] y Staphylococcus coagulasa negativa), tiene extenso uso empírico en infecciones nosocomiales. Farmacológicamente débil, de estrecho margen terapéutico y farmacocinética poco predecible, es un fármaco sub-estándar según criterios contemporáneos. Tiene excesivo uso, por sobrediagnóstico de infecciones bacterianas y, en infecciones genuinas, por sobre-estimación etiológica de patógenos β-lactámico-resistentes. Últimamente han surgido nuevas amenazas a su efectividad: peores desenlaces en infecciones por SARM con CIM en rango alto de sensibilidad y resistencia de enterococos. Hay frecuente administración inadecuada en: dosis e intervalos, ausencia de dosis de carga inicial, falta de monitoreo con concentraciones plasmáticas, inadecuada dosificación en presencia de insuficiencia renal o diálisis e, importantemente, mantención de uso en ausencia de clara documentación de su necesidad. Nuevos fármacos anti-estafilocócicos no han permitido un reemplazo generalizado de vancomicina por lo que ésta mantiene un importante rol en la medicina contemporánea. Conclusiones: Una comprensión de las fortalezas y debilidades del fármaco, así como de la cambiante epidemiología y propiedades microbiológicas de los patógenos relevantes, al igual que un uso prudente y selectivo, permitirán optimizar su uso y mantener su rol terapéutico en la medicina actual y futura.

Background: Vancomycin, standard parenteral therapy for Gram positive cocci resistant to traditional beta-lactam antibiotics (Staphylococcus aureus and coagulase negative staphylococci [CNS]) and Enterococcus spp, frequent agents of nosocomial infections, is extensively used empirically in that setting. However, its pharmacological weakness, narrow therapeutic margin and poorly predictable pharmacokinetics, make it a suboptimal drug according to contemporary criteria. Vancomycin is over utilized due to both, overestimation of bacterial infections and, in genuine cases, overestimation of the etiological role of these resistant cocci, either nosocomially or community acquired. New threats narrow further its therapeutic role: poorer outcomes in infections with higher vancomycin MIC and resistance by enterococci. It is frequently given at inappropriate dosage and intervals, failing to: give loading dose when recommended, measure blood levels, adjust dosing to changing renal function and continued use when not necessary. Newer anti staphylococcal drugs haven't replaced completely the role of vancomycin, which maintains its usefulness in contemporary medicine. Conclusion: Understanding the strengths and weaknesses of vancomycin, current epidemiology and microbiology of infections for which it may be indicated, as well as the proper administration and monitoring, together with a prudent and selective indication will allow to preserve its present and future utility in the changing medical scenario.

A cross sectional study to assess knowledge, attitude and practice of rational antibiotic prescription among resident doctors

Background: Irrational prescription is a major contributor to the antimicrobial resistance. Resident doctors are the major focus of interventional programs aimed at rational prescription of antibiotics. So, their knowledge, attitude and practice regarding rational antibiotic prescription need to be assessed to plan future strategies.Methods: A questionnaire based cross sectional study among interns and resident doctors of a Government Medical College was conducted. Questionnaire consisted of questions to assess knowledge, attitude and practice of resident doctors in rational antibiotic prescriptions and multiple-choice questions to assess practice of hospital antibiotic policy.Results: 80 participants were enrolled in the study. All participants responded to yes or no questions and 47 answered multiple choice questions. 40% were aware of the current hospital antibiotic policy and 29% knew the term antibiotic stewardship. Only 15% were confident in their knowledge on antimicrobial resistance. 87.5% think there is no use in prescribing an antibiotic in common cold. 36.3% overprescribes antibiotics in their daily practice. Only 32.5% practiced de-escalation. 90% were educating patients regarding correct use of antibiotics. 90% send samples for culture and sensitivity but only 22.2% waited for results to start antibiotics.Conclusions: There is a need for approaches that includes implementation of antibiotic policy and to plan for effective teaching programs regarding antibiotic resistance and importance of rational prescription of antibiotics which can improve the quality of antibiotic prescription and minimize antibiotic resistance.

Clinico-bacteriological profile of neonatal sepsis

Background: Neonatal sepsis is the commonest cause of neonatal mortality responsible for about 30-50% of total neonatal deaths in developing countries. Surveillance of causative organisms and their antibiotic sensitivity pattern promotes rational use of antibiotics and antibiotic stewardship.Methods: A retrospective study, relevant data regarding the neonates diagnosed with culture positive sepsis was obtained from the case records during the period from July 2014 to June 2017. Culture positive sepsis was defined as isolation of bacterial pathogen from blood in neonates with clinical suspicion of sepsis.Results: Of the 414 neonates with clinical suspicion of sepsis, 110 neonates had blood culture positive sepsis. Sepsis was predominant in males (64.5%). Low birth weight (47.2%) and prematurity (40.9 %) were important neonatal risk factors for sepsis. Early onset sepsis occurred in 58.1% of the cases and late onset sepsis in 41.9% of the neonates. Gram-positive cocci constituted 67.52% of all isolates and gram negative 30.76%. The most frequently isolated organism in blood was methicillin resistant coagulase negative staphylococcus(MRCONS) (32.47%). Gram positive organisms included MRCONS, methicillin resistant Staphylococci aureus (MRSA), group B Streptococci (GBS), Staphylococcus aureus and Enterococci. Among Gram-negative organisms, Acinetobacter was most frequently isolated followed by Klebsiella, Escherichia coli, Pseudomonas, Citrobacter and Burkholderia species. The mortality in the study group was 13.5%. Gram negative organisms were most resistant to ampicillin and cephalosporins. Gram positive isolates were least resistant to vancomycin and linezolid.Conclusions: Gram positive sepsis was the most common type of sepsis among the neonates, although mortality was more in gram negative sepsis.

Optimal antimicrobial therapy and antimicrobial stewardship in sepsis and septic shock

The management of sepsis and septic shock remains challenging. The aim is to apply the optimal antimicrobial therapy and antimicrobial stewardship to patients in state of sepsis or septic shock. To reduce the mortality of sepsis and septic shock, it is critical to promptly administer the appropriate antibiotics with an accurate diagnosis. De-escalation is needed 48 to 72 hours after the first administration of antibiotics depending on the findings of causative pathogens. In the case of antibiotic resistance, the importance of an antibiotic stewardship program is increasingly being emphasized. Antimicrobial stewardship implies coordinated interventions designed to improve the appropriate use of antibiotics by promoting the selection of an optimal drug regimen such as dosing, duration of therapy, and route of administration. An antibiotic stewardship program may also be applied to patients of both sepsis and septic shock. Efforts such as the selection of appropriate empirical antibiotics, de-escalation, and determination of whether to stop antibiotics with procalcitonin may improve the clinical prognosis of patients with sepsis as well as the successful implementation of an antibiotic stewardship program.

Factors associated with compliance to guidelines on the use of antibiotics and correlated with clinical outcomes of pregnant women admitted in the Department of Obstetrics and Gynecology of a tertiary hospital from January 1, 2018 to December 31, 2018

BACKGROUND@#Antimicrobial therapy is an integral part of an acceptable clinical practice in Obstetrics and Gynecology. However, in order for these antimicrobials to deliver the desired clinical outcome, the practice of judicious antibiotic stewardship should be observed. The objective of the study was 1.) To determine the proportion of pregnant women admitted at the Department of Obstetrics and Gynecology who received antibiotics from January 1, 2018 to December 31, 2018, 2.) To determine the proportion of indications for antibiotic administration, 3.) To determine if indications for antimicrobial usage is in accordance with the clinical case, policy guidelines, culture results and antibiogram report, 4.) To determine the percentage of cases not given antimicrobials that should have been started on antimicrobial therapy, 5.) To compare the association of the clinical outcomes among patients given and not given antimicrobials, 6.) To compare the association of the immediate neonatal outcomes among pregnant patients given and not given antimicrobials.@*METHODS@#A retrospective cohort study was done covering a period of 1 year from January to December 2018. The study included all pregnant patients who were admitted and listed based from the master list of the Department of Obstetrics and Gynecology. Included are all the retrieval charts from the records sections whereas gynecologic and those cases with medical records not retrieved were excluded. A total of 3,495 obstetrics patients admitted from January to December 2018 were retrospectively studied. From this group, the complete medical records of 1,092 obstetrics patients were retrieved and included in this study. Detailed clinical information, antibiotics administered, diagnostic and other relevant investigations, and clinical outcomes were recorded from case sheets. After the data were collected from patients' medical records, datas were manually entered into an electronic spreadsheet file, and the data processing and analysis were then carried out using statistical software Stata 13.@*RESULTS@#There were 1,092 women included in the current study with more than half of them administered or received antibiotics as part of their regimen (n = 663, 60.71 %) compared to those not administered antibiotics (n = 429, 39.29%). The results showed that the prevalence of obstetric patients (undelivered, delivered, ectopic pregnancy and abortion) prescribed and given antibiotics was between 57.75 to 63.62 per cent. There was no association between the comparison groups in terms of age (x 2 : 3.62, p: 0.31 ), marital status (x2 : 1.29, p: 0.26), body mass index classification (x 2 : 6.88, p: 0.08), hemoglobin level (x 2 : 1.74, p: 0.19), and number of prenatal consults (x2 : 3.13, p: 0.21 . There was a significantly higher proportion of women who delivered abdominally that were administered antibiotics (x 2 : 32.45, p<0.01) as compared to women who delivered vaginally (spontaneous or assisted), admitted due to ectopic pregnancy, abortion, and medical management. Cephalosporins are the most widely used antibiotics. Cefazolin (60.48%) followed by Cefuroxime (39.97%) were commonly used for pre-operative prophylaxis and urinary tract infection. Other commonly used antibiotics are Clindamycin (3.62%), Ampicillin (3.47%), Amikacin (2.56%), Ceftriaxone (2.11 %) and Doxycycline (1 .81 %). In 803 of cases (74.15%), reason for administration was not recorded in the chart and stated on working impression and final diagnosis. Majority of the antibiotics were empirically given (99.10%). The irrational use of antibiotics among those administered was observed in 564 cases (52.47%) (95% Cl: 49.46-55.47%). Rational use was only observed in 99 cases (19.08%). Among those not given antibiotics, 420 cases (80.92%) with adherence to antibiotic guidelines and 9 cases (52.47%) inappropriately not given antibiotics. It can also be noticed that there was an association between administration (and nonadministration) of antibiotics - and having an appropriate indication for such action (x2: 718.97, p<0.01 ). Maternal and neonatal outcomes showed that there was no noted association between the administration of antibiotics, and selected outcomes. Additional morbidity appeared to be slightly increased among those who were not given antibiotics than otherwise (z: -1.90, p: 0.60).@*CONCLUSION@#The study demonstrated that most of the antibiotic administration from January 1 to December 31, 2018

Prevalence of nonfermentative gram-negative bacilli and their antimicrobial susceptibility profiles in a tertiary care hospital of Eastern India

Background: Nonfermentative gram-negative bacilli (nonfermenters) have emerged as a major concern for nosocomial infections. They exhibit resistance not only to the beta-lactam and other group of antibiotics but also to carbapenems. This study was undertaken to know the prevalence of nonfermenters from clinical samples along with their antimicrobial susceptibility profile.Methods: A cross-sectional study over a period of 21 months in the microbiology laboratory of a tertiary care hospital was done. Clinical samples were processed by conventional bacteriological methods for isolation and identification. Susceptibility testing was done by Kirby-Bauer disc diffusion method as recommended by Clinical and Laboratory Standard Institute.Results: 411 nonfermenters (13.18%) were isolated from 3116 culture positive clinical samples. Out of these nonfermenters, most were Acinetobacter baumannii (51.34%) followed by Pseudomonas aeruginosa (42.09%), Burkholderia cepacia complex (4.38%) and others (2.19%). Others included Burkholderia pseudomellei, Acinetobacter lwoffii and Stenotrophomonas maltophilia. Highest sensitivity to gentamicin and amikacin were shown by A. baumannii and P. aeruginosa respectively while both were mostly resistant to ceftriaxone. Burkholderia and Stenotrophomonas species showed 100% sensitivity to cotrimoxazole. A. baumannii was the most prevalent nonfermenter in intensive care units.Conclusions: Timely identification of nonfermenters and monitoring their susceptibility patterns will help in proper management of infections caused by them. Improved antibiotic stewardship and infection control measures should be implemented to prevent nosocomial infections and spread of drug resistant nonfermenters.

Estrategias para reducir infecciones, uso de antimicrobianos y sus efectos en una unidad de neonatología / Strategies to reduce infections and antibiotic use and its effects in a neonatal care unit

Introduction: Late onset sepsis (LOS) remains an important cause of morbidity and mortality in neonatal intensive care units (NICU). The empirical use of vancomycin and other broad spectrum antibiotics is very frequent and is associated with the emergence of resistant agents, infection by gram-negative bacilli (GNB), fungal infections and increased morbidity and mortality. Objective: To evaluate the impact of 5 intervention protocols designed to reduce infections and promote the rational use of antibiotics (AB) in a single NICU. Patients and Method: Retrospective analysis included all hospitalized patients before (year 2012) and after interventions (August 2013 through July 2014). All episodes of positive cultures (blood, urine, tracheal and spinal fluid) were considered as late onset infections. Results: After intervention, a significant decrease of late onset infections was observed from 14.3 to 8.5 per 1,000 live births (p < 0.01); with a decrease in LOS from 5.7 to 2.9 per 1,000 live births, although no significant. There was a decrease in vancomycin and 3rd generation cephalosporin use without Candida spp infections in the intervention period. Mortality rates and length of hospital stay were similar in both study periods. Conclusion: After interventions, there was an important reduction in overall late onset infections and AB related costs.

Introducción: La sepsis tardía sigue siendo una causa importante de morbilidad y mortalidad en las unidades de cuidados intensivos neonatales. El uso de vancomicina y otros antimicrobianos de amplio espectro es frecuente y se asocia a la aparición de agentes resistentes, infecciones por bacilos gramnegativos, infecciones por hongos y una mayor morbimortalidad. Objetivo: Evaluar el impacto de cinco protocolos de intervención para reducir la incidencia de infecciones y promover el uso racional de antimicrobianos. Pacientes y Método: Análisis retrospectivo pre (control) y post intervenciones. Se revisaron todos los episodios de infecciones con cultivos positivos (sangre, orina, tráquea y líquido cefalorraquídeo) en pacientes hospitalizados entre enero de 2012 y junio de 2014. Resultados: Después de la intervención, hubo una disminución significativa en las infecciones tardías de 14,3 a 8,5 por 1.000 RNV (p < 0,01); con disminución de la sepsis tardía de 5,7 a 2,8 por 1.000 RNV, sin alcanzar significancia estadística. Hubo una disminución significativa del uso de vancomicina y de cefalosporinas de tercera generación, así como la desaparición de infecciones por Candida spp. La mortalidad y la estadía hospitalaria fueron similares en ambos períodos. Conclusión: Al incorporar estas intervenciones, se logró una disminución significativa de las infecciones tardías y de los costos asociados al uso de antimicrobianos.

Is there an improvement of antibiotic use in China? Evidence from the usage analysis of combination antibiotic therapy for type I incisions in 244 hospitals / 华中科技大学学报（医学）（英德文版）

The improvement of antibiotic rational use in China was studied by usage analysis of combination antibiotic therapy for type I incisions in 244 hospitals. Five kinds of hospitals, including general hospital, maternity hospital, children's hospital, stomatological hospital and cancer hospital, from 30 provinces were surveyed. A systematic random sampling strategy was employed to select outpatient prescriptions and inpatient cases in 2011 and 2012. A total of 29 280 outpatient prescriptions and 73 200 inpatient cases from 244 hospitals in each year were analyzed. Data were collected with regards to the implementation of the national antibiotic stewardship program (NASP), the overall usage and the prophylactic use of antibiotic for type I incisions. Univariate analysis was used for microbiological diagnosis rate before antimicrobial therapy, prophylactic use of antibiotics for type I incision operation, and so on. For multivariate analysis, the use of antibiotics was dichotomized according to the guidelines, and entered as binary values into logistic regression analysis. The results were compared with the corresponding criteria given by the guidelines of this campaign. The antibiotic stewardship in China was effective in that more than 80% of each kind of hospitals achieved the criteria of recommended antibiotics varieties. Hospital type appeared to be a factor statistically associated with stewardship outcome. The prophylactic use of antibiotics on type I incision operations decreased by 16.22% (P<0.05). The usage of combination antibiotic therapy for type I incisions was also decreased. Region and bed size were the main determinants on surgical prophylaxis for type I incision. This national analysis of hospitals on antibiotic use and stewardship allows relevant comparisons for bench marking. More efforts addressing the root cause of antibiotics abuse would continue to improve the rational use of antibiotics in China.

Emerging Infections and Role of Family Physician

Emerging infections may be defined as infectious diseases whose incidence in humans has increased in the past 2 decades or threatens to increase in the near future. They include: new infections resulting from changes or evolution of existing organisms; known infections spreading to new geographic areas or populations; previously unrecognised infections appearing in areas undergoing ecological transformation; and old infections re-emerging as a result of antimicrobial resistance in known agents. Emerging infections occur as the result of four groups of factors: novel zoonotic emergence factors; climate change; nonzoonotic emergence factors; and human practices. As frontline doctors, family physicians have at least five roles that they must perform well: participate in global and local surveillance of emerging infections; assist in societal learning; pandemic preparedness; legislation compliance; and antibiotic stewardship.

Revolutionising Bacteriology to Improve Treatment Outcomes and Antibiotic Stewardship

Laboratory investigation of bacterial infections generally takes two days: one to grow the bacteria and another to identify them and to test their susceptibility. Meanwhile the patient is treated empirically, based on likely pathogens and local resistance rates. Many patients are over-treated to prevent under-treatment of a few, compromising antibiotic stewardship. Molecular diagnostics have potential to improve this situation by accelerating precise diagnoses and the early refinement of antibiotic therapy. They include: (i) the use of 'biomarkers' to swiftly distinguish patients with bacterial infection, and (ii) molecular bacteriology to identify pathogens and their resistance genes in clinical specimens, without culture. Biomarker interest centres on procalcitonin, which has given good results particularly for pneumonias, though broader biomarker arrays may prove superior in the future. PCRs already are widely used to diagnose a few infections (e.g. tuberculosis) whilst multiplexes are becoming available for bacteraemia, pneumonia and gastrointestinal infection. These detect likely pathogens, but are not comprehensive, particularly for resistance genes; there is also the challenge of linking pathogens and resistance genes when multiple organisms are present in a sample. Next-generation sequencing offers more comprehensive profiling, but obstacles include sensitivity when the bacterial load is low, as in bacteraemia, and the imperfect correlation of genotype and phenotype. In short, rapid molecular bacteriology presents great potential to improve patient treatments and antibiotic stewardship but faces many technical challenges; moreover it runs counter to the current nostrum of defining resistance in pharmacodynamic terms, rather than by the presence of a mechanism, and the policy of centralising bacteriology services.

Implementación de un programa de uso regulado de antibióticos en 2 unidades de cuidado intensivo medico-quirúrgico en un hospital universitario de tercer nivel en Colombia / Implementation of a regulated antibiotic use program in two medical-surgical intensive units care in a third level mayor teaching hospital in Colombia

Objetivo: Evaluar el impacto de un programa de uso regulado de antibióticos en adherencia, consumo antibiótico y resistencia bacteriana en 2 unidades de cuidados intensivos (UCI) de un hospital universitario de tercer nivel en Colombia. Materiales y Método: Estudio prospectivo observacional de intervención que analiza 2 períodos en el tiempo en 2 UCI: preintervención (agosto de 2008 a febrero de 2009) y posintervención (marzo a septiembre de 2009). El estudio se llevó a cabo en el Hospital Universitario del Valle Evaristo García E.S.E. Se evaluaron: adherencia a guías de uso de antibióticos creadas por epidemiología hospitalaria, consumo antibiótico en dosis diaria definida e incidencia acumulada mensual de infección por Escherichia coli (E. coli) y Klebsiella pneumoniae (K. pneumoniae) BLEE, Pseudomonas aeruginosa (P. aeruginosa) resistente a quinolonas y cefalosporinas de cuarta generación, Staphylococcus aureus resistente a oxacilina y Acinetobacter baumannii multirresistente. Resultados: Se encontró adherencia a guías de uso de antibióticos superior al 80% para ambas UCI durante la intervención. Se redujo significativamente el consumo de meropenem (UCI-1 p = 0,009/UCI-2 p = 0,000), vancomicina (UCI-1 y UCI-2 p = 0,018), ceftriaxona (UCI-1 p = 0,015/ UCI-2 p = 0,018), ciprofloxacina (UCI-1 p = 0,027/UCI-2 p = 0,018), se incrementó el consumo de piperacilina/tazobactam (UCI-1 p = no significativa/UCI-2 p = 0,017) y cefepime (UCI-1 p = 0,028/UCI-2 p = 0,004). Se redujo la incidencia de infección por E. coli y K. pneumoniae BLEE + (UCI-1 83%/UCI-2 78%), P. aeruginosa resistente a ciprofloxacina (UCI-1 87%/UCI-2 82%) y cefalosporinas de cuarta generación (UCI-1 83%/UCI-2 76%). Conclusiones: La creación de un programa de uso regulado de antibióticos reduce significativamente el consumo y los costos de antibióticos en las UCI del Hospital Universitario del Valle y la infección por microorganismos resistentes.

Objective: To determine the impact of a Program of Regulated Use of Antibiotics in adherence, antibiotic use and bacterial resistance in two medical-surgical Intensive Units Care (ICU´s) in a third level mayor teaching hospital in Colombia. Materials and Methods: Prospective observational study of intervention that examines two time periods in two ICU: pre-intervention (august/2008 to February/2009) and post-intervention (march to September/2009). The study was carried out in the Hospital Universitario del Valle Evaristo García E.S.E. (H.U.V). We evaluated adherence to the antibiotic therapy guidelines established by Hospital Epidemiology, antibiotic use measured by Defined Daily Doses and monthly incidence of infection by ESBL producer E.coli and K.pneumoniae, P.aeruginosa fluoroquinolone and four generation cephalosporin resistant, oxacilin resistant S.aureus and multidrug resistant A.baumannii. Results: The adherence to the antibiotic guidelines of antibiotic use was greater to 80% for the both ICU during the intervention period. Antibiotic use was significantly reduced for meropenem (ICU1 p=0,009/ICU2 p=0,000), vancomycin (ICU1-ICU2 p=0,018), ceftriaxone (ICU1 p=0,015/ICU2 p=0,018), ciprofloxacin (ICU1 p=0,027/ICU2 p=0,018), and increased the used of piperacilin/tazobactam (ICU2 p=0,017), and cefepime (ICU1 p=0,028/ICU2 p=0,004). The incidences of infection by ESBL producer E.coli and K.pneumoniae (ICU1 83%/ ICU2 78%), ciprofloxacin resistant and four generation cephalosporin resistant P.aeruginosa (ICU1 87%/ ICU2 82%) and (ICU1 83%/ICU2 76%) ware also reduced. Conclusions: The implementation of a Program of Regulated Use of Antibiotics reduces antibiotics use and resistant micro-organism specific infection rate in the Hospital Universitario del Valle´s ICU.