Assessment of the appropriateness of antibiotic prescribing in an acute UK hospital using a national audit tool: a single centre retrospective survey.

INTRODUCTION: Antibiotic use drives antibiotic resistance. The UK antimicrobial resistance (AMR) strategy aims to reduce antibiotic use. We aimed to quantify excess antibiotic use in a district general hospital in south-west England. METHODS: Medical patients discharged in August 2020 who had received antibiotics were included. An audit tool of antibiotic prescribing appropriateness was used to collect relevant clinical information regarding each patient case. The appropriateness of antibiotic use was then determined by two infection specialists and excess days of therapy (DOTs) calculated. RESULTS: 647 patients were discharged in August 2020. Of the 1658 antibiotic DOTs for the 184 patients reviewed, 403 (24%) were excess DOTs. The excess antibiotic DOTs were prescribed in 92 patients (50%); 112/403 (27.8%) excess DOTs originated at the initiation of antibiotic therapy (time point A); 184/403 (45.7%) of excess DOTs occurred at the antibiotic review pre-72 hours (time point B); and 107/403 (26.6%) of excess DOTs were due to protracted antibiotic courses (time point C). CONCLUSION: 24% of antibiotic DOTs were deemed unnecessary. The greatest opportunity to reduce antibiotic use safely was the pre-72 hours antibiotic review, which may provide a target for reducing excess antimicrobial therapy in line with the national AMR strategy.

In recurrent C. difficile, the CRP response to the primary C. difficile infection predicts whether the same strain or a different strain will cause a second infection.

BACKGROUND: Clostridium difficile is the leading cause of antibiotic-associated diarrhoea and is associated with an increase in morbidity and mortality. There is a wide variance in disease severity with some patients suffering a single, self-limiting episode of diarrhoea while others suffer more intractable problems with recurrent attacks or toxic dilatation. Numerous different C. difficile ribotypes exist, some of which are considered hypervirulent. The magnitude of toxin production alone is not sufficient to explain the varying virulence of these ribotypes, suggesting the involvement of other mechanisms. METHODS: To test the same patient's response to infection with different C. difficile ribotypes, we reviewed 45 patients who suffered two episodes of C. difficile infection and determined by ribotyping and MLVA whether the second episode was due to the same strain or a different strain. RESULTS: Patients harbouring a different strain had significantly higher C-reactive protein (CRP) responses on the first assessed infection (143 mg/L ± 20 vs. 55 ± 9.63, p = 0.0001) and a significantly lower CRP on reinfection (p = 0.048). Same strain patients had a non-significant increase in CRP response on second infection. CONCLUSIONS: This suggests that the inflammatory response to C. difficile is determined by an interaction between host immunobiology, previous exposure and C. difficile strain.

Linezolid-resistant enterococci: report of the first isolates in the United Kingdom.

Linezolid, the first oxazolidinone antibacterial agent to be developed for clinical use, was licensed in the UK in early 2001. We report the first three examples of resistant enterococci (two isolates of Enterococcus faecium and one Enterococcus faecalis) isolated in the UK, which were obtained from patients who had received linezolid. The linezolid MICs for the resistant isolates were 64 mg/L. Pulsed-field gel electrophoresis (PFGE) analysis of the linezolid-susceptible and -resistant isolates from two of the patients, combined with sequence analysis of rRNA, indicated that resistance developed in previously susceptible strains, most probably via a point mutation in the 23S rRNA.