Bojana Beović

How can we improve antibiotic prescribing in primary care

ABSTRACT Antibiotic stewardship is a necessity given the worldwide antimicrobial resistance crisis. Outpatient antibiotic use represents around 90% of total antibiotic use, with more than half of these prescriptions being either unnecessary or inappropriate. Efforts to improve antibiotic prescribing need to incorporate two complementary strategies: changing healthcare professionals’ behaviour, and modifying the healthcare system. In this review, we present a broad perspective on antibiotic stewardship in primary care in high and high-middle income country settings, focussing on studies published in the last five years. We present the limitations of available literature, discuss perspectives, and provide suggestions for where future work should be concentrated.

The microbiological diagnosis of tuberculous meningitis: results of Haydarpasa-1 study

We aimed to provide data on the diagnosis of tuberculous meningitis (TBM) in this largest case series ever reported. The Haydarpasa-1 study involved patients with microbiologically confirmed TBM in Albania, Croatia, Denmark, Egypt, France, Hungary, Iraq, Italy, Macedonia, Romania, Serbia, Slovenia, Syria and Turkey between 2000 and 2012. A positive culture, PCR or Ehrlich-Ziehl-Neelsen staining (EZNs) from the cerebrospinal fluid (CSF) was mandatory for inclusion of meningitis patients. A total of 506 TBM patients were included. The sensitivities of the tests were as follows: interferon-γ release assay (Quantiferon TB gold in tube) 90.2%, automated culture systems (ACS) 81.8%, Löwenstein Jensen medium (L-J) 72.7%, adenosine deaminase (ADA) 29.9% and EZNs 27.3%. CSF-ACS was superior to CSF L-J culture and CSF-PCR (p <0.05 for both). Accordingly, CSF L-J culture was superior to CSF-PCR (p <0.05). Combination of L-J and ACS was superior to using these tests alone (p <0.05). There were poor and inverse agreements between EZNs and L-J culture (κ = -0.189); ACS and L-J culture (κ = -0.172) (p <0.05 for both). Fair and inverse agreement was detected for CSF-ADA and CSF-PCR (κ = -0.299, p <0.05). Diagnostic accuracy of TBM was increased when both ACS and L-J cultures were used together. Non-culture tests contributed to TBM diagnosis to a degree. However, due to the delays in the diagnosis with any of the cultures, combined use of non-culture tests appears to contribute early diagnosis. Hence, the diagnostic approach to TBM should be individualized according to the technical capacities of medical institutions particularly in those with poor resources.

Improvement of pneumococcal pneumonia diagnostics by the use of rt-PCR on plasma and respiratory samples

Abstract Background: The aim of the study was to assess the performance of a real-time polymerase chain reaction (rt-PCR) assay on plasma and respiratory samples for the diagnosis of pneumococcal pneumonia. Methods: Three hundred and forty patients (160 children and 180 adults) with community-acquired pneumonia were included prospectively from January 2011 to May 2012. Blood samples were obtained simultaneously for culture and rt-PCR targeting the lytA gene. Respiratory samples were also obtained: nasopharyngeal swab in nearly all patients and sputum or tracheal aspirate when available. Results: Streptococcus pneumoniae was detected in 222 (65%) of 340 patients: 143 (89%) children and 79 (44%) adults. Pneumonia was assigned as definite pneumococcal in 96 (28.2%) of 340 patients, according to S. pneumoniae detected in blood: in 54 (33.8%) children – by rt-PCR in 51 (31.9%) and by culture in 5 (3.1%); and in 42 (23.3%) adults – by rt-PCR in 41 (22.8%) and by culture in 12 (6.7%). Pneumonia was considered as probably pneumococcal in 19 (10.6%) adults according to S. pneumoniae detected in sputum/tracheal aspirate, by rt-PCR in 19 and by culture in 5. In 18 adults and 89 children with S. pneumoniae detected only in the nasopharynx, pneumonia was considered as possibly pneumococcal; however it should be noted that nasopharyngeal colonization with S. pneumoniae is also common in children with other aetiologies of pneumonia. Conclusions: rt-PCR on plasma and other samples performed significantly better than culture for the detection of pneumococcal pneumonia (p < 0.0005) in children and adults.

Human resources estimates and funding for antibiotic stewardship teams are urgently needed

1) Lorraine University, EA 4360 APEMAC, Nancy, France 2) Nancy University Hospital, Infectious Diseases Department, Nancy, France 3) ESCMID Study Group for Antimicrobial stewardshiP (ESGAP) 4) University of Geneva Medical School, Geneva, Switzerland 5) London School of Economics, London, United Kingdom 6) Infectious Diseases, Internal Medicine 1, DZIF Centre, Tübingen University, Germany 7) European Committee on Infection Control (EUCIC) 8) University Medical Centre Ljubljana, Slovenia 9) Faculty of Medicine, University of Ljubljana, Slovenia 10) University Hospital Carl Gustav Carus at the TU Dresden, Division of Infectious Diseases, Dresden, Germany 11) Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium 12) Infection Control Program and Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland 13) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK 14) Leeds Teaching Hospitals NHS Trust, Leeds, UK 15) Division of Infectious Diseases, Department of Medicine, Sinai Health System, University Health Network, University of Toronto, Toronto, Canada 16) Ninewells Hospital and Medical School, Dundee, UK 17) British Society for Antimicrobial Chemotherapy (BSAC), Birmingham, UK 18) Paediatric Infectious Diseases Research Group, St Georges, University of London, London, UK 19) IQ Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands 20) National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital at the Peter Doherty Institute, Melbourne, Australia 21) Centre for Disease Dynamics, Economics & Policy, New Delhi, India 22) Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa

The Impact of Total Control of Antibiotic Prescribing by Infectious Disease Specialist on Antibiotic Consumption and Cost

Abstract We analyzed the impact on antimicrobial consumption of antimicrobial therapy totally guided by an infectious disease specialist (ID). In a teaching hospital antibiotic con-sumption was recorded yearly from 1998 to 2005 in three units. Antibiotic policy was introduced in 1999. In Unit A, restricted antimicrobials were prescribed after approval by the head of the unit. The ID was involved as a consultant upon request. In unit B, restricted antimicrobials were approved by an ID. All other antimicrobials were pre-scribed by the physicians on the ward. In unit C, all antimicrobials were prescribed by an ID. A significant decreasing trend in antibiotic consumption in defined daily doses (DDD) per patient day and per admission, and cost of antimicrobials per patient was observed in unit C, a decreasing trend in antibiotic consumption per patient was ob-served in unit b as well. Totally ID guided antimicrobial therapy is an efficient method of antimicrobial policy.

Fatal Human Herpesvirus 6-associated Multifocal Meningoencephalitis in an Adult Female Patient

Human herpesvirus 6 (HHV 6) is a known cause of central nervous system infection in immunocompromised patients. Less is known about the clinical course of HHV 6 encephalitis in immunocompetent patients. We report a case of meningoencephalitis in a 42-y-old immunocompetent patient associated with HHV 6 infection.Human herpesvirus 6 (HHV 6) is a known cause of central nervous system infection in immunocompromised patients. Less is known about the clinical course of HHV 6 encephalitis in immunocompetent patients. We report a case of meningoencephalitis in a 42-y-old immunocompetent patient associated with HHV 6 infection.

Staffing for infectious diseases, clinical microbiology and infection control in hospitals in 2015: results of an ESCMID member survey

We aimed to assess the current status of infectious diseases (ID), clinical microbiology (CM) and infection control (IC) staffing in hospitals and to analyse modifiers of staffing levels. We conducted an Internet-based survey of European Society of Clinical Microbiology and Infectious Diseases members and affiliates, collecting data on hospital characteristics, ID management infrastructure, ID/IC-related activities and the ratio of physicians per 100 hospital beds. Regression analyses were conducted to examine factors associated with the physician-bed ratio. Five hundred sixty-seven hospital responses were collected between April and June 2015 from 61 countries, 81.2% (384/473) from Europe. A specialized inpatient ward for ID patients was reported in 58.4% (317/543) of hospitals. Rates of antibiotic stewardship programmes (ASP) and surveillance activities in survey hospitals were high, ranging from 88% to 90% for local antibiotic guidelines and 70% to 82% for programmes monitoring hospital-acquired infections. The median ID/CM/IC physician per 100 hospital beds ratio was 1.12 (interquartile range 0.56-2.13). In hospitals performing basic ASP and IC (including local antibiotic guidelines and monitoring device-related or surgical site infections), the ratio was 1.21 (interquartile range 0.57-2.14). Factors independently associated with higher ratios included compliance with European Union of Medical Specialists standards, smaller hospital size, tertiary-care institution, presence of a travel clinic, beds dedicated to ID and a CM unit. More than half of respondents estimated that additional staffing is needed for appropriate IC or ID management. No standard of physician staffing for ID/CM/IC in hospitals is available. A ratio of 1.21/100 beds will serve as an informed point of reference enabling ASP and infection surveillance.

Subcutaneous myiasis caused by Dermatobia hominis.

A case of subcutaneous myiasis caused by the larvae of the Dermatobia hominis fly is described, involving the ankle region of a 25-y-old man who had returned from Peru. After removal of 4 larvae from the affected sites, the lesions healed in 2 weeks without further treatment. Because of the increasing number of people travelling to tropical America, physicians in Slovenia will have to consider Dermatobia myiasis in the differential diagnosis of furuncular lesions in patients with a relevant travel history.A case of subcutaneous myiasis caused by the larvae of the Dermatobia hominis fly is described, involving the ankle region of a 25-y-old man who had returned from Peru. After removal of 4 larvae from the affected sites, the lesions healed in 2 weeks without further treatment. Because of the increasing number of people travelling to tropical America, physicians in Slovenia will have to consider Dermatobia myiasis in the differential diagnosis of furuncular lesions in patients with a relevant travel history.

Lactococcus garvieae septicaemia in a patient with artificial heart valves.

ZusammenfassungLactococcus garvieae ist in der Regel ein Tier-Erreger. Nur wenige Fälle von Infektionen sind beim Menschen beschrieben worden. Wir berichten über einen älteren Patienten mit Lactococcus garvieae Sepsis aber keine infektiöse Endokarditis trotz künstlicher Herzklappen und mit einem günstigeren klinischen Verlauf.SummaryLactococcus garvieae is usually an animal pathogen. Only a few cases of infections in humans have been described. We describe a case of an elderly patient with prosthetic heart valves with a septicaemia without infective endocarditis, and with a favourable clinical course.

Influence of fever on the pharmacokinetics of ciprofloxacin

The influence of fever on the pharmacokinetics of ciprofloxacin was investigated in seven patients with acute febrile diseases. Antibiotic serum concentrations were determined using high-performance liquid chromatograpy (HPLC). The analog computer and the Simulink software package were used to identify the pharmacokinetic model and Penoclin software package to obtain the secondary parameters. During fever, higher maximum serum concentrations (Cmax) of ciprofloxacin were observed in six out of seven patients. The result suggests that the influence of fever on the pharmacodynamics of ciprofloxacin is favorable.