Correlation between a Change of Drug Resistance of <i>Klebsiella pneumonia</i>and Defined Daily Doses of Antimicrobial Agents from 2014 to 2018

Introduction: The prevalence of Klebsiella pneumoniae has rapidly increased in recent years and the distribution differed greatly by region, We aimed to study the relationship between antibiotic resistance and K. pneumoniae, especially carbapenem-resistant Klebsiella pneumoniae (CRKP) in our tertiary hospitals from 2014 to 2018. Methodology: The antibiotic consumption data of K. pneumoniae were expressed as the defined daily dose (DDD) per 100 inpatient days (DDDs). K. pneumoniae which isolated from clinical samples in hospital between January 2014 and December 2018 were retrospectively analyzed, and the correlation between antibiotic resistance rate and antibiotic frequency was analyzed. Results: From 2014 to 2018, a total of 2295 strains of K. pneumoniae were isolated, with the detection rates of 8.2%, 9.2%, 11.9%, 13.4% and 14.0%. There were 423 strains of CRKP, with the detection rates of 7.5%, 5.8%, 17.8% 24.2% and 25.2% respectively. K. pneumoniae showed different degrees of resistance to antibiotics and showed an increasing trend year by year to carbapenems. The resistance rate of imipenem was 2.5%, 2.8%, 9.9%, 12.3%, 13.4%, and the resistance rate of meropenem was 2.0%, 3.0%, 8.8%, 12.6%, 12.7%, respectively. The resistance rate of most other drugs decreased. The DDDs values of cefoperazone/sulbactam, piperacillin-tazobactam and gentamicin showed a strong positive correlation with K. pneumoniae drug resistance rate (r > 0.8, P < 0.05). Conclusions: The detection rate of K. pneumoniae and CRKP increased year by year, which was closely related to the dose of antibiotics. Strengthening the management of antimicrobial drugs and standardising the use of antimicrobial prescriptions were of great significance for delaying the emergence of drug-resistant bacteria.

Ground level utility of Access, Watch, Reserve classification: Insights from a tertiary care center in North India

BACKGROUND The overuse and misuse of antimicrobials contribute significantly to antimicrobial resistance(AMR),which is a global public health concern.India has particularly high rates of AMR,posing a threat to effective treatment.The World Health Or-ganization(WHO)Access,Watch,Reserve(AWaRe)classification system was introduced to address this issue and guide appropriate antibiotic prescribing.However,there is a lack of studies examining the prescribing patterns of antimi-crobials using the AWaRe classification,especially in North India.Therefore,this study aimed to assess the prescribing patterns of antimicrobials using the WHO AWaRe classification in a tertiary care centre in North India.Ophthalmology,Obstetrics and Gynecology).Metronidazole and ceftriaxone were the most prescribed antibiotics.According to the AWaRe classification,57.61%of antibiotics fell under the Access category,38.27%in Watch,and 4.11%in Reserve.Most Access antibiotics were prescribed within the Medicine department,and the same department also exhibited a higher frequency of Watch antibiotics prescriptions.The questionnaire survey showed that only a third of participants were aware of the AWaRe classification,and there was a lack of knowledge regarding AMR and the potential impact of AWaRe usage.RESULTS The research was carried out in accordance with the methodology presented in Figure 1.A total of n=123 patients were enrolled in this study,with each of them receiving antibiotic prescriptions.The majority of these prescriptions were issued to inpatients(75.4%),and both the Medicine and Surgical departments were equally represented,accounting for 49.6%and 50.4%,respectively.Among the healthcare providers responsible for prescribing antibiotics,72%were Junior Residents,18.7%were Senior Residents,and 9.3%were Consultants.These findings have been summarized in Table 1.The prescriptions included 27 different antibiotics,with metronidazole being the most prescribed(19%)followed by ceftriaxone(17%).The mean number of antibiotics used per patient was 1.84±0.83.The mean duration of antibiotics prescribed was 6.63±3.83 days.The maximum number of antibiotics prescribed per patient was five.According to the AWaRe classification,57.61%of antibiotics fell under the Access,38.27%in Watch,and 4.11%in Reserve categories,suggesting appropriate antibiotic selection according to these criteria.The distribution of antibiotics prescribed according to the WHO AWaRe categories is presented in Figure 2.The difference in prescribing frequencies amongst departments can be noted.Most of the antibiotics prescribed in the Access category were from the Medicine department(75.4%),followed by Surgery(24.6%).For Watch antibiotics,Medicine had a higher proportion(63.4%)compared to Surgery(36.6%).In terms of seniority,Junior Residents prescribed the highest number of antibiotics for both Access and Watch categories in Medicine and Surgery departments.Senior residents and Consultants prescribed a lower number of antibiotics in all categories and departments.Only a few antibiotics were prescribed in the Reserve category,with most prescriptions being from the Medicine department.The study also evaluated the Knowledge and Awareness of Healthcare professionals towards the WHO AWaRe classi-fication through a questionnaire survey.A total of 93 participants responded to the survey.Among them,most parti-cipants were Junior Residents(69.9%),followed by Senior Residents(25.8%)and Faculty(4.3%).When enquired if they knew about the WHO AWaRe classification only 33.3%of the participants responded positively.Of those who were aware of the AWaRe classification,the most common source of information was the internet(31.2%),followed by the antimicrobial policy of their institution(15.1%)as seen in Table 2.The survey results on the knowledge and awareness of AMR among healthcare professionals are also presented in Tables 3 and 4.Out of the 93 participants,68(73.1%)agreed that the emergence of AMR is inevitable,while only 13(14.0%)disagreed that AWaRe usage will result in the inability to treat serious infections.Additionally,58(62.4%)agreed that it will lead to lengthier hospital stays,43(46.2%)agreed that the success of chemotherapy and major surgery will be hampered,and the majority also agreed that its use will lead to increased cost of treatment and increased mortality rates.Regarding the utilization of AWaRe in the hospital summarized in Tables 4 and 5,35.5%of the participants agreed that it should be used,while only 2.2%disagreed.Additionally,34.4%agreed that AWaRe reduces adverse effects of inappro-priate prescription.However,37.6%of the participants considered that AWaRe threatens a clinician's autonomy and 30.1%thought that its use can delay treatment.Additionally,the DDD of each drug was also evaluated.The usage of various antimicrobial drugs in a hospital setting,along with their daily doses and DDD according to the WHO's Anatomical Therapeutic Chemical classification system was calculated.Some of the important findings include high usage rates of ceftriaxone and metronidazole,and relatively low usage rates of drugs like colistin and clindamycin.Additionally,some drugs had wider ranges than others.Comparison of WHO defined DDD with Daily Drug dose(Mean)in the studied prescriptions is represented in the Clustered Bar chart in Figure 3.Finally,the Mean Daily Drug Dose for prescribed drugs was compared with WHO defined DDD for each drug using a Student’s T test.The mean daily drug dose of amoxy/clav was significantly higher than the WHO DDD(1.8 vs 1.50,P=0.014),while the mean daily drug dose of metronidazole and doxycycline were significantly lower than the WHO DDD(P<0.001 and P=0.008,respectively).The mean daily drug dose of piperacillin/tazobactam,amikacin,clindamycin,and levofloxacin did not show significant differences compared to the WHO DDD(P>0.05).CONCLUSION This research indicates an appropriate proportion of prescriptions falling under the Access category(57.61%),suggesting appropriate antibiotic selection,a significant proportion also belongs to the Watch category(38.27%),emphasizing the need for greater caution to prevent the escalation of AMR.There is a moderate level of awareness among healthcare professionals about AMR and the steps being taken to tackle it,highlighting the gap in implementation of policies and need for more steps to be taken in spreading the knowledge about the subject.However,there is a significant difference between the WHO DDD and the prescribed daily dose in the analysed prescriptions suggesting overuse and underuse of antibiotics.

Clinical pharmacists’ involvement in carbapenem antibiotics management at Wenzhou Integrated Hospital

BACKGROUND Carbapenem antibiotics are a pivotal solution for severe infections,particularly in hospital settings.The emergence of carbapenem-resistant bacteria owing to the irrational and extensive use of carbapenems underscores the need for meticulous management and rational use.Clinical pharmacists,with their specialized training and extensive knowledge,play a substantial role in ensuring the judicious use of carbapenem.This study aimed to elucidate the patterns of carbapenem use and shed light on the integral role played by clinical pharmacists in managing and promoting the rational use of carbapenem antibiotics at Wenzhou Integrated Traditional Chinese and Western Medicine Hospital.AIM To analyze carbapenem use patterns in our hospital and role of clinical pharmacists in managing and promoting their rational use.METHODS We performed a retrospective analysis of carbapenem use at our hospital between January 2019 and December 2021.Several key indicators,including the drug utilization index,defined daily doses(DDDs),proportion of antimicrobial drug costs to total hospitalization expenses,antibiotic utilization density,and utilization rates in different clinical departments were comprehensively analyzed.RESULTS Between 2019 and 2021,there was a consistent decline in the consumption and sales of imipenem-cilastatin sodium,meropenem(0.3 g),and meropenem(0.5 g).Conversely,the DDDs of imipenem-cilastatin sodium for injection increased in 2020 and 2021 vs 2019,with a B/A value of 0.67,indicating a relatively higher drug cost.The DDDs of meropenem for injection(0.3 g)exhibited an overall upward trend,indicating an increasing clinical preference.However,the B/A values for 2020 and 2021 were both>1,suggesting a relatively lower drug cost.The DDDs of meropenem for injection(0.5 g)demonstrated a progressive increase annually and consistently ranked first,indicating a high clinical preference with a B/A value of 1,signifying good alignment between economic and social benefits.CONCLUSION Carbapenem use in our hospital was generally reasonable with a downward trend in consumption and sales over time.Clinical pharmacists play a pivotal role in promoting appropriate use of carbapenems.