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ANTIMICROB IAL R E S I S TANCE


‘Medium priority’ includes: l Streptococcus pneumoniae (penicillin-non- susceptible)


l Shigella species (fluoroquinolone resistant) l Haemophilus influenzae (ampicillin resistant)


Prof. Tacconelli has had a key role in the development of the ESCMID guidelines for the management of the infection control measures to reduce transmission of multi- drug resistant Gram-negative bacteria in hospitalised patients. These guidelines look at the role of hand hygiene, contact precautions to prevent spread, active screening cultures, environmental cleaning, antimicrobial stewardship, decolonisation and use of topical Chlorhexidine and education.7


The analysis of 86 studies found


a failure rate of interventions of 31%; a key risk factor was not applying a bundle approach. However, the most successful interventions in the endemic setting were hand hygiene, education and contact precautions. In the epidemic setting, the most successful were hand hygiene, pre- emptive isolation, contact precautions and active surveillance (Tacconelli et al, 2014).8 Analysis of the evidence for antibiotic stewardship shows that guideline-adherent empirical therapy was associated with an RR reduction for mortality of 35% (Schuts, et al, 2016).9


Furthermore, antibiotic stewardship


intervention was associated with a reduction of multi-drug resistant Gram-negative bacteria by 51% (Tacconelli et al, 2017)10 The reduction of the multi-drug resistant Gram-negative bacteria was also confirmed in the subgroup of studies focusing on carbapenem resistance (43%). Prof. Tacconelli pointed out that there were fewer studies on extended-spectrum beta-lactamase-producing Gram-negative bacteria (ESBL-GNB). However, analysis of the evidence showed that antibiotic stewardship intervention is associated with a reduction of incidence of ESBL-GNB by 48%.11


Interestingly, the incidence of aminoglycoside resistant and quinolone resistant GNB was not significantly reduced.


Analysis of Gram-positive studies has shown that antibiotic stewardship intervention was associated with a reduction of incidence of MRSA by 37%. Again, the incidence of aminoglycoside resistant and quinolone resistant Gram-positive bacteria was not significantly reduced. Antibiotic stewardship intervention was also associated with a reduction of Clostridium difficile infection (CDI) incidence by 32%.12


This confirmed


the findings of another meta-analysis by Feazel et al (2014)13


which showed


similar results. She added that antibiotic stewardship programmes are more effective when implemented with infection control measures, showing very significant reductions – particularly when hand hygiene interventions are implemented. She highlighted a study by Lawes et which looked at the effects of


al (2015)14


national antibiotic stewardship and infection control strategies on hospital-associated and community-associated methicillin-resistant Staphylococcus aureus infections across a region of Scotland. The study included 1,289,929 hospital admissions and 455,508 adults registered in primary care in northeast Scotland. Interventions included antibiotic stewardship to restrict use of so- called ‘4C’ (cephalosporins, co-amoxiclav, clindamycin, and fluoroquinolones) and


When we see the resistance rates for carbapenem-resistant Acinetobacter, reported by the Epidemiology Network (EPI.Net), can we really believe we have the same healthcare standards across Europe? The difference in resistance rates must be considered a threat for EU public health and the rights of EU citizens for equal healthcare standards.


JANUARY 2021


macrolide antibiotics; a hand hygiene campaign; hospital environment inspections; and MRSA admission screening. During antibiotic stewardship, use of 4C and macrolide antibiotics fell by 47% in hospitals and 27% in the community. Combined with infection prevention and control measures, MRSA prevalence density was reduced by 50% in hospitals and 47% in the community. Another study, conducted at a 2,000-bed


tertiary hospital in South Korea, looked at the combination of antibiotic stewardship and hand hygiene programmes. The monthly mean antibiotic consumption was significantly reduced, while rates of hand hygiene performance increased from 43% in 2008 to 83% in 2011. The incidence of MRSA blood-stream infection (BSI) reduced from 0.71 per 1,000 patient days in 2009 to 0.116 per 1,000 patient days in 2011 (Kim et al, 2013).15


Other studies have looked at the impact of combining screening, cohorting, education and antibiotic stewardship on rates of carbapenem-resistant enterobacteriaceae bloodstream infection (CRE BSI). A quasi- experimental study by Viale et al (2015),16 for example, showed a significant risk reduction (0.96, 95% Cl 0.92-0.99, p 0.03) and CRE colonisation risk reduction of (0.96, 95% Cl 0.95-0.97, p<0.0001). Valiquette et al (2007)17


examined the


impact of antibiotic stewardship, combined with infection control, on incidence of CDI. Measures included staff education, infection control, environmental cleaning, local guidelines (including a pocket size antibiotic guide) on empirical treatment of common infections, but with no formal restriction (pharmacist phone call). The study found no change in nosocomial CDI incidence after strengthening of infection prevention, but implementation of the antibiotic stewardship programme was followed by a marked reduction of incidence. The authors theorised that the inefficacy of infection control measures targeting transmission through


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