This popular webinar is back for the third time soon, on March 5th, 2019.

The session will discuss on AUC based TDM for vancomycin. It will also highlight the pros and cons of using the current trough-only approach (supported by previous guidelines) vs. AUC method for vancomycin TDM.

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Imipenem + Relebactam and Ceftolozane plus tazobactam

The former is a totally new combination using an old carbapenem, imipenem plus a new non-beta lactam, beta lactamase inhibitor. This combo was formerly known as MK-7655A.

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The second one is a relatively new antibiotic, which now has proven to be efficacious (at higher dose) for pneumonia treatment too based on an RCT called ASPECT-NP.

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Both these drugs used the PDUFA for FDA approval.

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Top 5 Things About it

Omadacycline (Nuzyra) is a new antibiotic approved by the FDA last year (2018).

In this article, the authors list out 5 things that are deemed important for this new tetracycline based on papers and reviews published on it.

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In Case You Missed It

This resourceful website selects out 5 top ID/stewardship papers that trended on twitter in the month of January

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Can you guess these 5 papers first?

The clues are

1) Stick and stones (and oral antibiotics) may break my (infected) bones.

2) A paper on one of the most expensive antibiotics for GPC.

3) Cirrhotic patients may have low albumin levels. A possible way of mitigating an impact of increased VD on antibiotic levels will be?

4) 7 or 14? 

5) What can be as good as antibiotics in AEBA?

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Endorsed by ACCP, ESCMID, IDSA, ISAP, SCCM, and SIDP

This practice guideline provides consensus recommendations pertaining to the clinical use of the polymyxin antibiotics, colistin (polymyxin E) and polymyxin B, for the treatment of bacterial infections in adults. 

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It covers topics on;

1) Loading dose for polymyxins 

2) Maintenance regimens for both the polymyxins

3) Roles of TDM for polymyxins

4) Why the preference towards polymyxin B? 

Clinical development for non-developers Part 3

Fri, Mar 29, 2019 12:00 AM - 1:30 AM (local time)

The overall goal of this series of webinars is to provide, for the non-clinical developer, an understanding of the risks of development for various kinds of antibacterial products. The presentation will be followed by an interactive Q&A session.

Medical guidelines, simplified.

Search over 1000+ practice guidelines simply by entering a search term to get started.

May 8th – 11th in Orlando, Florida at the Rosen Centre Hotel

This yearly event will feature keynotes and workshops related to antimicrobial stewardship. A limited number of travel grants are available for students, residents or fellows whose abstracts are accepted at the annual meeting.

ESCMID event in Havana, Cuba (26 - 27 September 2018)

The event was organized jointly by the European  Society for Clinical Microbiology and Infectious Diseases (ESCMID), the Spanish Society for Infectious Diseases and Clinical Microbiology (SEIMEC), The Lancet Infectious Diseases and the Pan-American Association for Infectology (API)

April 23-27, 2019.

This program is among the highest-rated Harvard Medical School CME courses. Seating for the 2019 program is limited. To ensure your place in it, early registration is strongly recommended. Please note that an early registration discount is available for a limited time.

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Highlights of the 2019 Program

Treating Highly Resistant Infections, including:

• MRSA and vancomycin-intermediate Staph aureus (VISA)

• Extended spectrum beta-lactamase (ESBL)-producing gram negative rods

• Carbapenemase-producing gram negative rods, including the NDM-1 metallo-beta-lactamase-producing organisms

• Vancomycin-resistant enterococci (VRE)

• Azole-resistant fungal infections

Early bird registration closes on 29 January 2019.

Antibiotic stewardship is part of initiatives for quality and safety in our health care system. Join this and learn from the experts on this area of service and research.

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The International Forum will take place on 27-29 March 2019 in Glasgow SEC Centre, Scotland, United Kingdom.

(Photo by Jacco Rienks on Unsplash)

Membership for IATDMCT is totally free for Malaysians (inc. other developing countries) aged younger than 40 years old.

So what are the perks? Well, you can tap into its online resources, which include recorded podcasts, video presentations, drug monographs as well as many other very good stuffs.

Reactions to penicillin in the general population are common, with approximately 10% of patients reporting a penicillin allergy. 

The article here summarizes and appraises the data on cephalosporins that can be administered to penicillin-allergic patients.

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Rothia mucilaginosa was formerly known as Staphylococcus salivarius, Micrococcus mucilaginosus, and Stomatococcus mucilaginosus.

It was reclassified into a new genus belonging to the family Micrococcaceae in 2000  based on 16S rRNA sequencing.

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The organism was ID by an automated system called Phoenix, which is (somewhat) similar with Vitek system. In this case his left foot cellulitis was thought to be the portal of entry, which later allowed the bacteria to spread into his blood and seeded onto his prosthetic valve.

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(This clinical review was written by Allison Graner, UNMC College of Pharmacy PharmD candidate 2019, and supervised by Scott Bergman PharmD FIDSA, Clinical Pharmacy Coordinator of Nebraska Medicine Antimicrobial Stewardship Program)

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Do you know that fluconzole gets concentrated in urine 10 X that of the plasma level in patients with normal kidney function? 

It also penetrates the kidney tissues well,thus can be used in cases of pyelonephritis. 

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If you are faced with an isolate with a high MIC (>8 mg/L), think about the above and try to talk to your microbiologists reg. the use of fluconazole in this case as we can still use the drug if given in high dose. This is called dose-dependent susceptibility (or SDD).

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Doctors should avoid prescribing FQ to patients with an aortic aneurysm or who are at risk for an aortic aneurysm.

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These are the patients who might have an increased risk for aortic aneurysm; peripheral atherosclerotic vascular diseases, hypertension, certain genetic conditions such as Marfan syndrome and Ehlers-Danlos syndrome, and elderly patients. 

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SO THINK BEFORE YOU PRESCRIBE YOUR NEXT CIPROFLOXACIN.

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The HOW-TO.

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In the field of Antibiotic Stewardship, data is an important tool that we can tap into in promoting ASP as well as its application in clinical practice, Data can also be used as metrics that allow us to benchmark our performance and track the effectiveness/ the lack of when come to ASP interventions.

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We must also ensure that these data are highly visible and reachable by readers especially health care professionals. Below is a link to a webinar that provides viewers with useful tips in making one research visible.

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In the collection of new and "advanced-articles" under Clinical Infectious Diseases (CID), there is this new paper published recently on an RCT performed in 3 centers in Israel and Italy. This trial tried to answer the million-dollar question on whether we should treat GNB bacteremia for 14 days or lesser (viz. 7 days). 

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So which one will you choose in your patient on the seventh day when your patient is well and afebrile for the past 48 hours prior?

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This webinar reviews the basal requirements, indications and practical aspects for rational antibiotic TDM in the intensive-care setting, with a special focus on the beta-lactams that are the most widely used antibiotic class. 

In the past therapeutic drug monitoring (TDM) has been employed only for antimicrobials with narrow therapeutic ranges, such as aminoglycosides. However, in recent years the knowledge about the altered pharmacokinetics in critically ill patients has led to a paradigm shift. Nowadays TDM of antibiotics is also advocated as a tool to guide dosage, ameliorating adequate drug exposure and therapeutic success in patients with severe infection, and at the same time minimizing the antimicrobial resistance. 

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Indian government delivered a massive blow to both local and international pharmaceutical companies following the ban on 328 combination drugs

We are not talking about normal FDCs (fixed drug combination) like amoxi-clav. Rather the combinations include the above, which were reported to be manufactured and marketed under 15 different names by companies in India (source; clinical infectious diseases news in  Volume 67, Issue 12 -15 December 2018

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The webinar will be delivered by Michael Paal of the Institute of Laboratory Medicine University Hospital, LMU Munich, Germany.​

This webinar will review the basal requirements, indications and practical aspects for rational antibiotic therapeutic drug monitoring (TDM) in the intensive-care setting, with a special focus on the beta-lactams that are the most widely used antibiotic class. Quantification techniques and respective bottlenecks for affordable de-centralized testing will also be discussed.

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The Eurobact 2 study aims to obtain an up-to-date data on hospital acquired blood stream infections (BSI) in the ICU, worldwide.

It is an observational study, there is no intervention, no supplementary tests and all the data should be gathered from the patient's chart and what is available for their usual care.  The study is sponsored by the ESICM Trials Group, and endorsed by the The ESICM Infection Section, the ESCMID Study Group for Infections in Critically Ill Patients – ESGCIP and the Asia Pacific association of Critical Care Medicine – APACCM.

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We plan to include 10 consecutive patients (or for 3 months) from each ICU. The CRF will be electronic and the amount of required data has been kept to a minimum to facilitate data capture.  

Your ICU can be part of this concerted effort of mapping out BSI incidence worldwide including the details on pathogens and treatment for BSI. Let's contribute to this cohort fellow Malaysian doctors. If you are interested in joining this study or would like to know more, please email the national coordinator for Malaysia, Helmi Bin Sulaiman at edenhelmi@gmail.com.

In addition, please fill in the online form below if you would like to join us today!

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Field-Specific One-on-One Online Grant Tutoring - by NIH or other grant awardees (A Trialect Partnered Program)

Trialect has partnered with more than 200 faculty members from the United States to facilitate One-on-One online personalized grant tutoring by previous recipients of NIH or other Non-Profit grants. They can see your grant proposal with fresh eyes and help guide your students in the following

• Defining your project

• Proposal format

• Tips on writing the narrative

• Statement of need

• Background

• Approach

• Personnel

• Method of evaluation

• Project timeline

• Applicant Credentials

• Budgeting

• Supporting material/data

• Preliminary data

• A brief review of your grant proposal

• Feedback and comments

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The deadline for the submission is on 28th Nov 2018.

ECCMID (The European Congress of Clinical Microbiology and Infectious Diseases) is the largest, most comprehensive and most influential meeting in the fields of clinical microbiology, infectious disease and infection control.

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A systemic review on bacteriophage-based therapy for infections caused by ESKAPE organisms was recently published in CID.

They (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) are regarded as the most problematic bacteria, when comes to antibiotic resistance. 

Thus, alternatives to antibiotic as the sole agent to combat these bugs are currently being pursued and these include phage cocktails.

It is believed that such cocktail may avoid development of antibiotic resistance in bacterial genomes.

According to the authors, it can also degrade biofilms that act as safe havens for bacteria to hide/slumber and they can resist antibiotic activity when given at normal and approved dosages within these sanctuaries.

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The authors pooled 30 studies after sifting through 1,102 articles on phage therapy in this. A third of these cohorts were given antibiotic therapy in addition to phage and others received phage monotherapy only.The duration of phage therapy ranged from 1 day to 18 weeks.

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The pooled efficacy of phage cocktails/treatment against ESKAPE organisms was reported to be at 87% in this review. With such high rate of success, perhaps more robust studies can be planned and carried out to study its efficacy against SOC.

New call for international course proposals - 2019.

Upon the direction of the ESCMID Executive Committee, a call is now open for proposals of Postgraduate Educational Courses and Technical Workshops, to be run in the second half of 2019.

In particular, ESCMID is seeking 4 courses, one from each of the following regions:

• Asia

• Africa

• Central and South America

• Eastern Europe

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Support by ESCMID.

Selected courses will be administrated by the ESCMID executive office, and local organisers will receive a EUR 5000.- contribution towards organisation, as well as a further EUR 5000.- towards attendance grants for ESCMID Young Scientist Members.

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In November 2018, we had the chance of listening to a PKPD guru Deborah Marriott from St Vincent Sydney, Australia. She shared with us the ABC of fungal infections as well as antifungal treatments.

(I have attached the links to some of the studies used in the slides which were used to illustrate these in the link below)

These letters are;

A= Always consider fungus/fungal infections in your patients.

Especially in ICUs.

Why?

A big proportion/cases of fungal infections are unknown and will remain to be so in many patients.

Check out the paper in the link below.

B= Beware of fungal infections and incidence in your center

Different centers would have different fungi/candida species dominating the "fungal scene" in one's hospital. Candida auris of late has gained notoriety and Lockhart published a paper that narrates on "aurial infections" in India, Pakistan, South Africa as well as Venezuela.

C= consider biofilm.

Similar to bacteria, candida too can form biofilm and the MICs for candida in biofilm are multifold higher than the planktonic ones. Debby shared a few interesting papers in her talk on biofilm.

D= drug-drug interactions,

When one uses azole, one cannot run away from possible DDI. Azole interacts with meropenem, PPI and in one case, Debbie showed how a seemingly friendly beta lactam caused voriconazole to be metabolized extensively that the level was severely affected.

E= Echinocandins;

No two echinocandins are the same in term of exposure-response after dosing.

These papers and slides screamed PK as well as PD (to some extent).

In  2 large cohorts, micafungin and caspofungin levels were rendered insufficient in critically ill patients, which saw reductions in the areas under the curve for these echinocandins below the acceptable levels for these patients.

H and I point to the same thing which is G
You need G because of H, I as well as D really.

G = Go for TDM

Well this is so true especially for azole. Fluconazole levels for example may be low in patients with ATN and AKI. As ATN happens, patients would be excreting fluco too into their urine as there is no reabsorption happening in the renal tubules leading to the need for even higher dosages for patients with AKI.

Would you dare to do this?
I guess this is where TDM is very beneficial then.

H = hypoalbuminemia and increased Vd

Which also points to an increased risk of under dosing due to blunted dose-exposure response curve in patients receiving azole and echinocandins.

When your albumin is low, the holding power of plasma of the antifungal falters, leading to an increase in Vd as well as urinary excretion and liver metabolism.

I = Inflammation

In septic patients who receive azole (in this case voriconazole), patients may be exposed to supra-level(s) following inflammation 

(surrogate marker used for inflammation in this study was CRP).

Why? Perhaps metabolism would get disrupted following an increase in inflammation leading to high level of voriconazole free drug in one's plasma.

In ID week, there would be these sessions that would be repeated in ID week every year. "What's-Hot-in-ID" is one of them.

In this, Stan Deresinski from Stanford University, located just down the road from where the ID week 2018 was held at (San Francisco), talked about the boy in the picture.

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He was Leland Stanford Jr. and his parents named the university in remembrance of his passing. He died due to typhoid fever when the family went to Europe; their second grand tour, where he was first diagnosed with this in Greece and succumbed to the infection later in Florence, Italy.

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Then there was no treatment available in the world.

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He recounted this as a preamble to his first  "HOT STORY", as well as a warning to all of us. The story was about the current outbreak of extensively drug resistant Salmonella in Pakistan, and the warning was the grim prospect of this becoming pan drug resistant soon and what then?

Another stories of Leland Stanford Juniors?

MERINO trial

By now everyone has heard bits and pieces of this trial and Stan took a jab at this too. He was pro-carbapenem in this. He in his last slide for MERINO said, if anything MERINO favored pip tazo but yet pip tazo failed to prove non-inferiority. But Stan, how about the E-test issue and over representation of OXA enzymes in this trial?

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POET

One cannot run away from POET in "What's-Hot-in-ID" session, cause it is hot and relevant. How relevant, well... that will be up to interpretation and target groups that physicians would like to use this data for in treating patients with infective endocarditis.

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Repeat TB vaccination

Would you do this?

Apparently there is this new trial that looks into such efficacy in high endemic countries and they used surrogate marker for such effect. The surrogate was quantiferon conversion rate and based on this it worked.

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In the last week of October 2018, we got the chance of gathering together to listen to renown local and international speakers who shared with us, many new and exciting updates and science related to infectious disease field.

Here are some of these updates.

Many of us like them new (antibiotics) and shiny.

Professor George Karam presented to us a new array of "toys" that can be used to fight against Gram-negative bacteria and these include 2 truly broad spectrum antibiotics;

• Cefiderocol and 

• Aztreonam-avibactam

To know more head to THIS new review published in IJAA.

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Increase antibiotic consumption in both MIC and LIC but not HIC.

Low and middle income countries are using more and more antibiotics and this is not showing any sign of abatement. To read further please click HERE

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Australia has a great database for AMR called AURA

There is this great resource of AMR and antibiotic consumption from Australia and if you are interested to know more, please click HERE.

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Malaysia is still using colistin for systemic infection

Perhaps is about time that we use polymyxin B for systemic infection and find out further on which companies that has this listed in for use in Malaysia.

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India tapped into their private lab network

A few of Indian private labs pooled data together and reported the rate of resistance of major pathogens detected from blood culture. To read further on this please click HERE.

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A free online and phone based apps for optimizing antibiotic use and dosing

Yup this is free and it covers many major antibiotics including carbapenems and pip tazo as well as vancomycin. For vancomycin, they even have Bayesian to help one with dosing and TDM.  Please click HERE to know more.

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Ceftolozane-tazobactam.

The data on this new antibiotic was presented by one of the speakers during the event. It has a great potency against Pseudomonas aeruginosa including those with resistant phenotype.

Interestingly, Merck is seeking for FDA approval now following the success of this in treating both hospital and ventilator assc. pneumonia when pitted against meropenem

(doubled the dose of this drug was used in this trial, based on data from epithelial lining fluid and lung penetration PK study)

Please click HERE to know more.

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New and Better.

The World Antibiotic Awareness Week website has undergone a makeover by WHO and let's take a look at the goodies in it

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Do you have any event planned?

WHO would like to know about it and you can share it/them HERE.

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Fret not.

HERE are the slides presented by the 2 great speakers today on  vancomycin therapeutic drug moniotiring. They did a great job in presenting the data on both trough and AUC methods used for this.

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Any additional reading materials that I should read?

Jason Pogue mentioned that this new paper HERE can help one in understanding the rationale for AUC approach as well as calculation methods used for it.

Another paper (cited in one of the slides) that gives an overview on this would be HERE.

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Succinctly I would say,

TDM based on AUC is coming soon and they have sent the first draft of the document (of the guideline) for review by relevant association in the States.

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Prior to roll out for AUC (if one decides to do so), engagement with pharmacists, physicians (including ID and nephrologists) and nurses is important.

Detroit Medical Centers used a homegrown excel based calculators (based on trapezoidal rules and methods) and integrated these into EMR. 

Feedback to users on the impacts of AUC use is important too. They used the reduced rates of neprotoxicity as a marker of success in this.

Two in one as the review was of 2018 ID week and meant for non-ID physicians. It also links one to another rapid review by Paul Sax (one of a prominent ID/HIV researchers from the States).

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The review.

I believe this was written by Milana Bogorodskaya, an ID fellow who created FOAMid.com (FOAM stands for free open access medicine in ID). Do check this site out. It is packed with many goodies related to ID field.

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The review covers an array of relevant 2018 ID week sessions that would benefit both the ID and non-ID physicians too. The lower half of the review may seem less relevant with topics like CMV preemptive therapy as well as diagnosis of PCP, but these I believe would benefit physicians who are involved in transplant medicine as well as cancer management.

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One that piqued my interest is the highlight of an abstract that looked into the efficacy of high dose influenza vaccination in elderly. There was no benefit seen in protecting influenza-associated hospitalizations.

Why it piqued my interest?

A similar study was carried out recently in Singapore. The difference was, biannual flu vaccination with normal dosages was used instead and this was tested against annual one (SOC).

Why?

Tropic countries like ours would have year-long circulation of flu viruses with bi-annual peaks and thus this study would be relevant to us too. 

What were seen?

Amongst other things, one that merits a highlight would be the reduced rate of influenza-like illness in the arm that received bi-annual vaccination.

Based on this poster at #IDWeek2018: 1 gram would do just as good.

The data was from a large Japanese cohort of 3,817 possible candidates.

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Propensity scoring.

As the data was observational in nature, the authors tried to minimize  bias by performing this. 

(NB. Bias might lead to inaccurate measure of variable effects including treatment in this scenario on the outcome and population studied).

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Outcomes

From the above, they managed to match 175 subjects in both the arms and what they found was; the cure rate was similar.

The mortality rate was similar too (with low rate of mortality perhaps reflecting the non-severe CAP amongst studied subjects?).

Few things worth mentioning.

- No clear definition/details were given for cure rate assessment.  

- No severity score was given/shared.

However, basing on the median age (with corresponding upper and lower quartiles), respiratory rate, blood urea, as well as blood pressure; recruited subjects may belong to CURB 2 at the very least (moderate CAP). 

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Thus extrapolating this to severe CAP may be a bit difficult.

Let's await for the full paper then.

Based on this session at #IDWeek2018.

Presented by Dr. Amy Mathers.

Argument presented was that;

the colistin dose was NOT the problem as the high dose was pitted against the lower dose and higher dose did not improve outcome and in fact increases risk for AKI. 

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The evidence.

Based on a paper published in 2016 which pooled subjects from 2 big cohorts (total of 529 subjects) and 27.2% of them received the dose we would use today (9MU per day).

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The propensity adjusted odd for mortality showed possible increase in chance of death (1.07; CI-95%, 0.63-1.83 - yup it crosses one thus it should read non-significant) but the risk for AKI is significant when subjects received high colistin dose by more than 2-fold (OR; 2.12; CI-95%, 1.29-3.48).

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In my opinion (Helmi Sulaiman), this may be explained by;

1) erratic behavior of colistin precursor in vivo which is colistimethate sodium -CMS that disintegrates slowly to colistin.

2) Companion drug that may not help colistin at all, when the MICs of the companion against offending organisms were way higher than their MIC breakpoints as well as the possible target attainment, thus leaving the poor colistin to battle against the bugs alone in these 2 cohorts, Same fate was seen in AIDA study published HERE.

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According to Vidya Menon et. al,; NOT really.

At least based on the dose-exposure response data sourced from 12 subjects.

(presented at #IDWeek2018)

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Thus they argue that we need to do TDM for colistin.

Wait a minute, TDM for colistin???

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And this is not really poly B, meaning one needs to ensure conversion from colistimethate sodium -CMS to colistin must be kept at minimum (ex vivo) during TDM.

Add the issue of colistin (as well as poly B) predilection to stick to plastic (polymyxins are highly polar so they readily form many weird bondings with surrounding plastic), then one would have major headache to translate this from bench to clinical practice.

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By the way what we saw on the left is a graph with 12 points of colistin Css, avg (average steady state level) and one could see that almost all the points (except one) did not even achieve the target of 2 mg/L (which corresponds to its optimal fAUC/MIC ~ 25) and increment of above 50% of serum creatinine was not predicted or associated with Css, avg at all.

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Thus the recommendation/conclusion of TDM for colistin

(with the above caveats).

The image is grainy and the outlook for colistin is grim (and grainy too) on this slide presented in #IDWeek2018

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Let's talk about the paper where this was sourced from.

The slide was based on a paper published this year in JAC 2018. We know that there is no MIC breakpoint for Enterobacteriacea when come to colistin and CLSI guideline. It is extrapolated from breakpoints meant for Acinetobacter and Pseudomonas.

Colistin concentration at steady state (average) of 2 mg/L has been used as surrogate to get us to its "ideal" pharmacodynamic target of AUC/MIC of about 25 (anything higher you risk losing your kidneys/hearing and suffer from other neurological complications).

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Using the usual dose of 9 MU per day, we can only reach a good coverage (aka PTA/probability of target attainment) when the MIC is less than 0.5 mg/L. 

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Anything higher, who knows what would happen and even at 1 mg/L of MIC, the range is so wide reflecting a very high degree of uncertainty (aka BSV; between subject variability).

Conclusion: colistin efficacy is suspect when MIC is above 0.5 mg/L.

(BTW even when  authors said "best described", look at that R2 values. These were not good to begin with)

According to Owen et. al, it is indeed important.

(presented at #IDWeek2018)

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The event (death) free survival was higher in those with microbiological cure.

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But, when one looks at a few details, it is hard not to think of possible drivers for this which may not be accounted for;

1) Pseudomonas aeruginosa and non-lactose fermenters were significantly more in those with microbiological failure BUT antibiotic treatment was longer in those with microbiological cure.

One wonders whether such differences matter?

2) In addition, were the antibiotic treatments active and balanced in the 2 arms and what about the time to appropriate therapy. Was it the same?

VERY. This was just tweeted from #IDWEEK2018 and these are the top papers in ASP field for the year 2018.

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Head to Twitter and join those in ID week now from the comfort of your seat.

Merely type and search for above hashtag and you are good to go. However, if you want to go a step further and watch these sessions, click HERE and you can watch them all at USD 399.

In this activity, participants will better understand appropriate utilization of AUC-based dosing, including evidence-based support of usage and implementation strategies.

A discussion for and against estimation of AUC values will be had, along with potential guideline changes practitioners may prepare for.

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Why this is a good webinar?

Speakers would help outline key strategies to successful implementation of an AUC based dosing protocol.

Odd right? NO vancomycin in the picture. What we need according to a randomized controlled trial done in Spain, is a concoction of 

1) Daptomycin AND

2) Fosfomycin

instead.

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Succinctly:

Screened; 674 patients between December 2013 and November 2017

Recruited: 155 subjects in each of the arms (controlled by an arm without fosfomycin addition)

Absolute difference = 12.1%; 95% CI, 0%-27%, in favor of combo arm (concerning test-of-cure endpoint).

This is such an odd phenomenon. Well before we point our fingers to any directions let's see what were the ways that subjects (patients) got their prescription replenished.

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Where did they get them?

10% over the phone, 4% during order-only encounters when prescriptions were entered into the system with no explanation, 4% via refill orders and 1% through online patient portals.

These totaled up to 20%.

And.... 46% of antibiotic prescribed were not for infection.

GASP!!!

Her name is; Candida auris. Her ability is not limited to antifungal resistance only. Worryingly, she even has an ability to trick mycologists into thinking that they belong to other group of candida or fungi all together.

They could be misidentified as;  

C. haemulonii complex, Rhodotorula glutinis, C. lusitaniae, C. famata, and C. guilliermondii

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So what?

It does not affect Malaysia.

Wrong. It has indeed reached our shore.

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CDC reported that JE virus is maintained in a cycle involving mosquitoes and vertebrate hosts, mainly pigs and wading birds.

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In Cambodia for example, the  virus is capable of causing infection in both rural and peri-urban farm pigs once they pass the age of 6 months old.

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What happens after 6 months?

The maternal antibodies that circulate in these piglets would drop, causing an increase in susceptibility for infection.

• There is an ongoing outbreak of extensively drug-resistant (XDR) typhoid fever in Pakistan that does not respond to most antibiotics

• All travelers to Pakistan are at risk of getting XDR typhoid fever. 

• Travelers to South Asia, including Pakistan, should take precautions to protect themselves from typhoid fever, including getting a typhoid fever vaccination and should also take extra care to follow safe food and water guidelines.

World Health Organization (WHO), Food and Agriculture Organization of the United Nations (FAO), and World Organization for Animal Health (OIE) evaluated countries' responses to a self-assessment survey on their efforts to address AMR in humans, animals, and the environment.

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 While there has been sustained progress on developing national action plans to address antimicrobial resistance (AMR),, MAJOR GAPS REMAIN . 

In almost all domains—surveillance, education, monitoring, and regulating consumption and use—more activity can be seen in the human sector. 

The animal, agriculture, and environment sectors must be further engaged in AMR prevention efforts to ensure that a One Health approach can be pursued and so that the world can meet its AMR goals.

WANNA DISH OUT CIPROFLOXACIN AND THE LIKES TO YOUR PATIENTS?

You may want to consider these new warnings by FDA USA before using this class of antibiotics for your patient. On July 10, 2018, FDA strengthen the warnings about the risks of mental health side effects and serious blood sugar disturbances.

These warnings apply to both IV and oral forms. Clinicians are advised to weight the risks and benefits of fluoroquinolones and both clinicians and patients/clients should make an informed decision before their use.

DO YOU SPREAD YOUR BUTTER LIKE THIS???

CDC in a simple yet thought provoking video below showed just how messed up and messy it could be if one uses the wrong tools for the wrong job...

The same can be said for antibiotics...

We cannot use them to treat viruses. Nor can we use them to treat cough or runny nose. They may have some anxiolytic activity to both parents and doctors.

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Time to use our ANTIBIOTICS THE RIGHT WAY.  

"Don't ask for antibiotic when your doctors don't prescribe them. Instead, ask your doctors if it's necessary when they are being prescribed"

NUDGE THEM!!!

At least that was what a group of researchers from Australia reported in their DHS website HERE. And it WORKED.

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More interestingly, the team was made up of behavioral economics and research team of BERT and BETA of Australia.

The Australia's Chief Medical Officer (Professor Brendan Murphy) nudged the GPs in Australia by sending personalized letters to them. Who were these GPs?

There were the top 30% antibiotic prescribers in the region and they received either one of 4 possible love letters.

The details can be found below. 

HOW MUCH IS ENOUGH?

Date: Wed, Jun 27, 2018 1230 AM (Local Malaysian time)

A webinar by The Global Antibiotic Research & Development Partnership (GARDP)

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This webinar featured Prof William Hope from University of Liverpool. He is one of the top experts in PKPD field. In this, he talked about the role of pharmacokinetics and pharmacodynamics for antimicrobial drug development.

He discussed the EMA guideline on the use of PK/PD and basic studies to inform dose finding strategies. There was also an interesting discussion on dose fractionation studies in PKPD field.

If you missed it, the copy of the talk in PDF form is as attached 

Forbes Week is an annual event of a series of talks including a visiting International Fellow.

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Talks and keynote presentations will be presented over 3-days duration at several different hospitals, and promises to be a multifaceted and interesting event.

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The event will be held from: 29th till 31st October,

Venue: Austin Health, Peter MacCallum Cancer Centre, and Alfred Health, Melbourne

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Forbes Fellow 2018 will be:

Professor Marc Mendelson, University of Cape Town.

Prof Mendelson studied Medicine at St Mary’s Hospital, London and specialised in Infectious Diseases at Addenbrookes Hospital, Cambridge, where he attained his PhD in Cytomegalovirus latency

This year, ESCMID is offering 10 grants to cover the cost of registration for deserving applicants. To apply, please write 100 words or less describing why it would be beneficial for you to attend the conference with the support of the ESCMID grant.

After the selection process has been completed, Applicants showing the ability to be in Havana at the time of the conference will have their registration fee paid for by ESCMID.

Any queries may be directed to Carla Seiler: cubaconf2018@escmid.org

Following a long tradition of paper reading and review in ICAAC/Microbe, this year Dr Tamma from John Hopkins presented a list of papers as well as blockbuster RCTs that had the ID world talking in term of results (MERINO and AIDA)

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Other sub sessions include top papers in

"Gram-positive world"

Transplant ID (this is NEW to me)

HIV

ID Diagnostics (New too) 

We are proud to have 3 Malaysian projects shortlisted for the award. They are;

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1. Ms Lyna Irawati, a PhD student from the School of Pharmaceutical Sciences, Universiti Sains Malaysia (USM). Her work entitled " Impact of an educational Intervention on Community Residents' Knowledge, Attitudes and Perceptions towards Antibiotics and Antibiotic Resistance in the state of penang, Malaysia", is under catergory of " Best Student of the Year"

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2. Mdm Farizan Abdul Ghaffar and the team of pharmacists from Hospital Serdang. The work entitled " Promoting rational antimicrobial prescribing at Cardiology Centre Serdang Hospital, Malaysia" is under category "Prescribing & Stewardship"

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3. Datin Mariani Ahmad Nizaruddin representating Malaysia Pharmaceutical Society with the work entitled " Antibiotic Resistance Awareness Campaign" under category " Public Engagement"

The Swiss Society for Infectious Diseases expert group “Infections of the musculoskeletal system has published and provided the above book for free 

HERE is the link

Human and nonhuman antibiotic use has contributed to antibiotic resistance. How is the situation in Malaysia and what can be done locally? 

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Check out this hot from the oven publication by our local author, in collaboration with ReAcT group

An RCT result was released recently in ECCMID 2018 to answer the above. Click HERE for the slides.

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The study showed 7 days did just fine when compared to 14 days when dealing with GNB bacteremia. This was a multicenter, open-label, noninferiority randomized controlled trial, whereby 684 subjects were recruited in total. 

The ECCMID now has uploaded many good slides and recorded talks/plenary sessions of ECCMID 2018 in Spain.

Head to eccmidlive.org to enjoy the full coverage on this (some of the slides are yet to be uploaded) 

This is a chance to highlight your good works being an Antibiotic Guardian on international platform. There are 10 awards categoriesincluding diagnostic, prescribing public engagement, etc...  What you have to do is simply fill up your details on the link down there and you may be one of the winner! 

This free book is on antibiotic stewardship and it was launched in  March 2018 from BSAC.

(from principle to practice)

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All you have to do is simply fill up your details on the link down there and you can then have the book for free

This online learning is on 

antibiotic stewardship from Stanford University.

(Endorsed by WHO)

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The range covered in this cousera course is extensive and includes antibiotic prescribing principles too​