Antimicrobial resistance is a global public health challenge, which has accelerated by the overuse of antibiotics worldwide. Increased antimicrobial resistance is the cause of severe infections, complications, longer hospital stays and increased mortality. Overprescribing of antibiotics is associated with an increased risk of adverse effects, more frequent re-attendance and increased medicalization of self-limiting conditions. Antibiotic overprescribing is a particular problem in primary care, where viruses cause most infections. About 90% of all antibiotic prescriptions are issued by general practitioners, and respiratory tract infections are the leading reason for prescribing. Multifaceted interventions to reduce overuse of antibiotics have been found to be effective and better than single initiatives. Interventions should encompass the enforcement of the policy of prohibiting the over-the-counter sale of antibiotics, the use of antimicrobial stewardship programmes, the active participation of clinicians in audits, the utilization of valid rapid point-of-care tests, the promotion of delayed antibiotic prescribing strategies, the enhancement of communication skills with patients with the aid of information brochures and the performance of more pragmatic studies in primary care with outcomes that are of clinicians’ interest, such as complications and clinical outcomes.

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Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem:

Antimicrobial resistance is recognized as one of the greatest threats to human health worldwide [1]. Drugresistant infections take a staggering toll in the United States (US) and across the globe. Just one organism, methicillin-resistant Staphylococcus aureus (MRSA), kills more Americans every year ( 19,000) than emphysema, HIV/AIDS, Parkinson’s disease, and homicide combined [2]. Almost 2 million Americans per year develop hospital-acquired infections (HAIs), resulting in 99,000 deaths [3], the vast majority of which are due to antibacterial (antibiotic)-resistant pathogens. Indeed, two common HAIs alone (sepsis and pneumonia) killed nearly 50,000 Americans and cost the US health care system more than $8 billion in 2006 [4]. In a recent survey, approximately half of patients in more than 1,000 intensive care units in 75 countries suffered from an infection, and infected patients had twice the risk of dying in the hospital as uninfected patients [5]. Based on studies of the costs of infections caused by antibiotic-resistant pathogens versus antibiotic-susceptible pathogens [6–8], the annual cost to the US health care system of antibioticresistant infections is $21 billion to $34 billion and more than 8 million additional hospital days. The discovery of antibiotics in the 1930s fundamentally transformed the way physicians care for patients, shifting their approach from a focus on diagnoses without means to intervene to a treatment-focused approach that saves lives. Seven decades of medical advances enabled by antibiotics are now seriously threatened by the convergence of relentlessly rising antibiotic resistance and the alarming and ongoing withdrawal of most major pharmaceutical companies from the antibiotic market. Without effective antibiotics, diverse fields of medicine will be severely hampered, including surgery, the care of premature infants, cancer chemotherapy, care of the critically ill, and transplantation medicine, all of which are feasible only in the context of effective antibiotic therapy. Our ability to respond to national security threats (e.g., bioterrorism and pandemics) also is in serious jeopardy. Ultimately, the loss of effective antibiotics will result in a great increase in morbidity and mortality from infections. Antimicrobial resistance is of such tremendous global concern that the World Health Organization (WHO) has proclaimed it the central focus of World Health Day 2011 (April 7). This policy paper summarizes the Infectious Diseases Society of America’s (IDSA) recommendations about how best to address the synergistic crises of rising rates of antibiotic resistance and waning approvals of new antibiotics. IDSA’s goal is to represent the best interests of patients and health care professionals by recommending public policy strategies and research activities that reverse antibiotics’ decline and save lives. Specific recommendations for Congress related to legislative action and funding needs are summarized in Tables 1 and 2, Received 14 February 2011; accepted 15 February 2011. *This policy paper, written by Brad Spellberg, Martin Blaser, Robert J. Guidos, Helen W. Boucher, John S. Bradley, Barry I. Eisenstein, Dale Gerding, Ruth Lynfield, L. Barth Reller, John Rex, David Schwartz, Edward Septimus, Fred C. Tenover, and David N. Gilbert, was developed for and approved by the IDSA Board of Directors on February 9, 2011. IDSA represents more than 9300 physicians, scientists and other health care professionals who specialize in infectious diseases. IDSA seeks to improve the health of individuals, communities, and society by promoting excellence in patient treatment and care, education, research, public health, and prevention relating to infectious diseases. Correspondence: Robert J. Guidos, 1300 Wilson Boulevard, Suite 300, Arlington, VA 22209 (rguidos@idsociety.org). Clinical Infectious Diseases 2011;52(S5):S397–S428 The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com. 1058-4838/2011/52S5-0001$37.00 DOI: 10.1093/cid/cir153

Combating antimicrobial resistance: policy recommendations to save lives.

In this IDSA policy paper, we review the current diagnostic landscape, including unmet needs and emerging technologies, and assess the challenges to the development and clinical integration of improved tests. To fulfill the promise of emerging diagnostics, IDSA presents recommendations that address a host of identified barriers. Achieving these goals will require the engagement and coordination of a number of stakeholders, including Congress, funding and regulatory bodies, public health agencies, the diagnostics industry, healthcare systems, professional societies, and individual clinicians.

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Better tests, better care: improved diagnostics for infectious diseases.

https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)64194-X/pdf

Routine use of point-of-care tests: usefulness and application in clinical microbiology.

Background Group A streptococcus (GAS) accounts for 20% to 40% of cases of pharyngitis in children; the remaining cases are caused by viruses. Compared with throat culture, rapid antigen detection tests (RADTs) offer diagnosis at the point of care (within five to 10 minutes). Objectives To determine the diagnostic accuracy of RADTs for diagnosing GAS in children with pharyngitis. To assess the relative diagnostic accuracy of the two major types of RADTs (enzyme immunoassays (EIA) and optical immunoassays (OIA)) by indirect and direct comparison. Search methods We searched CENTRAL, MEDLINE, EMBASE, Web of Science, CDSR, DARE, MEDION and TRIP (January 1980 to July 2015). We also conducted related citations tracking via PubMed, handsearched reference lists of included studies and relevant review articles, and screened all articles citing included studies via Google Scholar. Selection criteria We included studies that compared RADT for GAS pharyngitis with throat culture on a blood agar plate in a microbiology laboratory in children seen in ambulatory care. Data collection and analysis Two review authors independently screened titles and abstracts for relevance, assessed full texts for inclusion, and carried out data extraction and quality assessment using the QUADAS-2 tool. We used bivariate meta-analysis to estimate summary sensitivity and specificity, and to investigate heterogeneity across studies. We compared the accuracy of EIA and OIA tests using indirect and direct evidence. Main results We included 98 unique studies in the review (116 test evaluations; 101,121 participants). The overall methodological quality of included studies was poor, mainly because many studies were at high risk of bias regarding patient selection and the reference standard used (in 73% and 43% of test evaluations, respectively). In studies in which all participants underwent both RADT and throat culture (105 test evaluations; 58,244 participants; median prevalence of participants with GAS was 29.5%), RADT had a summary sensitivity of 85.6%; 95% confidence interval (CI) 83.3 to 87.6 and a summary specificity of 95.4%; 95% CI 94.5 to 96.2. There was substantial heterogeneity in sensitivity across studies; specificity was more stable. There was no evidence of a trade-off between sensitivity and specificity. Heterogeneity in accuracy was not explained by study-level characteristics such as whether an enrichment broth was used before plating, mean age and clinical severity of participants, and GAS prevalence. The sensitivity of EIA and OIA tests was comparable (summary sensitivity 85.4% versus 86.2%). Sensitivity analyses showed that summary estimates of sensitivity and specificity were stable in low risk of bias studies. Authors' conclusions In a population of 1000 children with a GAS prevalence of 30%, 43 patients with GAS will be missed. Whether or not RADT can be used as a stand-alone test to rule out GAS will depend mainly on the epidemiological context. The sensitivity of EIA and OIA tests seems comparable. RADT specificity is sufficiently high to ensure against unnecessary use of antibiotics. Based on these results, we would expect that amongst 100 children with strep throat, 86 would be correctly detected with the rapid test while 14 would be missed and not receive antibiotic treatment.

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Rapid antigen detection test for group A streptococcus in children with pharyngitis.

Acute pharyngitis is commonly seen in children. Group A β-hemolytic Streptococcus is the most common bacterial cause of acute pharyngitis and accounts for approximately 15% to 30% of cases in children, but this condition is generally overdiagnosed and overtreated. The availability of rapid s

Impact of rapid streptococcal test on antibiotic use in a pediatric emergency department.

Many children are brought to the emergency department because of respiratory symptoms including wheezing. Asthma is the most common but not the only cause of wheezing in children. There are many conditions, both pulmonary and extrapulmonary, which may cause recurrent wheezing. The diagnosis in children with congenital diaphragmatic hernia may be delayed. The late presentation of congenital diaphragmatic hernia poses a considerable diagnostic challenge. We report an 18-month-old child with congenital diaphragmatic hernia who presented with recurrent respiratory symptoms and localized physical findings. This case underscores the need to consider alternative diagnoses including congenital diaphragmatic hernia in the evaluation of recurrent respiratory symptoms; this is especially true if the presentation is not consistent with asthma or there are asymmetric findings on auscultation.

A wheezing child: breath sounds or bowel sounds?

We present the case of an 18-year-old young man with severe persistent knee pain secondary to a popliteal artery thrombosis. This occurred as a result of a fall from a bicycle. Acute compartment syndrome refers to the sequelae that can occur because of increased fascial compartment pressures, such as crush injuries, burns, traumatic or spontaneous hemorrhage, or constrictive casts. Increased pressures in nonelastic fascial compartments result in decreased perfusion distally, leading to ischemia of muscles and neurovascular tissue. In addition to highlighting recognition of the classic signs and symptoms of this limb-threatening condition, this case illustrates the importance of obtaining a thorough history; this is necessary in order to have a high index of suspicion for this diagnosis. A significant degree of clinical insight and prompt surgical intervention may save the functions of both the muscles and the nerves. These are at risk of permanent damage due to possible elevated compartment pressures. Language: en

Frances Quee

Papers

Impact of rapid streptococcal test on antibiotic use in a pediatric emergency department.

A wheezing child: breath sounds or bowel sounds?

Persistent knee pain after falling off of a bicycle