Giorgia Sulis1, Sena Sayood2, Shashi Katukoori3, Neha Bollam4, Ige George2, Lauren H Yaeger5, Miguel A Chavez2, Emmanuel Tetteh2, Sindhu Yarrabelli6, Celine Pulcini7, Stephan Harbarth8, Dominik Mertz9, Mike Sharland10, Lorenzo Moja11, Benedikt Huttner11, Sumanth Gandra12. 1. Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, McGill University, Montreal, Canada. 2. Division of Infectious Diseases, Washington University School of Medicine in St. Louis, MO, USA. 3. Division of Hospital Medicine, University of Alabama Medical School, Birmingham, AL, USA. 4. University of North Carolina, Chapel Hill, NC, USA. 5. Bernard Becker Medical Library, Washington University School of Medicine in St. Louis, MO, USA. 6. Samraksha Healthcare, Warangal, Telangana, India. 7. Infectious Diseases Department, Université de Lorraine, CHRU-Nancy and APEMAC, Université de Lorraine, Nancy, France. 8. Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland. 9. Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada. 10. Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George's University London, London, UK. 11. Secretariat of the Model List of Essential Medicines, Department of Essential Health Products and Standards, World Health Organization, Geneva, Switzerland. 12. Division of Infectious Diseases, Washington University School of Medicine in St. Louis, MO, USA. Electronic address: gandras@wustl.edu.
Abstract
BACKGROUND: Antibiotic use drives antibiotic resistance. OBJECTIVES: To systematically review the literature and estimate associations between prior exposure to antibiotics across World Health Organization's (WHO) AWaRe categories (Access, Watch, Reserve) and isolation of critical and high-priority multidrug resistant organisms (MDROs) on the WHO priority pathogen list. DATA SOURCES: Embase, Ovid Medline, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov (from inception to 20/08/2020). STUDY ELIGIBILITY CRITERIA: Case-control, cohort, or experimental studies that assessed the risk of infection/colonization with MDROs. PARTICIPANTS: Inpatients or outpatients of any age and sex. INTERVENTIONS: Prior exposure to antibiotics that could be categorized into the AWaRe framework. DATA ANALYSIS: Tailored design-specific checklists applied to each included study. For each antibiotic/class, crude odds ratios (ORs) were pooled through random-effects meta-analyses, both overall and by MDRO. Heterogeneity was examined. RESULTS: We identified 349 eligible studies. All were observational, prone to bias due to design and lack of adjustment for confounding, and not primarily designed to compare associations across AWaRe categories. We found statistically significant associations between prior exposure to almost all antibiotics/classes across AWaRe categories and colonization/infection with any MDRO. We observed higher ORs for Watch and Reserve antibiotics than with Access antibiotics. First generation cephalosporins (Access) had the least association with any MDRO colonization/infection (58 studies; OR = 1.2 [95% CI: 1.0-1.4]), whereas strongest associations were estimated for linezolid (Reserve) (22 studies; OR = 2.6 [95% CI: 2.1-3.1]), followed by carbapenems (Watch) (237 studies; OR = 2.3 [95% CI: 2.1-2.5]). There was high heterogeneity for all antibiotic/MDRO associations. CONCLUSIONS: Optimising use of Access antibiotics is likely to reduce the selection of MDROs and global antibiotic resistance. Despite data limitations, our study offers a strong rationale for further adoption of AWaRe as an important tool to improve antibiotic use globally.
BACKGROUND: Antibiotic use drives antibiotic resistance. OBJECTIVES: To systematically review the literature and estimate associations between prior exposure to antibiotics across World Health Organization's (WHO) AWaRe categories (Access, Watch, Reserve) and isolation of critical and high-priority multidrug resistant organisms (MDROs) on the WHO priority pathogen list. DATA SOURCES: Embase, Ovid Medline, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov (from inception to 20/08/2020). STUDY ELIGIBILITY CRITERIA: Case-control, cohort, or experimental studies that assessed the risk of infection/colonization with MDROs. PARTICIPANTS: Inpatients or outpatients of any age and sex. INTERVENTIONS: Prior exposure to antibiotics that could be categorized into the AWaRe framework. DATA ANALYSIS: Tailored design-specific checklists applied to each included study. For each antibiotic/class, crude odds ratios (ORs) were pooled through random-effects meta-analyses, both overall and by MDRO. Heterogeneity was examined. RESULTS: We identified 349 eligible studies. All were observational, prone to bias due to design and lack of adjustment for confounding, and not primarily designed to compare associations across AWaRe categories. We found statistically significant associations between prior exposure to almost all antibiotics/classes across AWaRe categories and colonization/infection with any MDRO. We observed higher ORs for Watch and Reserve antibiotics than with Access antibiotics. First generation cephalosporins (Access) had the least association with any MDRO colonization/infection (58 studies; OR = 1.2 [95% CI: 1.0-1.4]), whereas strongest associations were estimated for linezolid (Reserve) (22 studies; OR = 2.6 [95% CI: 2.1-3.1]), followed by carbapenems (Watch) (237 studies; OR = 2.3 [95% CI: 2.1-2.5]). There was high heterogeneity for all antibiotic/MDRO associations. CONCLUSIONS: Optimising use of Access antibiotics is likely to reduce the selection of MDROs and global antibiotic resistance. Despite data limitations, our study offers a strong rationale for further adoption of AWaRe as an important tool to improve antibiotic use globally.
Authors: Amira A Moawad; Helmut Hotzel; Hafez M Hafez; Hazem Ramadan; Herbert Tomaso; Sascha D Braun; Ralf Ehricht; Celia Diezel; Dominik Gary; Ines Engelmann; Islam M Zakaria; Reem M Reda; Samah Eid; Momtaz A Shahien; Heinrich Neubauer; Stefan Monecke Journal: Antibiotics (Basel) Date: 2022-08-08
Authors: Aashna Mehta; Petra Brhlikova; Patricia McGettigan; Allyson M Pollock; Peter Roderick; Habib Hasan Farooqui Journal: Bull World Health Organ Date: 2022-08-22 Impact factor: 13.831