Sublingual immunotherapy for the treatment of allergies

The treatment of allergies often involves pharmacological therapy and recommendations by healthcare workers that the allergen should be avoided. Allergen-specific immunotherapy has emerged as an alternative to effectively decrease the immunoglobulin (Ig) E:IgG4 ratio. Two routes of administration are described, namely subcutaneous immunotherapy, which has always been considered to be the gold standard of treatment, and sublingual immunotherapy, which has recently been shown to have fewer systemic side-effects and improved compliance by patients.Keywords: AIT, allergic disease, allergen-specific immunotherapy, allergic rhinitis, clinical efficacy, SCIT, SLIT, subcutaneous immunotherapy, sublingual immunotherap

Development of a web-based application to improve data collection for antimicrobial point prevalence surveys in the public health care system in South Africa; findings and implications

Background: Surveillance of antimicrobial use is one of the main recommended strategies in combating growing antimicrobial resistance (AMR) rates and a key part of developing pertinent policies and initiatives to reduce growing AMR rates in South Africa and wider. However, determining antimicrobial utilisation at a patient-level among public hospitals in South Africa can be a challenge given personnel and resource constraints. There are also currently no standardized data collection tools. Most countries in Africa currently undertake antimicrobial utilisation surveillance using paper-based data collection tools including point prevalence surveys (PPS). Unfortunately, paper-based systems have disadvantages including the time taken to complete the forms and analyse the findings, increasing costs and manpower hurdles. Electronic tools offer many advantages including mobile and real time data collection and also the opportunity for rapid analytics. Objectives: Develop and test a web-based application (APP) for future PPS studies to successfully address identified challenges. Methods: A web based application (APP) was developed based on previous PPS in Botswana and South Africa using a paper-based data collection tool and tested during July 2017 in a leading public hospital in South Africa. The developed APP was also evaluated for data quality by measuring the number of errors, work flow, and time taken for the survey versus the previous paper-based system. User acceptance was also measured via a questionnaire to the data collectors. Results: A total of 187 patients' files were surveyed in this leading hospital using the APP whilst also documenting the challenges and areas of improvement for the APP. The identified areas of improvement have now been incorporated into the revised APP for future studies. The data collectors agreed that surveying the patients' files took appreciably less time with the APP compared to the paper based tool, and should be used in the future. In addition, data analysis was hastened using the APP. Conclusions: The APP development process has been successful and the APP is a potential tool for future PPS in South Africa and wider. The APP methodology is now being tested in new studies across South Africa to help instigate pertinent educational and other interventions to improve the future use of antimicrobials among public hospitals in South Africa

A point prevalence survey of antimicrobial utilisation patterns and quality indices amongst hospitals in South Africa; findings and implications

Objectives: Antimicrobial use is growing, driven mainly by rising demands in developing countries. Knowing how antimicrobials are prescribed is important. Consequently, we undertook a point prevalence survey (PPS) quantifying antimicrobial consumption among 18 public sector hospitals across South Africa. Method: A purpose-built web-based application was used to collect PPS data. Results: Out of 4407 adult patients surveyed, 33.6% were treated with an antimicrobial. The most frequently prescribed groups were a combination of penicillins including β-lactamase inhibitors. Amoxicillin combined with an enzyme inhibitor accounted for 21.4% total DDDs. In the medical and surgical wards, Access antimicrobials (54.1%) were mostly used, while in the ICU, Watch antimicrobials (51.5%) were mostly used. Compliance with the South African Standard Treatment Guidelines and Essential Medicines List was 90.2%; however, concerns with extended use of antimicrobials for surgical prophylaxis (73.2% of patients). Conclusion: The web-based PPS tool was easy to use and successful in capturing PPS data since the results were comparable to other PPS studies across Africa. High use of amoxicillin combined with an enzyme inhibitor, possibly because it was among the broad-spectrum antimicrobials in the Access group. The findings will assist with future targets to improve antimicrobial prescribing among public sector hospitals in South Africa

A national, multicentre web-based point prevalence survey of antimicrobial use and quality indices among hospitalised paediatric patients across South Africa

Objectives: Data on antimicrobial consumption among the paediatric population in public hospitals in South Africa are limited. This needs to be addressed to improve future antimicrobial use and reduce antimicrobial resistance rates. This study aimed to quantify antimicrobial usage and to identify and classify which antimicrobials are used in the paediatric population in public sector hospitals in South Africa according to the World Health Organization (WHO) AWaRe list of antimicrobials. Methods: A point prevalence survey was conducted among 18 public sector hospitals from nine provinces using a newly developed web-based application. Data were analysed according to the WHO AWaRe list to guide future quality improvement programmes. Results: A total of 1261 paediatric patient files were reviewed, with 49.7% (627/1261) receiving at least one antimicrobial and with 1013 antimicrobial prescriptions overall. The top five antimicrobials included ampicillin (16.4%), gentamicin (10.0%), amoxicillin/enzyme inhibitor (9.6%), ceftriaxone (7.4%) and amikacin (6.3%). Antimicrobials from the 'Access' classification were the most used (55.9%), with only 3.1% being from the 'Reserve' classification. The most common infectious conditions for which an antimicrobial was prescribed were pneumonia (14.6%; 148/1013) and clinical sepsis (11.0%; 111/1013). Parenteral administration (75.6%; 766/1013) and prolonged surgical prophylaxis (66.7%; 10/15) were common concerns. Only 28.0% (284/1013) of prescribed antimicrobials had cultures requested; of which only 38.7% (110/284) of culture results were available in the files. Conclusion: Overall, antimicrobial prescribing is common among paediatric patients in South Africa. Interventions should be targeted at improving antimicrobial prescribing, including surgical prophylaxis, and encouraging greater use of oral antibiotics

Point prevalence survey of antimicrobial utilisation patterns among public hospitals in South Africa using a newly developed app; findings and implications

Background and objectives: Antimicrobial use is growing world-wide driven by increasing demand especially in developing countries. Concerns with rising antimicrobial resistance rates (AMR) have resulted in national action plans (NAPs) to improve future prescribing. A key element of NAPs is understanding current prescribing patterns. In hospitals, this typically involves point prevalence surveys (PPS). In sub-Saharan African countries, PPS study forms were updated to include Human Immunodeficiency Virus (HIV), tuberculosis, malaria and malnutrition as these were absent from Global and ECDC studies. Concerns with the length of time for data collection, need for rapid feedback and costs to undertake PPS studies amongst African countries, led to the development of a specific web-based App. The pilot study with the App in a tertiary hospital in South Africa signalled good acceptance and appreciably reduced data collection and feedback times. Additional PPS studies using the refined App have now been undertaken among a range of public hospitals in South Africa including paediatric populations, and we wish to consolidate the findings. Method: A purpose-built web-based application was used to collect PPS data among 18 public sector hospitals including paediatric populations involving over 5600 patients. Quality indicators included adherence to current guidelines and prescribing broken down by WHO AWaRe classification. Results: A third (33.6%) of adult patients were treated with an antimicrobial, similar to the initial study (37.7%) involving the group. The rate was higher among the paediatric population with nearly half (49.7%) receiving at least one antimicrobial. In the adult study, in the medical and surgical wards, antimicrobials from the Access group were mostly used (54.1%), while in ICUs, antimicrobials from the Watch list were mostly used (51.5%). Compliance with the South African Standard Treatment Guidelines and Essential Medicines List was 90.2%. Among paediatric patients, penicillins with/ without an enzyme inhibitor and gentamicin were the most prescribed antibiotics, with 55.9% from the Access group, 27.8% from the Watch group, and only 3.1% from the Reserve group. There were concerns with prolonged antibiotic administration for surgical prophylaxis and high use of IV administration that needs addressing. Conclusion: The web-based PPS App was successful in capturing PPS data, able to reduce data collection time, produce rapid feedback and easy to use. Furthermore, the PPS provided targets to improve future antimicrobial prescribing among public sector hospitals in South Africa including IV administration and surgical prophylaxis. The web-based tool is now being used in Eswatini, with potentially wider applications

Development of a web-based application to improve data collection of antimicrobial utilization in the public health care system in South Africa

OBJECTIVE: Determining antimicrobial utilization patterns in hospitals can be a challenge given personnel and resource constraints with paper-based systems. A web-based application (APP) was developed in South Africa to address this, building on a recent point prevalence survey (PPS) using a paper-based system. Consequently, there was a need to test and evaluate the ease of use of a newly developed app and potential time saving versus paper-based methods for PPS. The findings can be used to further refine the APP. METHODS: The developed app was tested in a large academic public hospital in a PPS in South Africa. During data collection, the app was evaluated for functionality on 35 variables and subsequently refined. After data collection, the app was evaluated in terms of its time-saving potential and ease of use. RESULTS: 181 patient's files were surveyed across 13 wards in the hospital, with the antimicrobial usage findings similar to the previous paper-based study in the same hospital. The median age for males was 45.5 years and 42 years for females. Overall 80 out of 181 (44%) patients received antibiotics. Whilst 38% (12 out of 31) of patients in the adult surgical ward received antimicrobials, the prevalence was the highest (78%) in the pediatric medical wards. All the data collectors were confident in using the app after training and found the tool is not complex at all to use. In addition, the time taken to plan for the study and to collect data was considerably reduced. Reduced time spent in data collection and analysis is important for timely instigation of quality improvement programs in resource limited settings. CONCLUSIONS: All data collectors would recommend the app for future PPSs. Several concerns with data entry were identified, which have now been addressed. The app development has been successful and is now being deployed across South Africa as part of a national PPS as well as wider

Antibiotic consumption and antimicrobial resistance in Poland; findings and implications

Background: The problem of inappropriate use of antibiotics and the resulting growth in antimicrobial resistance (AMR) has implications for Poland and the world. The objective of this paper was to compare and contrast antibiotic resistance and antibiotic utilisation in Poland in recent years versus other European countries, including agreed quality indicators, alongside current AMR patterns and ongoing policies and initiatives in Poland to influence and improve antibiotic prescribing. Methods: A quantitative ten-year analysis (2007-2016) of the use of antibiotics based on European Centre for Disease Prevention and Control (ECDC) data combined with a literature review on AMR rates and antimicrobial stewardship initiatives. Results: The system of monitoring AMR and appropriate strategies to address AMR rates remain underdeveloped in Poland. The role of microbiological diagnostics and efforts to prevent infections is currently underestimated by physicians. Overall, Poland had one of the highest rates of total consumption of antibiotics in the analysed European countries. Total consumption of antibacterials for systemic use and relative consumption of beta-lactamase sensitive penicillins were characterized by small but statistically significant average annual increases between 2007 and 2016 (from 22.2DIDs to 23.9 DIDs and from 0.8% to 1.3%, respectively). Conclusions: The integrated activities around appropriate antibiotic prescribing in the pre- and post-graduate training of physicians and dentists seem to be particularly important, as well as changes in policies on prescribing antibiotics within ambulatory care. AMR and appropriate prescribing of antibiotics should be the focus of health policy actions in Poland

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

Introduction: Antibiotics are indispensable to maintaining human health; however, their overuse has resulted in resistant organisms, increasing morbidity, mortality and costs. Increasing antimicrobial resistance (AMR) is a major public health threat, resulting in multiple campaigns across countries to improve appropriate antimicrobial use. This includes addressing the overuse of antimicrobials for self-limiting infections, such as upper respiratory tract infections (URTIs), particularly in lower- and middle-income countries (LMICs) where there is the greatest inappropriate use and where antibiotic utilization has increased the most in recent years. Consequently, there is a need to document current practices and successful initiatives in LMICs to improve future antimicrobial use. Methodology: Documentation of current epidemiology and management of URTIs, particularly in LMICs, as well as campaigns to improve future antimicrobial use and their influence where known. Results: Much concern remains regarding the prescribing and dispensing of antibiotics for URTIs among LMICs. This includes considerable self-purchasing, up to 100% of pharmacies in some LMICs. However, multiple activities are now ongoing to improve future use. These incorporate educational initiatives among all key stakeholder groups, as well as legislation and other activities to reduce self-purchasing as part of National Action Plans (NAPs). Further activities are still needed however. These include increased physician and pharmacist education, starting in medical and pharmacy schools; greater monitoring of prescribing and dispensing practices, including the development of pertinent quality indicators; and targeted patient information and health education campaigns. It is recognized that such activities are more challenging in LMICs given more limited resources and a lack of healthcare professionals. Conclusion: Initiatives will grow across LMICs to reduce inappropriate prescribing and dispensing of antimicrobials for URTIs as part of NAPs and other activities, and these will be monitored

A Liposome-Based Mycobacterial Vaccine Induces Potent Adult and Neonatal Multifunctional T Cells through the Exquisite Targeting of Dendritic Cells

BACKGROUND: In the search for more potent and safer tuberculosis vaccines, CAF01 was identified as a remarkable formulation. Based on cationic liposomes and including a synthetic mycobacterial glycolipid as TLR-independent immunomodulator, it induces strong and protective T helper-1 and T helper-17 adult murine responses to Ag85B-ESAT-6, a major mycobacterial fusion protein. Here, we assessed whether these properties extend to early life and how CAF01 mediates its adjuvant properties in vivo. METHODS/FINDINGS: Following adult or neonatal murine immunization, Ag85B-ESAT-6/CAF01 similarly reduced the post-challenge bacterial growth of M. bovis BCG, whereas no protection was observed using Alum as control. This protection was mediated by the induction of similarly strong Th1 and Th17 responses in both age groups. Multifunctional Th1 cells were already elicited after a single vaccine dose and persisted at high levels for at least 6 months even after neonatal priming. Unexpectedly, this potent adjuvanticity was not mediated by a massive targeting/activation of dendritic cells: in contrast, very few DCs in the draining lymph nodes were bearing the labeled antigen/adjuvant. The increased expression of the CD40 and CD86 activation markers was restricted to the minute portion of adjuvant-bearing DCs. However, vaccine-associated activated DCs were recovered several days after immunization. CONCLUSION: The potent adult and neonatal adjuvanticity of CAF01 is associated in vivo with an exquisite but prolonged DC uptake and activation, fulfilling the preclinical requirements for novel tuberculosis vaccines to be used in early life

Cationic Liposomes Formulated with Synthetic Mycobacterial Cordfactor (CAF01): A Versatile Adjuvant for Vaccines with Different Immunological Requirements

It is now emerging that for vaccines against a range of diseases including influenza, malaria and HIV, the induction of a humoral response is insufficient and a substantial complementary cell-mediated immune response is necessary for adequate protection. Furthermore, for some diseases such as tuberculosis, a cellular response seems to be the sole effector mechanism required for protection. The development of new adjuvants capable of inducing highly complex immune responses with strong antigen-specific T-cell responses in addition to antibodies is therefore urgently needed. (cell-mediated/humoral) and malaria (humoral) immunization with CAF01-based vaccines elicited significant protective immunity against challenge.CAF01 is potentially a suitable adjuvant for a wide range of diseases including targets requiring both CMI and humoral immune responses for protection