The role of antimicrobial stewardship programmes in children: a systematic review.

The United Nations and the World Health Organization have designated antimicrobial resistance (AMR) as a major health priority and developed action plans to reduce AMR in all healthcare settings. Establishment of institutional antimicrobial stewardship programmes (ASPs) is advocated as a key intervention to reduce antibiotic consumption in hospitals and address high rates of multi-drug resistant (MDR) bacteria. We searched PUBMED and the Cochrane database of systematic reviews (1/2007-3/2017) to identify studies reporting about the effectiveness of ASPs in general paediatric wards and paediatric intensive care units (PICU), on reducing antibiotic consumption, on using broad spectrum/restricted antibiotics, and on antibiotic resistance and healthcare-associated infections (HAIs). Neonatal units and antifungal agents were excluded. Of 2509 titles and abstracts, nine articles were eligible to be included in the final analysis. All studies reported on the reduction of broad spectrum/restricted antibiotics or antibiotic consumption. One study reported on the reduction of HAI in a PICU, and another evaluated bacterial resistance, showing no effect following ASP implementation. Prospective audit on antibiotic use was the most common ASP core component (eight of nine studies). Antibiotic pre-authorisation was described in two articles. Other described interventions were providing guidelines or written information (five of nine articles), and training of healthcare professionals (one article). There is limited evidence about reducing antibiotic consumption and broad-spectrum/restricted agents following ASP implementation, specifically in PICU. Data evaluating the impact of ASPs on HAI and AMR in PICU is lacking. In addition, there is limited information on effective components of a successful ASPs in PICUs

El desafío de la administración adecuada de antimicrobianos en pediatría.

Background: Antibiotics are among the drugs most commonly prescribed to children in hospitals and communities. Unfortunately, a great number of these prescriptions are unnecessary or inappropriate. Antibiotic abuse and misuse have several negative consequences, including drug-related adverse events, the emergence of multidrug resistant bacterial pathogens, the development of Clostridium difficile infection, the negative impact on microbiota, and undertreatment risks. In this paper, the principle of and strategies for paediatric antimicrobial stewardship (AS) programs, the effects of AS interventions and the common barriers to development and implementation of AS programs are discussed. Discussion: Over the last few years, there have been significant shortages in the development and availability of new antibiotics; therefore, the implementation of strategies to preserve the activity of existing antimicrobial agents has become an urgent public health priority. AS is one such approach. The need for formal AS programs in paediatrics was officially recognized only recently, considering the widespread use of antibiotics in children and the different antimicrobial resistance patterns that these subjects exhibit in comparison to adult and elderly patients. However, not all problems related to the implementation of AS programs among paediatric patients are solved. The most important remaining problems involve educating paediatricians, creating a multidisciplinary interprofessional AS team able to prepare guidelines, monitoring antibiotic prescriptions and defining corrective measures, and the availability of administrative consensuses with adequate financial support. Additionally, the problem of optimizing the duration of AS programs remains unsolved. Further studies are needed to solve the above mentioned problems. Conclusions: In paediatric patients, as in adults, the successful implementation of AS strategies has had a significant impact on reducing targeted- and nontargeted-antimicrobial use by improving the quality of care for hospitalized patients and preventing the emergence of resistance. Considering that rationalization of antibiotic misuse and abuse is the basis for reducing emergence of bacterial resistance and several clinical problems, all efforts must be made to develop multidisciplinary paediatric AS programs in hospital and community settings

Eating disorders and the intergenerational transmission of attachment

Over the past decade, results concerning the eventual associations between eating disorders (ED) and attachment styles (IWM) were very inconsistent and problematic. Definitions of the ED populations seldom took into consideration the distinction between diagnoses such as restricting anorexia, purging anorexia, bulimia, and binge eating disorder. Rarely was the link between ED patients’ and their parents’ IWM studied, and in no study the match between the IWMs of a patients’ mother and father has ever been considered. The present study was designed to address these points by analyzing individual and parental attachment styles in both a set of ED patients and a control sample of individuals. The results obtained show that the two groups differed significantly in their attachment status distribution, with a high prevalence of ambivalent and avoidant IWM found in patients and their mothers, and a high prevalence of avoidant IWM found in the fathers. Furthermore, a different distribution of IWMs emerged in the four ED subtypes, with several HOMALS analyses revealing complex structures underlying the match between fathers’ and mothers’ IWM, as well as regarding the agreement between children’s and parents’ mental states. Such findings include: the ED population showed a greater mismatch than the controls; the disagreement between mothers’ and fathers’ IWM was greater in restricting anorexia; disagreements between subjects’ and mothers’ IWM were greater in Bulimia. All these findings are discussed in terms of the implications of an intergenerational transmission of attachment in the clinical psychology and research of ED

Patients with Eating Disorders: Structure of Comorbidity and Psychopathological Symptoms

Until now, studies concerning the morbidities and psychopathological behaviors associated with eating disorders (ED) have considered each subtype of such disorders separately, with the investigation of the differences between them being very much neglected. Furthermore, no study has ever applied techniques such as Multidimensional Scalogram Analysis -an iterative HOMALS algorithm which represents a modernized version of the study by Guttman (1941)- in order to shed light not only on the psychopathological behaviors associated to ED disorders, but also upon the complex structure of the symptoms underlying each different ED subtype. The present study was designed to address these points. One hundred and thirty five subjects participated in the study: fifty five patients (mean age of 17.8 years, 50 female) and eighty controls (mean age of 16.5 years, all female). Diagnoses were made by clinicians experienced in the area of eating disorders using the DSM-IV-TR diagnostic criteria. Comorbidity in terms of anxiety, depression, hostility, interpersonal sensitivity, obsessive compulsive symptoms, paranoid ideation, phobic anxiety, psychoticism, and somatization was assessed by the Symptom Checklist-90 (SCL-90); psychopathological eating behavior (Diet, Bulimia, Oral Control) was assessed by the Eating Attitude Test (EAT-40). From all the Multidimensional Scalogram techniques, HOMALS analyses were used. The results showed that there were different symptom structures not only between clinical and non-clinical population, but also in the different ED subtypes. These findings are discussed in terms of the uses of the information regarding correlations between symptoms within the field of clinical psychology and research

Statin therapy is associated with better ambulatory blood pressure control: A propensity score analysis

OBJECTIVE: Statin therapy was associated with lower blood pressure (BP) in some but not all studies. We evaluated the association between statin therapy and ambulatory BP in a large hypertensive population using 'propensity score matching'. METHODS: Retrospective observational study on 1827 consecutive essential hypertensive patients evaluated with 24-h ambulatory BP monitoring. Antihypertensive treatment intensity (ATI) was calculated to compare different drug associations. We used a propensity score matching to compare two equally-sized cohorts of patients with similar characteristics according to statin therapy. Matching was performed on log-transformed propensity score in a 1 : 1 fashion with a caliper of 0.1, in order to account for the different baseline characteristics between statin and no-statin group. RESULTS: Mean age: 58.1 ± 13.8 years; male sex: 55%. Patients on statin therapy: 402 (22%). These patients showed lower 24-h BP (-2.8/-7.1 mmHg), daytime (-3.3/-7.6 mmHg) and night-time BP (-2.5/-6.0 mmHg, all P < 0.001). They also showed better ambulatory BP control, even after adjustment for confounding factors. The analyses on the groups derived from the 'propensity score matching' (369 patients in each group) confirmed these results (OR 1.8 for 24-h BP control; OR = 1.6 for daytime BP control; OR = 1.7 for night-time BP control, all P < 0.001). CONCLUSION: Statin therapy is associated with better ambulatory BP control in essential hypertensive patients. This result is not affected by the intensity of the antihypertensive treatment or by the several cofactors analyzed