Kouhsari, E.

Mehr, S.H.

Sholeh, M.

eprints Iran University of Medical Sciences

lable at ScienceDirectAnaerobe 61 (2020) 102141Contents lists avaiAnaerobejournal homepage: www.elsevier .com/locate/anaerobeComments on the published systematic review and meta-analysis onthe increasing antibiotic resistance in Clostridioides difficileKeywords:C. difficileAntimicrobial resistanceMeta-analysisTable 1Comparing AST breakpoints in EUCAST and CLSI.Antibiotic CLSI Breakpoint (mg/l) R  EUCTetracycline 16 0.2Moxifloxacin 8 4Metronidazole 32 2Vancomycin -a 2a CLSI hove not vancomycin breakpoint for C. diffiaureus vancomycin breakpoint (16 mg/l).https://doi.org/10.1016/j.anaerobe.2019.1021411075-9964/© 2020 Elsevier Ltd. All rights reserved.inaccurascript, ifTo the EditorConcerning the published article " Saha, Srishti, et al. Increasingantibiotic resistance in Clostridioides difficile: A systematic reviewand Meta-analysis. Anaerobe 58 (2019): 35e46.” [1]. We read thismanuscript with interest and found some drawbacks in the catego-rization of data implementation.The resistance rate of C. difficile to some antibiotics was investi-gated in this article. Antibiotic resistance data were extracted fromreports in the searches of Ovid MEDLINE In Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Cen-tral Register of Controlled Trials, Ovid Cochrane Database of System-atic Reviews, Web of Science, and Scopus from inception throughMarch 31, 2017 database searches. Eventually, 60 articles wereused for the final analysis. Subgroup analysis was performed bystudy period, continent, antibiotic resistance testing method. Dataof ribotype 027 were analyzed separately. There was no mentionof quality assessment of the included studies in this meta-analysis.All antibiotic susceptibility testing’s (AST) guidelines were groupedas the same category and were analyzed; whereas for some of theantibiotics breakpoints there were variations between AST guide-lines (Some of these differences were shown in Table 1) [2,3].In this study, the reports were used in theMeta-analysis withoutperforming an appropriate quality assessment which means aggre-gating resistance rate of isolate that do not have a clear origin or hasbeen isolated from a particular section of the hospital. So, the biasrisk of the low-quality articles was confirmed. The result, due toAST breakpoint (mg/l) R >5cile and some article used S.cy in this method, was affected. According to the manu-the articles reported the number of susceptible, intermedi-ate resistance and resistant strains, only the number of resistantisolates was extracted and included. The AST guidelines that wereused in these studies, were obtained as a data. Due to the passage,most articles have cited CLSI (27 research) as reference and alsosome other AST such as EUCAST and etc. Despite extraction fromAST guidelines data; unfortunately, the data analyzed in unity,regardless of the differences in the AST guidelines were cited inthe papers. Thus, the disparity in the breakpoint was inherent ineach AST guidelines, for example, in the case of Metronidazole.The result of AST was presented by EUCAST breakpoint (>2mg/l)as it is different from the result of a report based on CLSI breakpoint(32mg/l). They also analyzed articles with another AST breakpointin a single batch. Therefore, the total resistance values and propor-tion does not accurately correlate. The results of continental sub-group analysis get an error due to the generality of usingparticular AST guideline in each continent.Our recommendation for conducting a systematic review andMeta-analysis in this subject, especially at the global level, primar-ily, is to develop a suitable questionnaire of quality assessment forthe study and perform it accurately. Analyzing the results of thequality assessment as a subgroup to discover the relation betweenquality of studies on reported resistance rate, in order to identifythe risk bias of poor-quality studies. Accordingly, the presence ofvarious AST guidelines causes multiple breakpoints in use. It isadvisable to categorize the data according to the reported break-point for each piece in order to obtain an accurate antibiotic resis-tance rate. It should be mentioned that the results of the analysisbased on each AST guidelines breakpoint should be categorizedseparately.References[1] S. Saha, S. Kapoor, R. Tariq, A.N. Schuetz, P.K. Tosh, D.S. Pardi, et al., IncreasingAntibiotic Resistance in Clostridioides Difficile: A Systematic Review and Meta-Analysis, 58, 2019, pp. 35e46.[2] CLSI, Performance standards for antimicrobial susceptibility testing, in: CLSISupplement M100, 29th ed., Clinical and Laboratory Standards Institute, Way-ne.PA, 2019.[3] The European Committee on Antimicrobial Susceptibility Testing, BreakpointTables for Interpretation of MICs and Zone Diameters V, 2019.Ebrahim KouhsariClinical Microbiology Research Center, Ilam University of MedicalSciences, Ilam, IranLaboratory Sciences Research Center, Golestan University of MedicalSciences, Gorgan, IranE. Kouhsari et al. / Anaerobe 61 (2020) 1021412Sara Hayati Mehr, Mohammad Sholeh*Department of Microbiology, School of Medicine, Iran University ofMedical Sciences, Tehran, IranNima MohammadzadehDepartment of Microbiology, Faculty of Biology, Shahid BeheshtiUniversity, Tehran, IranDepartment of Molecular Biology, Cancer Biomedical Center (CBC),Tehran, Iran* Corresponding author. Department of Microbiology, Faculty ofMedicine, Iran University of Medical Sciences, Hemmat Highway,14 Tehran, IR, Iran, P.O. box: 354-14665.E-mail address: Mohammad.Sholeh.mail@gmail.com (M. Sholeh).9 November 2019Available online 20 January 2020Handling Editor: Elisabeth Nagy

Comments on the published systematic review and meta-analysis on the increasing antibiotic resistance in Clostridioides difficile

Golestan University of Medical Sciences Repository

http://eprints.iums.ac.ir/24118/1/Comments-on-the-published-systematic-review-and-metaanalysis-on-the-increasing-antibiotic-resistance-in-Clostridioides-difficile2020Anaerobe.pdf

Comments on the published systematic review and meta-analysis on the increasing antibiotic resistance in Clostridioides difficile

Abstract

Similar works

Full text

Available Versions

eprints Iran University of Medical Sciences

Golestan University of Medical Sciences Repository