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A bug in the ointment: Topical antimicrobial usage and resistance in New Zealand

103 NZMJ 4 December 2015, Vol 128 No 1426
ISSN 1175-8716 © NZMA
A bug in the ointment:
topical antimicrobial usage
and resistance in
New Zealand
Deborah A Williamson, Stephen R Ritchie, Emma Best, Arlo Upton, Alison
Leversha, Alesha Smith, Mark G Thomas
New Zealand has unenviably high rates of bacterial resistance to topical antimicrobials. In this Viewpoint,
we review the history and usage of topical antimicrobials in New Zealand, and suggest some strategies to
mitigate further increases in antimicrobial resistance to topical agents.
Antimicrobial resistance has been
described as a “crisis for the health and
wealth of nations”.1 One of the key strat-
egies to mitigate this public health crisis is to
ensure that existing antimicrobials are used
responsibly and judiciously. In general, New
Zealand has relatively low rates of antimi-
crobial resistance threats deemed as ‘critical’
or ‘urgent’ by the Centers for Disease Control
and Prevention.2 However, this may reect
relatively low levels of consumption of
many antimicrobials in previous decades,
rather than our relatively high levels of
antimicrobial consumption in more recent
years.3 In particular, high usage of topical
antimicrobial agents over the past three
decades in New Zealand has resulted in an
ill-fated series of national population-level
experiments, which clearly illustrate
the relationships between antimicrobial
consumption and resistance. Throughout
the 1990s, the topical antimicrobial agent
mupirocin (Bactroban©) was available to
purchase ‘over-the-counter’ (OTC), which led
to very high levels of use, and subsequent
high rates of resistance, such that by 2000,
approximately 14% of S. aureus isolates
displayed high-level resistance to mupi-
rocin.4 From April, 2000, regulatory changes
meant that mupirocin could be obtained
by ‘prescription only’, with a subsequent
decrease in usage, and a fall in the preva-
lence of high-level mupirocin resistance in S.
aureus from 14.2% in 2000, to 8.3% in 2014.5
Interestingly, the authors of a 2003 study
describing mupirocin resistance in New
Zealand concluded that:
“In cautioning against the use of
mupirocin, we do not advocate using
fusidic acid topically as an alter-
native. Resistance to this topical
agent is reported, and unlike mupi-
rocin, it is available in oral and
intravenous formulations that are
used for treatment of multiresistant
S. aureus infections”.4
Similarly, an Australian commentary in
2006 on fusidic acid use stated:
“Ensuring that… the use of topical
fusidic acid is either abolished or
restricted will be vital if we are to
prevent the loss of this potentially
useful agent”, and “Common sense
would suggest that antibiotics used
topically should be ones that are not
used systemically”.6
Despite these unambiguous warnings,
regulatory changes and the promulgation
of guidelines promoting the use of topical
fusidic acid ointment and cream contributed
to a signicant increase in topical fusidic
acid dispensing in New Zealand throughout
the 2000s (Figure 1), with an associated
increase in the prevalence of resistance in S.
aureus from 17% in 1999, to 28% in 2013.7 At
104 NZMJ 4 December 2015, Vol 128 No 1426
ISSN 1175-8716 © NZMA
present, topical fusidic acid is available by
prescription only, although it is fully subsi-
dised by the New Zealand Ministry of Health,
unlike mupirocin, which is only partially
The evidence for and against
topical antimicrobial use
Theoretically, the use of topical anti-
microbials is an attractive option to treat
minor skin ailments. Topical application
allows delivery of high concentrations of
antimicrobial at the site of infection, while
minimising systemic absorption. In practice
however, topical antibiotic use has long
been recognised as a very ecient method
of rapidly promoting the emergence
and proliferation of antibiotic resistant
microbes.6 Furthermore, evidence-based
prescribing supports the use of topical
antimicrobial agents for only a few specic
indications, including nasal eradication of S.
aureus, treatment of acne, and treatment of
mild impetigo.8-10
Despite concerns about ecacy and
the promotion of even higher rates of
resistance, fusidic acid remains the recom-
mended agent in New Zealand for the
empiric treatment of impetigo.11,12 Impor-
tantly, rates of resistance to fusidic acid
in S. aureus remain comparatively lower
in countries that have not adopted the
widespread use of topical fusidic acid.13-15
In general, Streptococcus pyogenes, the
other pathogen commonly associated with
impetigo, is less susceptible to fusidic acid
than S. aureus.16
One of the largest randomised control
trials (RCTs) assessing the ecacy of topical
fusidic acid vs placebo in the treatment of
mild impetigo, conducted in the Nether-
lands between 1999 and 2000, found that
cure rates after one week of treatment
with topical fusidic acid were signicantly
higher than with placebo (55% vs 13%, odds
ratio [OR] 12.6, 95% condence interval
[CI], 5.0–31.5).17 However, this difference
reduced over time, with 92% of treated
patients displaying cure at 28 days, vs 88%
of patients in the placebo arm. It also must
be noted that no fusidic acid resistance
was detected in S. aureus isolates from
this study population, meaning that these
study ndings are not directly applicable
to the New Zealand setting, where contem-
porary fusidic acid resistance rates are
high. In addition, another RCT conducted
in the UK, Germany and Sweden in 1994,
found no statistically signicant difference
in cure rates between topical fusidic acid
and hydrogen peroxide in the treatment
of localised impetigo (82% vs 72%, respec-
tively).18 Again, caution should be exercised
when extrapolating these results to the New
Figure 1: Community dispensing rates per 1,000 population for topical fusidic acid and mupirocin in the
New Zealand community setting, January, 1993,–August, 2013. Reproduced from Reference 7.
105 NZMJ 4 December 2015, Vol 128 No 1426
ISSN 1175-8716 © NZMA
Figure 2: Community dispensing rates per 1,000 population for topical fusidic acid in the New Zealand
community setting stratied by age group, January, 2006,–August, 2013.
Figure 3: Community dispensing rates per 1,000 population for topical fusidic acid in the New Zealand
community setting stratied by ethnicity, January, 2006,–August, 2013.
106 NZMJ 4 December 2015, Vol 128 No 1426
ISSN 1175-8716 © NZMA
Zealand setting, as rates of fusidic acid resis-
tance in these countries are markedly lower
than New Zealand.14 However, despite the
limited application of overseas ndings to
the New Zealand setting, such studies have
been used as the basis for guidelines that
actively recommend topical fusidic acid
in the empiric treatment of impetigo.11,12
Importantly, there are no published studies
comparing the use of topical fusidic acid
vs placebo, or vs antiseptic treatment for
impetigo in high prevalence resistance
settings, such as New Zealand. In particular,
it is not yet known whether topical
hydrogen peroxide is a feasible alternative
for New Zealand children compared to
topical fusidic acid.
Demographics of topical fusidic
acid use in New Zealand
In addition to therapeutic usage, data
suggest that, in some settings, topical
antimicrobials may also be used prophy-
lactically, particularly in elderly patients.
For example, a study from the US assessing
national usage of topical antimicrobials
found that 40% of all topical antimicrobial
usage was in the over-50 age group, with
benign or malignant skin neoplasms being
the most common diagnosis associated
with topical antimicrobial usage.19 These
authors hypothesised that in such instances,
topical antimicrobials were being used
as post-operative wound ‘prophylaxis’
following minor surgery, a practice that is
not supported by available evidence.20,21
Information on the demographics and
geographic variation of antimicrobial
usage in a population is essential in under-
standing how and why antimicrobials are
utilised, and identifying potential areas
for reduction in usage. Information on all
community prescriptions in New Zealand
are maintained in a central data warehouse,
the ‘Pharmaceutical Collection’. Data from
this collection between January, 2006, and
August, 2013, demonstrates that the highest
rates of topical fusidic acid dispensing were
in the under-5 year age group, followed by
the 75 year and over age group (Figure 2).
When stratied by ethnicity, the highest
rates of dispensing were in Māori and
Pacic Peoples (Figure 3), and when strat-
ied by geographic region, the highest rates
of dispensing were in the Northern region
of New Zealand (Figure 4).
These dispensing patterns are consistent
with recent work showing the high rates
of skin infections in Pacic and Māori
Figure 4: Community dispensing rates per 1,000 population for topical fusidic acid in the New Zealand
community setting stratied by geographic region, January, 2006–August, 2013. (Northern = Northland
DHB, Waitemata DHB, Auckland DHB, Counties Manukau DHB; MidCentral = Waikato DHB, Lakes DHB,
Bay of Plenty DHB, Tairawhiti DHB, Taranaki DHB; Central = Hawkes Bay DHB, MidCentral DHB, Whan-
ganui DHB, Capital and Coast DHB, Hutt DHB, Wairarapa DHB; Southern = Nelson Marlborough DHB,
West Coast DHB, Canterbury DHB, South Canterbury DHB, Southern DHB).
107 NZMJ 4 December 2015, Vol 128 No 1426
ISSN 1175-8716 © NZMA
children,22 and further emphasise the
considerable burden of skin disease in
these groups. In addition, the high rates of
dispensing in the Northern region reect
the higher incidence of skin disease in this
region, which has the highest population of
Māori and Pacic Peoples in New Zealand.
Furthermore, the relatively high rates of
topical fusidic acid usage in the over-75
year age group are concerning, partic-
ularly given the limited evidence-based
indications for prescribing topical anti-
microbials in older age groups.19 To date
however, there are no available data on
the clinical indications for topical antimi-
crobial prescribing in elderly patients in
New Zealand. Such information is critical
for determining whether current usage of
topical antimicrobials is clinically indicated,
and identifying strategies to reduce inap-
propriate prescribing.
Collateral damage caused by
high levels of fusidic acid usage
in New Zealand
Recent data suggest that, as might be
expected, the high usage of topical fusidic
acid in New Zealand is driving the increase
in fusidic acid resistant S. aureus clones.5,7,23
Of specic concern is the emergence of a
fusidic acid-resistant community-associated
methicillin-resistant S. aureus (MRSA) clone,
known in New Zealand as the ‘AK3’ clone.23
This clone has rapidly become the most
common type of MRSA causing illness in
New Zealand.5 Genomic data indicates that
the gene conferring fusidic acid resistance
(fusC) and the gene conferring methicillin
resistance (mecA) are located together
on the same mobile genetic element.7 In
simple terms, this means that large-scale
use of topical fusidic acid has favoured the
proliferation of the AK3 MRSA clone, and
has provided a ‘helping hand’ in allowing
this clone to become established in New
Zealand. In addition, a recent national study
of antimicrobial resistance in New Zealand
found that 36% of all fusidic acid-resistant
methicillin-susceptible S. aureus (MSSA)
strains were also resistant to mupirocin,
highlighting the potential for treatment
with one antimicrobial to select for multi-
resistant bacterial clones.5 In this context,
it is important for practitioners to be aware
of the wider ecological implications (or
‘collateral damage’) that can occur when
prescribing what may be regarded as a
benign treatment.
Collective action requires
collective responsibility
It is clear from available data that the rate
of fusidic acid resistance in New Zealand
is one of the highest in the developed
world, and that high levels of usage have
contributed to proliferation of the AK3
MRSA clone. It is also important to note that
a considerable proportion of topical anti-
microbial usage in New Zealand may be
considered ‘appropriate’, particularly given
the high burden of childhood skin infec-
tions in our setting.22,24 However, in the face
of high bacterial resistance, we question
the value of continuing to recommend
topical fusidic acid as empiric therapy in
New Zealand, and suggest a multipronged
approach aimed specically at reducing
rates of resistance:
1. Consistent, evidence-based, national
guidelines around the appropriate
use of topical antimicrobials.
2. Reduce the volume of agent
dispensed to patients (eg, a 5g tube
instead of a 15g tube).
3. Regulatory measures around the use
of topical fusidic acid, such as moving
to ‘specialist-only’ prescribing in the
4. Improved education to primary care
practitioners about evidence-based
prescribing of topical antimicrobials,
particularly in elderly patients.
5. Clear messaging to the public about
the importance of not sharing topical
antimicrobials amongst a household,
and discarding any remaining topical
agent once the treatment course has
been completed.
6. Robust clinical trials, conducted in
a setting with a high prevalence of
resistance to topical agents, assessing
the clinical utility of antiseptic agents
in the treatment of localised impetigo.
A key rst step would be identication
and gathering of relevant stakeholders,
and formation of a clear ‘road-map’ to
address this signicant problem. These
stakeholders should include prescribers, the
Ministry of Health, PHARMAC and patient
representatives. New Zealand has already
108 NZMJ 4 December 2015, Vol 128 No 1426
ISSN 1175-8716 © NZMA
had considerable success in reducing
rates of topical antimicrobial resistance
encountered in S. aureus isolates. This is
highlighted by the reversal in mupirocin
resistance in New Zealand over the past
15 years, which was, in part, due to both
educational and regulatory measures. A
similar concerted approach, involving
prescribers, policy makers, and patients, is
urgently required to tackle our unenviably
high rates of fusidic acid resistance, and
confront our over prescription of topical
antimicrobial agents.
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Competing interests: Nil
Author information:
Deborah A Williamson, Institute of Environmental Science and Research, Wellington, New
Zealand, and University of Otago, Wellington, New Zealand; Stephen R Ritchie, Faculty of
Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Emma Best,
Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand;
Arlo Upton, LabTests, Mount Wellington, Auckland, New Zealand; Alison Leversha, Faculty
of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Alesha
Smith, School of Pharmacy, University of Otago, New Zealand and bpacnz, Dunedin, New
Zealand; Mark G Thomas, Faculty of Medical and Health Sciences, University of Auckland,
Auckland, New Zealand.
Corresponding author:
Dr Deborah Williamson, Department of Pathology and Molecular Medicine, PO Box 7343,
Wellington South, 6242, New Zealand
109 NZMJ 4 December 2015, Vol 128 No 1426
ISSN 1175-8716 © NZMA
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JD, Jones RN. Fusidic
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Sader HS et al. In vitro
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kom-Smit LW, Nouwen
JL, Verduin CM, Bernsen
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Corrigan MA, Hill AD,
Humphreys H. The role
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ley A. Wound colonization
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22. Williamson DA, Zhang
J, Ritchie SR et al.
Staphylococcus aureus
infections in New Zealand,
2000-2011. Emerg Infect
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23. Williamson DA, Roberts
SA, Ritchie SR et al. Clinical
and molecular epidemiol-
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6NZMJ 4 December 2015, Vol 128 No 1426
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Drug misuse in sport: a New Zealand perspective
Andrew Curtis, David Gerrard, Peter Burt, Hamish Osborne
Drug misuse in sport is an international phenomenon that has not escaped the attention
of health professionals in New Zealand. Young athletes are vulnerable to the use of perfor-
mance-enhancing substances and the increasing use of sports supplements reects a
particularly worrying trend fostered by unscientic endorsements. Drug-Free Sport New
Zealand is the national anti-doping agency responsible for the oversight and education of our
athletes in an environment where sport is an integral part of our culture. Doctors respon-
sible for the care of athletes have an obligation to respect the Code of the World Anti-Doping
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A person needs to understand the nature, purpose and consequences of treatment and
non-treatment in order to give a legally valid agreement to healthcare. However, New Zealand
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Zealand law infers that children under the age of 16 years may give or withhold consent to
healthcare, independent of their parents, so long as they are competent to do so. This article
raises the questions; what is ‘child competence’, why is it so important to acknowledge and
how do healthcare professionals assess for child competence? Unfortunately, there is meagre
research in this area and no clear answers. The assessment, recognition and respect for a
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A bug in the ointment: topical antimicrobial usage and
resistance in New Zealand
Deborah A Williamson, Stephen R Ritchie, Emma Best, Arlo Upton, Alison Leversha,
Alesha Smith, Mark G Thomas
New Zealand has extremely high rates of bacterial resistance to topical antibiotics such as
Bactroban and Foban. This is because we use a lot of these antibiotics. In this article, we look
at who gets prescribed topical antibiotics in NZ, and suggest some ways in wihch we might
control and reduce rates of resistance.
Reproduced with permission of the copyright owner. Further reproduction prohibited without
... Since the early 2000s, New Zealand has experienced high prescribing rates of the topical antibiotic fusidic acid; rates of dispensing are highest for preschool children, followed by those age 75+ and 5-14 years. Dispensing is also highest in Pacific Island and Māori ethnicities [7,8]. Following the increase in prescribing, a subsequent rise in fusidic acid resistant S. aureus isolates has been reported; resistance is now demonstrated in 28% of NZ S. aureus isolates [9]. ...
... This demonstrated "a tendency towards somewhat lower efficacy in [hydrogen peroxide] compared to [fusidic acid]" with no significant difference between the groups [13]. Since that time, antimicrobial resistance patterns to fusidic acid have changed within NZ [7,8]. and potentially within other countries where it is used topically or systemically. ...
Full-text available
Background Impetigo is a common and contagious bacterial skin infection, affecting children worldwide, but it is particularly prevalent in socioeconomically disadvantaged communities. In New Zealand, widespread prescribing of the topical antibiotic fusidic acid had led to an increase in antimicrobial resistance of Staphylococcus aureus. Alternative treatments are urgently being sought, and as impetigo is a superficial infection, it has been suggested that topical antiseptics such as hydrogen peroxide or simple wound care alone may treat impetigo while avoiding the risk of increased antimicrobial resistance. Methods This protocol for a non-inferiority, single-blind randomised controlled trial compares topical fusidic acid with topical hydrogen peroxide and with simple wound care in the treatment of childhood impetigo. Participants are randomised to one of the three treatments for 5 days. The primary outcome is clinical improvement assessed through paired photographs analysed by graders blinded to treatment arm. The trial is based in school health clinics in an urban centre in New Zealand. Comparison of antimicrobial resistance patterns pre- and post-treatment is also performed. Discussion Special note is made of the need to involve the communities most affected by impetigo in the design and implementation of the clinical trial to recruit the children most in need of safe and effective treatments. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) 12616000356460. Registered on March 10, 2016 Protocol amendment number: 05 EB and AL contributed equally as senior authors.
... The respondents in the current study might have reported the use of topical antimicrobials for eye and ear ailments, leading to deviation from the guidelines. The excessive use of topical antimicrobials also serves as a key driver for emergence of AMR in S. aureus isolates [27]. The guidelines might vary based on the resistance patterns observed at various geographical locations; however, the findings of the current study warrant the necessity of formulation and strict implementation of guidelines on antimicrobial usage in India. ...
Full-text available
The indiscriminate usage and overuse of antimicrobials in pets or companion animals are underlying causes of antimicrobial resistance (AMR). Despite the multi-faceted global challenge presented by antimicrobial resistance, very few studies have appraised pet practitioners’ factors, such as written policy on antimicrobials, dose rate prescribed, use of critically important antimicrobials, and antimicrobial prescription in clean surgical procedures, which can contribute to AMR. In the present study, an online cross-sectional survey among randomly selected pet practitioners (n = 104) of various Indian provinces and union territories was conducted using a questionnaire comprising 33 closed-ended questions on different parameters, viz., the dosage regimen and level of compliance towards guidelines of the World Health Organization (WHO), other relevant veterinary associations, and their opinion while prescribing antimicrobials. Almost every practitioner of the 104 respondents had revealed the difficulties with owner compliance; i.e., incomplete course of the antibiotics, inappropriate follow-ups, and improper care of the sick animals. The majority of practitioners (95%) reported self-prescription of antimicrobials by the owner before presenting the pet(s) to the veterinary clinic, whereas more than half of the respondents (64%) revealed unavailability of antibiogram facilities. Furthermore, a large number (76%) of practitioners stated empirical treatment based on their experience as the main criteria for antimicrobial choice in the absence of timely results from the laboratory. Although non-necessitated use of antimicrobials in clean surgical procedures has been claimed, surprisingly, the majority of pet practitioners (97%) reported their use to reduce the post-operative complications. The use of the highest priority, critically important antimicrobials (HPCIA) listed by the WHO for humans, particularly quinolones and third-generation cephalosporin, also has been reported for different infections. The treatment durations were nearly as per the recommended guidelines issued by the Danish Small Animal Veterinary Association (DSAVA) for different ailments. Analysis using chi-square tests exhibited a significant correlation between less experienced veterinarians (less than 5 years) and prescription of antimicrobials restricted for critically important infections in human medicine. However, there seems to be no association between the experience of the practitioner and the further studied parameters, namely, antimicrobial regimen prescription, weighing the animals before prescription, dose rate calculation, and antimicrobial selection and use after clean surgical operations. The findings suggest periodic awareness campaigns among practitioners regarding the implementation of the official guidelines, the need for systematic surveillance of AMR, awareness among pet owners about antimicrobial resistance, and the importance of rational use of antimicrobials on their pets.
... More detailed studies to characterize the wound healing efficacy and antimicrobial activity of Tri-Solfen ® treatment following disbudding are warranted, particularly if it can be shown that Tri-Solfen ® treatment can reduce the incidence of wound infections similarly or with greater efficacy than the prophylactic use of topical antimicrobial sprays. This has potential beneficial effects to reduce the need for antibiotic use both for prophylaxis and/or to treat wound infections, the latter antibiotic treatments contributing to the emergence of antimicrobial resistance [65]. ...
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Tri-Solfen® is a combination topical anaesthetic and antiseptic solution containing lidocaine, bupivacaine, adrenaline and cetrimide. Applied to wounds, it is reported to reduce the pain experienced by calves following thermocautery disbudding. While lidocaine and bupivacaine are widely used in medicine, conflicting data exist on the impact of these compounds when applied directly to the surgical wound. To investigate the safety of Tri-Solfen® applied to thermocautery disbudding wounds of calves, experiments were performed to measure (i) the safety of Tri-Solfen® (including in overdose situations); and (ii) the impact of Tri-Solfen® application at recommended doses on disbudding wound healing under field conditions. Haematological, biochemical and urinalysis parameters did not show clinically significant differences between placebo and Tri-Solfen® groups (1×, 3× and 5× dose). No adverse health impacts were reported. Histopathological analysis of wounds noted a reduction in bacterial colonies in Tri-Solfen®-treated wounds. Under field conditions, no negative impacts on wound healing were noted. Conversely, there was reduced incidence of abnormal wounds, with an associated trend toward improved average daily gain at days 11–12 in Tri-Solfen®-treated animals. These data are considered to support the safety of topical anaesthesia, as formulated in Tri-Solfen®, to the thermocautery disbudding wound in calves.
... Of note, NZ NICU isolates were commonly resistant to fusidic acid, mediated by plasmid-borne fusB. Fusidic acid is used extensively in NZ (13), and consequently, NZ has one of the highest rates of fusidic acid resistance among S. aureus bacteria in the developed world (14). Under selection pressure from fusidic acid, dominant clones of ST1 methicillin-susceptible S. aureus and ST5 MRSA have emerged in the NZ setting (14,15). ...
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Coagulase-negative staphylococci (CoNS) such as Staphylococcus capitis, are major causes of bloodstream infections in neonatal intensive care units (NICUs). Recently a distinct clone of S. capitis (designated S. capitis NRCS-A) has emerged as an important pathogen in NICUs internationally. Here, 122 S. capitis isolates from New Zealand (NZ) underwent whole genome sequencing (WGS), and these data were supplemented with publicly available S. capitis sequence reads. Phylogenetic and comparative genomic analyses were performed, as were phenotypic assessments of antimicrobial resistance, biofilm formation and plasmid segregational stability on representative isolates. A distinct lineage of S. capitis was identified in NZ, associated with neonates and the NICU environment. Isolates from this lineage produced increased levels of biofilm, displayed higher levels of tolerance to chlorhexidine, and were multidrug-resistant. Although similar to globally circulating NICU-associated S. capitis at a core genome level, NZ NICU S. capitis isolates carried a novel, stably maintained multidrug-resistant plasmid that was not present in non-NICU isolates. Neonatal blood culture isolates were indistinguishable to environmental S. capitis isolates found on fomites such as stethoscopes and neonatal incubators, but were generally distinct from those isolates carried by NICU staff. This work implicates the NICU environment as a potential reservoir for neonatal sepsis caused by S. capitis, and highlights the capacity of genomics-based tracking and surveillance to inform future hospital infection control practices aimed at containing the spread of this important neonatal pathogen.
Background: In canine otitis externa (OE), biofilm-producing bacteria are frequently present but biofilm may be underdiagnosed clinically. Hypothesis/objectives: The study aimed to investigate an association between clinical and cytological findings with bacteriological data from dogs with OE, to establish, through Environmental Scanning Electron Microscope (ESEM) examination, whether the presence of biofilm in vivo can be predicted and to evaluate the impact of biofilm on antimicrobial susceptibility tests. Materials and methods: Fifty-six dogs showing clinical signs of OE were enrolled. One cotton swab each was collected for ESEM, bacterial culture and susceptibility testing and for cytology. Staphylococcus pseudintermedius (n = 42, 48.8%) and Pseudomonas aeruginosa (n = 26, 30.2%) were tested for their ability to form biofilm. Minimum Inhibitory Concentrations (MIC), Minimal Biofilm Inhibitory Concentrations (MBIC) and Minimal Biofilm Eradication Concentrations (MBEC) towards enrofloxacin, gentamicin, polymyxin B and rifampicin were determined. Results: Pseudomonas aeruginosa was positively associated with the biofilm clinical evaluation (p < 0.01) and neutrophils (p < 0.05), nuclear streaks (p < 0.01) and rods bacteria (p < 0.01) on cytology. S. pseudintermedius was associated with a low presence of neutrophils. There was a statistical correlation between clinical and cytological biofilm presence (p ≤ 0.01), but none with the biofilm production assay nor ESEM biofilm detection. No differences were found comparing the results of MIC and MBIC. MBEC results showed higher values than MIC and MBIC for all antimicrobials tested (p ≤ 0.001). Conclusions and clinical relevance: Biofilm presence in OE was often underdiagnosed. Even if there is no specific clinical or cytological pattern related to biofilm, its presence should always be suspected.
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Background Impetigo is a common and contagious bacterial skin infection, affecting children worldwide but it is particularly prevalent in deprived communities. In New Zealand widespread prescribing of the topical antibiotic fusidic acid had led to an increase in antimicrobial resistance of Staphylococcus aureus . Alternative treatments are urgently being sought and as impetigo is a superficial infection, it has been suggested that topical antiseptics such as hydrogen peroxide or simple wound care alone may treat impetigo while avoiding the risk of increased antimicrobial resistance.Methods This protocol for a non-inferiority, single-blind randomised controlled trial compares topical fusidic acid with topical hydrogen peroxide and with simple wound care in the treatment of childhood impetigo. Participants are randomised to one of the three treatments for five days and the primary outcome is clinical improvement. This is assessed through paired photographs analysed by graders blinded to treatment arm. The trial is based in school health clinics in an urban centre in New Zealand. Comparison of antimicrobial resistance patterns pre- and post-treatment is also performed.DiscussionSpecial note is made of the need to involve the communities most affected by impetigo in the design and implementation of the clinical trial in order to recruit the children most in need of safe and effective treatments. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR) 12616000356460
This chapter aims at describing the caesarean section (C-section) in cows and at discussing the different approaches for complicated and non-complicated surgeries. The C-section is a surgical procedure that allows the foetal extraction when it is contraindicated or it is not possible to use vaginal delivery. In addition to the elective surgery due to predictable dystocia, the C-section is considered as an emergency procedure. Its ultimate goal is to ensure the life and the health of both the dam and the offspring. Several factors mainly related to the dam, foetus, surgical procedures and farm affect the decision to perform the C-section and the respective surgical approach. One of the nine possible surgical approaches is selected according to the obstetrical evaluation. For weak or depressed dams, recumbency is recommended. The preoperative care can include the administration of sedative, analgesic, antimicrobial and uterine relaxant drugs. Line block, paravertebral or inverted-L anaesthesia can be obtained by the perineural infiltration of procaine hydrochloride 2–4%. Usually, an incision between 30 and 40 cm of length is enough to perform the laparotomy and uterine incision for non-large dams. The adequate exteriorization of the uterus is crucial to avoid contamination of the peritoneal cavity and uterine adhesions. These adverse effects have a significant impact on the dam’s viability and fertility. A pattern suture of the uterus using the Utrecht method also prevents uterine adhesions. After laparotomy closure, the postoperative care should be established, and the cow re-evaluated within the next 24–48 hours.
Background Australian residential aged care facilities (RACFs) are encouraged to participate in an annual Aged Care National Antimicrobial Prescribing Survey. This data source was analysed to describe patterns of topical antimicrobial prescribing and thereby provide insight into antimicrobial stewardship (AMS) changes that might be required. Methods 2018 and 2019 survey data was analysed. Results The overall prevalence of the 52,431 audited residents (629 facilities) who were prescribed one or more topical antimicrobials was 2.9%. Of all prescribed antimicrobials (n=4899), 33.0% were for topical application. Most frequently prescribed topical antifungals were clotrimazole (85.3%) and miconazole (9.1%), and antibacterials chloramphenicol (64.1%) and mupirocin (21.8%). Tinea (38.3%) and conjunctivitis (23.8%) were the two most common indications. Topical antimicrobials were sometimes prescribed for prn administration (38.8%) and greater than six months (11.3%). The review or stop date was not always documented (38.7%). Conclusions To reduce the possibility of adverse consequences associated with antimicrobial use, AMS programs in Australian RACFs should at least ensure mupirocin is appropriately used, first line antimicrobial therapy is prescribed for tinea, chloramphenicol is prescribed for conjunctivitis only if necessary, prn orders for prescriptions are discouraged and to avoid prolonged duration of prescriptions, review or stop dates are always documented.
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Topical antibiotic preparations, such as fusidic acid (FA) or mupirocin, are used in the prevention and treatment of superficial skin infections caused by staphylococci. Previous genomic epidemiology work has suggested an association between the widespread use of topical antibiotics and the emergence of methicillin resistant Staphylococcus aureus in some settings. In this study, we provide experimental proof of co-selection for multidrug resistance in S. aureus following exposure to FA or mupirocin. Through targeted mutagenesis and phenotypic analyses, we confirmed that fusC carriage confers resistance to FA, and mupA carriage confers high-level resistance to mupirocin in multiple S. aureus genetic backgrounds. In vitro experiments demonstrated that carriage of fusC and mupA confer a competitive advantage in the presence of sub-inhibitory concentrations of FA and mupirocin, respectively. Further, we used a porcine skin colonisation model to show that clinically relevant concentrations of topical antibiotics can co-select for presence of unrelated antimicrobial resistance determinants, such as mecA , blaZ , and qacA , in fusC or mupA harbouring S. aureus . These findings provide valuable insights on the role of acquired FA or mupirocin resistance in co-selecting for broader antibiotic resistance in S. aureus , prompting greater need for judicious use of topical antibiotics.
Aims To compare wound healing 7 days after cautery disbudding of dairy calves treated immediately after disbudding with a traditional antimicrobial spray (OXY) or with a topical anaesthetic gel containing cetrimide, adrenaline and two local anaesthetics, lignocaine and bupivacaine (TA). Method Eighty-one female dairy calves between 6–8 weeks of age were disbudded using a standard cautery disbudding protocol (sedation, cornual block and analgesia), with complete removal of the horn bud. After disbudding, the wound on the right and left horn buds within each animal were randomly allocated to receive either OXY or TA. One week after disbudding, wounds were visually assessed for presence of exudate, necrotic tissue, crust or granulation tissue which were each assigned a grade from 1–3, where 1= no evidence, 2= moderate presence; and 3 =marked presence. Results At 7 days after disbudding, the prevalence of wounds with exudate or necrotic tissue was very low, and independent of treatment. The odds of a disbudding wound treated with TA being scored as having granulation tissue and was 5.2 (95% CI = 1.72–15.7) times that of a wound treated with OXY. Conversely, the odds of a wounds treated with TA being scored as having crusts was 0.18 (95% CI = 0.06–0.57) that of a wound treated with OXY . No sign of infection was seen in any calves. Conclusion and clinical relevance The greater prevalence of granulation tissue and reduction in crusting in disbudding wounds treated with topical anaesthetic gel compared to those treated with the antimicrobial spray suggests that use of the topical anaesthetic gel may speed wound healing compared to using antimicrobial spray. This should be further tested in a larger study undertaken over a longer period.
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