There has been external criticism of the compliance of military health personnel with internationally agreed principles in military medical ethics (MME). In response, a number of authors have called for clarity on the principles and topics within the domain of MME. This complements an increased acknowledgment of the need for education in MME for military health personnel. Our paper utilizes bibliometric techniques to identify key themes in MME to inform the development of a curriculum for this subject.We designed a search strategy to find publications over the period January 1, 2000-December 31, 2020 in the domain of MME from the three databases, PubMed, Web of Science, and Scopus, using the search string  AND military AND . We obtained a total of 1,115 publications after duplication removal. After exclusion based on topic, year, and study design, we analyzed a total of 633 publications using Scopus’s embedded analysis tool and the software VOSViewer. We generated a co-occurrence word map from the abstracts of each of the publications. We deduced themes of MME based on the clusters shown in the word map, and we categorized each publication into one of these themes to analyze the change of themes over time.We observed a 10-fold increase in annual publications on MME between 2000 and 2020. The majority of papers were written by U.S. (72%) and UK (13%) authors, although a total of 15 countries were represented. After using VOSViewer to identify co-occurring keywords in titles and abstracts from these publications, nine themes were identified: biomedical research, care to detained populations, disaster/triage, mental health, patient-focused foundations, technology, dual loyalty, education/training, and frameworks. The relative proportion of each of these themes changed over the study period, with mental health being dominant by the end.This study has identified key themes that might inform the development of a curriculum for teaching MME. It is noticeable that the majority of themes cover MME from the perspective of professional practice on military operations; noting, the research and technology themes also pertain to the generation of knowledge for military operations. There were a limited number of publications covering practice in the non-deployed or garrison settings, and these were codified under the themes of “framework” and “dual loyalty”. The results are skewed toward English-speaking countries and exclude non-academic publications. Further work will search for other open-source information and non-English publications. To our knowledge, this exploratory bibliometric analysis on MME in the academic literature is the first of its kind. This article has demonstrated the use of bibliometric techniques to evaluate the evolution of knowledge in MME, including the identification of key themes. These will be used to support further work to develop a curriculum for the teaching of MME to military medical audiences. Later in 2015, the International Committee of the Red Cross published a consensus document in concert with the World Medical Association, the International Committee of Military Medicine, the International Council of Nurses, and the International Pharmaceutical Federation entitled “Ethical Principles of Health Care in times of Armed Conflict and other Emergencies”. The first principle of the document states “ethical principles of health care do not change in times of armed conflict and other emergencies and are the same as the ethical principles of health care in times of peace.” The document also asserts the principle that “the primary task of health care personnel is to preserve human physical and mental health and to alleviate suffering.”5The past two decades of conflict, especially in Iraq and Afghanistan, have led to public debate about the ethical professional practice by members of military health services.6 This ethics education is vital to ensure that military healthcare providers act appropriately when discharging their dual professional obligations, both medical and military. A more thorough understanding of the moral challenges and ethical dilemmas encountered in military service will improve service members’ ability to identify and address ethical concerns in practice. Improving this ability became a priority for U.S. and UK Militaries following widespread attention and concern over violations of human rights of detainees in the early 2000s. However, as warfare has become more congested and unconventional in the subsequent 20 years, ethical dilemmas within MME have broadened, become more complex, and have received greater research interest. In response, in 2020, the U.S. DoD published an instruction outlining a code of medical ethics in its military health system that is now driving an educational program led by the Defense Medical Ethics Centre at the Uniformed Services University of the Health Sciences.7 Initiatives like this one should be underpinned by an evidence-based curriculum for teaching MME to military health professionals that establishes the baseline knowledge of MME and issues that might arise while in practice. To ensure the broad and relevant applicability of MME education, the profession of military medicine will benefit from a comprehensive overview of the ethical dilemmas arising in military health practice over the past 20 years. The purpose of this exploratory study, using bibliometric techniques, was to determine the MME topics and themes that have been covered in the academic literature in order to inform the development of a curriculum for teaching MME.Although these principles are a step forward, they still need to be adapted into a military training context so that uniformed health care providers are educated in the ethical aspects of their role in order that they comply with International Humanitarian Law and the ethical standards set by their professional regulatin g bodies. Withnall and Brockie have proposed that education in military ethics should be an operational priority to all uniformed health professionals.8 A further application of bibliometric techniques to the text within publications is called text mining and is used to analyze unstructured data like text in abstracts and draw semantic relationships between the text to better classify themes within a body of literature.9 A bibliometric approach was chosen for this study because of the objectivity it provides compared to qualitative methodologies like phenomenology or grounded theory. Thomas et al. recommend a logical, objective component of the content creation within curriculum development, especially when there is the potential for disagreement between professionals and/or practitioners.10 Because debated opinions are the essence of ethical dilemmas and are often the topic of MME publications, this study utilizes mostly quantitative bibliometric approach to capture relevant debates over the past 20 years, which are essential content for military medical practitioners.Bibliometric analysis is a technique that quantifies the bibliographic data  of a collection of publications and further draws relationships between these publications if they exist.This study sought to identify all academic papers on the topic of MME published between January 1, 2000 and December 31, 2020 and then categorize them by date of publication, country of origin, and academic theme.Three academic literature databases were searched: PubMed by US National Library of Medicine, Web of Science (WoS) by Clarivate Analytics, and Scopus by Elsevier. We used the search string,  AND military AND  against titles, keywords, and abstracts. We found 2029 publications, with 530 from PubMed, 511 from WoS, and 989 from Scopus. Of note, we collected 53 publications that were non-English in origin but had translated titles and usually translated abstracts. This finding aligns with the fact that these databases predominantly collate English language publications.11: (1) publication subject must be relevant to the years 2000-2020, (2) publication must be relevant to MME, specifically referring to a medical ethics topic concerning the military (as opposed to just providing the military as an example), (3) publication must focus on ethical implications of issues within military medicine . M.B. informed the database selection and inclusion criteria, and Z.B. performed all collections of publications and inclusion evaluation. Following this exclusion process, a total of 666 publications met the criteria, of which 37 were non-English in origin but had abstracts and titles in English. After removing duplicates based on title and author pairings using the Excel add-in Ablebits (Version 2021.1.2588 by 4Bits Ltd.), we reviewed the remaining 1,115 publications by title and abstract against the following inclusion criteria using Rayyan literature review organizer (Qatar Computing Research Institute)For the bibliometric analysis, we first consolidated all results into Scopus to aggregate data on affiliations and journals. We did this by manually searching Scopus for individual articles that were found by PubMed or WoS but not Scopus in the initial search. We could not find 33 of the publications on Scopus, so we conducted all analyses on just 633 publications rather than the full 666, losing primarily low relevance publications. The tools within Scopus allowed for data extraction of author information, affiliation information (both institution and country), publication dates, and publication journal.12 to visualize these data, and we used the bibliometric software tool VOSViewer (Version 1.6.16 by the Centre for Science and Technology Studies at Leiden University)13 to visualize the text mining performed on the abstracts of the included publications. We uploaded the Scopus publication list into VOSViewer and performed a co-occurrence analysis on the text within the abstracts of all 633 publications, determining which words occurred most frequently across all papers. After text mining the abstracts, a total of 432 words were used at least 15 times throughout the text. To determine the most relevant words to include in the co-occurrence analysis, we first eliminated common verbs and nouns and then terms that are common to all academic publications and terms pertaining to demographics, occupations, or locations, reducing the number of words to 91. Finally, we conducted an internal consensus-building process, with the goal of narrowing the range of words to those whose presence could not be explained by anything except relevance to the topic of MME. This process used a survey that asked the authors of this article to include or exclude the remaining terms. Terms were then included if three or more individuals chose to include the term. We proceeded to the construction of themes based on a final list of 50 words. Z.B. performed data visualization in Tableau and VOSViewer. P.M. and M.M. were part of the process to select terms for inclusion in the VOSViewer map, and they both contributed significantly to the writing and revision of the introduction and discussion.We then utilized Tableau (Version 2020.4)14 The relatedness algorithm takes into account how many times words are used within the same abstract, in addition to how closely these words are used together within that abstract. The higher the relatedness between two terms, the smaller the distance will be between those two terms on the co-occurrence map. Therefore, the repetition of the above process for every word leads to spatial cluster formation as seen in The co-occurrence word map , ResultsThe most prominent trend that arose in the literature review was the increase in publications on MME from 4 or 5 per year to 55+ from 2017 onwards. Although there is a long-term upward trend of publications, significant spikes have occurred from 2005 to 2008 (+220%) and from 2012 to 2018 (+280%), with a small dip from 2009 to 2011, where the number of publications fluctuated up and down.From the 633 collected publications, we extracted aggregate information on authors, affiliations, and journal titles. These publications represented a total of 159 authors from 15 different countries. A rank order of the most prevalent authors, countries, affiliations, and journals is shown in We observed that majority of affiliations were civilian as opposed to military. 67% of the affiliations were civilian universities, hospitals, or other institutions. Furthermore, of the 209 military-affiliated publications, nearly 85% were from the USA.14 VOSViewer determines the spatial distance (mapping) and color-coding (clustering) of each node using a unified approach of related formulas.This section combines the results of the thematic analysis with the rise in publications within MME to demonstrate the change in themes from 2000 to 2020. We used VOSViewer to generate the cluster co-occurrence word map, shown in From this cluster analysis, we created a hierarchy of the words to elucidate themes from the map itself. We used the identified clusters as reference guides for forming themes, although the chosen themes overlap the colored clusters in some areas. By starting with the clearly differentiated edges of the word map, we worked toward the center of the map to create the following themes: biomedical research (green), care to detained populations (C2DP) (yellow), disaster/triage (red), mental health (blue), patient-focused foundations (PFF) (purple), technology (brown), dual loyalty, education/training, and frameworks. The final three themes listed are not listed by color because they are not differentiable by their color in the word map. Instead, those three themes arose from the remaining publications after we had classified each publication into one of the six themes that are clearly identified by color in To complement and build upon this thematic identification, we classified each publication into one of the nine themes drawn from The theme identification and subsequent publication classification revealed a sharp increase in publications concerning Mental Health starting in 2014, alongside smaller, but steady, increases in technology, biomedical research, and PFF MME publications over the past 20 years. There has been a consistent number of training, dual loyalty, and framework publications since 2006. Finally, there have been two periods of time for increases in C2DP publications, 2005-2009 and 2013-2018.This discussion section includes an examination of the suitability and role of methodology for curriculum development, followed by an analysis of the findings in 10 A key component of the needs assessment is obtaining information on needs, which can be done primarily in three ways: a review of available knowledge, use of experts in multi-stakeholder consultation and consensus-building, and the collection of new information.15 In the review of available knowledge, it is necessary to codify the current state of knowledge through an analysis of the published literature. Bibliometrics has become an increasingly important tool that can summarize large volumes of academic literature to provide an overview of the state of knowledge in a particular field.16 This article presents the first bibliometric analysis on the subject of MMEs in academic publications, which functions as a tool for problem identification and a review of available knowledge. By characterizing MME into a collection of themes, this study defines the themes that should be contained within a curriculum for teaching MME, which is a key question in problem identification. This defined scope, along with the typified literature, will provide an underlying structure and the content with which an expert panel can build consensus around MME dilemmas.According to Thomas et al., the first stage of curriculum development in medical education is problem identification and assessment of the learners’ needs against measures of the current state of knowledge in the field.17 especially as military personnel may be constrained by military law from publicly criticizing the armed forces.18 Looking at the country affiliation of the MME publications, the majority have originated from the USA and the UK. This prominence could reflect the relative scale of military commitments to combat operations for these two countries, but because only English language databases and English search terms were used, the significant bias against countries with native languages other than English is the explanatory factor most responsible.When looking at the pool of available knowledge in the academic literature, This study uses VOSViewer as a tool to identify and illustrate key terminology and their relationship across the literature as shown in 19–22 that often have opposing priorities of national and personal security. The disaster/triage theme is a prime example of opposing priorities for access to clinical care imposed by dual loyalties because warfare complicates the objectivity of standard casualty care by introducing enemies, allies, prisoners, non-combatants, non-state actors, etc.24 Many of the PFF publications focused on the limits of confidentiality in a hierarchical military setting25–29 and justice in medical treatment with respect to gender and sex.30–33 Although there was some discussion of patient autonomy and informed consent regarding soldiers and vaccinations34 within the PFF publications, the majority of publications concerning informed consent fell under the biomedical research theme.This thematic categorization also collates publications ready for a more detailed literature review of each theme. The themes “dual loyalty” and “PFF” are the most enduring and should provide the underlying principles in an MME curriculum. The dual loyalty publications constitute the heart of the competing obligations of two professions35–38 and physical39–41 enhancement and the compliance of this research with military subjects with ethical practice and regulations.42–45 Although not all military health professionals will conduct biomedical research, the basic principles should be taught to all healthcare providers to increase internal accountability among those conducting military biomedical research. We separated this theme from the theme of “technology” in order to differentiate between biomedical research and the ethical implications of the use of existing or new technologies for military purposes, such as novel uses of electromagnetic radiation46 or biological agents48 as bioweapons or drone technology used for medical surveillance or telehealth.49–51The biomedical research theme covers both the topics for biomedical research in military research and development programs, like neurological52 to the U.S. Government to ensure necessary protections to detainees, the mistreatment of detainees following Iraq and Afghanistan led to the rapid increase in “C2DP” publications from 2005 to 2009, specifically with respect to prisoners held at Abu Ghraib and Guantanamo Bay. In 2014, a further increase of publications followed U.S. Congressional Research Reports on the same issue of detainee treatment.53 The combination of this surge of publications in this theme and the parallel increase in publications from civilian institutions further demonstrates the desire for civilian oversight of the military. The heaviest criticism and subsequent publications have explored physician responsibility to report mistreatment55 and handling of life-sustaining treatments, such as “force-feeding” those under hunger strikes.57Despite Singh’s 2003 advice59; however, the rapid increase in 2012 probably reflects an increase in the use of the term “moral injury” as an explanation for the mental health consequences of undertaking or witnessing acts that conflict with an individual’s ethical or moral beliefs.60–62 Aligning with Farnsworth and Capone, we anticipate that preparatory training and education in the types of scenarios that may lead to moral injury could provide some preventative protection.64 In regard to the Training theme, a consistently low number of publications are indicative of a lack of attention to proper curriculum development for MME education and training. Although the U.S. DoD has formalized a Defense Medical Ethics Center and developed a code of MME,7 there has been less done to translate the code into an educational MME curriculum or appropriate platform, further highlighting the value of this present study and future work.The mental health theme also increased following Iraq and Afghanistan as a new generation of soldiers battled PTSDIn addition to developing these themes, we also noticed that there seem to be gaps in the literature. There were a limited number of publications covering practice in the non-deployed or garrison settings or specific MME dilemmas from the perspectives of nursing or allied health professions. The deployed military setting has garnered significant public attention and subsequent criticism, alongside increased publication rates. This realization might suggest that military medical professionals would benefit from greater self-interest in MME research areas that do not draw as much public attention, like a non-deployed setting or role-specific dilemmas.This study has successfully identified key themes within the MME academic literature, and it has also demonstrated a repeatable methodology with which to derive themes from a large body of literature. Given the limitations outlined below, we will revisit this methodology with various other sources to get a more complete picture of MME. The three significant limitations were the lack of other languages besides English, the lack of gray literature, and finally, the lack of analysis into individual themes.66 We plan to employ a similar method to identify relevant open-source publications using an internet search engine and to search non-English language databases using researchers with appropriate language skills. After collating these additional papers, the process of thematic categorization will be repeated to determine if further themes or perspectives can be identified from authors from other countries or writing in other languages. This process will form the basis of further work for curriculum development of educational packages in MME. In addition to broader resources, the subsequent curriculum development would benefit from a deeper exploration of each theme that we derived from the VOSViewer map. Each of the 633 publications has already been sorted into respective themes to create We conducted this bibliometric analysis on academic publications in the three databases of PubMed, WoS, and Scopus with titles and abstracts in English. Our choice of databases excluded non-academic publications, particularly policy documents, although these might have been the subject of analysis of the academic papers identified. Furthermore, these databases have been shown to miss non-English origin publications in comparison to a broader search engine like Google Scholar.The topic of MME has become more prominent in the academic literature over the first 20 years of the 21st century. This has been reflected by the call for specific education in this field by a number of authors. This article has demonstrated the use of bibliometric techniques to evaluate the evolution of knowledge in MME, including the identification of nine key themes: biomedical research, C2DP, disaster/triage, mental health, PFF, technology, dual loyalty, education/training, and frameworks. This analysis is biased toward English language academic publications, reducing the influence of non-English language authors and gray literature. The themes are weighted toward deployed healthcare/operational issues with a relative under-representation of garrison healthcare and non-physician professions. It is intended to extend the methodology to identify and collate additional literature resources, including gray literature and other languages. It is also intended to deepen the analysis by conducting literature reviews of publications within each theme. This information will be utilized to inform a board of subject matter experts to build consensus on ethical issues in each of these themes. This work will form the foundations of a curriculum for MME, pending the evaluation of education techniques for the implementation of the curriculum.


To assess the prevalence of antibiotic-resistant gram-negative bacteria (R-GNB) among patients without recent hospitalization and to examine the influence of outpatient antibiotic exposure on the risk of acquiring R-GNB in this population.2-year retrospective cohort study.Regional Veterans Affairs healthcare system.Outpatients at 13 community-based clinics.We examined the rate of acquisition of R-GNB within 90 days following an outpatient visit from 2018 to 2019. We used clinical and administrative databases to determine and summarize prescriptions for systemic antibiotics, associated infectious diagnoses, and subsequent R-GNB acquisition among patients without recent hospitalizations. We also calculated the odds ratio of R-GNB acquisition following antibiotic exposure.During the 2-year study period, 7,215 patients had outpatient visits with microbiological cultures obtained within 90 days. Of these patients, 206 (2.9%) acquired an R-GNB. Among patients receiving antibiotics at the visit, 4.6% acquired a R-GNB compared to 2.7% among patients who did not receive antibiotics, yielding an unadjusted odds ratio of 1.75  for a R-GNB following an outpatient visit with versus without an antibiotic exposure. Regardless of R-GNB occurrence, >50% of antibiotic prescriptions were issued at visits without an infectious disease diagnosis or issued without documentation of an in-person or telehealth clinical encounter.Although the rate of R-GNBs was low (2.9%), the 1.75-fold increased odds of acquiring a R-GNB following an outpatient antibiotic highlights the importance of antimicrobial stewardship efforts in outpatient settings. Specific opportunities include reducing antibiotics prescribed without an infectious diagnosis or a clinical visit. From 2010 to 2011, ∼13% of outpatient visits resulted in an antibiotic prescription, of which an estimated 30% were likely inappropriate. Injudicious prescriptions of antibiotics in outpatient settings are associated with billion-dollar healthcare expenditures and contribute to the public health threat of antibiotic-resistant bacteria, including an array of gram-negative pathogens. Recent data indicate that an increasing proportion of hospitalizations for infections caused by antibiotic-resistant gram-negative bacteria (R-GNB), particularly extended-spectrum β-lactamase–producing Enterobacterales (ESBLs), are community associated. These reports indicate a pressing need to better understand risk factors associated with acquisition of R-GNB in community settings.Most patients receive their health care in outpatient settings, culminating in nearly 1 billion office visits annually. Whether improved antibiotic stewardship in the outpatient setting can achieve similar effects has not been firmly established, in part because the contribution of outpatient antibiotic exposure to the risk of acquiring R-GNB is not well characterized. Unlike allergic reactions or other adverse effects that come to clinical attention within hours to days of antibiotic administration, events related to acquisition of antibiotic-resistant bacteria can occur weeks after an antibiotic exposure and, in the case of colonization, may never come to clinical attention. Care received across separate healthcare systems, including hospitals and other outpatient settings can further obscure efforts to quantify the relationship between any given antibiotic exposure and the subsequent acquisition of antibiotic-resistant bacteria.Hospital settings have made strides in reducing the risk of acquisition, transmission, and infection due to R-GNB through the advancement of antibiotic stewardship among inpatients as well as other infection control and prevention measures.The Veterans Health Administration (VHA) uses a common electronic medical record to document and support comprehensive care for patients across the continuum of healthcare, which include hospitals, nursing homes, emergency departments, as well as clinics for primary, urgent, and specialty care. Furthermore, pharmacy and laboratory records, including antibiotic prescriptions and results of microbiological cultures, are also fully embedded within the same system. This integrated EMR facilitates assessment of a wide array of factors potentially associated with acquisition of R-GNB. To assess the risk factors related to outpatients acquiring R-GNB, we conducted a retrospective cohort study of veterans who received care at community-based outpatient clinics associated with a large Veterans Affairs medical center (VAMC). The objectives of our study were to assess the incidence of R-GNB among outpatients and to examine risk factors associated with acquisition of R-GNB. The exposure of interest was prescription of antibiotics in the outpatient setting. The Institutional Review Board of the VA Northeast Ohio Healthcare System approved the study protocol.We conducted a retrospective study of patients who received care at any of 13 free-standing community-based outpatient clinics associated with the VA Northeast Ohio Healthcare System (VA NEOHS) between January 1, 2018, and December 31, 2019. We used the VA Informatics and Computing Infrastructure (VINCI) to access the VHA Corporate Data Warehouse (CDW), which contains integrated databases from national clinical and administrative data sets, to identify the study population.In this study, we included patients who had at least 1 outpatient encounter with a community-based primary care provider during the study period with a microbiological culture collected 7–90 days following that encounter. The microbiological cultures were used to assess the outcome of interest, acquisition of R-GNB. The cultures could have been collected in the outpatient setting or within 72 hours of a hospital admission because pathogens identified within this window are considered community acquired. We considered patients who received an antibiotic prescription issued through a primary care provider in the absence of a documented clinical encounter  to have had a “no clinic” outpatient encounter.Pseudomonas aeruginosa, Escherichia coli, Citrobacter koseri, and Klebsiella, Enterobacter, Serratia, Proteus, and Providencia spp. Organisms with antimicrobial susceptibility results other than what is considered the wild type for the species were considered to represent a R-GNB. P. aeruginosa resistance was based on the following agents: fluoroquinolones, cefepime, piperacillin–tazobactam, and imipenem–cilastin. For the remaining GNB, we considered the following 4 phenotypes to indicate resistance: fluoroquinolone resistance; resistance to extended-spectrum cephalosporins ; resistance to β-lactam–β-lactamase inhibitor combinations , and resistance to carbapenems  and Tenth Revision (ICD-10) codes, and common infectious diseases diagnoses and comorbid conditions, from which the Charlson comorbidity index (CCI) was derived. We also assessed encounters in the VA NEOHS in the year prior to the index visit, including antibiotic exposures and the number of primary care visits, outpatient visits with a specialist, emergency room visits, and hospital admissions. Antibiotic prescriptions and infectious disease diagnoses were assessed for each patient’s index visit. Infectious disease diagnoses associated with visits were based on ICD-10 codes and classified into common infectious syndromes, as previously described.The following data were obtained from the CDW and were used to describe the patients at their index visit: age, sex, race, ethnicity and, using t tests or Wilcoxon rank-sum tests to compare continuous variables and χ2 tests to compare categorical variables. We also estimated the odds ratio of R-GNB acquisition for antibiotic exposure relative to no antibiotic exposure at the index visit. To adjust for additional risk factors, we used a multivariable logistic regression including patient characteristics, infectious diseases diagnoses, and recent healthcare utilization. All statistical analyses were performed using R version 4.0.1 software  and implementing functions from the epitab package.The primary outcome was the acquisition of any R-GNB in the 90 days following the index visit. We compared patients with and without acquisition of R-GNB, using independent sample P = .006), more likely to be female , and more likely to be of Black race . We did not detect significant differences in individual chronic conditions or in healthcare exposures prior to the index visit between those with and without R-GNBs detected.During the 2-year study period, 7,215 patients had qualifying visits at 13 outpatient clinic settings. Most patients were older adults (65.5 ± 14.2 years), male (90%), and White (84%). The most common comorbid condition was diabetes mellitus (35%), followed by chronic lung disease (25%). R-GNBs were detected in microbiological cultures of 206 (2.9%) of patients in the 7–90 days following their index visit (Table P = .004). Overall, the most commonly prescribed antibiotics were fluoroquinolones  or a rectal swab (27%) collected prior to a prostate biopsy. Table P = .010) . Even after adjusting for other factors that were significantly associated with R-GNB acquisition , the odds ratio for R-GNB acquisition following a primary care visit with an antibiotic prescription remained statistically significant  was ∼4:1. Third, this retrospective cohort study relied on administrative data, which have inherent limitations, for example, lack of certainty regarding whether or not patients took the antibiotics prescribed. Finally, our approach only accounted for new R-GNB acquisitions among patients via clinical cultures, which may have underestimated the number of individuals colonized with these organisms.Our study has several limitations. First, the work was performed at a single VA healthcare system, which may limit the generalizability of the results. VA healthcare users differ from the general US population in that they are predominantly older, White, non-Latino males with a higher burden of chronic medical conditions.Despite these limitations, the findings presented here shed new light on the risk factors associated with community-acquired R-GNB in the context of a comprehensive healthcare system. Although hospitalizations during the year prior contributed, antibiotics prescribed during the index outpatient visit also contributed. Curtailing unnecessary antibiotic exposure, which includes using narrow-spectrum agents as well as avoiding prescriptions altogether, is the most readily modifiable risk factor that clinicians can use to improve the health and safety of their patients. Our results also suggest 2 specific actions prescribers could take to help improve antibiotic stewardship in the outpatient setting. The first action is to associate diagnostic codes with the clinical encounter that led to an antibiotic prescription. The second action is to avoid prescribing these agents in the absence of a clinical encounter. This recommendation does not preclude the use of telehealth but does call for documentation of the evaluation and clinical decision-making process involved with the antibiotic prescribing event. Given that most healthcare visits take place in outpatient settings, improved efforts to reduce unnecessary antibiotic exposures in that sphere can yield a considerable reduction on the acquisition of R-GNB and potentially enhance the health of a large number of individuals.


Globally, Antibiotic resistance is a major public health concern, with antibiotic use contributing significantly. Targeting informal healthcare providers (IHCPs) is important to achieve universal health coverage and effective antibiotic stewardship in resource-constrained settings. We, therefore, aimed to analyse the internal and external drivers that influence IHCPs’ prescribing behaviour for common illnesses in children under five, with an emphasis on antibiotic use in rural areas of India. A total of 48 IHCPs participated in focus group discussions. Thematic framework analysis with an inductive approach was used, and findings were collated in the theoretical framework based on knowledge, attitude, and practice model which depicted that the decisions made by IHCPs while prescribing antibiotics are complex and influenced by a variety of external and internal drivers. IHCPs’ internal drivers included the misconception that it is impossible to treat a patient without antibiotics and that antibiotics increase the effectiveness of other drugs and cure patients faster in order to retain them. Formal healthcare providers were the IHCPs’ sources of information, which influences their antibiotic prescribing. We found when it comes to seeking healthcare in rural areas, the factors that influence their choice include ‘rapid cure’, ‘cost of treatment’, ‘distance’ and ‘24 h availability’, instead of qualification, which may create pressure for IHCPs to provide a quick fix. Targeted and coordinated efforts at all levels will be needed to change the antibiotic prescribing practices of IHCPs with a focus on behaviour change and to help resolve misconceptions about antibiotics. Antibiotic resistance is a multi-sectoral public health risk on a global scale, posing a threat to patient safety worldwide . BetweenThe Indian government took action in April 2017 to combat antibiotic resistance and enacted the National Action Plan on Antimicrobial Resistance, following the approach taken by the WHO in drafting a global antimicrobial resistance action plan. The National Action Plan has numerous goals, including reducing the number of infections, strengthening surveillance, encouraging research, and improving the judicious use of antibiotics . DespiteIHCPs play important roles in rural healthcare, and their role cannot be overlooked in the effort to achieve Universal Health Coverage (UHC) and designing effective antimicrobial stewardship, especially in resource-limited settings. For them to be more efficiently involved in the provision of healthcare services, it is important to gain an understanding of their knowledge and practice—including how they interpret adequate care and rational treatment. Our aim was, therefore, to analyse the internal and external drivers that influence IHCPs prescribing behaviour for common illnesses in under-five (U-5) children, with an emphasis on antibiotic use, in rural areas of India.Our findings suggest that antibiotic prescribing decisions by IHCPs are complex and influenced by multiple drivers at the knowledge, attitude, and practice level. We present our themes grouped into internal and external drivers below, supported by illustrative quotes.According to our study findings, both internal and external drivers influence IHCPs’ practice, including patient behaviour and demand, availability and access to diagnostic testing, information exchange from formal healthcare providers, and referral facility and sociodemographic characteristics of the IHCPs. In order to give an illustrated overview of the internal and external factors that influence IHCPs prescription behaviours with emphasis on antibiotic prescribing, we compiled our data into a model known as knowledge, attitude, and practices (KAP), proposed by Rodrigues et al. 23]..23].IHCPs with a long history of providing care are well established and hold a decent reputation among members of their communities. There is hardly any rural community without IHCPs. They are among the vital components of the community since they tend to be less professionally distant and more social by being more interactive with the patients, always having an available source of medicine for their patients, and also adding some personal component to their approach to providing healthcare. These IHCPs and their practices are strongly supported by the villagers. Therefore, IHCPs’ are the major source of healthcare and antibiotics for residents of rural areas.Like we are practicing and government try to stop us from practicing. Government officials come to the village. So villagers meet head-on with them. They will not let us stop practicing as long as the government doesn’t appoint good doctors or open a government hospital in the village. Also, said that these people will work for us until and unless the government makes other arrangements’.‘(Focus Group Discussion (FGD-4); Male 4)IHCPs have been perceived as a better choice, as they were believed to accelerate therapeutic interactions. As they were primarily local to the patients, they could be more promptly available 24 h, could work a more flexible schedule, and had a readily available supply of medicines and antibiotics. Treatments were expedited as a result of these situations, so IHCPs were seen as a preferable option. Patients who arrived late at night were given antibiotics without hesitation, believing that they were a vital element of the treatment.Patient came at night and obviously, he cannot go to town at that hour so we give him primary treatment like paracetamol for fever and antibiotics for the night and tell him to go to the paediatrician in the morning’.‘Patients’ paying capacity is taken into consideration by healthcare professionals working in the informal sector, which in turn affects the selection of antibiotics and their doses, resulting in a large number of inadequate doses being administered. IHCPs were supposed to provide more than just good healthcare. Low-income patients benefit from their low-cost therapy and flexible payment alternatives, which reduces their financial burden while enhancing accessibility.We write 3 days antibiotic dose properly. Actually, in rural areas, it should be at least 5–7 days dose. If we prescribe for complete 7 days, he will find it costly and so he will not take the dose’.‘Patients might easily receive credit from IHCPs for consultation fees and prescription medicines. On occasions, they would even take produce in exchange for money. People in rural areas, many of whom are employed seasonally in agriculture and farming, sometimes do not have the money to pay for healthcare. This was a distinct benefit for IHCPs, as their fees were significantly lower than those charged by traditional healthcare providers.It appears that IHCPs believe antibiotics as a mandatory part of the treatment. They regarded antibiotics as vital for primary care because they believed antibiotics could heal the majority of diseases. The most common perception was that antibiotics are not for any specific disease and that it is impossible to treat a patient without antibiotics.Antibiotic is a sure-shot drug. It can cure any disease. Any kind of disease, the patient doesn’t get well without antibiotics. Even if fever is there antibiotic is compulsory, for cough and a cold antibiotic is compulsory, for wounds antibiotic is compulsory, any infection of the body, immunity is enhanced by antibiotics, it is necessary for any disease’.‘Other IHCPs reiterated that antibiotics increase the effectiveness of other drugs if given along with them and enhance the immunity of the body. They also mentioned that antibiotics are already there in the human body:I mean it boosts up the body, other drugs start working in the body. They are not effective if antibiotics aren’t given. If antibiotics are not included in the treatment it takes a very long time to get better and many a time there is no effect at all’.‘Another perception of some IHCPs was that more antibiotics cure faster and if any antibiotic resistance is at all present, at least one of the antibiotics in the combination or one of the antibiotics among the two or three prescribed will work:Knowledge also and they also want fast results. Like they are giving a combination of 2 antibiotics, whether it is needed or not, so accordingly he is adding and giving believing that the patient will get well fast. The patient might not get cured by giving only cefixime, so cloxacillin in combination is given or something else and he thinks that patient will get fine because cases of resistance are also coming as patients are not taking full dose’.‘One more reason for practicing more antibiotic prescribing, as mentioned by one of the IHCP, was to retain the patients. In the opinion of IHCPs, patients wanted the fastest cure possible; otherwise, they would go to other providers; hence, antibiotics were deemed absolutely necessary as part of the treatment plan:Also happens when the provider is having competition and do not want to lose his patients to another provider thinking that if the single antibiotic prescribed did not affect and the patient does not get better soon he will go to another provider and so they prescribe more than one antibiotic’.‘Antibiotics, they reasoned, were necessary for primary care since they could treat the majority of infections. The decision to use an antibiotic is not based on scientific evidence. Antibiotic selection and dose were based on IHCPs’ personal experiences with the effectiveness of various antibiotics for certain illnesses. The ‘hit-and-try’ approach is used to choose antibiotics for a certain disease. Over time, they’ve come to realise which antibiotics to administer for which symptoms and diseases.Prescription of antibiotics, we do it from our experience like if the patient has a fever, in a normal way we give simple medicines many times, the fever didn’t subside then second-time small antibiotic is given, Amoxicillin, MOX syrup with the fever and so we got the result. Madam, we learnt with our experience that in fever if one antibiotic is given with antipyretic then the body will get relief faster. Yes, experience teaches everything, we keep track that this was the condition, and for this condition, this medicine was better’.‘Knowledge of the cause and development of antibiotic resistance varies widely among the IHCPs. Many of the IHCPs did not know about antibiotic resistance. Some of the IHCPs identified incorrect duration and incorrect dose of the drug as causes of occurrence of antibiotic resistance.They get treatment of cough cold in the village for 2 days, but they will take treatment for only 1 day, we explain them properly, that it is very necessary to take antibiotics for 3 days and sometimes for 5 days if needed if you don’t take the complete course resistance will develop and it will stop acting on you’.‘Furthermore, only a small number of IHCPs recognise that antibiotic resistance is a result of incorrect intake and that they themselves may be at fault. They justified this by stating that they do not have a thorough understanding of how and when to administer antibiotics.We are not educated in medicine; it is possible that we could be the reason for the resistance’.‘The study results revealed that there was no knowledge of the different types of common acute illnesses in U-5 children among IHCPs. Their understanding of the causative organism was limited to simple inferences such as that indicated in the following statement:According to my experience, the tiny beings which we can’t see from our naked eyes, they are bacteria. The ones which are tinier than bacteria, they are viruses which are dead when outside and when they reach inside the body they become alive’.‘Formal healthcare providers are the IHCPs’ source of information on the treatment of illnesses which thus influence their antibiotic prescribing. IHCPs gather knowledge by working as assistants under formal healthcare providers in their clinics or pharmacies, while some have also taken one-time certificate courses organised by the government. Most of the practice of the IHCPs is based on the learning gained by studying and following the prescriptions written by formal healthcare providers or by consulting these formal healthcare providers, and in return, when needed, they refer their patients to them.I worked at the medical retail counter for 11 years so I have the knowledge of medicines and from time to time we get training from the civil hospital, welfare society, Pushpa Mission Hospital, etc. Apart from this whenever needed we take advice from child specialists’.‘Madam, this we have learned during ‘Jan sawasthya rakshak’  training. Also, doctors give lectures to us and tell us to come to see patients, make groups of five, and take one group every day. To study what he had diagnosed and written on a treatment pad. You have to stand there and observe’.‘IHCPs who participated in FGDs had varying perspectives on patients’ knowledge of antibiotics; infact, it is possible that some patients have never ever heard of them; hence, there was little evidence of patients demanding antibiotics while sick. However, the majority of patients need rapid cure owing to the insecure nature of their daily wage jobs, and at a reasonable cost, which translates into a shorter course of antibiotic treatment. They relied heavily on IHCPs for healthcare and antibiotics. Additionally, several other IHCPs remarked that there are demanding patients who are difficult to convince, show dissatisfaction when they do not obtain what they desire, and frequently shift to other healthcare providers. As a result, IHCPs’ decisions about whether or not to administer antibiotics are impacted. They feared that if they did not prescribe antibiotics, patients would not recover, and they would lose their patients.In village what happens, labour class are there, they don’t have time, they come in a hurry that they have to go back for their work, for labour work, the kid should be alright instantly; if he doesn’t get relief in next 2 h, they will come to me, we both are from the same village, if I am unable to give relief, they will go to him; if he is not able to provide the relief, they will go to someone else. But the kid should get relief in 1 h. Take treatment here for one day, if it gets alright, then it is ok; otherwise, we have to go to Ujjain or show to the big doctor. In such situations, we are also not able to make a decision that what type of medicine should be given’.‘IHCPs noted that incredibly, some patients were able to name certain antibiotics even though they had no idea how or why they had been provided with these medications/antibiotics. This is because many patients in rural areas have been accustomed to the instant relief of symptoms with antibiotics obtained from a medical shop, without fully comprehending the hazards or uses of these medications. We also discovered that patients put pressure on their doctors to give injectables instead of oral drugs because they believe that injectables work faster.They purchase from medical, by directly saying give us cefixime, give us monoxil, amoxicillin. Just like zandu balm (Ayurvedic ointment for pain relief), the head is aching so give us zandu balm. They take antibiotics like that which they have learned from medical stores. If anybody goes to the store and tell them their symptoms, the medical storekeeper will make a complete dose for them and give and tell them that this is antibiotic, this is for fever, and this is for cough cold, so this is how they learn’.‘We identified key internal and external drivers and interconnection among drivers influencing the prescribing behaviour of IHCPs, with emphasis on antibiotic prescribing for common illnesses in U-5 children in rural areas in central India, in order to guide the implementation of a customised social marketing intervention. The study results also reflect that despite the lack of official recognition, IHCPs are part of wider rural social systems and settings, and their prescription practices are influenced by all of the different parts of this system. A KAP model was used to visualise and summarise these factors in order to better understand the complexities of prescribing behaviour of IHCPs. Such models can help to investigate and determine the healthcare providers’ subjective views or the type of healthcare providers’ related attitudes and knowledge . While oThe National Health Mission, which was implemented in 2005, envisioned the use of accredited social health activists (ASHAs) as the first point of contact for community health-related problems in order to strengthen the existing three-tier rural public health delivery system . The resOur study findings show that prescribing by the IHCPs was influenced by a combination of misperceptions about antibiotics as a medical requirement. This outcome is consistent with previous research indicating that IHCPs believe antibiotics are critical for patient retention and financial stability . IHCPs dOur research team also studied the prescriptions by IHCPs in the same setting in the different studies and reported that 75% of prescriptions by IHCPs contained antibiotics and were prescribed more frequently than any other medicine . HoweverPrevious studies comparing IHCPs to formal health providers have shown that IHCPs’ knowledge and methods differ, with lack of adequate training highlighted as a significant underlying issue . HoweverThe IHCPs were difficult to convince to participate and share details related to their practice, so the first strength of the study is that we were able to conduct these FGDs with this hard-to-reach group. Another strength of our study stems from the depth of our data. It made it possible for us to present our findings in accordance with the KAP model, where it was demonstrated that antibiotic prescribing behaviour is influenced by a plethora of internal and external drivers at all levels of the model. The FGDs provided extensive insights into IHCPs’ prescribing behaviour. Though most of our respondents were male, and this represents the distribution of IHCPs in this setting, we aimed to include participants of both sexes and years of work experience. There is a possibility of information bias; respondents might be influenced to offer an answer that was either right or positive. This is a preliminary study, and our results’ transferability is limited to areas with similar settings. It is vital to note that our study does not include informal pharmacists, which is critical for future studies. Further research is needed involving multiple stakeholders, such as patients and informal pharmacists, to have a deeper knowledge of individual aspects at all levels of the model. This would aid in a more thorough understanding of and response to the factors that drive antibiotic prescriptions, guiding an effective antibiotic stewardship programme.The study was conducted in rural areas in the Ujjain District of Madhya Pradesh state, India. A vast, three-tiered rural public healthcare system exists in India, with the goal of ensuring primary care to all individuals regardless of socioeconomic status . The subThe Ujjain District is located in the Indian state of Madhya Pradesh. It has a population of 1.9 million people, with 61% residing in rural regions . The disA qualitative approach was deemed appropriate to address our study aim. Following a literature search and gathering expert opinions, a discussion topic guide  was deveThe first author (S.K.), experienced in qualitative methods, conducted all the FGDs with the assistance of a research assistant skilled in moderating discussions, between December 2016 and February 2017. At the beginning of the FGD, IHCPs were given different case scenarios; for example, if a parent with a child U-5 years of age visits their clinic and complains about frequent watery stools since last night, how would they treat the child’s illness? What treatment would they prescribe, and why would they that treatment? Then, the facilitator used a topic guide to help participants discuss their treatment experiences. The FGDs were conducted in Hindi in which the participants, as well as the data collectors, were conversant. In total, 5–8 people participated in each FGD. After the seventh FGD, we discovered that no new information had emerged, and the sampling was then closed. One FGD was conducted with a group of female IHCPs; six were conducted with groups of male IHCPs. Audio recordings of the FGDs were performed with the participants’ permission, and each discussion lasted for around 60–90 min. In addition, field notes and reflections were taken during the interviews. A light snack was provided to the attendees following the FGDs. Participants in the study were not given any additional incentives.Transcription was carried out in Hindi, and the content was translated into English by S.K. and research assistants. S.K. and S.A.  analysed FGD transcripts iteratively, using the thematic framework analysis with an inductive approach .BeginninWe identified key drivers under the knowledge, attitude, and practice component of the model, where knowledge to practice was not always unidirectional, and the attitude of the IHCPs often affected their knowledge, as they showed interest in more training, to collect more knowledge, and improve practice. Similarly, the practice also helped to improve their knowledge, as they were untrained in medicine but with experience of working under formal healthcare providers and then with independent practice, they acquired more knowledge. By using a KAP model, we were able to discern the extent of the problem’s complexity and the many implications it has for IHCPs’ decisions and behaviour when it came to prescribing antibiotics. Therefore, these areas can be targeted to successfully improve IHCPs’ prescribing behaviour with emphasis on antibiotics for common illnesses in U-5 children. IHCPs are a vital part of the rural healthcare system. However, they were unable to deliver proper treatment and care due to a lack of training and knowledge. Their treatments were not always consistent with guidelines, and a number of barriers reported in the study prevented them from providing proper treatment. In addition, we found that IHCPs had a limited understanding of antibiotic resistance and the risks of irrational antibiotic use. When establishing a successful antibiotic stewardship strategy, it is critical that regulatory bodies recognise and acknowledge their role in the health system and then lawfully offer different interventions targeting the factors that affect their practices with a combination of regulatory, educational, and behaviour modification interventions. Under the Government of India’s flagship ‘skill development’ programme, planned short-term training and courses to upgrade the skills of IHCPs can focus on improving diagnosis, enhancing IHCPs’ and patients’ understanding of antimicrobial resistance and rational use of antibiotics, and monitoring behavioural changes among these groups, as well as improving the referral of patients from rural areas. In addition, the services provided by IHCPs in rural areas can be supported with incentives. Finally, more study is needed to better understand the opinions and behaviour of the general public and informal pharmacists in order to develop effective intervention strategies that involve all important stakeholders.


IntroductionSurgical site infections (SSIs) are common and carry a significant risk of morbidity and mortality and lead to increased healthcare costs. Perioperative antibiotic prophylaxis decreases the risk of SSIs. There are several guidelines on the use of perioperative antibiotic prophylaxis. The American College of Surgeons (ACS) recommends weight-based antibiotic administration within 60 minutes prior to (two hours for vancomycin/fluoroquinolones) incision and redosing by drug half-life. There are limited data regarding adherence to existing recommendations. Furthermore, there are scarce data on the relationship between adherence to recommendations and the risk of postoperative SSI.ObjectivesIn this study, we aimed to assess the adherence to ACS guidelines for perioperative antimicrobial prophylaxis in the Seattle Children’s Hospital (SCH) National Surgical Quality Improvement Program (NSQIP) pediatric cohort and to determine whether adherence to ACS guidelines is associated with a decreased risk of SSI. the secondary objective was to identify risk factors associated with SSI in our patient population.Materials and methodsWe conducted a secondary analysis of an institutional NSQIP pediatric data cohort between Jan 1, 2012, and Dec 31, 2017. We calculated summary statistics to assess adherence to ACS recommendations and fit a logistic regression model to identify factors associated with the risk of SSI. Patients who did not receive antibiotic prophylaxis were excluded.Results A total of 6,072 surgeries among 5,532 patients met the inclusion criteria. Adherence was achieved for weight-based dosing in 35% of surgeries, administration prior to the incision in 91%, administration within 60 minutes (two hours for vancomycin/fluoroquinolones) in 86%, correct redosing in 97%, and to all recommendations in 29%. There were no significant associations between any adherence metrics and SSI, although confidence intervals were wide for some metrics. Factors associated with SSI when adherence was met included urgent case status, wound class 2 or 4, the American Society of Anesthesiologists (ASA) class 2-5, and surgery duration.ConclusionThere was varying adherence to ACS recommendations on antibiotic prophylaxis in our cohort. More evidence is needed to better understand the effects of adherence to any or all components of the recommendations on SSI. We identified a group of pediatric patients at risk of SSI and a need for further research and targeted interventions. Surgical site infections (SSI) are one of the most common nosocomial infections and account for significant morbidity, mortality, and healthcare costs -3. The uRecommendations and guidelines for the type and duration of prophylaxis have been provided by several organizations with some variability in the indications for prophylaxis and the ideal agent between organizations. The general consensus in terms of the timing and duration of antibiotic prophylaxis among different organizations is that one-time intraoperative dosing within 60 minutes prior to (or two hours for vancomycin of fluoroquinolones) of the surgical incision  is sufficient, but that up to 24 hours of antibiotics is acceptable. The most recent publications from the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and American College of Surgeons (ACS) recommend against administering antibiotics after skin closure in clean and clean-contaminated procedures, even with the presence of a postoperative drain -13. AlthIn this study, our primary objectives were to assess adherence to the ACS guidelines for perioperative antimicrobial prophylaxis in the Seattle Children’s Hospital (SCH) National Surgical Quality Improvement Program (NSQIP) pediatric data cohort and to determine whether adherence to ACS guidelines is associated with a decreased risk of SSI. The secondary objective was to identify risk factors associated with SSI in the SCH patient population.Study designThis study received ethical approval from the SCH Institutional Review Board (STUDY00001702). We conducted a retrospective cohort study of the SCH NSQIP Pediatric (Peds) database cohort between January 1, 2012, and December 31, 2017. Once the eligible patients were identified, information was collected, de-identified, and stored in a password-protected file. Patients who did not receive intraoperative antibiotics or those with missing data regarding intraoperative antibiotics were excluded.Antibiotic prophylaxis guidelinesAntibiotic prophylaxis guidelines were determined according to the ACS guidelines on SSI prevention updated in 2016. There were no pertinent differences between prior guidelines and the 2016 update. The recommendations included (1) antibiotic administration prior to incision, (2) weight-based antibiotic dosing Table , (3) antDemographic and clinical data were extracted from the SCH NSQIP Peds database and included age, sex, race, ethnicity, weight, medical comorbidities, surgical specialty, date, and time of surgery. Data on prophylactic antibiotic administration including type, dose, and timing were extracted from the electronic medical records.Surgical site infectionsThe primary outcome was SSI within 30 days after surgery, as defined by NSQIP Peds. NSQIP Peds records 30-day postoperative outcomes (including SSIs) on a sample of operations performed at participating hospitals as previously described. Surgical procedures included in NSQIP Peds were identified using a list of Current Procedural Terminology (CPT) codes defined by NSQIP and updated yearly ,15. For Statistical analysisSummary statistics were used to assess adherence to ACS recommendations. For each ACS recommendation, the existence of an association between SSI after surgical procedure and adherence to this recommendation was evaluated using a chi-square test of independence. The existence of an association between SSI after surgical procedure and adherence to all ACS recommendations was evaluated in a similar fashion. To assess the association between surgical procedures and adherence to recommendations while controlling for potential confounding factors , and to identify factors associated with the risk of SSI, we used a logistic regression model fit via generalized estimating equations to account for correlation across procedures performed in the same patient. All statistical analyses were performed using R Studio , and all statistical tests were conducted using a significance level of α=0.05.Of the 7,182 surgeries in the SCH NSQIP Peds database spanning the five-year time period identified, 6,072 (84.5%) had data available on perioperative antibiotic use and were therefore included in the analysis. These surgeries were performed on a total of 5,532 patients. Adherence to ACS recommendations was met for weight-based dosing in 35% of surgeries, for administration prior to the incision in 91% of surgeries, for the timing of administration of antibiotics prior to the incision in 86% of surgeries, and for antibiotic redosing in 97% of surgeries. Adherence to all ACS recommendations was achieved in 29% of surgeries  and the development of SSI in pediatric patients. Mohamed Rizvi et al. reported low adherence to guidelines for antimicrobial surgical prophylaxis in pediatric patients (39.6%) but did not evaluate the association between adherence and the development of SSI . Bardia Previous studies investigating the relationship between antimicrobial prophylaxis and SSI have yielded conflicting results. We did not find an association between weight-based antibiotic dosing and SSI in our patient population, but this may be due to the large statistical uncertainty resulting from the low rate of SSIs in this population. To our knowledge, there are no published studies investigating this relationship.Hawn et al. found no association between the timing of antibiotic prophylaxis and the development of SSI in adult patients who underwent hip or knee arthroplasty . Litz etAlthough we did not identify any relationship between appropriate intraoperative antibiotics redosing and SSI in the SCH patient population, similar previously published studies in adult patients have demonstrated some benefits. Zanetti et al. have demonstrated that redosing of antibiotics decreased the risk of SSI after cardiac surgery if the duration of surgery was >400 minutes . SimilarIn the SCH patient population, we found that urgent case status, wound classifications of 2 and 4, ASA class of 2-5, and longer surgery duration were associated with an increased risk of SSI in patients where adherence to recommendations was met. Prospero et al. found that adherence to an antibiotic prophylaxis protocol decreased the risk of SSI in adult patients, and they also identified several risk factors associated with SSI including ASA score 2-5, wound class 2-4, longer duration of surgery, and urgent surgery . AdditioThere are several limitations to our study. The data we studied included patients from a single institution and were retrospectively collected, and hence our results may not be generalizable. There may also be unmeasured confounding variables, such as intraoperative temperature, intraoperative glucose, preoperative or intraoperative skin preparation, obesity, and diabetes mellitus, which were not accounted for in our analysis. In addition, the cohort studied consisted of patients captured by the SCH NSQIP Peds database, which includes only a sampling of patients undergoing a defined set of surgical procedures. As a result, the sample is not necessarily representative of all pediatric patients undergoing surgical intervention. As there are no current guidelines from ACS as to which patients should receive antibiotics, we also excluded patients who did not receive perioperative antibiotic prophylaxis. Excluding this group of patients likely introduced a selection bias that cannot be accounted for in this study. Furthermore, since existing guidelines on the need for antibiotic prophylaxis and choice of antibiotic prophylaxis are extremely limited in the pediatric patient population, we did not evaluate the appropriateness of administration of antibiotics or choice of antibiotics.Based on our findings, adherence to current perioperative antibiotic prophylaxis guidelines is limited. In the SCH NSQIP Peds cohort of patients who received perioperative antibiotic prophylaxis, we did not find significant associations between adherence to ACS guidelines and the development of SSIs. We found that urgent cases status, wound classifications of 2 and 4, ASA class of 2-5, and longer surgery duration were associated with an increased risk of SSI in this patient population. Further research is needed to better understand the relationship between adherence to existing antibiotic prophylaxis guidelines and SSIs, especially in pediatric patients.


Most children with leukemia and lymphoma experience febrile neutropenia. These are treated with empiric antibiotics that include β-lactams and/or vancomycin. These are often administered for extended periods, and the effect on the resistome is unknown.We examined the impact of repeated courses and duration of antibiotic use on the resistome of 39 pediatric leukemia and lymphoma patients. Shotgun metagenome sequences from 127 stool samples of pediatric oncology patients were examined for abundance of antibiotic resistance genes (ARGs) in each sample. Abundances were grouped by repeated courses  and duration  of β-lactams, vancomycin and “any antibiotic” use. We assessed changes in both taxonomic composition and prevalence of ARGs among these groups.We found that Bacteroidetes taxa and β-lactam resistance genes decreased, while opportunistic Firmicutes and Proteobacteria taxa, along with multidrug resistance genes, increased with repeated courses and/or duration of antibiotics. Efflux pump related genes predominated (92%) among the increased multidrug genes. While we found β-lactam ARGs present in the resistome, the taxa that appear to contain them were kept in check by antibiotic treatment. Multidrug ARGs, mostly efflux pumps or regulators of efflux pump genes, were associated with opportunistic pathogens, and both increased in the resistome with repeated antibiotic use and/or increased duration.Given the strong association between opportunistic pathogens and multidrug-related efflux pumps, we suggest that drug efflux capacity might allow the opportunistic pathogens to persist or increase despite repeated courses and/or duration of antibiotics. While drug efflux is the most direct explanation, other mechanisms that enhance the ability of opportunistic pathogens to handle environmental stress, or other aspects of the treatment environment, could also contribute to their ability to flourish within the gut during treatment. Persistence of opportunistic pathogens in an already dysbiotic and weakened gastrointestinal tract could increase the likelihood of life-threatening blood borne infections. Of the 39 patients, 59% experienced at least one gastrointestinal or blood infection and 60% of bacteremia’s were bacteria found in stool samples. Antimicrobial stewardship and appropriate use and duration of antibiotics could help reduce morbidity and mortality in this vulnerable population. To reduThe GIT is colonized by large numbers of microorganisms, including bacteria, viruses and fungi, with Firmicutes and Bacteroidetes being the main bacterial phyla . At diagvia a gene transfer event). Bacteria can carry ARGs specific to a single antibiotic or to multiple antibiotics , and directly effects the microbiome . Common Children with leukemia and lymphoma are treated with multiple antibiotics, which can change bacterial diversity, increase the overall frequency of ARGs in the GIT, and change distribution of ARGs within both pathogens and non-pathogens. The pioneering work of Margolis and coauthors (2021) examined the impact of prophylactic levofloxacin on the resistome during leukemia induction. They found that the use of prophylactic levofloxacin increased the prevalence of ARGs specific to this antibiotic. However, their study did not address (i) other antibiotics routinely used in leukemia and lymphoma patients, (ii) the entirety of the treatment period or (iii) the impact of repeated courses or duration of treatment. A better understanding of the prevalence of ARGs in the GIT resistome, and its dynamics during antibiotic treatment, will have direct relevance to the choice and duration of optimal antibiotic treatment and inform antimicrobial stewardship programs . Current22.1We investigated 39 pediatric patients with either leukemia (33) or lymphoma (6) from the Atlantic Maritime provinces of Canada, undergoing care at the IWK Health Centre in Nova Scotia, Canada Table 1.2.2Quality controlled and decontaminated paired-end shotgun metagenomic sequences from a set of 48 matched oral and stool samples from 24 pediatric oncology patients of varying cancer types see  to creat2.3https://github.com/LangilleLab/microbiome_helper/wiki/Metagenomics-standard-operating-procedure-v2). Paired forward and reverse reads were run through the kneaddata pipeline for sequence pre-processing. Low quality sequences  were removed using Trimmomatic (DNA was extracted from 127 stool samples using Norgen stool DNA isolation kits as per manufacturer’s protocol. A minimum of one nanogram of extracted DNA was prepared using the Nextera XT library preparation kit (Illumina) following manufacturer’s protocol. Libraries were pooled and sequenced using paired end NextSeq sequencing (150 bp) (Illumina). The Microbiome Helper metagenomic standard operating procedure was followed , 2) genes that occurred in multiple antibiotic classes , were coded as “multidrug” antibiotic class genes. Counts within samples assigned to the same gene were summed for downstream analysis. Only genes present in ≥5% of samples were used. Genes in four antibiotic classes were selected for closer analysis: β-lactam antibiotic class, glycopeptide antibiotic class, peptide antibiotic class, and multidrug antibiotic class. These classes were specifically selected as the β-lactam antibiotic class and multidrug antibiotic class potentially contains genes for resistance to β-lactam antibiotics, and the glycopeptide antibiotic class, peptide antibiotic class (a parent class to glycopeptide antibiotics), and multidrug antibiotic class potentially contains genes for resistance to vancomycin. All analyses were carried out on gene sequence data, no allele or SNP information was used.The quality-controlled, decontaminated forward and reverse paired sequences from the 127 leukemia and lymphoma samples were mapped to the pediatric-oncology-ARG-database created using bowtie2 . Counts 2.5post hoc Tukey’s test was employed to examine changes in richness and evenness in samples with repeated courses  and increased duration  of antibiotics.The diversity of species in a community depends on both the number of species observed (species richness) and the relative abundance of species in the community (species evenness). Two communities can have similar numbers of species, but in one community a single species could dominate resulting in differences in evenness between communities. ANOVA and not caused by non-random selection or removal of patients. Nevertheless, we wanted to ensure that the groups did not contain a large number of samples originating from just one patient. Hence, we tested for uniform contribution of patients to the samples within a group via the G-test (α<0.05) as implemented in the DescTools R package . Note that variation in sampling among groups was  package . In eachBH<0.05).Differential abundance analysis of taxa abundance based on number of courses (1-2 vs 3+) of β-lactams, vancomycin and AAb, and duration of courses (short vs LM) of β-lactam and vancomycin were investigated using ANOVA-like differential expression (ALDEx2) . ALDEx2 BH<0.05). For the purpose of discovering candidate ARGs and generating novel hypotheses we employ αBH<0.1 (Differences in mean abundance of the ARGs in samples was examined under three scenarios based on multiple courses of: 1) β-lactam antibiotics, 2) vancomycin antibiotic and 3) “any antibiotic” (AAb) prior to sampling. Mean abundance of each ARG was compared between groups  based on multiple-courses. In addition, abundance of ARGs were compared to number of courses of β-lactam, vancomycin and “any antibiotic” (AAb) prior to sampling. Differences in mean abundance of the ARGs in samples was also examined under two scenarios based on duration of courses of: 1) β-lactam antibiotics, and 2) vancomycin antibiotic prior to sampling. The duration of a course of AAb was not assessed, as the duration was nearly entirely governed by β-lactam antibiotic use. Mean abundance of each ARG was compared between groups  based on duration. In addition, abundance of ARGs were compared to number of days of β-lactam, and vancomycin antibiotics prior to sampling. Multivariate linear models using LIMMA  was appl αBH<0.1 .BH<0.05).Genes identified as significant belonging to the β-lactam, glycopeptide, peptide and multidrug antibiotic classes were examined for correlation with taxa present in samples using spearman correlation implemented using corr.test in the psych R package version 2.1.9 . Signifi33.1C. difficile), 51% experienced one or more blood infection, and 18% both gastrointestinal and blood infections. Among the 51% that experienced blood infections 60% of those patients had at least one infection with a bacterium that was identified within the 127 stool samples . Due to timing of sample collection however we could not directly examine if there was a link between the presence of these bacteria in the stool and blood infections.Among the 39 pediatric patients, 28 had acute lymphoblastic leukemia (ALL), five had acute myeloid leukemia (AML), two had hodgkin lymphoma (HL) and four had non-hodgkin lymphoma (NHL). A total of 127 stool samples were collected among the 39 patients. The average number of days among all samples between chemotherapy start and stool sample collections was 88 days, . Within cancer types ALL patient samples were on average 101.8 days from start of chemotherapy , AML patient samples were on average 57 days from start of chemotherapy , HL patient samples were on average 2 days from start of chemotherapy , and NHL patient samples were on average 23 days from start of chemotherapy . Eight patients (ten stool samples) received no antibiotics prior to collection of stools with remaining stool samples collected following some form of antibiotic. Information on the mean days since start of chemotherapy, days of β-lactam use, and vancomycin antibiotics use, for samples in each group are summarized in To avoid potential overrepresentation of one or more patients to a particular group, we used the G-test to evaluate the hypothesis (null) that sampling was approximately uniform among patients within each group. Uniform sampling was rejected in several cases, and backward elimination was employed to remove the patient(s) with the largest number of samples until a uniform distribution could not be rejected in those cases. This resulted in the removal of two patients (12 and 11 samples) in the 1-2 courses of β-lactam, one patient (11 samples) in vancomycin no use, one patient (12 samples) in the 1-2 courses of vancomycin, one patient (12 samples) in the 1-2 courses of AAb, and two patients (10 and 9 samples) in the 3+ courses of AAb . Here we3.2Using shotgun metagenome sequence data, 366 taxa were identified in the 127 leukemia and lymphoma samples. This included two Archaea, 348 Bacteria, seven Ascomycota taxa and nine viruses. Mean number of taxa per sample was 42 . For species level analyses, only those taxa present in >10% of samples were included, this resulted in 141 taxa  with the mean number of taxa per sample of 38 . Among the bacterial taxa, most were members of Firmicutes (83) followed by Bacteroidetes (23), Proteobacteria (16), Actinobacteria (6), and Verrucumicrobia (1) taxa. The distribution of the 141 taxa in the 127 samples are in supplemental material  was only marginally significance (p=0.052)  of antibiotics by using ANOVA and Tukey’s ) and AAb (p=0.005) only . Four species decreased with repeated courses of β-lactam antibiotics . Five species increased in relative abundance with repeated courses of β-lactam antibiotics; these included opportunistic Proteobacteria  and Firmicutes . Interestingly, no taxa differed significantly with repeated courses of vancomycin. Examining repeated course of AAb we found that the relative abundance of 18 species differed significantly. Eight species decreased with repeated courses of AAb . Ten species increased with repeated courses of AAb . Like β-lactam antibiotics, repeated courses of AAb were associated with an increase in opportunistic pathogens.The species that changed significantly with repeated courses of antibiotics are shown in Clostridium symbiosum, Oscillibacter, Faecalibacterium prausnitzii, Ruminococcus obeum, Eggerthella sp) including those involved in bile acid and short chain fatty acid production. In addition, many of the taxa that increased in abundance with repeated courses  have been implicated in infections in immunocompromised patients.The overall trend of taxonomic change with repeated course of antibiotics was a decrease in relative abundance in taxa important for gut health and integrity  we used ANOVA and Tukey’s test. A significant effect of duration on species richness was only observed for β-lactams, where richness decreased with increasing duration (We investigated the impact of short versus LM duration of antibiotic treatment (β-lactams and vancomycin) on the relative abundance of individual taxa within the microbial community by using ALDEx2. At the phylum level, longer duration of β-lactam was associated with a significant decrease in relative abundance of Bacteroidetes (p=5.2e-4), and increase in Proteobacteria, and Fusobacteria  Table 3.3.5β-lactam and vancomycin antibiotics as well as combined antibiotic use on the 119 resistance genes from the following four antibiotic classes: β-lactam (18 genes), glycopeptide (19 genes), peptide (13 genes), and multidrug (69 genes). These classes were specifically selected as the β-lactam antibiotic class and multidrug antibiotic class potentially contains genes for resistance to β-lactam antibiotics, and the glycopeptide antibiotic class, peptide antibiotic class and multidrug antibiotic class potentially contains genes for resistance to vancomycin.We identified 264 ARGs spanning 24 antibiotic classes present in at least 1 of the 127 leukemia and lymphoma patient samples  increased with increased courses Table 4.3.6.2Examining significant and candidate genes with repeated courses measured either as course groups or counts of courses identified 6 glycopeptide ARGs, all decreased with increased courses Table 4.3.6.3Examining significant and candidate genes with repeated courses measured either as course groups or counts of courses identified 10 peptide ARGs, with all increased with increased courses Table 4.3.6.4Examining significant and candidate genes with repeated courses measured either as course groups or counts of courses identified 31 multidrug ARGs with most (27) increased with increased courses Table 4.3.73.7.1Examining significant and candidate genes with increased duration measured either as duration groups or days of antibiotics identified 14 β-lactam ARGs, with 10 genes increased with increased duration and or days Table 5.3.7.2Examining significant and candidate genes with increased duration measured either as duration groups or days of antibiotics identified seven glycopeptide ARGs, all decreased with increased duration and or days Table 5.3.7.3Examining significant and candidate genes with increased duration measured either as duration groups or days of antibiotics identified eight peptide ARGs, with all genes increased with increased duration and or days Table 5.3.7.4Examining significant and candidate genes with increased duration measured either as duration groups or days of antibiotics identified 39 multidrug ARGs, with 36 genes increased with increased duration and or days Table 5.3.8BH<0.05) associations in 512 of the 10,998 tested comparisons between taxa and ARGs  were all from the phylum Proteobacteria , we used Spearman correlation analysis to investigate associations between the abundance of the 141 species and the 78 ARGs we identified as associated with antibiotic use 5. We foAnalysis of the significant gene-taxon correlation coefficients showed two distinct clusters of gene-taxon pairs 3. In adC. difficile, Enterococcus faecalis, and Coprobacillus sp., three Firmicutes taxa, two of which increased with repeated courses of antibiotics  on the resistome in the gastrointestinal tract. We examined the abundance of specific ARGs and taxa related to β-lactam antibiotics (β-lactam genes), vancomycin (glycopeptide and peptide antibiotic genes) and multi-drug resistance. We found that there were sets of taxa and genes that increased or decreased in relative abundance after repeated courses of β-lactams and vancomycin and with longer duration of these antibiotics. Many of the significantly changing taxa and identified genes were positively correlated with each other, increasing and decreasing in abundance together.Granulicatella, Streptococcus, Clostridioides difficile and Enterococcus faecalis increased in abundance with repeated courses of β-lactams. Conversely, other “good” Firmicutes like Faecalibacterium prausnitzii, Oscillibacter, Clostridium symbiosum, and Ruminococcus obeum, that help keep pathogenic and opportunistic pathogens in check  declined with repeated β-lactam antibiotic courses and increased duration, which was reflected in the decreased abundance of Bacteroidetes, we found the relative abundance of Proteobacteria and Firmicutes phyla increased. Closer examination of Firmicutes taxa identified opportunistic taxa like in check  through in check  were decin check , our resbundance . In addiVancomycin is more narrowly focused than broad-spectrum β-lactams in its target and is routinely used to treat Gram-positive bacteria. While richness declined with vancomycin use, it was not significant for either repeated courses or duration. We postulate that this was a result of the overlap of samples (36/46) that received no vancomycin but had received at least one course of a β-lactam antibiotics. We showed that use of β-lactam in this population changes the relative abundance of taxa in general, and Firmicutes taxa in particular; hence, its use is likely causing a significant change in the microbiome community that makes it more difficult to detect taxonomic shifts that result from vancomycin use.via β-lactam gene  products and/or through overexpression of multidrug efflux pump genes  were sensitive to β-lactam antibiotics  included a β-lactam class as a target. In addition, most of the increased multidrug genes (92%) were antibiotic efflux genes, and many of these efflux genes were resistance-nodulation-division (RND) efflux pumps. Identified efflux genes included multiple genes creating proteins complexes: acrA, acrB and tolC (AcrAB-TolC efflux pump); kpnE and kpnF (KpnEF efflux pump); acrE and acrF (AcrEF efflux pump). In addition to the efflux gene, we also identified multidrug genes that regulated these efflux pump genes, including: acrR, acrS, marA, H-NS, cpxA, sdiA, soxS, and ramA. The identified multidrug efflux-related genes were predominately correlated with  cloacae . Finallybacteria . It is oE. coli, Enterococcus faecalis, Klebsiella oxytoca, and Enterobacter cloacae) with increased relative abundance and associated with increased multidrug genes related to efflux pumps.Efflux pumps have been shown to be important in pathogenicity, along with bacterial metabolism, and physiology . They plGiven the strong associations between these opportunistic pathogens and multidrug genes related to efflux pumps, we suggest these genes may be important in allowing these taxa to persist or increase in abundance with repeated courses and duration of antibiotics. While the most direct explanation involves their ability to remove antibiotics, other mechanisms that confer enhanced ability to handle environmental stress, or other aspects of the treatment environment, could contribute to their ability to flourish within the gut microbiome during treatment.Finally, we note increases in some ARGs from one antibiotic class were associated with exposure to another antibiotic class. Although this finding is significant in terms of monitoring and predicting the prevalence of ARGs in a clinical setting, the phenomenon should not be taken as evidence of a causal functional role for such genes within the treatment environment. Antibiotic exposure results in ecological changes that shift community composition of the human microbiome , and theChemotherapy can alter the microbiome resulting in dysbiosis which can lead to diarrhea and further depletes the healthy gut microbes . To atte5In summary, in this cohort of children and adolescents with leukemia/lymphoma we found that repeated courses and longer duration of antibiotics commonly given during periods of febrile neutropenia was associated with an increase in pathogenic bacteria and a decrease in “good” bacteria in the microbiome. This is important since the changes in the microbiome with repetitive long courses of broad-spectrum antibiotics are potentially creating an environment that favors ARGs and their associated pathogenic infections. The concern for this population is that increased ARGs in the GIT resistome coincide with a dysregulated immune environment and weakened gut epithelium, and this increases the likelihood of antibiotic-resistant life-threatening bacteremias, which increases morbidity and mortality in this population.Further studies are needed to evaluate the clinical and epidemiological effects of long duration use of empiric broad-spectrum antibiotics on the resistome and on breakthrough infections with resistant organisms, as well as to evaluate the appropriate duration of empiric antibiotic treatment. Future efforts should also look at the impact of administering probiotics and different nutrition strategies in this population in an attempt to restore the “good” bacteria in the microbiome affected so drastically by antibiotic use. Antimicrobial stewardship program to reduce antibiotic overuse remains essential in this vulnerable population and should be considered in all decisions regarding antibiotic use.https://www.ebi.ac.uk.ena), under accession numbers PRJEB29237, PRJEB41463, PRJEB46214, PRJEB53954, PRJEB59728.The data presented in the study are deposited in the European Nucleotide Archive . Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.TM, KK and KD contributed to the conception and design of the study and interpretation of the results. KD and JM performed analyses. KD, JB, and TM wrote the manuscript. All authors secured funding for the project, contributed to manuscript revision, and read, and approved the submitted version.