Critical Appraisal of Antimicrobial Resistance - Research Paper Example

Critical Appraisal - Epidemiology Name Institution Table of Contents Table of Contents 2 Introduction 3 Methods 4 Critical Appraisal 6 Validity 6 Results 8 Clinical relevance 11 Conclusion 12 References 13 Introduction The introduction of antibiotics into modern medicine was a major milestone. However, microbial resistance to antibiotics continuous to be recognised as the single-most greatest threat to human health, as a reversal to the pre-antibiotic era would imply that several routine infections would become untreatable (Ong et al, 2007). Antimicrobial resistance is therefore a critical concern, specifically because it has the potential to lead to difficulty in disease control and effective delivery of health services (Gottlieb & Nimmo, 2011). Several research studies have explored antimicrobial determinants, use, interventional strategies and development of antimicrobial resistance (Spellberg et al, 2013); Raghunath, 2008). Still, there has been a divergence of the findings on effective interventions to control the resistance. Indeed, the resistance impacts are making successful empirical therapy increasingly difficult to attain. Still, a large body of these researches have recommended that while resistance may not be prevented, its spread and development can be curtailed once effective interventions are implemented (Nabavizadeh et al, 2011; Huang et al, 2013; Ong et al, 2007). Indeed, a variety of researches has been published on antimicrobial resistance over the last decade. In spite of this, a survey of literature shows lack of substantive literature related to epidemiological aspects of antimicrobial resistance, especially in developing countries (Kumar et al, 2013). This prompts the need for critical appraisal of literature on causes of antimicrobial resistance and possible interventions, hence the rational for the research question: What interventional strategies can effectively control antibiotic resistance? The research question is significant as it strives to provide an insight into the causes of antibiotic resistance and how effective interventional strategies can be developed. Methods The criteria used in reviewing the article comprised searching online for articles on antimicrobial resistant bacteria, mainly a mixture of observational and randomised controlled trial (RCTs), systematic review and supporting, and not supporting the hypothesis. Data was extracted from studies that met these criteria. Focus was on articles documented in English language. The databases searched included Medline, CINAHL, PLOS ONE, Google Scholar, Scopus, Academic Search Complete and others. The key words employed for search included ‘Antimicrobial resistance,’ ‘antimicrobial resistance interventions,’ ‘antimicrobial resistance determinants,’ ‘antimicrobial resistance interventions strategies.’ In the end, 12 articles were identified that explored antimicrobial resistance. All the articles related directly to the research question. Five were selected for critical appraisal. To establish their consistency with the research question, the reviewer summated and reviewed the findings. All articles critically appraised were peer-reviewed articles published between 2002 and 2014. The main research barrier experienced was the limited number of researches that explored antibiotic resistance. The search was conducted for information pertinent to the developing nations between 2002 and 2014, which yielded 12 references, out of which 5 articles were selected that effectively met the criteria. A sum of two articles included relate to animal studies, while 3 relate to human studies. The articles were critically appraised based on the FORM framework proposed by Hillier et al (2011). The FORM framework provides a structured a structured process for determining a body of evidence pertinent to a clinical question or research question within the context of the setting it is applied. The framework explores the level of evidence ascribed to a study, the level of evidence base, the consistency of the findings, the generalisability of the results and the applicability of the results. Critical Appraisal Skills Program (CASP) was applied in critical appraisal of the five articles (Oxman et al, 1994). RANKING the Studies Based On FORM Studies reviewed Rank Evidence base Consistency Clinical Impact Generalisability Applicability Tekle et al (2012) 1 A A A A A Derde et al (2014). 2 A B A A A Azevedo et al (2013) 3 B C C D B Balsalobre et al (2014) 4 C B C D C Derde et al (2014) C C B D C Figure 1: Figure 1: Ranking of studies based on FORM Figure 2: Definition of grades Critical Appraisal Critical Appraisal Skills Program (CASP) is a framework for developing the skills needed to gain logical comprehension of scientific evidence. The CASP strategy suggests critical appraisal checklist for analysis of study design, which cover three key areas: validity, results and clinical relevance (Burls, 2009). Validity In the first study, Balsalobre et al (2014) used current and past research data published between 2000 and 2011 to explore the implication of antimicrobial resistance within the public health. The researchers reviewed 32 articles. This indicates that Balsalobre’s et al (2014) work is authentic in regards to objectivity and comprehensiveness. The articles Balsalobre et al (2014) reviewed are relevant to their research topic. Indeed, in using Burls (2009), suggests that the evidence base should be assessed based on the quality and quantity of studies reviewed in systematic literature review for the clinical question investigated. There is a link between the ideas Balsalobre’s et al (2014) developed from the review literature to explore how antibiotic resistance manifests increased infection of extended clinical symptomatology, rise of costs of health systems and increase in hospital stay. While there is some evidence of bias in Balsalobre’s et al (2014) review, objectivity is strengthened by the large number of articles explored. Additionally, the researchers tended to acknowledge the complexities of the areas explored. Tekle et al (2012) also conducted systematic review of literature. The quality and quantity of studies Tekle et al (2012) reviewed in systematic literature review for the clinical question investigated are valid. Like, Balsalobre et al (2014), Tekle et al (2012) used current and past research data. Tekle’s et al (2012) spanned the years between 1996 and 2011 to explore the implication of antimicrobial resistance within the public health. Tekle et al (2012) reviewed 48 articles. This shows that Tekle’s et al (2012) work is both objectivity and comprehensiveness. Like Balsalobre et al (2014), the articles Tekle et al (2012) reviewed are relevant to their research topic. However, Tekle’s et al (2012) work could be more objective since, negative, neutral, and positive studies were used. Still, it could be argued that Balsalobre’s et al (2014) may not have been absolutely objective in their discussion on exploring antibiotic resistance as ‘an expected but induced enemy,’ where they attempted to review the evidence correlating the environmental and clinical resistance highlights. At this stage, Balsalobre’s et al (2014) explained that culture collections from different time periods are a significant source of information once combined with new data based on their personal experience. In this regard, no external research was used to support the analysis. A level of bias therefore exists. In yet another study to explore the possible interventions for antimicrobial resistance, Azevedo et al (2013) examined the role of health education within formal and informal context. Like, Tekle et al (2012), Azevedo et al (2013) performed systematic review of literature. Overall, 45 articles were reviewed, which compare to Tekle’s et al (2012) in number and strength. Like Tekle et al (2012), Azevedo et al (2013) used current and past research data, which howewer spanned the years 1996 - 2011 to explore the possible interventions for antimicrobial resistance in the public health. This therefore establishes the objectivity and comprehensiveness of the research. The articles Azevedo et al (2013) reviewed are relevant to their research topic. Still, compared to Tekle’s et al (2012) work, Azevedo’s et al (2013) is less objective since only positive studies were used. More differently, Derde et al (2014) used cluster randomised trial and interrupted time series study to explore the interventions necessary for reducing colonisation and transmission of antimicrobial-resistant bacteria in European intensive care units. The control groups and the interventions are similar except in the case of receiving the treatment Derde et al (2014) tested, which makes the study valid. The researchers therefore avoided things that may lead to differences in the groups. The study design is less prone to biases since the research methods were combined with systematic review of 36 peer-reviewed literature, whose quality and quantity reflected objectivity as negative, neutral, and positive studies were used. In another study, Gould (2009) explored antibiotic resistance and its implications on antibiotic therapy. Gould (2009) also performed systematic review of literature, like Tekle et al (2012) and Azevedo et al (2013). In total, the researcher only reviewed 26 peer-reviewed articles, which makes the study less generalisable. Only current literature spanning 2005-2008 were examined, which makes the study less perceptive of the burden of antibiotic resistance and its implications on antibiotic therapy. Like Azevedo’s et al (2013) study, Gould’s (2009) study is less objective since only positive studies were used. Results Burls (2009) pointed out that in using the CASP, the findings will be valid when the research designs are right. The researchers presented their results in different ways. In using systematic review of literature, the researcher compared varied case-control, RCTs, and cohort studies, where results were generally presented as relative risk, such as division of the outcome in the intervention group by that in the control group to get odds ratio that is less than one. Balsalobre et al (2014) results showed that following the emergence and distribution of the resistance and manifestation of new bacterial pathogens, the urgency to discover new drugs that should be treated as priority has reduced, linked with the new discoveries, controlling, surveillance programs. Additionally, the pharmaceutical companies have reduced the volume of new antibiotics they develop. According to Balsalobre et al (2014), of the relative risk in CASP less than one, then outcome happened less frequently. However, while this is so, there may exist some uncertainty regarding whether the results are true, since Balsalobre et al (2014) did not conduct any follow up study. As stated by Hillier et al (2011), consistency in results is concerned with the degree to which the findings are consistent with the studies reviewed. The likely consistencies in any research, according to Hillier et al (2011), include divergence in the results of the studies, risk of bias in the quality of studies, the population surveyed, and the different definitions in the outcome. The findings established by Balsalobre’s et al (2014) are consistent across the literature reviewed and are therefore likely to be replicable or only get to happen under specific conditions. Judgement regarding Balsalobre’s et al (2014) may be made regarding the direction of effects across a range of effects across several studies with reference to clinical objectivity. Balsalobre et al (2014) established that antimicrobial resistance is a problem requiring rigorous campaigns where all sectors involved aim to agree on the most effective [proposal treatment common in situations of infections to enable it to reflect positively. The research established that the threats of anti-bacterial resistance call for a multifaceted and coordinated response. Surveillance is a critical factor for creating a pathway to exploring the effects resulting from resistance. In Tekle’s et al (2012) findings, the researchers illustrated that, vaccines that target drug-resistant serotypes could be the initial clinical intervention as they have the potential to force the evolution of pathogenic populations to drug-sensitivity. They further showed the feasibility of the approach through modeling a hypothetical vaccine targeting subset of methicillin-resistant Staphylococcus aureus (MRSA) genotypes along with drug treatment intended for drug-sensitive genotypes and established that a combined intervention strategy potentially limits nosocomial outbreaks despite inefficacy of vaccine efficacy. Tekle’s et al (2012) results are valid, as the authors considered the rigour of the studies they identified. Additionally, there is consistency between the hypothesis, the literature reviewed and the findings, which make the findings valid. The correctness and consistency of the research design also imply that the results are right. In the third study, Azevedo et al (2013) established that lack of sufficient knowledge on proper use of antibiotics, therefore a multi-faceted strategy is continuously needed to improve antibiotic prescribing and control the rise of antimicrobial resistance through public health campaigns in formal and informal contexts. Azevedo’s et al (2013) results are less valid compared to that of Tekle’s et al (2012) as while the researchers used rigourous review of the studies, there was no followup study. Still, the consistency between the hypothesis, the literature reviewed and the findings make the findings valid. Derde et al (2014) established that that improved hand hygiene in addition to body-washing using chlorhexidine are effective interventions since they reduce acquisition of antimicrobial-resistant bacteria, specifically Staphylococcus aureus MRSA. The results are more valid compared to that of Azevedo’s et al (2013). Derde et al (2014) used a controlled group method to study the population combined with systematic review of literature. There is also consistency between the hypothesis, the literature reviewed and the findings. Gould (2009) established that the causes of antibiotic resistance is linked to irregular drug prescription, and therefore the most appropriate intervention as life-long re-education of prescribers and that the need for antibiotic prescribing to be reserved strictly for doctors and certified medical practitioners. Compared to Derde’s et al (2014) results, Gould (2009) results are less valid as there was no follow up study, despite the consistency in the literature reviewed and the findings. Clinical relevance In using CASP, Burls (2009) suggests that it is significant to determine whether the study being reviewed is applicable to the decision being made for a certain population or patients. In which case, a significant difference between participation in trial and the population being targeted has to be identified. In Balsalobre’s et al (2014) study, it is difficult to determine whether the researchers considered all significant outcomes, since there was more follow up study to explore the findings. In Balsalobre’s et al (2014) study, although there was consideration of the intervention and outcomes, there was no information on the population studies. In Tekle’s et al (2012) study, there is no difference between the patients investigated and the participants in the trial. It can also be argued that the research considered all outcomes, as they attempted to investigate all possible outcomes. The local setting is therefore unlikely to different from the one the researchers reviewed. Unlike Tekle et al (2012), Azevedo et al (2013) identified their population as the general population. Overall, there is no a significant difference between participation in trial and the population being targeted to justify their conclusion that since the patients’ expectations influence the prescription of antibiotics by physicians, an urgent need for education of the general population is critical. In Derde’s et al (2014) study, there is no a significant difference between the patients in ICUs who took part in the trial and the population being targeted to justify the conclusion that improved hand hygiene in addition to body-washing using chlorhexidine are effective interventions. Similarly, in Gould’s (2009) study, the researcher failed to identify the population for study. Therefore, the patients covered in the reviews could be significantly different from the population targeted to justify the findings that the most appropriate intervention as life-long re-education of prescribers and that the need for antibiotic prescribing to be reserved strictly for doctors and certified medical practitioners. Conclusion In Tekle’s et al (2012) and Derde’s et al (2014) are the highest quality studies. They have low risk of bias. Additionaly, all the studies reviewed were consistent. The two studies also have very large clinical impacts. Additionally, the population studied in the body of evidence are similar to the target populations and lastly, they are directly applicable to a healthcare setting. The two studies therefore answer the research question fittingly. It is therefore concluded, based on Tekle’s et al (2012) findings that vaccines, which target drug-resistant serotypes, should be the proper clinical intervention as they have the potential to force the evolution of pathogenic populations to drug-sensitivity. Second, improved hand hygiene in addition to body-washing using chlorhexidine are effective interventions since they reduce acquisition of antimicrobial-resistant bacteria, specifically Staphylococcus aureus MRSA as established by Derde’s et al (2014). The findings can be implemented to the policy and practice. The main research gap is the study is less generalisable due to limited study sample. Future longitudinal studies as a follow up to the two findings are suggested. References Azevedo, M., Capela, C. & Baltzar, F. (2013). Relationship between antibiotic use and resistance - impact on educational campaigns. Formatex, 1542-1547 Balsalobre, L., Dropa, M. & Matte, M. (2014). An overview of antimicrobial resistance and its public health significance. Brazilian Journal of Microbiology 45(1), 1-6 Burls. A. (2009). What is Critical Appraisal? Hayward Group: Oxford Derde, L., Cooper, B., Goossens, H. et al. (2014). Interventions to reduce colonisation and transmission of antimicrobial-resistant bacteria in intensive care units: an interrupted time series study and cluster randomised trial. The Lancet Infectious Diseases, 14(1), 31-39 Gould, I. (2009). Antibiotic resistance: the perfect storm. International Journal of Antimicrobial Agents 34(1), S3-S5 Gottlieb, T. & Nimmo, G. (2011). Antibiotic resistance is an emerging threat to public health. An urgent call to action at the Antimicrobial Resistance Summit 2011. MJA 194(6), 281-283 Hillier, S., Grimmer-somer, K., Merlin, T. et al. (2011). FORM: An Australian method for formulating and grading recommendations in evidence-based clinical guidelines. 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