https___antibiotic.ecdc.europa.eu_ga_bi-ar-eolas_priomhtheachtaireachtai_priomhtheachtaireachtai-do-ghairmithe-curam-slainte-ospideil-0_1.xml
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General key messages for healthcare professionals in hospitals and other healthcare settings What is the problem? Antibiotic resistance threatens the health and safety of patients in all healthcare settings in Europe [1]. Note: With the word “antibiotics”, ECDC means antibacterial agents or antibacterials. However, the key messages proposed for antibiotics could be extended to other antimicrobial agents based on the specific needs of countries and of hospitals and other healthcare settings. The emergence of bacteria resistant to multiple classes of antibiotics is particularly concerning. Such multidrug-resistant bacteria are a real and constant threat to clinical practice in all healthcare settings in Europe [1]. Infections with multidrug-resistant bacteria can be severe, fatal and costly and can directly lead to [2-11] [expert consensus]: a) Delayed access to effective antibiotic therapy for individual patients, causing treatment failures, longer illnesses, prolonged stays in hospital and increased morbidity and mortality; b) More adverse events, because alternative antibiotic therapies, that are more toxic, must often be used; c) Fewer effective antibiotic treatments for immunosuppressed patients and those undergoing surgical operations; d) Reduced quality of patient stay due to anxiety because of the need for rigorous infection control measures; e) Higher direct and indirect hospital costs. Examples: - Patients with bloodstream infections have a threefold higher mortality rate, prolonged hospital stays, and higher costs if their infection is due to third-generation cephalosporin-resistant Escherichia coli, compared with third-generation cephalosporin-susceptible isolates [12]. - Patients have a 24% increased risk of mortality with any antibiotic-resistant Pseudomonas aeruginosa infection [13]. - Patients are up to three times more likely to die if their infections is caused by carbapenem-resistant Klebsiella pneumoniae, compared with carbapenem-susceptible isolates [14]. Misusing antibiotics increases the risk of infections with multidrug-resistant bacteria [15]. Example: Gram-negative bacteria, such as Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, and Acinetobacter spp., are becoming resistant to most available antibiotics [16,17]. Antibiotics are misused when they are prescribed unnecessarily (i.e. antibiotic treatment is not clinically needed) or when they are prescribed inappropriately, i.e. one of the following [18]: a) Delayed administration of antibiotics in critically ill patients; b) The spectrum of antibiotic therapy is either too narrow or too broad; c) The dose of antibiotic is either too low or too high; d) The duration of antibiotic therapy is either too short or too long; e) Antibiotic therapy is not reviewed after 48-72 hours, or the choice of antibiotic is not streamlined when microbiological culture data become available. Misusing antibiotics increases the incidence of Clostridium difficile infections [19-22]. Example: In European hospitals, Clostridium difficile infections can lead to up to a 42% increase in mortality, 19 extra days of hospital stay, and more than EUR 14,000 of additional costs per patient [23,24]. Many prescribers do not know antibiotic resistance prevalence rates in their local setting [25,26], and recognise lacks in their training regarding antibiotic use [27]. Availability of guidelines, consultation with infectious diseases specialist, and trainings represent the most helpful interventions to promote better use of antibiotics [25,27]. Only a few antibiotics in the research and development pipeline may be effective against existing multidrug-resistant bacteria [28-30]. Losing effective options for the treatment and prevention of infections is a global health security threat [31]. How is our use of antibiotics contributing to the problem Misuse of antibiotics accelerates the emergence and dissemination of antibiotic resistance [8,31-34]. Antibiotics are given to many hospital inpatients [35,36]. Up to a half of all antibiotic use in European hospitals is unnecessary or inappropriate [6,37,38]. Antibiotic resistance is more likely to develop and spread when [39] [expert consensus]: • Broad-spectrum antibiotics are used; • Long durations of antibiotics are used; • Too low doses of antibiotics are used. Example: Cephalosporins, carbapenems, fluoroquinolones and anti-anaerobe antibiotics have a high risk of selecting for multidrug-resistant Gram-negative bacteria [40]. Antibiotics have long-term effects on the development and persistence of antibiotic resistance in the microbiota. This resistance may be transferred to other bacteria [41]. Antibiotics are often prescribed to patients in hospitals without explaining the importance of prudent antibiotic use [expert consensus]. Why hospitals should be promoting antibiotic stewardship? Promoting prudent antibiotic use is both a patient safety and a public health priority [31,42]. Example: Increasingly, many European countries have national guidance on antimicrobial stewardship programmes for hospital prescribers. The ECDC directory (link) contains online resources for developing guidelines. Antimicrobial management initiatives that promote prudent antibiotic use are called antibiotic stewardship programmes [19,42-45]. Antibiotic stewardship programmes, can contribute to [42,45,46] [expert consensus]: a) Optimising how infections are treated; b) Increasing infection cure rates and reduce treatment failures; c) Reducing adverse events from antibiotic use; and d) Preventing and reducing antibiotic resistance, together with infection prevention and control measures. Examples: In a recent survey of hospitals that had implemented an antibiotic stewardship programme [47]: • 96% hospitals reported reduced inappropriate prescribing; • 86% reported reduced use of broad-spectrum antibiotics; • 80% reported reduced expenditures; • 71% reported reduced healthcare-associated infections; • 65% reported reduced length of stay or mortality; • 58% reported reductions in antibiotic resistance. Note: Some examples refer to antimicrobial stewardship programmes. The objectives of antimicrobial and antibiotic stewardship programmes, including the appropriate indication, selection, dosing, route of administration, and duration of antimicrobial therapy, are the same. Antibiotic stewardship programmes can successfully reduce Clostridium difficile infection rates [19,22,43,44,48]. Example: The incidence of Clostridium difficile infections decreased in the medical and surgical wards of an acute general hospital in the United Kingdom in response to revised empirical antibiotic treatment guidelines for common infections and restrictive measures for fluoroquinolone and cephalosporin usage [48]. Antibiotic stewardship programmes can reduce patient care costs [42,45,46]. Example: In a pooled analysis of antibiotic stewardship programmes, total consumption fell (by 19% hospital-wide and by 40% in intensive care units), overall antibiotic costs were reduced (by about one third), and the hospital length of stay shortened (by 9%). These improvements did not cause any increase in adverse patient outcomes [46]. How do antibiotic stewardship programmes work? Antibiotic stewardship programmes consist of multifaceted actions, such as [19,42,43,44,48-57]: a) Leadership commitment: ensuring the necessary resources in terms of staff, technology and budget are available. b) Appointing leaders that are responsible for the overall programme and for antibiotic use. c) Hospital-based teams, which include infectious disease specialists, clinical pharmacists and microbiologists, providing support to prescribers; d) Proactive auditing of antibiotic prescriptions with feedback to team members; e) Training and education for medical, pharmacy, laboratory, nursing, and non-clinical staff, as well as patients and their families; f) Using evidence-based antibiotic guidelines and policies; g) Using restrictive measures for antibiotic prescriptions (e.g., pre-approval and post-authorization requirements for specific antibiotics); h) Monitoring antibiotic resistance and use, and making this information available to prescribers. Examples of antibiotic stewardship strategies, actions and outcomes in European countries include: France - Restricting use of fluoroquinolones reduced consumption of this class of antibiotics and decreased the rate of meticillin-resistant Staphylococcus aureus in a teaching hospital [58]. France – Using information technology support for antibiotic prescriptions decreased antibiotic consumption in many hospitals [59]. Germany - Implementing a computerised decision support system led to higher adherence to locally adapted guidelines, increased antibiotic-free days and reduced mortality over a five-year period in five intensive care units [60]. Hungary - Infectious disease specialist consultation in a surgical intensive care unit, together with a restricted prescribing policy, led to lower use of all antibiotics and a marked reduction in use of broad-spectrum antibiotics [61]. Italy – A four-year infection control programme decreased the incidence of infections and colonisation caused by carbapenem-resistant bacteria in a teaching hospital. The programme included antibiotic stewardship measures targeting carbapenem use [62]. Netherlands – Implementing rapid processing of microbiology tests increased the proportion of patients receiving appropriate treatment within the first 48 hours in a teaching hospital [63]. Netherlands - Case audits for the reassessment of antibiotic use after 48 hours reduced antibiotic consumption and length of stay in a urology ward of an academic hospital, and also had a positive direct return on investment [64,65]. Poland - Developing guidelines for antibiotic prescriptions and pre-authorisation approval for restricted antibiotics decreased total antibiotic consumption in a general paediatric ward [66]. Spain – After only one year, education on guidelines combined with regular feedback led to a 26% improvement in the rate of appropriate treatments, and a 42% reduction of antibiotic consumption at a tertiary teaching hospital [67]. Sweden – Twice weekly audit and feedback in an internal medicine department led to an absolute 27% reduction of antibiotic use , especially of broad-spectrum antibiotics (cephalosporins and fluoroquinolones), as well as shorter antibiotic treatment durations and earlier switching to oral therapy [68].
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Príomhtheachtaireachtaí ginearálta do ghairmithe cúram sláinte in ospidéil agus i suíomhanna eile cúram sláinte Cad é an fhadhb atá ann? Cuireann frithsheasmhacht in aghaidh antaibheathach sláinte agus sábháilteacht othar i ngach suíomh cúram sláinte san Eoraip i mbaol [1]. Ábhar imní ar leith is ea teacht chun cinn baictéar atá frithsheasmhach in aghaidh aicmí éagsúla antaibheathach. Baictéir den sórt sin atá frithsheasmhach in aghaidh ildrugaí, bíonn siad ina bhfíorbhagairt sheasta ar an gcleachtas cliniciúil i ngach suíomh cúram sláinte san Eoraip [1]. Is tromchúiseach, marfach agus costasach a bhíonn ionfhabhtuithe le baictéir atá frithsheasmhach in aghaidh ildrugaí. Is féidir leo a bheith ina gcúis leis na nithe seo a leanas [2-11] [comhdhearcadh saineolaithe]: a) Moill ar rochtain a thabhairt d’othair aonair ar theiripe éifeachtach antaibheathach, rud is cúis le teipeanna cóireála, le tinnis níos faide, le sealanna fada san ospidéal agus le méadú ar ghalracht agus ar mhortlaíocht; b) Méadú ar theagmhais dhíobhálacha, toisc gur minic is gá dul i muinín teiripí malartacha antaibheathach atá níos tocsainí fós; c) Laghdú ar chóireálacha éifeachtacha antaibheathach d’othair atá imdhíon-sochta agus dóibh sin atá ag dul faoi ghnáthaimh mháinliachta; d) Laghdú ar cháilíocht fhanacht an othair mar gheall ar imní a bheith orthu faoin ngá atá le dianbhearta um ionfhabhtú a chosc; e) Méadú ar chostais dhíreacha agus indíreacha don ospidéal. Samplaí - Bíonn rátaí mortlaíochta trí huaire níos airde i measc othar a bhfuil ionfhabhtú sruth fola orthu ná i measc daoine eile. Bíonn sealanna níos faide san ospidéal acu freisin. Chomh maith leis sin, is airde an costas a bhaineann lena gcóireáil i gcás go bhfuil a n-ionfhabhtú inchurtha i leith Escherichia coli tríú glúin atá frithsheasmhach in aghaidh ceifileaspóiriní ná i gcás go bhfuil sé inchurtha i leith aonraígh thríú ghlúin atá soghabhálach i leith ceifileaspóiriní [12]. - Méadaítear riosca mortlaíochta an othair faoi 24% i gcás go bhfuil ionfhabhtú Pseudomonas aeruginosa atá frithsheasmhach in aghaidh antaibheathach orthu [13]. - Is mó faoi thrí an dóchúlacht go bhfaighidh othar bás i gcás go bhfuil Klebsiella pneumoniae atá frithsheasmhach in aghaidh carbaipeineimí ina chúis lena n-ionfhabhtú ná i gcás go bhfuil aonraígh atá soghabhálach i leith carbaipeineimí ina gcúis leis [14]. Má bhaintear mí-úsáid as antaibheathaigh, méadófar an baol go bhfulaingeofar ionfhabhtú le baictéir atá frithsheasmhach in aghaidh ildrugaí [15]. Sampla Bíonn baictéir Ghram-dhiúltacha, amhail Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa agus Acinetobacter spp., ag éirí frithsheasmhach in aghaidh fhormhór na n-antaibheathach atá ar fáil [16,17]. Baintear mí-úsáid as antaibheathaigh nuair a oideasaítear iad gan ghá (i.e. nuair nach bhfuil cóireáil antaibheathach ag teastáil ón taobh cliniciúil de) nó nuair a oideasaítear iad ar bhealach míchuí, i.e. ar cheann amháin de na bealaí seo a leanas [18]: a) Tá moill ann ar antaibheathaigh a thabhairt d’othair atá i mbaol báis; b) Tá speictream na teiripe antaibheathach róchúng nó róleathan; c) Tá dáileog an antaibheathaigh ró-íseal nó ró-ard; d) Tá fad na teiripe antaibheathach róghearr nó rófhada; e) Ní dhéantar athbhreithniú ar an teiripe antaibheathach tar éis tréimhse 48-72 uair, nó ní chuíchóirítear an rogha antaibheathaigh a luaithe a bhíonn sonraí faoi shaothráin mhicribhitheolaíocha ar fáil. Má bhaintear mí-úsáid as antaibheathaigh, méadófar minicíocht ionfhabhtuithe Clostridium difficile [19-22]. Sampla In ospidéil Eorpacha, bíonn ionfhabhtuithe Clostridium difficile ina gcúis le méadú 42% ar rátaí mortlaíochta, le méadú 19 lá ar fhanachtaí ospidéil agus le méadú os cionn EUR 14,000 ar chostais in aghaidh an othair [23,24]. Ní eol do chuid mhór oideasóirí na rátaí leitheadúlachta frithsheasmhachta in aghaidh antaibheathach ina suíomh áitiúil [25,26]. Aithníonn siad easnaimh ar an oiliúint atá faighte acu in úsáid antaibheathach freisin [27]. Tá treoirlínte, comhairliúchán le speisialtóirí galar tógálach agus seisiúin oiliúna i measc na n-idirghabhálacha is cuidiúla maidir le húsáid níos fearr antaibheathach a chur chun cinn [25,27]. Tá seans ann nach mbeidh ach cúpla antaibheathach is ábhar do thaighde agus forbairt faoi láthair éifeachtach maidir le dul i ngleic le baictéir reatha atá frithsheasmhach in aghaidh ildrugaí [28-30]. Bagairt ar shlándáil sláinte ar fud an domhain is ea roghanna éifeachtacha um ionfhabhtuithe a chóireáil agus a chosc a chailleadh [31]. Cén dóigh a mbíonn ár n-úsáid antaibheathach ag cur leis an bhfadhb? Cuireann mí-úsáid antaibheathach dlús le teacht chun cinn agus scaipeadh na frithsheasmhachta in aghaidh antaibheathach [8,31-34]. Tugtar antaibheathaigh do chuid mhór othar cónaitheach [35,36]. Is neamhriachtanach nó míchuí a bhíonn suas le leath na húsáide antaibheathach ar fad in ospidéil Eorpacha [6,37,38]. Bíonn seans níos fearr ann go dtiocfaidh frithsheasmhacht in aghaidh antaibheathach chun cinn agus go scaipfear í [39] [comhdhearcadh saineolaithe]: • Nuair a úsáidtear antaibheathaigh speictrim leathain; • Nuair a úsáidtear antaibheathaigh ar feadh tréimhse fhada; • Nuair a úsáidtear dáileoga antaibheathach atá ró-íseal. Sampla Bíonn ardbhaol ann go dtiocfaidh ceifileaspóiriní, carbaipeineimí, fluaracuineolóin agus antaibheathaigh frithanaeróib faoi réir baictéir Ghram-dhiúltacha atá frithsheasmhach in aghaidh ildrugaí [40]. Bíonn tionchar fadtéarmach ag antaibheathaigh ar theacht chun cinn agus marthanacht na frithsheasmhachta in aghaidh antaibheathach sa mhicreaflóra. D’fhéadfadh an fhrithsheasmhacht sin aistriú chuig baictéir eile freisin [41]. Is minic a oideasaítear antaibheathaigh d’othair in ospidéil gan an tábhacht a bhaineann le húsáid stuama antaibheathach a mhíniú dóibh [comhdhearcadh saineolaithe]. Cén fáth ar cheart d’ospidéil maoirseacht antaibheathach a chur chun cinn? Tosaíocht ó thaobh sábháilteacht othar de agus ó thaobh sláinte poiblí de araon is ea úsáid stuama antaibheathach a chur chun cinn [31,42]. Sampla Bíonn ag méadú i gcónaí ar an líon tíortha Eorpacha a bhfuil treoir náisiúnta um chláir mhaoirseachta antaibheathach i bhfeidhm acu d’oideasóirí ospidéil. Tá in eolaire ECDC (nasc) acmhainní ar líne le haghaidh treoirlínte a fhorbairt. Tugtar cláir mhaoirseachta antaibheathach ar thionscnaimh bhainistíochta ábhar frithmhiocróbach lena gcuirtear úsáid stuama antaibheathach chun cinn [19,42-45]. Is féidir le cláir mhaoirseachta antaibheathach cur leis na nithe seo a leanas [42,45,46] [comhdhearcadh saineolaithe]: a) Barrfheabhsú a dhéanamh ar an dóigh a gcóireáiltear ionfhabhtuithe; b) Rátaí téarnaimh ó ionfhabhtuithe a mhéadú agus teipeanna cóireála a laghdú; c) An líon teagmhas díobhálach a eascraíonn as úsáid antaibheathach a laghdú; agus d) Frithsheasmhacht in aghaidh antaibheathach a chosc agus a laghdú, mar aon le bearta um ionfhabhtú a chosc agus a rialú. Samplaí I suirbhé a rinneadh le déanaí ar ospidéil a raibh clár maoirseachta antaibheathach curtha chun feidhme acu [47]: • Thuairiscigh 96% díobh gur tháinig laghdú ar oideasú míchuí; • Thuairiscigh 86% díobh gur tháinig laghdú ar úsáid antaibheathach speictrim leathain; • Thuairiscigh 80% díobh gur tháinig laghdú ar chaiteachas; • Thuairiscigh 71% díobh gur tháinig laghdú ar ionfhabhtuithe atá bainteach le cúram sláinte; • Thuairiscigh 65% díobh gur tháinig laghdú ar fhad fanachta nó ar mhortlaíocht; • Thuairiscigh 58% díobh gur tháinig laghdú ar fhrithsheasmhacht in aghaidh antaibheathach. Is féidir le cláir mhaoirseachta antaibheathach rátaí ionfhabhtaithe Clostridium difficile a laghdú go rathúil [19,22,43,44,48]. Sampla Tháinig laghdú ar mhinicíocht ionfhabhtuithe Clostridium difficile sna bardaí míochaine agus máinliachta d’ospidéal géarmhíochaine ginearálta sa Ríocht Aontaithe mar thoradh ar threoirlínte eimpíreacha athbhreithnithe um chóireáil antaibheathach le haghaidh ionfhabhtuithe coitianta agus mar thoradh ar bhearta sriantacha maidir le húsáid fluaracuineolón agus ceifileaspóiriní [48]. Is féidir le cláir mhaoirseachta antaibheathach costais chúram othar a laghdú [42,45,46]. Sampla Bunaithe ar anailís chomhthiomsaithe ar chláir mhaoirseachta antaibheathach, thit an tomhailt iomlán (faoi 19% ar fud na n-ospidéal agus faoi 40% in aonaid dianchúraim), laghdaíodh costais fhoriomlána antaibheathach (faoi thart ar aon trian) agus giorraíodh an fad fanachta san ospidéal (faoi 9%). Ní raibh aon mhéadú ann ar dhrochthorthaí othar de bharr na bhfeabhsuithe sin [46]. Conas a fheidhmítear cláir mhaoirseachta antaibheathach? Cuimsíonn cláir mhaoirseachta antaibheathach roinnt gníomhartha ilghnéitheacha, cosúil leo seo a leanas [19,42,43,44,48-57]: a) Tiomantas i measc an lucht ceannaireachta: a chinntiú go mbíonn na hacmhainní riachtanacha foirne, teicneolaíochta agus buiséid ar fáil; b) Ceannairí a cheapadh atá freagrach as an gclár foriomlán agus as úsáid antaibheathach; c) Foirne ospidéalbhunaithe, lena n-áirítear speisialtóirí galar tógálach, cógaiseoirí cliniciúla agus micribhitheolaithe cliniciúla, a bheith ag tabhairt tacaíocht d’oideasóirí; d) Iniúchadh réamhghníomhach a dhéanamh ar oidis antaibheathach agus aiseolas a thabhairt do bhaill foirne; e) Oiliúint agus oideachas a chur ar fáil do bhaill foirne míochaine, cógaslainne, saotharlainne, altranais agus neamhchliniciúla agus d’othair agus dá dteaghlach; f) Úsáid a bhaint as treoirlínte fianaisebhunaithe agus as beartais fhianaisebhunaithe um úsáid antaibheathach; g) Úsáid a bhaint as bearta sriantacha le haghaidh oidis antaibheathach (e.g. ceanglais réamhcheadaithe agus iarúdaraithe le haghaidh antaibheathaigh shonracha); h) Faireachán a dhéanamh ar fhrithsheasmhacht in aghaidh antaibheathach agus ar úsáid antaibheathach agus an fhaisnéis sin a chur ar fáil d’oideasóirí. Is iad seo a leanas samplaí de na straitéisí agus na gníomhartha maoirseachta antaibheathach atá ar bun i dtíortha Eorpacha agus de na torthaí atá orthu: An Fhrainc - Trí úsáid fluaracuineolón a shrianadh, laghdaíodh tomhailt na haicme sin d’antaibheathaigh agus laghdaíodh ráta Staphylococcus aureus atá frithsheasmhach in aghaidh meiticilline in ospidéal teagaisc [58]. An Fhrainc - Trí úsáid a bhaint as tacaíocht teicneolaíochta faisnéise le haghaidh oidis antaibheathach, laghdaíodh tomhailt antaibheathach i gcuid mhór ospidéal [59]. An Ghearmáin - Trí chóras ríomhairithe tacaíochta cinntí a chur chun feidhme, méadaíodh comhlíonadh treoirlínte arna n-oiriúnú go háitiúil, méadaíodh an líon laethanta a bhí saor ó antaibheathaigh agus laghdaíodh mortlaíocht i gcúig aonad dianchúraim thar thréimhse cúig bliana [60]. An Ungáir - Trí dhul i gcomhairle le speisialtóirí galar tógálach in aonad dianchúraim mháinliachta, agus trí bheartas um oideasú srianta a chur i bhfeidhm, laghdaíodh an úsáid a bhí á baint as gach cineál antaibheathaigh agus rinneadh laghdú suntasach ar an úsáid a bhí á baint as antaibheathaigh speictrim leathain [61]. An Iodáil - Trí chlár ceithre bliana um ionfhabhtú a rialú a reáchtáil, laghdaíodh an mhinicíocht ionfhabhtuithe agus coilínithe a raibh baictéir atá frithsheasmhach in aghaidh carbaipeineimí ina gcúis leo in ospidéal teagaisc. Mar chuid den chlár, tugadh faoi bhearta maoirseachta antaibheathach lenar díríodh ar úsáid carbaipeineimí [62]. An Ísiltír - Trí mhearphróiseáil tástálacha micribhitheolaíocha a chur chun feidhme, méadaíodh an céatadán d’othair a bhí ag fáil cóireáil chuí laistigh den chéad 48 n-uaire in ospidéal teagaisc [63]. An Ísiltír - Trí dhul i mbun iniúchtaí cáis ar úsáid antaibheathach a athmheasúnú tar éis 48 n-uaire, laghdaíodh tomhailt antaibheathach agus an fad fanachta i mbarda úireolaíochta d’ospidéal acadúil. Baineadh toradh dearfach díreach amach ar infheistíocht freisin [64,65]. An Pholainn - Trí threoirlínte a cheapadh um oidis antaibheathach agus um cheadú réamhúdaraithe le haghaidh antaibheathaigh shrianta, laghdaíodh tomhailt iomlán antaibheathach i mbarda péidiatrach ginearálta [66]. An Spáinn - Trí oideachas a chur ar fáil ar threoirlínte agus trí aiseolas rialta a sholáthar, cuireadh feabhas 26% ar an ráta cóireálacha cuí agus rinneadh laghdú 42% ar thomhailt antaibheathach in ospidéal teagaisc threasaigh. Baineadh an dá éacht sin amach laistigh de bhliain amháin freisin [67]. An tSualainn - Trí iniúchadh a dhéanamh dhá uair sa tseachtain ar rannóg míochaine inmheánaí agus trí aiseolas a thabhairt ina leith, rinneadh dearbhlaghdú 27% ar úsáid antaibheathach, go háirithe antaibheathaigh speictrim leathain (ceifileaspóiriní agus fluaracuineolóin) agus laghdaíodh fad na cóireála antaibheathach. Bhíothas in ann aistriú níos luaithe go teiripe bhéil freisin [68].