Digital stewardship cuts antibiotics for respiratory infections in UK study

Electronically delivered prescribing feedback and decision support interventions reduced antibiotic prescribing for respiratory infection (RTI) in adults by 12%, according to the results of a clinical trial published this week in the British Medical Journal.

In the open label cluster randomized controlled trial, British researchers evaluated the impact of a 12-month antimicrobial stewardship intervention that included a brief training webinar, automated monthly feedback reports of antibiotic prescribing sent by email, and electronic decision support tools to inform clinicians when an antibiotic is indicated. Intervention components were supported by a local practice champion. The primary outcome was the rate of antibiotic prescriptions for respiratory tract infection (RTI) per 1,000 patient years.

The trial included 79 general practices across the United Kingdom; 41 practices were in the stewardship arm, and 38 were in the usual-care arm. The overall adjusted rate ratio for antibiotic prescribing for RTI was 0.88 (95% confidence interval [CI], 0.78 to 0.99, P = 0.04), with prescribing rates of 98.7 per 1,000 patient years in the stewardship group (31,907 prescriptions) and 107.6 per 1,000 patient years for usual care (27,923 prescriptions).

Results of the subgroup analysis showed that the intervention had the greatest impact on prescribing for adults aged 15 to 84 (adjusted rate ratio, 0.84; 95% CI, 0.75 to 0.95), with one antibiotic prescription per year avoided for every 62 patients (95% CI, 40 to 200). But there was no evidence of an effect for children under 15 (adjusted rate ratio, 0.96; 95% CI, 0.82 to 1.12) or adults over 85 (adjusted rate ratio, .97; 95% CI, 0.79 to 1.18). There was also no evidence of an increase in serious bacterial complications in the stewardship arm (rate ratio, 0.92; 95% CI, 0.74 to 1.13).

"Although the absolute impact is moderate, it is likely to be important for public health in the drive to reduce antibiotic prescribing and the risks of antimicrobial resistance," the authors of the study concluded. "Interventions using data from electronic health records might be used to promote antimicrobial stewardship in primary care and might be readily scaled up. The needs of very young or old patients need specific consideration." 
Feb 13 BMJ study

Cephalosporin resistance may raise risk of recurrent UTIs

In a retrospective cohort study yesterday in BMC Infectious Diseases, researchers with the University of Pennsylvania Perelman School of Medicine reported that extended-spectrum cephalosporin (ESC) resistance in community-onset urinary tract infection (UTI) caused by Enterobacteriaceae (EB) is significantly associated with increased risk of recurrent UTI within 12 months compared with ESC-susceptible EB.

The researchers evaluated all patients presenting to emergency departments or outpatient practices within the University of Pennsylvania Health System from December 2010 through April 2013. Exposed patients were defined as those with an EB UTI demonstrating resistance to an ESC, and unexposed patients were those who had a UTI with ESC-susceptible EB. The primary outcome was time to first recurrent UTI.

A total of 302 patients with an index community-onset EB UTI were included, with 151 exposed and 151 unexposed. Overall, 163 (54%) patients experienced a recurrent UTI with a median time to recurrence of 69 days (interquartile range, 25 to 183). On multivariable analyses, ESC-resistance was associated with an increased hazard of recurrent UTI (adjusted hazard ratio [aHR], 1.39, 95% confidence interval [CI], 1.01 to 1.91, P = 0.04). Other variables that were independently associated with recurrence included a history of UTI 6 months prior to the index UTI (aHR, 1.59; 95% CI, 1.17 to 2.15, P < 0.01) and presence of a urinary catheter at the time of the index UTI (aHR 1.59; 95% CI, 1.06 to 2.38, P = 0.03).

Secondarily, the researchers found that when the treatment for the index UTI was adjusted for initial inappropriate antibiotic therapy, there was no longer a significant association between ESC-resistance and time to recurrent UTI (aHR 1.26; 95% CI, 0.91 to 1.76, P = 0.17), suggesting that the increased risk of recurrence with an ESC-resistant EB UTI could be related to the timing and selection of the treatment regimen.

The researchers say further studies are needed to determine interventions that may reduce the risk of recurrence, including different antibiotic regimens and durations.
Feb 14 BMC Infect Dis study

Survey highlights room for improvement in pediatric C diff testing

The results of an electronic survey sent to pediatric infectious disease (PID) members of the Infectious Diseases Society of America's (IDSA's) Emerging Infections Network suggest there are opportunities to improve Clostridioides difficile infection (CDI) diagnostic stewardship practices in children. The findings appear today in Infection Control and Hospital Epidemiology.

The objective of the survey was to determine the prevalence of CDI diagnostic practices in the United States as they relate to avoiding detection of asymptomatic C difficile carriage in children. Misclassification of asymptomatic carriers as having CDI can lead to unnecessary CDI antibiotic therapy and inaccurate CDI surveillance. One particular concern is the use of nucleic acid amplification tests (NAATs) without additional toxin testing. NAATs can detect C difficile strains that have the potential to produce toxins, but do not detect secreted toxins in the stool and therefore have poor diagnostic predictive value for CDI. Another is unnecessary testing in infants and young children, who have a low likelihood of CDI.

Among 345 eligible respondents, 196 (57%) responded; 162 of these (83%) were aware of their institutional policies for CDI testing and management, and 159 (98%) respondents knew their institution’s C difficile testing method. Among these respondents, 99 (62%) said they use NAAT without toxin testing and 60 (38%) use toxin testing, either as a single test or a multistep algorithm.

Of 153 respondents aware of symptom-based restrictions on C difficile testing, 10 (7%) reported that formed stools were tested for C difficile at their institution, and 76 of 151 (50%) respondents who were aware of age-based restrictions on testing reported that their institution does not restrict testing in infants and young children. The frequency of symptom- and age-based testing restrictions did not vary between institutions using NAAT alone compared with those using toxin testing for C difficile diagnosis. Of 143 respondents at institutions with neonatal intensive care units (NICUs), 26 (16%) permit testing of NICU patients and 12 of 26 (46%) treat CDI with antibiotics in this patient population.

The survey data were gathered shortly before publication of updated clinical practice guidelines for CDI from IDSA and the Society for Healthcare Epidemiology of America (SHEA), which include recommendations to limit testing in pediatric patients with low likelihood of CDI and to avoid detection of asymptomatic carriage.

The authors of the study conclude, "In summary, these data suggest that there are pervasive opportunities to improve CDI diagnostic stewardship practices in children and to develop institutional policies to align with recently updated IDSA/SHEA guidance, particularly in hospitals using NAATs alone for CDI diagnosis in children."
Feb 15 Infect Control Hosp Epidemiol abstract

Survey finds low postgrad stewardship training in pharmacists, nurses

Originally published by CIDRAP News Feb 14

British investigators conducted an international survey and found that postgraduate training and support in antibiotic prescribing remain low among nurses and pharmacists, and, although antibiotic policies and committees are established in most institutions, surveillance of antibiotic use is not, according to a new report in Antimicrobial Resistance & Infection Control.

The authors polled 505 professionals who had taken a Massive Online Open Course (MOOC) on antibiotic stewardship. Their aim was to assess their organizations' resources for antimicrobial stewardship. Of the respondents, 36% were physicians, 26% pharmacists, 18% nurses, and 20% other professions.

Post-graduate training in infection management and stewardship was reported by 56% of physicians, 43% of nurses, and 35% of pharmacists. The researchers also found that 65% of primary care centers had antibiotic policies, compared with 83% of teaching hospitals and 79% of regional hospitals.

Fifty-eight percent of teaching hospitals and 62% of regional hospitals reported a surveillance mechanism for antibiotic consumption. Respondents identified antimicrobial resistance, patient needs, policy, peer influence, and specialty-level culture and practices as important determinants for stewardship decision-making.
Feb 12 Antimicrob Resist Infect Control study

Use of antibiotics to promote growth in food animals down, OIE report says

Originally published by CIDRAP News Feb 14

The use of antimicrobials for growth promotion in food animals worldwide is down, and more nations are reporting specific data on the use of the drugs in livestock, according to the World Organization for Animal Health's (OIE's) third annual report on antimicrobial agents in animals, published today.

A total of 110 countries of 155 surveyed (71%) did not use any antimicrobial drugs for growth promotion as of 2017, which is up from 86 of 146 (59%) reported in the second annual report, published in 2017. Of the 45 countries that used antimicrobials to promote growth, according to today's report, 18 (40%) had a regulatory framework that either provided a list of antimicrobials that can be used as growth promoters or provided a list of those that should not be used as growth promoters.

In addition, today's report noted that 118 nations of 155 (76%) reported quantitative data for one or more years from 2015 to 2017, up slightly from 107 of 146 countries (73%) in the 2017 report. In the OIE's first such report, published in 2016, the rate was 89 of 130 nations (68%).

The authors of the report conclude, "The OIE remains strongly committed to supporting our Members in developing robust measurement and transparent reporting mechanisms for antimicrobial use, but the challenges for many of our Members must not be under-estimated."
Feb 14 OIE report

Dental antibiotic stewardship program shows promising results

Originally published by CIDRAP News Feb 13

A team of dentists, pharmacists, and physicians at the University of Illinois reported today in Open Forum Infectious Diseases that implementation of a comprehensive antibiotic stewardship intervention in a dental practice was associated with a significant improvement in antibiotic prescribing.

After conducting a baseline needs assessment and literature evaluation to identify opportunities to improve antibiotic prescribing, faculty from the University of Illinois at Chicago (UIC) College of Dentistry, UIC College of Pharmacy, and the University of Illinois Hospital and Health Sciences System devised and implemented a multimodal intervention that focused on antibiotic use for acute oral infections, a common condition in the UIC dental clinic.

The intervention, which is consistent with the Centers for Disease Control and Prevention's (CDC's) Core Elements of Outpatient Antibiotic Stewardship, included patient and provider education, clinical guideline development, and an assessment of the antibiotic prescribing rate per urgent care visit before and after the educational intervention.

The results of the assessment showed that, among all providers in the practice, the antibiotic prescribing rate per urgent care visit decreased by 72.9% before and after the multimodal intervention (pre-intervention urgent care prescribing rate [September 2017], 8.5% [24/283]; post-intervention [May 2018], 2.3% [8/352], P < 0.001). Clinical providers also reported that they had become more conscious of appropriate prescribing since implementation of the educational guidelines.

The authors of the study say the results suggest that simple educational interventions may decrease antibiotic prescribing in the dental setting, which accounts for 10% of all outpatient prescribing, and may be adapted to other dental practices.
Feb 13 Open Forum Infect Dis abstract

Study weighs value of antibiotics for resistant Staph in pandemic settings

Originally published by CIDRAP News Feb 13

An effective antibiotic that can treat secondary Staphylococcus aureus infections in a pandemic flu outbreak is worth more than $3 billion, according to a new study by researchers from the Center for Disease Dynamics, Economics, and Policy (CDDEP) and their colleagues in Scotland and the Netherlands.

Writing in Health Economics, the authors said though antibiotic reserves are part of pandemic preparedness plans, experts haven't explores the value of stockpiling or conserving the effectiveness of antibiotics, despite the high morbidity of secondary bacterial infections and the growing ineffectiveness of antibiotics because of emerging antibiotic-resistant organisms.

Using a mathematical framework based on UK preparedness plan assumptions the scientists estimated the value of investing in developing and conserving an antibiotic to lessen the burden of bacterial infections from resistant S aureus during a pandemic flu outbreak.

The team found that the value of withholding an effective new oral antibiotic can be positive and significant unless the pandemic is mild, with few secondary illnesses involving the resistant strain or if most patients can be treated intravenously.

Ramanan Laxminarayan, PhD, MPH, CDDEP director and the study's senior author, said in a CDDEP press release that secondary bacterial infections are a major cause of death and disability with flu, and antibiotic resistance is a major barrier to treating those infections. "This study shows that the value of an effective antibiotic against Staph infections, as an insurance policy against future pandemics, is between $3 [billion] and 4 billion at baseline," he said.
Feb 11 Health Econ abstract
Feb 12 CDDEP press release

Study: Hospital readmission for Staph bacteremia patients common, costly

Originally published by CIDRAP News Feb 12

New research by scientists with the University of Mississippi Medical Center indicates that 30-day hospital readmission among patients who survived initial hospitalization with S aureus bloodstream infections is common and costly. The findings appeared yesterday in Clinical Infectious Diseases.

Using the 2014 Nationwide Readmissions Database, the researchers examined 30-day readmission, mortality, length of stay, and costs associated with initial hospitalization for methicillin-susceptible and methicillin-resistant S aureus (MSSA and MRSA) bacteremia. Although research on mortality from S aureus bacteremia is extensive, less is known about hospital readmission, and greater understanding of readmission, and its risk factors, could result in improved patient care.

From January 2014 through November 2014, the researchers identified 92,089 patients with S aureus bacteremia, 48.5% of whom had MRSA bacteremia. The all-cause 30-day readmission rate was 22% overall, with no significant difference between MRSA and MSSA cases. But patients with MRSA bacteremia were 17% more likely to have 30-day readmission with S aureus bacteremia recurrence (hazard ratio, 1.17; 95% confidence interval [CI], 1.02 to 1.35). In addition, patients with MRSA bacteremia had higher in-hospital mortality (odds ratio,1.15; 95% CI, 1.07 to 1.22), and longer hospital stays (incidence rate ratio, 1.08; 95% CI, 1.06 to 1.11).

Readmission with bacteremia recurrence was particularly associated with endocarditis, congestive heart failure, end stage renal failure, underlying immunocompromising comorbidities, and drug abuse. The mean overall cost of readmission was $12,425 per patient, and $19,186 per patient in those with bacteremia recurrence.

The authors of the study conclude, "Efforts should continue to optimize patient care, particularly for those with risk factors for readmission, to decrease readmissions and associated morbidity and mortality in the context of S aureus bacteremia." 
Feb 11 Clin Infect Dis abstract

Review of hospital stewardship programs finds economic impacts

Originally published by CIDRAP News Feb 12

A systematic review of previous research suggests that hospital antimicrobial stewardship programs (ASPs) help save costs by decreasing length of stay and antibiotic expenditures.

The review, published today in Antimicrobial Resistance and Infection Control, looked at studies published from 2000 through 2017 that evaluated patient and/or economic outcomes after implementation of hospital ASPs. Key economic outcomes were costs associated with antibiotics, length of stay, and total costs (including operation and implementation). A total of 146 primary research studies were included on the final analysis, the majority of which were conducted in 500-1,000 bed hospitals in North America (49%), Europe (25%), and Asia (14%).

Of the studies that evaluated length of stay and antibiotic expenditure, 85% (58 of 68 studies) showed a reduction in length of stay and 92% (80 of 87 studies) showed a decrease in antimicrobial costs following ASP implementation. Average cost savings were $732 per patient in US studies and €198 per patient ($224 US) in European studies, with length of stay being a key driver of cost savings. Savings were higher among hospitals with ASPs that included therapy review and antibiotic restrictions.

"Overall, this systematic review demonstrates that ASPs can offset or reduce costs while improving some patient outcomes, thereby suggesting high value for certain healthcare systems," the authors of the review write. "However, for the findings to be globally relevant, more studies, particularly in real world settings across a diverse range of geographies and resource settings are required, so that a full critical appraisal of the true value of these programs can be made."
Feb 12 Antimicrob Resist Infect Control study

Fleming Fund selects UK partners for African stewardship program

Originally published by CIDRAP News Feb 12

The Fleming Fund, a UK government aid program to help low- and middle-income countries fight antimicrobial resistance (AMR), today announced the 12 hospitals and research institutions that will work with partners in four African countries to promote antimicrobial stewardship.

Through the Commonwealth Partnerships for Antimicrobial Stewardship program, clinicians, nurses and pharmacists from 12 National Health Service (NHS) trusts and UK academic institutions will work with partner teams in hospitals in Ghana, Tanzania, Uganda, and Zambia to improve stewardship practices and protocols and develop tools that help reduce the spread of AMR. The winners were chosen for their strong records in antimicrobial stewardship.

"The quality of all the proposals received was extremely high and the selected NHS teams will make a great impact working in partnership with teams on stewardship practices across Africa," Keith Ridge, England's Chief Pharmaceutical Officer, said in a press release.

The Fleming Fund will provide £1.3 million ($1.68 million US) to support the projects, which will last up to 15 months. 
Feb 12 Fleming Fund press release

CDC: 19 states may have raw milk exposure to drug-resistant Brucella

Originally published by CIDRAP News Feb 11

Today the CDC announced that health workers are investigating potential exposures to a drug-resistant Brucella strain RB51 in 19 states. The strain comes from raw (unpasteurized) milk from Miller's Biodiversity Farm in Quarryville, Penn.

"One case of RB51 infection (brucellosis) has been confirmed in New York, and an unknown number of people may have been exposed to RB51 from drinking the milk from this farm," the CDC said. "This type of Brucella is resistant to first-line drugs and can be difficult to diagnose because of limited testing options and the fact that early brucellosis symptoms are similar to those of more common illnesses like flu.­"

In November of 2018, a New York resident became the third American to be diagnosed as having brucellosis caused by the RB51 strain. Two cases (unrelated to the Quarryville farm) were also reported in 2017, in New Jersey and Texas.

The 19 states in question are Alabama, California, Connecticut, Florida, Georgia, Iowa, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, and Virginia.

The CDC said anyone who has consumed raw milk from the farm between January of 2016 and January 2019 may have been exposed to the strain. 
Feb 8 CDC alert

Study: MDROs prevalent in California nursing homes, long-term acute care

Originally published by CIDRAP News Feb 11

A team of researchers studying nursing homes and long-term acute care facilities in southern California reported today in Clinical Infectious Diseases that a large majority of residents and patients in these facilities harbor multidrug-resistant organisms (MDROs).

The one-day point prevalence study was conducted by researchers with the Shared Health Intervention to Eliminate Life-Threatening Dissemination of MDROs in Orange County (SHIELD OC), a regional public health collaborative to measure the impacts of a coordinated infection prevention initiative on MDRO carriage and infection at 18 nursing homes (NHs), 17 short term acute care hospitals, and 3 long term acute care facilities (LTACs). The aim was to establish baseline MDRO prevalence in the NH and LTACS settings, as patients and residents in these facilities are transferred frequently and are known to serve as a source of MDRO transmission.

From September 2016 to March 2017, a random sampling of 1,050 patients from the 21 facilities were screened for MRSA, vancomycin-resistance Enterococcus spp. (VRE), extended-spectrum beta-lactamase producing organisms (ESBL), and carbapenem-resistant Enterobacteriaceae (CRE) using nares, axilla/groin, and peri-rectal swabs. In addition, researchers performed multivariate analyses of swab data to evaluate person-level and facility-level characteristics associates with MDRO carriage.

The overall prevalence of MDROs in the 21 facilities was 67%, with at least one MDRO found in 65% of NH residents and 80% of LTAC residents. Twenty-seven percent of NH residents and LTAC patients were found to carry multiple MDRO pathogens. The most common MDROs in NHs were MRSA (42%) and ESBL (34%); in LTACs they were VRE (55%) and ESBL (38%). MDRO status was known for only 18% of NH residents and 49% of LTAC patients. Multivariable models indicated that history of MRSA (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2 to 2.4, P = 0.04), VRE (OR 2.1; 95% CI, 1.2 to 3.8, P = 0.01), ESBL (OR, 1.6; 95% CI, 1.1 to 2.3, P = 0.03) and diabetes (OR, 1.3; 95% CI, 1.0 to 1.7, P = 0.03) were associated with any MDRO carriage.

"In summary, MDRO colonization prevalence is high within the NH and LTAC setting, far exceeding published reports in acute care hospitals. These data demonstrate the importance of NH/LTACs as a dominant MDRO reservoir in the healthcare system," the authors of the study write. "Investment in universal strategies of infection prevention and antimicrobial stewardship that are applicable to nursing homes and long term acute care hospitals are greatly needed and arguably overdue."
Feb 11 Clin Infect Dis abstract