Stewardship / Resistance Scan for Oct 20, 2020

News brief

VA study finds increased antibiotic use during early months of COVID-19

Data from inpatient Veterans Administration (VA) hospitals show a significant increase in antibiotic use from January to May, largely negating a downward trend over the previous 5 years, researchers reported today in Infection Control and Hospital Epidemiology.

To provide a broad overview of changes in antibiotic use at VA facilities during the COVID-19 pandemic, researchers examined data from acute inpatient care units at 84 VA facilities from 2015 through 2020, using only data from Jan 1 to May 31 of each year. They measured the impact in days of therapy (DOT) per 1,000 days-present (DP), but also examined the changes in the total antibiotic DOT to account for decreases in healthcare use during the pandemic.

From 2015 through 2019, antibiotic use decreased each year for Jan 1 to May 31 from 638 to 602 DOT/1,000 PD, a mean decrease of 9.1 DOT/1,000 PD per year. Consistent year-to-year declines were observed for broad-spectrum agents for community-onset infections, broad-spectrum agents for hospital-onset infections, and agents used for antibiotic-resistant gram-positive infections.

In contrast, the same period in 2020 saw antibiotic use increase from 602 to 628 DOT/1,000 PD, with increases observed for broad-spectrum agents used for community-onset and hospital-onset infections. The largest increase in the rate of use was for antibiotics typically prescribed for empiric therapy for community-acquired pneumonia (CAP). Total antibiotic DOT decreased from 721,761 in 2019 to 643,455 in 2020, likely because of a decline in DP (a 14.5% decline from 2019 to 2020) linked to fewer elective procedures and fewer emergency department visits.

A subset analysis that excluded VA facilities in states that were hit hard early in the pandemic showed similar results.

The authors say that while overall institutional antibiotic use fell, the increased density of antibiotic use (as measured by the use per patient per day) may adversely affect patient outcomes and institutional antibiotic resistance patterns.
Oct 20 Infect Control Hosp Epidemiol abstract

Clinical decision support tied to improved antibiotic use for pneumonia

A single-center study found that a clinical decision support (CDS) tool supplemented by antimicrobial stewardship program (ASP) audit and feedback led to robust improvements in antibiotic use for pneumonia patients, University of Utah researchers reported yesterday in Open Forum Infectious Diseases.

The study, conducted at the University of Utah Hospital, was a pre-post intervention analysis of inpatients with pneumonia that evaluated a CAP pathway built around a CDS advisory that aimed to help providers identify appropriate antibiotic therapy for CAP patients on admission, promote early transition from intravenous (IV) to oral therapy, and shorten overall durations of antibiotic therapy.

The study compared three 6-month phases of intervention—education alone, education and a CDS-driven CAP pathway coupled with active ASP and provider feedback, and a CDS-driven CAP pathway without stewardship—with the 12 months preceding the interventions. The primary outcomes were length of intravenous (IV) antibiotic therapy and total antibiotic therapy. Secondary outcomes included clinical, process, and cost outcomes.

A total of 400 CAP patients were included in the baseline period and 623 in the intervention phases. When compared to the baseline period, length of IV antibiotic therapy and total antibiotic therapy was unchanged in phase 1, while phase 2 of the intervention was associated with significantly lower length of IV and total antibiotic therapy, higher procalcitonin lab use, and a 20% cost reduction. Phase 3 was also associated with shorter IV antibiotic therapy and increased procalcitonin testing, and a non-significant reduction of 16% in costs.

There was no change in inpatient mortality or 30-day readmissions between any of the phases.

The authors attribute the success of phase 2 to its being the most intensive, with the ASP conducting prospective audit and feedback of all CAP patients in addition to using the CAP pathway.

"The early initiation of a CDS-driven CAP pathway supplemented by ASP review appears to improve healthcare value through decreased IV antibiotic length of therapy, decreased total length of therapy and decreased costs with similar clinical outcomes," the authors wrote.
Oct 19 Open Forum Infect Dis abstract

News Scan for Oct 20, 2020

News brief

Minorities in food, agriculture jobs especially hard hit by COVID-19

Racial and ethnic minority workers have been disproportionately affected by COVID-19 in food manufacturing and agriculture workplaces, according to a study yesterday in Emerging Infectious Diseases.

Demographics were not available for all 742 sites surveyed across 30 states, but for those that were, 83.2% of confirmed cases involved minorities even though they made up only 47.4% of all workers.

Researchers from the Centers for Disease Control and Prevention (CDC) and their state partners looked at state health department data for workers in food manufacturing and agricultural workplaces from Mar 1 through May 31, finding 8,978 cases and 55 (0.6%) deaths. High-contact jobs, high-density workplaces, and shared housing and transportation all increased risk factors. Of the 5,957 cases that included information on symptoms, 4,957 (83.2%) of patients reported symptoms, while 1,000 (16.8%) were asymptomatic or presymptomatic.

Only 5,721 cases in 28 states included racial or ethnic information, and 4,164 of those infections (72.8%) were found in Hispanic employees—a population that made up only 36.5% of the studied workforce. White workers made up 52.6% of the workforce and 16.8% of the cases, black workers 5.9% and 6.3%, and Asian/Pacific Islander workers 1.5% and 4.1%, respectively. Other characteristics that were tabulated when possible were sex (61.6% of cases were found in men and 38.4% in women) and age (44.3% of infections occurred in people 20 to 39 years old).

The authors conclude, "These findings should be considered when implementing workplace interventions to ensure communication and training are culturally and linguistically tailored for each workforce." They add that better testing strategies, contact tracing, and symptom screening are needed. These findings are similar to earlier CDC studies that focused on the meat and poultry industries (May 8, Jul 10).
Oct 19 Emerg Infect Dis study

H5N8 avian flu strikes poultry farm and nature park in Israel

Israel has reported two more highly pathogenic H5N8 avian flu outbreaks, one at a commercial poultry farm and the other at a nature preserve, according to the latest notifications from the World Organization for Animal Health (OIE).

The poultry farm outbreak began on Oct 17 in one pen at a poultry breeding facility in Hazafon, killing 65 of 34,000 susceptible birds. The survivors were slated for culling. Officials said the source of the virus is probably contact with wild migratory birds and the event is the first at a farm since April 2019.

Also, the country reported an outbreak at a nature preserve in Tel Aviv that started on Oct 17 with the discovery of a young swan found dead in the water of a lake. Investigators said the virus likely came from contact with wild species, given that about 500 million migratory birds from Europe are currently passing over Israel. The country recently reported a similar outbreak at a Jerusalem zoo.
Oct 19 OIE report on H5N8 at Israeli poultry farm
Oct 19 OIE report on H5N8 at Israeli nature park