Israeli study finds antibiotics overused in some end-of-life patients
A survey of Israeli physicians and analysis of patient data has found that antibiotics are overused in patients with end-of-life advanced directives, Israeli researchers reported today in Infection Control and Hospital Epidemiology.
In the descriptive cross-sectional study, the researchers administered a questionnaire to 213 physicians at four acute care and two post-acute care hospitals and collected data on 932 of their patients, all of whom had died in the 4 months preceding the survey. The data included end-of-life patient diagnoses, medical treatment, antibiotic days of therapy (DOT), and consultations with infectious disease (ID) physicians. The survey contained questions on sociodemographic and organizational factors, physician knowledge, and burnout.
Of the 932 deaths, 435 of 664 were end-of-life patients with advanced directives. The rate of most treatments in end-of-life patients with advanced directives was significantly lower than in those with no advanced directives, except for antibiotics and blood products.
Of the end-of-life patients with advanced directives, 74% received antibiotics; 29.9% of those who received antibiotics had cultures with multidrug-resistant organisms, and antibiotics were discontinued in only 5%. Half of the physicians lacked knowledge concerning antibiotics use issues, and physicians caring for end-of-life patients with advanced directives had significantly fewer consultations with ID physicians (mean rate, 0.27) than those caring for patients without advanced directives (mean rate, 0.47).
ID physicians reported significantly higher emotional exhaustion levels (mean rate, 29) than other medical specialties (mean rate, 19.2). Antibiotic DOT was significantly higher when patients had ID consultations (mean rate, 21.6) than in patients who did not (mean rate, 16.2). Antibiotic DOT was significantly higher in post–acute-care hospitals or geriatric wards than in other types of hospitals or wards.
In light of the findings, the authors of the study recommend supplementing antibiotic stewardship guidelines in Israeli hospitals with guidance on end-of-life prescribing, adding simulation-based education to deal with end-of-life issues, and encouraging providers to consult with ID physicians.
Aug 28 Infect Control Hosp Epidemiol abstract
Vaccine for hypervirulent Klebsiella pneumoniae shows promise in mice
A vaccine targeting hypervirulent strains of Klebsiella pneumoniae has shown early promise in mouse experiments, researchers from the Washington University School of Medicine in St. Louis and biotechnology start-up VaxNewMo reported yesterday in the Proceedings of the National Academy of Sciences.
The bioconjugate vaccine was designed to target the two most common hypervirulent serotypes of K pneumoniae, K1 and K2, which account for 70% of hypervirulent K pneumoniae cases. While most K pneumonia infections occur in hospital patients with compromised immune systems, hypervirulent strains that cause invasive infections in otherwise healthy people are on the rise, and there have been increasing reports of hypervirulent, multidrug-resistant strains that are extremely difficult to treat. The researchers believe a vaccine against these strains could help avert a serious public health threat.
In preclinical studies, the researchers tested the vaccine, which was produced using genetically modified Escherichia coli cells, in four groups of five mice each, with one group receiving a placebo. After three doses, they then infected the mice with K1 and K2 strains of K pneumoniae, using an amount of bacteria that had previously been shown to be lethal in mice.
The results showed that 80% of the placebo-treated mice challenged with the K1 strain died, while only 20% of the vaccine-treated mice died. Of the mice infected with the K2 strain, 30% of those who received the placebo died, compared with none of the mice who received the vaccine. The vaccine was less successful when the mice were exposed to higher doses of the K1 strain, but the vaccinated mice still had a statistically significant increase in survival compared with the placebo group.
"We are very happy with how effective this vaccine was," study co-author Mario Feldman, PhD, a professor of molecular microbiology at Washington University School of Medicine and co-founder of VaxNewMo, said in a university press release. "We're working on scaling up production and optimizing the protocol so we can be ready to take the vaccine into clinical trials soon."
Aug 27 Proc Natl Acad Sci study
Aug 27 Washington University press release
Pre-entry TB screening linked to reduced TB incidence in UK immigrants
A pre-entry screening program for active tuberculosis (TB), along with early primary care registration and post-entry screening for latent TB, is associated with reduced TB incidence in new migrants to the United Kingdom, researchers reported yesterday in the Lancet Infectious Diseases.
In the study, researchers from Imperial College London and Public Health England followed a cohort of migrants from 66 countries with high TB incidence who tested negative for active TB at pre-entry screening from 2011 through 2014, then compared TB incidence in this group with a control group of migrants who were not screened for active TB. The aim of the study was to assess the effectiveness of the pre-entry screening program (rolled out in 2012) and a voluntary latent TB infection (LTBI) screening and treatment program for all new migrants from high-incidence countries.
The cohort comprised 224,234 migrants who were screened for active TB, and 118,738 migrants who were not. Of the screened migrants, 103,990 (50%) registered in primary care, while all individuals in the control group were registered in primary care. Overall, 1,828 TB cases were identified during the study. There were 26 incident active TB cases in migrants with no evidence of primary care registration, and 1,771 cases in the entire cohort of migrants who registered in primary care, for an incidence rate (IRR) of 174 (95% confidence interval [CI], 166 to 182) per 100,000 person-years.
Of the 103,990 screened migrants, 672 (0.64%) went on to develop TB, compared with 1,099 (0.93%) of 118,738 who were not screened (IRR, 1.49; 95% CI, 1.33 to 1. 67; P < 0.0001). Of the 222,728 migrants registered in primary care, 2,451 (1.10%) were screened for LTBI, of whom 421 (17.2%) tested positive and 1,961 (80.0%) tested negative; none developed active TB within the observed period. Time from arrival to primary care registration of 1 year or longer was associated with increased risk of active TB (IRR, 2.96; 95% CI, 2.59 to 3.38; P < 0.0001).
The study also found that migrants who settled in the least socioeconomically deprived areas of Britain had a lower risk of active TB by about 26%.
The authors of the study conclude, "Our study supports the hypothesis that the pre-entry screening programme for active tuberculosis and the post-entry screening programme for LTBI are probably responsible, at least in part, for the reduction in tuberculosis incidence in the UK in the past 6 years, as suggested in a previous study. Furthermore, our results suggest that promoting early access to health services for new migrants entering the UK would substantially reduce the burden of tuberculosis in this population."
Aug 27 Lancet Infect Dis study
