Survey suggests end-of-life situations affect views on antibiotic use

The results of a survey of physicians published today in Infection Control and Hospital Epidemiology indicate that when treating patients at the end of life, physicians' decisions about continuing antimicrobial use are influenced by many factors.

The 51-item survey containing both closed and open-ended questions on end-of-life antimicrobial use—estimated by some studies to be as high as 87%—was administered to physicians affiliated with the University of Pennsylvania and Children's Hospital of Philadelphia from January through April 2017. The objective was to examine reasons why physicians continue or discontinue antibiotics at end of life, and whether they prefer to continue antibiotics use in certain situations.

Of the 637 physicians surveyed, 283 (44.4%) responded. Most physicians agreed that overuse of antibiotics contributes to antibiotic resistance (96.1%) and that medical practitioners have a responsibility to reduce the use of unnecessary antibiotics (99.3%), but less than half (49.8%) agreed that antibiotic use in end-of-life care contributes to resistance. In addition, 86.2% responded that it was important to respect a patient's request to continue antibiotic treatment for an infection at the end of life.

For every infection surveyed, a higher proportion of pediatricians said they would often or always continue antibiotic treatment for active infections, and 19.9% of pediatricians said they would often or always continue antibiotic therapy for patients in hospice care whose death was imminent, compared to 2.7% of adult physicians. Analysis of free-text answers by 73 respondents revealed three overarching answers for continuing antibiotic therapy at end of life: to avoid being seen as withholding treatment, to prolong life in the face of diagnostic uncertainty, and to reduce pain.

"In conclusion, many factors, including patient-centeredness, workplace culture, and clinical considerations, contribute to the decision framework that physicians utilize when prescribing antimicrobials at the end of life," the authors write. They suggest further research is needed to assess the attitudes and factors that shape decision-making in order to guide antibiotic recommendations at the end of life.
Feb 12 Infect Control Hosp Epidemiol study

Paper explains why ID physicians should lead ASPs

A new white paper by members of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, and the Pediatric Infectious Diseases Society makes the case that infectious disease (ID) physicians are best-suited to lead antimicrobial stewardship programs (ASPs).

The paper, published today in Clinical Infectious Diseases, argues that ID physicians possess unique experience and skills by virtue of their training that make them a natural choice for leading ASPs and maximizing the potential of members of multidisciplinary ASP teams. Among their skills  are expertise in monitoring and managing patients with infections across all healthcare settings, comprehensive knowledge of antimicrobial use and adverse consequences, knowledge of microbiologic principles that inform rational prescribing, and the ability to drive quality improvement. And because ID physicians also frequently serve in both formal and informal leadership roles in quality improvement and patient safety initiatives, they are accustomed to managing multidisciplinary teams and recognizing opportunities for change and improvement.

"ASP ID physicians can influence antimicrobial prescribing patterns by raising awareness of harms associated with unnecessary antimicrobial use and by drawing on their experience as leaders of multidisciplinary teams to build trust and consensus," the authors write.

The paper goes on to cite several examples of robust results achieved by ID physician-led ASPs, including significant reductions in broad-spectrum antibiotic use, antimicrobial days of therapy, antimicrobial costs, and Clostridium difficile rates. It also provides suggestions for arrangements that can extend the reach of ID physicians to facilities with limited resources, such as telemedicine programs and contractual agreements that permit ID physicians to combine off-site leadership with limited in-person visits.

The authors add that ASP teams should also include ID pharmacists, nurses, microbiologists, and infection preventionists, and that team members should be provided with appropriate resources.
Feb 12 Clin Infect Dis paper

Commentary supports use of gloves and gowns for MRSA, VRE

A commentary today in the Journal of the American Medical Association (JAMA) argues that despite the lack of a strong clinical evidence base and concerns about costs and impact on patients, contact precautions remain an important strategy for infection prevention, particularly for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE).

In recent years, large clinical trials have failed to clarify whether the use of gloves and gowns is an effective strategy for preventing transmission of all types of drug-resistant pathogens, and as a result, there have been some calls for more selective use of contact precautions in settings of endemic MRSA and VRE. But the authors of the paper argue that contact precautions have an important role in clinical care and infection control. In particular, they cite a decline in healthcare-associated MRSA infections in the United States and Europe over the past 10-12 years that has coincided with the implementation of infection-control practices that include contact precautions, along with hand hygiene and active surveillance.

The authors say part of the problem is estimating the effectiveness of contact precautions is hard. That's because contact precautions are rarely used as the sole infection-prevention intervention in healthcare settings, so it's difficult to isolate their impact in observational studies. But they argue there are rational reasons to believe they play an important role in preventing pathogen transmission. Among them is the fact without the use of gloves and gowns, multidrug-resistant pathogens like MRSA would end up on healthcare workers' clothing and hands, and some proportion of those organisms would get transmitted to patients given the lackluster adherence to hand hygiene.

They also contend that while contact precautions may be burdensome to healthcare workers and may affect patient flow, studies have shown that use of contact precautions does not cause more adverse events or increase anxiety or depression among patients.

"Current evidence suggests that more rigorous evaluation of infection-prevention practices is needed before easing the use of CP in settings of endemic MRSA and VRE," the authors write. "Facilities should increase efforts to prevent the transmission of pathogens that can cause serious infections, not decrease them."
Feb 12 JAMA commentary

US farm antibiotic use 5 times higher than in UK, report says

US farmers use almost five times the amount of antibiotics their UK counterparts use, according to a new report from the Alliance to Save Our Antibiotics (ASOA).

ASOA experts based their calculations on species data published by the UK's Veterinary Medicines Directorate and the US Food and Drug Administration, supplemented by recent data published by British supermarkets. They found that antibiotic use in the United States is 9 to 16 times higher per beef steer, 3 times higher for chickens, almost twice as high for pigs, and 5.5 times higher for turkeys than it is in the United Kingdom.

For all food animals, the US/UK ratio was 4.9, or about five times higher.

"We should note that one reason for the fivefold difference in overall farm antibiotic use between the two countries is that the UK has many more sheep than the US, and sheep are low users of antibiotics," the authors of the report write. "Nevertheless, as we have seen in this document, large differences also exist in each animal species, particularly cattle."

"At present, the European Union has a ban on the importation of US beef, due to the use of growth hormones in the cattle in the US," the authors add. "However, post-Brexit, there exists the possibility that the UK will allow US beef to be imported as part of a trade deal with the US. The finding that antibiotic use in US cattle is 9 to 16 times higher than it is in British cattle, raises further concerns about the ways in which US beef is produced, and the potential dangers it may pose to consumers."

Kath Dalmeny of the Sustain food and health charity, said in an ASOA news release, "Cheap meat comes at a high price—often lower standards of cleanliness, animal welfare and high use of antibiotics. Any trade deals must aim to support high standards so that human and animal health and welfare are protected."
Feb 8 ASOA report
Feb 8 ASOA news release