ASP Scan (Weekly) for Mar 18, 2022

News brief

Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans

Study finds dramatic drop in antimicrobial use in Japan in 2020

Japan saw a marked reduction in antimicrobial use (AU) in 2020 that's linked to the COVID-19 pandemic but could also reflect increased antimicrobial stewardship, according to a study yesterday in the International Journal of Infectious Diseases.

Using nationwide antimicrobial sales data, researchers from Japan's National Center for Global Health and Medicine examined annual and monthly trends in AU from 2016 to 2020 according to the World Health Organization AWaRe (Access, Watch, and Reserve) classification system and administration route (oral and injectable). They compared AU trends in 2020 with those observed from 2016 to 2019. To assess the impact of the pandemic, they compared actual AU in 2020 to a hypothetical scenario in which the pandemic did not occur.

The analysis showed a general decline in the use of oral antimicrobials from 2016 through 2020, especially those in the Watch category (from 9.69 defined daily doses per 1,000 inhabitants per day [DID] in 2016 to 7.22 DID in 2020), with substantially lower AU in 2020 that exceeded the downward trend observed from 2016 to 2019.

The analysis of monthly trends showed a significant drop in overall AU in May 2020 that was not observed in the same month in previous years. In addition, AU for both oral (1.10 DID to 0.59 DID) and injectable antimicrobials (10.6 DID to 6.62 DID) fell in May 2020, as did AU for Access (2.36 DID to 1.56 DID) and Watch (9.14 DID to 5.54 DID) antimicrobials.

When compared with the scenario of no pandemic, the reductions for AU in total antimicrobials and Watch antimicrobials for 2020 were greater than predicted.

"The observed reduction in AU in 2020 was likely due to the COVID-19 pandemic, which led to a decline in hospital visits and lower incidences of other infectious diseases," the study authors wrote. "However, AU had been decreasing every year before 2020, which might reflect an increase in antimicrobial stewardship measures following the National Action Plan on AMR [antimicrobial resistance]."
Mar 17 Int J Infect Dis study

Hydrogen peroxide contamination tied to less C difficile infection

Originally published by CIDRAP News Mar 17

Implementation of a touchless hydrogen peroxide decontamination system at an acute care hospital was associated with a significant reduction in Clostridioides difficile infection (CDI) rates over a 10-year period, researchers reported today in the American Journal of Infection Control.

The restrospective study compared rates of healthcare-associated CDI at an acute care hospital in Pennsylvania before and after implementation of the aerosolized hydrogen peroxide (aHP) system, a whole-room fogging unit that generates an aerosolized dry-mist fog that covers all surfaces exposed to C difficile spores. The aHP system was used in patient rooms in conjunction with standard bleach cleaning upon discharge or transfer of a CDI patient.

The first study period included 27 months before implementation of aHP (July 2009 to September 2011) and 33 months after implementation (April 2012 to December 2014). The researchers also examined the effects of continued aHP usage over the following 5 years (January 2015 to December 2019).

The before-and-after period showed a reduction in CDI rates from 4.6 per 10,000 patient-days to 2.7 per 10,000 patient-days—a 41% reduction. Over 5 years of continued aHP, CDI rates continue to decline consistently, to 1.4 per 10,000 patient-days. The standardized infection ratio fell from 0.77 in 2015 to 0.5 in 2019.

Although the study authors note they could not account for potential confounders such as hand hygiene compliance, antibiotic usage rates, patient demographics, and cleaning practices, they are confident the aHP system contributed to the decline in CDI rates at the hospital. They suggest future studies should include a large randomized trial of aHP, especially in high-risk environments such as oncology units.
Mar 17 Am J Infect Control abstract

Education, consensus tied to less pediatric vancomycin use

Originally published by CIDRAP News Mar 16

A quality-improvement (QI) initiative at a children's hospital was associated with a drastic reduction in vancomycin use in critically ill children, researchers reported yesterday in Pediatrics.

The QI project at Children's Hospital of Philadelphia involved three strategies implemented in the pediatric intensive care unit (PICU) over a 3-year period: 1) provider education; 2) creation of a consensus-based guideline for empiric vancomycin use; and 3) implementation of the guideline through clinical decision support tools.

The aim was to reduce overall days of therapy (DOT) of vancomycin, which is commonly used in children's hospitals but often unnecessarily, by at least 10% over the 3-year period. At the start of the project, vancomycin was the most commonly used antibiotic in the PICU.

In the baseline period prior to implementation of the QI project (July 2016 to June 2017), researchers analyzed 1,276 episodes of suspected bacterial infection and found 19 cases of bacteremia (1.5%) caused by organisms requiring vancomycin therapy, including 6 cases caused by methicillin-resistant Staphylococcus aureus (MRSA). Baseline use of vancomycin was 182 DOT per 1,000 patient-days.

During the 3-year QI project, vancomycin use fell by 40%, from 182 to 109 DOT per 1,000 patient-days. No MRSA bacteremias were missed with empiric therapy, and there was no increase in 30-day mortality or new or progressive respiratory, renal, or cardiovascular organ dysfunction.

The study authors credit education and consensus-building among key stakeholders as the biggest factors associated with reduced vancomycin use in the PICU, as the 40% reduction in vancomycin use occurred before the implementation of the clinical decision support tools.

"These findings are significant because they support the idea that focused education and stakeholder-engaged consensus guidelines can be effective strategies for improving antibiotic use in the PICU setting," they wrote.
Mar 15 Pediatrics abstract

Support tool tied to better antibiotic prescribing for pneumonia patients

Originally published by CIDRAP News Mar 14

A real-time electronic decision support tool helped clinicians at community hospitals provide best practice care for emergency department (ED) patients with pneumonia and was associated with decreased intensive care unit (ICU) admission, more appropriate antibiotic use, and 38% lower overall death according to a study last week in the American Journal of Respiratory and Critical Care Medicine.

For the study, researchers at Intermountain Healthcare in Salt Lake City, Utah, deployed the health system's electronic, open loop, clinical decision support (ePNa) system to 16 of its community hospitals from December 2017 to June 2019. During that span, those hospitals had 6,848 pneumonia cases, and a treating clinician used ePNa in 67% of eligible patients.

The support tool gathers more than 50 key patient indicators, including age, fever, oxygen saturation, laboratory and chest imaging results, and vital signs to make care decisions, including appropriate antibiotic therapy, lab studies, and treatment setting recommendations, such as ICU admittance, hospital admittance, or discharge. Median patient age was 67 years, 48% were female, and 64.8% were admitted to the hospital.

Using the tool, Intermountain researchers found a range of positive outcomes for patients, including a 38% relative reduction in mortality 30 days after a pneumonia diagnosis, with the largest reduction in death rates in patients admitted directly from the ED to the ICU. Guideline-concordant antibiotic prescribing increased from 83.5% to 90.2% (P < 0.001).

Other findings were a 61% increase in patients treated as outpatients (increasing from 29.2% to 46.9%), decreased ICU admissions without safety concerns, and lowered mean time from ED admission to start of first antibiotic, dropping from 159.4 minutes to 150.9 minutes.

The researchers say the findings are consistent with a previous study involving use of the ePNa system in Intermountain's larger hospitals.

"Our study found that clinicians were able to make better treatment decisions with this resource," said first author Nathan Dean, MD, in an Intermountain news release. "Some of our community hospitals have as little as 20 beds. We wanted to validate the effectiveness of ePNa in very different healthcare settings."
Mar 9 Am J Respir Crit Care Med study
Mar 9 Intermountain Healthcare news release

News Scan for Mar 18, 2022

News brief

US flu activity continues slow rebound

Flu activity continued to rise in most of the nation last week, with three more pediatric flu deaths reported, but markers are still below epidemic baselines, the US Centers for Disease Control and Prevention (CDC) said today in its latest update.

The national percentage of outpatient visits for flulike illness rose slightly, to 1.7%. The level had reached a season high at the end of 2021 and was declining until early February, when it started to creep up again. Oklahoma reported high flu activity, another measure of clinic visits for flu, while Arkansas and Idaho reported moderate activity.

The percentage of respiratory specimens that were positive for flu at clinical labs was 6.8% last week, up from 5.8% the week before. The CDC said the highest positivity rates at the labs were in the central and south-central regions of the country. At public health labs, all specimens were influenza A, and, of subtyped samples, all were the H3N2 strain.

Hospital admissions rose for the sixth straight week, but the cumulative rate is still lower for this time of year that the last four pre-COVID flu seasons.

The 3 pediatric flu deaths occurred between the middle of January and early March. All involved unsubtyped influenza A viruses. So far, 13 pediatric flu deaths have been reported to the CDC this season.
Mar 18 CDC FluView update

High-path avian flu found in Michigan waterfowl, other states

In ongoing surveillance in wild birds to monitor the spread of highly pathogenic H5N1 avian flu, the US Department of Agriculture (USDA) reported nine more positives, including the first in Michigan, according to an update.

The positive H5 sample from Michigan was from a mute swan harvested in Monroe County, which is located in the far southeastern part of the state on the Lake Erie shore, according to an update from the USDA's Animal and Plant Health Inspection Service (APHIS). Earlier this month, Michigan reported an outbreak, its first, in a backyard flock in Kalamazoo County.

The other new H5 positives in wild birds were from already affected states: Florida, New Hampshire, Iowa, and Illinois.

So far, the USDA has confirmed 385 positive wild bird detections and 38 appearances in poultry flocks since the middle of January. They involve the Eurasian H5N1 strain that has fueled outbreaks in wild birds and poultry in a number of world regions and resulted in one human case—involving a person who had very close contact with infected birds.
USDA APHIS wild bird avian flu detection page

Study finds dramatic drop in antimicrobial use in Japan in 2020

When compared with the scenario of no pandemic, the reductions for AU in total antimicrobials and Watch antimicrobials for 2020 were greater than predicted.

COVID-19 Scan for Mar 18, 2022

News brief

COVID-19 patients may owe thousands for after-hospital care

Even when insurance companies waived charges for COVID-19 hospitalizations, 10% of patients still had out-of-pocket costs of $2,000 or more for care that took place in the 6 months after they were released, finds a new study in the American Journal of Managed Care.

The same team published a study Feb 14 in JAMA Network Open showing that COVID-19 hospitalizations alone could cost patients, on average, $1,600 to $4,000.

University of Michigan at Ann Arbor researchers analyzed medical and pharmacy claims in Optum's Clinformatics Data Mart from privately insured and Medicare Advantage patients hospitalized with COVID-19 from March to June 2020. They compared the findings with those of pneumonia patients after hospitalization in the same period.

Among 7,932 COVID-19 patients, 26.0% were privately insured. For all patients, estimated median out-of-pocket costs after hospital release was $287 for privately insured patients and $271 for Medicare patients. Costs exceeded $2,000 for 10.9% and 9.3% of these patients, respectively.

Median spending for patients hospitalized with pneumonia was $276 for privately insured patients and $570 for Medicare patients. Out-of-pocket spending was more than $2,000 for 12.1% and 17.2%, respectively.

The study authors noted that many COVID-19 survivors need extensive care after hospitalization, and now that most insurers have stopped issuing waivers, survivors could face substantial costs for both hospitalization and aftercare.

The researchers said that COVID-19 patients hospitalized in 2021 and after likely face even higher costs, because the data are from 2020, before insurers stopped issuing waivers. They called for insurers to reinstate the waivers to reduce patients' financial burden and lower the risk that ill people will avoid seeking care owing to cost concerns.

In a University of Michigan press release, lead author Kao-Ping Chua, MD, PhD, noted that the costs of extended care is on top of large bills for hospitalization. "The collective costs of hospitalization and care after discharge could result in financial toxicity for thousands of Americans," he said.
Mar 16 Am J Manag Care study
Mar 17 University of Michigan press release

Study highlights durability of antibodies in kids after SARS-CoV-2 infection

The vast majority of children previously infected with SARS-CoV-2 developed natural circulating antibodies that lasted for at least 7 months, but they declined after that, according to a study today in Pediatrics involving 218 Texas children.

Researchers from UTHealth Houston examined data from children across Texas aged 5 to 19 years who were enrolled in the Texas CARES survey, which began in October 2020 with the goal of assessing COVID-19 antibody status over time. They assessed the duration of the nucleocapsid antibody response— a measure of past infection rather than vaccination, which elicits antibodies to the virus's spike protein.

Volunteers provided the researchers with three separate blood draws before vaccine rollout for this group and before Delta and Omicron were predominant.

The investigators found that 96% of children infected with SARS-CoV-2 continued to have antibodies up to 7 months later. But that number dropped to 42% at their final assessment.

Lead author Sarah Messiah, PhD, MPH, said in a UTHealth news release, "The information we collected from children infected with COVID-19 didn't differ at all by whether a child was asymptomatic, severity of symptoms, when they had the virus, were at a healthy weight or had obesity, or by gender. It was the same for everyone."

She added, "While our study is encouraging in that some amount natural antibodies last at least six months in children, we still don't know the absolute protection threshold. We have a great tool available to give children additional protection by getting their vaccine, so if your child is eligible, take advantage of it."

In an accompanying commentary, pediatricians Andrea T. Cruz, MD, MPH, of Baylor College of Medicine, and Mark R. Denison, MD, of Vanderbilt University Medical Center, said the study "provides some reassuring data regarding the durability of the response." They add, "However, a qualitative antibody response should not provide false reassurance."
Mar 18 Pediatrics study and commentary
Mar 18 UTHealth Houston news release