Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans
Study highlights antibiotic stewardship targets in kids with pneumonia
A study of children hospitalized with community-acquired pneumonia (CAP) suggests that antibiotic decisions made in the emergency department (ED) have a significant impact on inpatient antibiotic use, researchers reported today in Pediatrics.
The study also found and that nearly a third of children without radiographic evidence of pneumonia received antibiotics, suggesting overuse is common.
In the prospective cohort study, which included children ages 3 months to 18 years who presented to the ED of a children's hospital with symptoms of a lower respiratory tract infection from July 2013 through December 2017, researchers estimated the risk factors associated with receipt of one or more doses of inpatient antibiotics and a full treatment course (5 or more days). Of the 1,142 children enrolled, 477 (median age, 2.8 years) met the criteria for inclusion; 51% had radiographic CAP or equivocal chest radiograph (CXR), and 49% had non-radiographic CAP.
Of the 477 children, 285 (60%) received at least one dose of antibiotics in the inpatient setting, and 254 (53%) received a full treatment course. Most patients (90%) who received antibiotics in the ED received inpatient antibiotics. In adjusted analyses, receipt of antibiotics in the ED (relative risk [RR], 4.33; 95% confidence interval [CI], 2.63 to 7.13), history of fever (RR, 1.66; 95% CI, 1.22 to 2.27), and use of supplemental oxygen (RR, 1.29; 95% CI, 1.11 to 1.50) were associated with an increased risk of inpatient antibiotic use, with similar findings for a full treatment course.
Children with radiographic CAP or equivocal CXRs had an increased risk of inpatient antibiotics compared with those with normal CXRs, but the increased risk was modest when antibiotics were given in the ED. Among the children with non-radiographic CAP, 29% received antibiotics, 21% received a full course, and ED antibiotics increased the risk of inpatient antibiotics.
The study authors say the frequent continuation of antibiotics in the inpatient setting may be explained by the concept of therapeutic momentum—the failure of clinicians to stop or reduce therapy that is not needed.
"Targeting therapeutic momentum and implementing other antibiotic stewardship strategies, focusing particularly on children with non-radiographic CAP, could help improve judicious antibiotic use," they wrote.
Jul 1 Pediatrics abstract
Trial data supports outpatient antibiotic management for appendicitis
A secondary analysis of data from a randomized clinical trial suggests that outpatient antibiotic management for select patients with acute appendicitis is safe, researchers reported today in JAMA Network Open.
The Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial, which involved 1,552 adults with image-confirmed appendicitis and was conducted from May 2016 through February 2020 at 25 US hospitals, found antibiotics to be non-inferior to appendectomy.
In this secondary analysis, researchers with the CODA Collaborative focused on the 776 patients in the trial who had been randomized to receive a 10-day course of antibiotics (intravenous followed by oral), nearly half of whom met stability criteria and were discharged from the ED within 24 hours with antibiotics. They compared outcomes among those who were discharged and those who received inpatient care.
Of the 776 patients included in the analysis, 335 were discharged within 24 hours, and 391 were discharged after 24 hours (inpatients). Over 7 days, severe adverse events (SAEs) occurred in 0.9 (95% CI, 0.2 to 2.6) per 100 outpatients, versus 1.3 (95% CI, 0.4 to 2.9) per 100 inpatients.
Appendectomies occurred in 9.9% (95% CI, 6.9% to 13.7%) of outpatients, versus 14.1% (95% CI, 10.8% to 18%) of inpatients (adjusted risk difference, –4.0 percentage points). Within 30 days, SAEs occurred in 1.8 (95% CI, 0.7 to 3.9) per 100 outpatients, versus 3.1 (95% CI, 1.6 to 5.4) per 100 inpatients, and appendectomies occurred in 12.6% (95% CI, 9.1% to 16.7%) of outpatients, versus 19% (95% CI, 15.1% to 23.4%) of inpatients.
Outpatients also missed fewer workdays (2.6 days; 95% CI, 2.3 to 2.9 days) than did inpatients (3.8 days; 95% CI, 3.4 to 4.3 days) and had similar frequency of return healthcare visits and high satisfaction and EuroQol 5-dimension (EQ-5D) scores.
"It appears that most patients who choose antibiotics can avoid hospitalization without incurring increased risk of serious complications or appendectomy," the study authors wrote. "Outpatient management should be included in shared decision-making discussions of patient preferences for outcomes associated with nonoperative and operative care."
Jul 1 JAMA Netw Open study
UK report finds low level of resistant E coli in beef, pork
Originally published by CIDRAP News Jun 30
A report yesterday from the United Kingdom's Food Standards Agency (FSA) shows that that the prevalence of antibiotic-resistant Escherichia coli in retail beef and pork samples remains low.
The survey of E coli in retail meat analyzed 105 beef and 105 pork samples sold in stores in England, Scotland, Wales, and Northern Ireland for resistance to 20 antibiotics and for the presence of extended-spectrum beta-lactamase (ESBL) and AmpC enzymes, which mediate resistance to third-generation cephalosporin antibiotics and are carried on mobile genes that can be transferred to other bacteria. Commensal bacteria like E coli can be a reservoir for these genes; yearly surveys of E coli in retail meat have been conducted in the United Kingdom since 2015.
The analysis revealed that one beef sample (0.95%) and four pork samples (3.81%) were positive for ESBL- and/or AmpC-producing E coli. None of the five samples were resistant to the three carbapenem antibiotics tested, or to the last-resort antibiotic colistin. The report also notes that none of the meat samples prior to bacterial enrichment had "background" AmpC- or ESBL-phenotype E coli counts above European Union (EU) detection levels, which indicates there were low numbers of these bacteria on the samples.
The results are similar to surveys conducted in 2015, 2017, and 2019, the FSA said, and compare favorably to results from EU countries.
Jun 29 FSA surveillance report
Carbapenem-resistant infections linked to higher costs, longer hospital stays
Originally published by CIDRAP News Jun 30
A study of hospitalized patients in Japan found that carbapenem-resistant infections were associated with higher costs and longer hospital stays than carbapenem-susceptible infections, researchers reported yesterday in BMC Infectious Diseases.
Using data from electronic medical records of patients treated at 55 Japanese hospitals from April 2016 through March 2020, researchers estimated the impact of carbapenem resistance on cost, length of hospital stay, and in-hospital mortality in patients diagnosed with pneumonia, urinary tract infection, biliary infection, and sepsis. Among 9,517 patients included in the study, 86 (0.9%) had carbapenem-resistant (CR) infections and 9,431 had carbapenem-susceptible (CS) infections.
Compared to CS infections, the patients with the CR infections were significantly more likely to receive mechanical ventilation (37.2% vs 21.2%), antibiotics (88.4% vs 63.0%), and carbapenem antibiotics (31.4% vs 8.3%) before the bacterial culture test. CR infections also had significantly higher costs (measured in US dollars) than CS infections in the categories of medications ($3,477 vs $1,609), laboratory tests ($2,498 vs $1,845), and hospital stay ($14,307 vs $10,560).
In a multivariable regression analysis, the length of stay was 42.1% longer and the cost was 50.4% higher in the CR infections than in the CS infections. The risk of in-hospital mortality did not differ between the two groups (odds ratio ,1.24; 95% CI, 0.72 to 2.11), due to the small sample size. A propensity score analysis using the inverse probability treatment weighting method produced similar results.
The study authors note that patients with longer hospital stays are more likely to experience inappropriate antibiotic use, which may increase the chance for CR bacteria to emerge and in turn prolong hospitalization and increase costs.
"Our results suggest that reducing unnecessary hospital stays and using antimicrobial agents appropriately are rational ways to reduce the incidence of carbapenem-resistant organisms, control costs, and shorten hospital stays," they wrote.
Jun 29 BMC Infect Dis study
Antimicrobial use in animals on the decline globally, new report finds
Originally published by CIDRAP News Jun 29
A new report from the World Organisation for Animal Health (WOAH, formerly OIE) shows global use of antimicrobials in animals fell by 27% from 2016 through 2018.
The sixth annual report on animal antimicrobial use, which focuses on drugs given to animals raised for human consumption and is based on data provided by WOAH member-states, found that, among the 72 nations that provided consistent data (representing 65% of global animal biomass), antimicrobial use fell from 120 milligrams of antimicrobials per kilogram of estimated animal biomass (mg/kg) in 2016 to 88 mg/kg in 2018. The declining trend was observed across all WOAH regions and confirms trends observed on the fifth report.
Analysis of trends by antimicrobial class showed a 21% decline in the use of tetracyclines (the most widely used antimicrobial in food-producing animals), a 43% decline in macrolide use, and a 62% decline in polypeptides. Data provided for 2018 by 109 countries showed that the total amount of antimicrobials intended for use in animals oscillated between 69,445 and 76,704 tons. Bovine species like cattle accounted for 43% of total use, followed by swine (20%), poultry (18%), and aquatic species (8%).
The report also found that, among the 157 countries that provided data for 2020, 108 (69%) no longer use antimicrobials for growth promotion. In addition, progress has been made in phasing out the use of high-priority critically important antimicrobials in animals, such as colistin.
WOAH officials say the data indicate that a growing number of farmers, animal owners, and animal health professionals are adapting their practices to use antimicrobials more judiciously. They note that a new interactive information technology system for data collection, scheduled to be delivered later this year, could help provide more granular data for future reports on global and regional trends and help countries develop national guidance.
"We are on the right track in the animal sector—we must now seize this momentum and continue to use antimicrobials prudently if we want to preserve their efficacy for future generations," WOAH Director-General Monique Eloit, DVM, said in a press release.
Jun 27 WOAH report
Jun 27 WOAH press release
Discharged patients may be getting antibiotics longer than necessary
Originally published by CIDRAP News Jun 29
An analysis of patients treated for common infections at an academic medical center found that antibiotics were given for longer than necessary on discharge for multiple conditions, researchers reported today in Antimicrobial Stewardship & Healthcare Epidemiology.
The retrospective chart review included 300 adult patients discharged from Temple University Hospital who were on oral antibiotics for acute infections from January to March 2019. The infections included community- and hospital-acquired pneumonia, cystitis, pyelonephritis, skin and other soft-tissue infection (SSTI), intra-abdominal infection (IAI), chronic obstructive pulmonary disease exacerbation, bronchitis, and pharyngitis.
The primary outcome was total prescribed duration of antibiotic therapy, compared with the duration recommended by Infectious Diseases Society of America (IDSA) guidelines, the minimum supported by clinical guidelines and trials, and the duration beyond the point of clinical stability.
Of the 300 patients, 171 (57%) were women, and the median age was 59 years; 73% of inpatients received intravenous therapy, 76% received oral antibiotics, and 70% of those prescribed oral antibiotics were transitioned to these patients prior to discharge. The most common antibiotics prescribed were fluoroquinolones (30%), amoxicillin-clavulanate (18%), and azithromycin (18%).
Overall, patients received a median of 8 total days of antibiotics—a median of 2 days of excessive antibiotics compared with IDSA guidelines, 3 days compared with the minimum possible duration based on clinical guidelines and published literature, and 6 days past the point of clinical stability. The most inappropriate prescription durations were seen with SSTI, IAI, and cystitis.
"This finding supports the results from several other studies; despite the growth of data supporting shorter courses of therapy for multiple common infections and the inclusion in clinical guidelines, patients are often prescribed longer courses than clinically indicated," Temple University School of Pharmacy researchers wrote.
The authors said a pilot program targeting transitions of care has been initiated at the hospital to address the problem.
Jun 29 Antimicrob Resist Healthc Epidemiol study
US study highlights elevated risk of resistant urinary tract infections
Originally published by CIDRAP News Jun 28
A multicenter study of US patients who presented to the ED for a complicated urinary tract infection (cUTI) caused by Enterobacterales bacteria found high levels of resistance to the most commonly used oral antibiotics, researchers reported late last week in Open Forum Infectious Diseases.
To quantify the prevalence of resistance and co-resistance to commonly used oral cUTI agents across US regions, researchers analyzed data from the Premier Healthcare Database on adult cUTI patients with an Enterobacterales pathogen who presented to the ED for care from 2013 through 2018. Dividing the cohort into patients who were treated only in the ED and those who were admitted to the hospital, the researchers determined the proportion of patients within each US census region with resistance and co-resistance to fluoroquinolones, trimethoprim-sulfamethoxazole, nitrofurantoin, and third-generation cephalosporins.
There were 60,006 patients in the ED-only cohort and 86,743 in the inpatient cohort; the ED-only cohort was younger, less likely to be male, and had fewer baseline comorbid conditions. E coli was the most predominant Enterobacterales pathogen in both cohorts, accounting for roughly 33% of all cases combined. In the ED cohort, 40% to 50% of cUTIs in each US census region displayed resistance to at least one agent, and 10% to 18% in each region had resistance to two or more agents. Resistance to nitrofurantoin and fluoroquinolones exceeded 15%, and resistance to trimethoprim-sulfamethoxazole exceeded 25%.
In the inpatient cohort, 55% to 65% of cUTIs in each region were resistant to at least one agent, and 25% to 35% were resistant to two or more. Resistance to nitrofurantoin and fluoroquinolones exceeded 30%.
"These findings have important clinical implications," the study authors wrote. "Given the high observed rates of resistance observed in both cohorts, adult patients who present to the ED with a cUTI have an elevated risk for receiving an inappropriate empiric agent if prescribed a fluoroquinolone, TMP-SMX, nitrofurantoin, or an oral third generation cephalosporin."
They added that the findings indicate that many cUTI patients will require intravenous antibiotics for their treatment, which highlights the clear need for new oral antibiotic options.
Jun 24 Open Forum Infect Dis abstract
