Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans
Study highlights benefits of penicillin allergy testing in pregnant women
Most pregnant women with a reported history of penicillin allergy who were tested were found not to be allergic and could tolerate penicillin during labor, according to a small retrospective study presented today at the annual scientific meeting of the American College of Allergy, Asthma and Immunology (ACAAI).
Of the 32 women pregnant women evaluated in the study, 25 consented to penicillin skin testing, and all were found to be negative for a penicillin allergy. Eight of the 25 patients had uncomplicated pregnancies and thus were not exposed to penicillin administration throughout the pregnancy. Two received antibiotics prior to completion of a graded-oral challenge as a result of unexpected skin lacerations related to vaginal delivery. Thirteen tested positive for Group B Streptococcus (GBS) and had both skin testing and an oral amoxicillin challenge performed, then received penicillin administration during labor, with no reported issues.
GBS can cause invasive infections in newborns, and intrapartum antibiotic prophylaxis may be administered to prevent transmission during labor and delivery.
Allergist and chair of the ACAAI Task Force on Drug Allergy Mariana Castells, MD, PhD, said penicillin testing and de-labeling ahead of the potential need for penicillin could help avoid unnecessary use of broader-spectrum antibiotics.
"A pregnant woman with GBS may need penicillin for treatment," Castells said in an ACAAI press release. "If she is labelled as allergic, she will be offered a less effective, and possibly more harmful antibiotic."
The study abstract was published in the Annals of Allergy, Asthma & Immunology.
Nov 5 ACAAI press release
Nov 1 Ann Allergy Asthma Immunol abstract
Mayo study adds to data on antibiotic prescribing during pandemic
More than a third of COVID-19 patients treated at the Mayo Clinic in Minnesota over a 9-month period in 2020 received antibiotic therapy, with most receiving antibiotics within 48 hours of admission, researchers reported today in JAC-Antimicrobial Resistance.
Of 654 adult COVID-19 patients treated at Mayo from Mar 1, 2020, through Nov 30, 2020, 248 (37.9%) received antibiotics targeting suspected or confirmed bacterial respiratory infections. The incidence of antibiotic prescribing increased with disease severity, with 16.9%, 29.8%, and 64.6% of patients with mild, moderate, and severe disease, respectively, receiving antibiotics. Of the patients who received antibiotics, 212 (85.5%) received empiric therapy within 48 hours of admission. A specific pathogen was identified in the respiratory cultures of 47.1% of the 104 patients who had cultures collected. Over the study period, antibiotic prescribing rates decreased by 8.7% per month, despite an increase in COVID-19—related admissions.
Multivariable analysis found that intensive care unit admission, obtainment of procalcitonin values within 24 hours of admission, intubation, heart failure, hemodialysis, and nursing home residence were associated with empiric prescribing.
The study authors said antimicrobial stewardship programs (ASPs) should carefully monitor unnecessary antimicrobial use in COVID-19 patients with these patient-specific factors.
"Institutional ASPs should take an active role in intervening on unnecessary antimicrobial use in these patients by specifically understanding their local prescribing patterns, trending these patterns over time and identifying patient populations most likely to derive benefit from programmatic interventions," the team wrote.
Nov 5 JAC-Antimicrob Resist study
Trial supports low-dose, short-course antibiotics for kids' pneumonia
Originally published by CIDRAP News Nov 2
Among children with community-acquired pneumonia (CAP) who were discharged from the hospital within 48 hours but required further outpatient treatment, a lower dose of oral amoxicillin was non-inferior to a higher dose, and a 3-day duration was non-inferior to 7 days, according to the results of a randomized clinical trial published today in JAMA.
In the CAP-IT trial, conducted in 28 hospitals in the United Kingdom and 1 in Ireland, investigators enrolled children ages 6 months and older who were diagnosed as having CAP, had been discharged from a hospital ward or emergency department, and were set to receive a course of amoxicillin and randomly assigned them to four treatment groups: 35 to 50 milligrams per kilogram per day (mg/kg/d) of amoxicillin for 3 days, 35 to 50 mg/kg/d for 7 days, 70 to 90 mg/kg/d for 3 days, and 70 to 90 mg/kg/d for 7 days. The aim was to determine the optimal amoxicillin dose to minimize antibiotic exposure while achieving high clinical cure rates.
A total of 824 children (median age, 2.5 years) were randomized into one of the four groups. The primary outcome was clinically indicated antibiotic retreatment at 28 days post-randomization. The non-inferiority margin was 8%. Secondary outcomes included severity/duration of nine parent-reported CAP symptoms.
The primary outcome occurred in 12.6% of children who received the lower dose compared with 12.4% of those who received the higher dose and in 12.5% who received 3 days of amoxicillin versus 12.5% who received 7 days. Both the lower-dose and shorter-duration groups achieved statistical non-inferiority with no significant interaction between dose and duration. Among a subgroup of children with severe CAP, the primary end point occurred in 17.3% of lower-dose recipients vs 13.5% of higher-dose recipients and in 16.0% with 3-day treatment vs 14.8% with 7-day treatment.
For the secondary end points, cough persisted longer in children who received 3 days of treatment compared with 7 days (median 10 days vs 12 days; hazard ratio [HR], 1.2; 95% confidence interval [CI], 1.0 to 1.4), but sleep disturbed by cough was similar (median 4 days vs 4 days; HR, 1.2; 95% CI, 1.0 to 1.4).
Nov 2 JAMA abstract
Urology stewardship linked to drops in antibiotic use, costs, resistance
Originally published by CIDRAP News Nov 2
Antibiotic stewardship interventions for urology outpatients at a Japanese hospital contributed to reducing the use of broad-spectrum agents, reducing yearly antibiotic costs, and improving susceptibilities in certain bacteria, researchers reported yesterday in the American Journal of Infection Control.
Using data on 2,739 urology outpatients with lower urinary tract infection (UTI) symptoms who were treated at a rehabilitation hospital from 2011 through 2020, the researchers compared antimicrobial use density (AUD), antimicrobial agent costs, and antimicrobial susceptibility in UTI-causing bacteria during two different periods of antibiotic use oversight at the hospital: the infection control team (ICT) era (pre-2014), and the antibiotic stewardship program (ASP) era (post-2014).
ASP interventions included asking urologists to consider discontinuing broad-spectrum antibiotics, such as third-generation cephalosporins and quinolones, and to prescribe more specific antibiotics for shorter periods.
The analysis found that, during the ASP era, overall AUD and AUD for individual antibiotics, including second-generation cephalosporins, cefotiam, cefdinir, levofloxacin, sitafloxacin, and tosufloxacin, showed significant decreases, as did overall and individual antimicrobial agent costs. In a median comparison, there was an overall 49% decrease in antimicrobial costs, with particularly large decreases for broad-spectrum antimicrobials. Regarding drug susceptibility among UTI-causing pathogens, Escherichia coli showed increased susceptibility to cefotiam, levofloxacin, and sulfamethoxazole/trimethoprim during the ASP era, and Klebsiella pneumoniae showed increased susceptibility to minocycline.
"Appropriate interventions have shown to reduce antibiotic use, antibiotic resistance, and health care costs," the study authors wrote. "Further prospective studies with a wider patient cohort need to be performed to draw more definitive conclusions."
Nov 1 Am J Infect Control abstract
Canadian studies find pandemic-related drops in antibiotic prescribing
Originally published by CIDRAP News Nov 1
Antibiotic prescribing during the early COVID-19 months in Canada dropped sharply, according to two new studies, one that looked at retail pharmacy trends across the country and one that focused on outpatient prescribing patterns in Ontario.
In the first study, published in Clinical Microbiology and Infection, researchers examined antibiotic dispensing through retail pharmacies across the country from Nov 2014 to Oct 2020. They found that, during Canada's first 8 months of COVID-19 activity, the overall dispensing levels dropped by 26.5%, and the drop was even sharper for children. For comparison, the decline in the years before the pandemic—from 2015 to 2019—was just 3.0%.
Prescribing rates for antibiotics targeting respiratory infections declined more sharply than those targeting urinary tract and skin and other soft-tissue infections. The team said similar findings have been reported by the United States and United Kingdom and that decreased access to prescribers and public health measures during the early part of the pandemic that reduced communicable disease levels may have played roles.
Oct 29 Clin Microbiol Infect abstract
In the second study, researchers evaluated data from an antibiotic prescribing database to gauge trends in Ontario from January 2017 to December 2020, designating March to December of 2020 as the COVID-19 period.
They found a 31.2% drop in antibiotic prescriptions during the pandemic months. Their deeper look at the data revealed that the reduction in prescribing was driven more by fewer doctor's visits for respiratory than by less prescribing for respiratory indications.
Oct 30 Open Forum Infect Dis abstract
Israeli study reveals frequent antibiotic use in kids with RSV
Originally published by CIDRAP News Nov 1
Roughly a third of children hospitalized with respiratory syncytial virus (RSV) at a hospital in Israel over a 10-year period received unnecessary antibiotics, researchers reported last week in the Journal of Global Antimicrobial Resistance.
Among 1,227 children hospitalized at Hillel Yaffe Medical Center from 2008 through 2018 for RSV-bronchiolitis, which is a common cause of respiratory infections in Israeli children, 335 (27.3%) received unnecessary antibiotic treatment. But when they examined only children ascertained not to have a bacterial co-infection, unnecessary antibiotic treatment climbed to 33.4%. Among patients who had no bacterial cultures drawn, 19% received antibiotics.
Using a logistic regression model, the researchers identified several variables associated with unnecessary antibiotics. They included drawing of any bacterial culture (blood culture, urine culture, cerebrospinal culture), prior emergency room visit, lower oxygen saturation, higher body temperature, and abnormally rapid breathing. Girls and older children were also more likely to receive unnecessary antibiotics.
"The findings of this study indicate that the high rates of unnecessary antibiotic therapy in RSV-bronchiolitis patients may be largely due to the physicians' perception of disease severity," the authors wrote. "A better balance between prescribing and withholding antibiotics must be achieved to mitigate future rates of antibiotic resistance."
Oct 28 J Glob Antimicrob Resist study