Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans
Study links audit and feedback to improved screening for resistant bacteria
An audit-and-feedback intervention at a hospital in Israel was associated with improved compliance with guidelines for screening patients for carbapenemase-producing Enterobacteriaceae (CPE) and decline in CPE transmission, researchers reported today in Infection Control & Hospital Epidemiology.
In the study, researchers evaluated compliance with CPE screening at Israel's Hillel Yaffe Medical Center from 2016 through 2019. Starting in 2016, patients were screened weekly for CPE if the result on admission was negative and isolated if the result was positive. In 2017, a strategy of real-time feedback on compliance with in-hospital screening guidelines and quarterly point-prevalence interventions by infection control staff was implemented. The researchers also assessed CPE acquisition and transmission in the hospital, hand hygiene compliance, and compliance with isolation practices.
A total of 3,131 patients were eligible for CPE screening over the study period. Compliance with CPE screening increased from 67% in 2016 to 95% in 2019. A decrease in CPE transmission from 12% in 2017 to 2% in 2019 was also observed. The researchers did not find any correlation between hand hygiene and isolation practice compliance and CPE screening and acquisition.
"As far as we know, our study is the first to use real-time audit and feedback regarding appropriate CPE screening, to decrease CPE transmissions in a hospital, and this is the first time a correlation has been demonstrated quite straightforwardly," the study authors wrote. "We suggest that this tool be used in as many infection control measures as possible because we know that only a bundle of interventions can make a real difference in infection rates and thus improve patient care."
Sep 9 Infect Control Hosp Epidemiol abstract
Female physicians more likely to accept telehealth antibiotic advice
A study published last week in Open Forum Infectious Diseases found that recommendations by telehealth-based antimicrobial stewardship programs (TeleASPs) were more likely to be accepted by female physicians and less likely to be accepted by physicians with more experience.
The study looked at acceptance of TeleASP recommendations at two community hospitals in Western Pennsylvania that launched the program in 2018. The program includes remote infectious diseases (ID) physicians who review patient medical records and make antibiotic recommendations to local pharmacists and primary care teams during weekly phone calls. From February 2018 through July 2020, researchers collected data on the number and acceptance rate of TeleASP antibiotic recommendations and tracked the variables potentially affecting acceptance of those recommendations.
Over the 30-month study period, 5,333 TeleASP recommendations were made to 135 physicians, with an overall acceptance rate of 91.2%. In multivariable analysis, recommendations made to female physicians had significantly higher odds of acceptance than recommendations made to male physicians (93.1% vs 90.3% acceptance, odds ratio [OR], 1.65; 95% confidence interval [CI], 1.3 to 2.2). Compared with physicians with less than 3 years of experience, who had the highest rate of acceptance (96.3%), physicians with 21 or more years of experience had the lowest (87.1%; OR, 0.26; 95% CI, 0.15 to 0.45).
Multivariable analysis also found that recommendations for antibiotic dose/frequency adjustment (OR, 2.63; 95% CI, 1.6 to 4.3) and orders for labs/tests (OR, 3.30; 95% CI, 2.1 to 5.2) were associated with higher odds of acceptance, while recommendations for antibiotic de-escalation (OR, 0.75; 95% CI, 0.60 to 0.95) and antibiotic discontinuation (OR, 0.57; 95% CI, 0.42 to 0.76) were associated with lower odds of acceptance.
The study authors say the high rate of acceptance "helps highlight the viability of the TeleASP model as an alternative to fully on-site ASPs for facilities without sufficient local expertise." They suggest the clinician-level variables associated with acceptance of recommendations should be further explored to inform future educational initiatives and targeted interventions.
Sep 3 Open Forum Infect Dis abstract
Quality improvement linked to better antibiotics for kids' skin infections
Originally published by CIDRAP News Sep 8
A quality-improvement (QI) program implemented at a children's healthcare system in Georgia was associated with improved antibiotic selection and duration for children with skin infections, researchers reported today in Pediatrics.
The QI program, implemented in three emergency departments (EDs) and eight urgent care centers (UCs) within Children's Healthcare of Atlanta, aimed to optimize outpatient antibiotic selection and duration for uncomplicated skin/soft tissue infections (SSTIs). Optimal treatment was defined as 5 days of cephalexin for nonpurulent (not containing pus) SSTIs and 7 days of clindamycin or trimethoprim/sulfamethoxazole for purulent SSTIs.
Interventions included revised SSTI treatment guidelines, provider education, a discharge order set, and participation in a maintenance of certification (MOC) QI project that involved education sessions, monthly group feedback, and individual scorecards. The MOC QI project included 50 ED and UC physicians (27% of eligible physicians).
To evaluate the success of the program, researchers compared antibiotic prescribing data for SSTIs during the baseline period (January 2018 to June 2019) and the postintervention phase (July 2019 to March 2021).
A total of 9,306 SSTIs were included, with 5,507 ED visits (59.2%) and 3,799 UC visits (40.8%). For all providers (MOC and non-MOC participants), optimal antibiotic choice plus duration for purulent SSTIs increased from 28% at baseline to 64%. For nonpurulent SSTIs, optimal antibiotic choice plus duration increased from 2% to 43%.
MOC participants had a similar baseline performance but showed greater improvement in optimal antibiotic prescribing for purulent (84%) and nonpurulent SSTIs (68%). Return visits requiring escalation of care did not significantly change pre- to post-intervention.
The study authors suggest the greater improvement among MOC participants may have been driven by monthly scorecards with individual performance.
"Although other QI projects have focused on inpatient management of SSTIs, this multisetting QI project focused on evidence-based outpatient antibiotic prescribing for pediatric SSTIs," the study authors wrote. "Our results could be readily generalized to other large, tertiary pediatric care centers looking to implement QI initiatives surrounding outpatient antibiotic stewardship."
Sep 8 Pediatrics abstract
Multidrug-resistant Shigella outbreak in Spain tied to cases in Belgium, UK
Originally published by CIDRAP News Sep 8
A study published this week in JAC-Antimicrobial Resistance confirms that a strain of multidrug-resistant (MDR) Shigella sonnei found in men who have sex with men (MSM) in Spain is similar to strains found elsewhere in Europe.
In the study, researchers from Seville, Spain, conducted genomic and molecular analysis of isolates from seven patients with shigellosis caused by MDR S sonnei that had similar epidemiologic characteristics. The cases were reported at a university hospital in Seville from October to December 2021, and of the six patients who reported sexual history, four identified as MSM.
All isolates showed resistance to penicillins, cephalosporins, fluoroquinolones, cotrimoxazole, and azithromycin, and whole-genome sequencing identified several resistance determinants, including azithromycin resistance genes and the blaCTX-M-27 gene, which carries an extended-spectrum beta-lactamase (ESBL) enzyme.
Further analysis found that all of isolates belonged to the same outbreak strain and were closely related to isolates from recent outbreaks of extensively drug-resistant (XDR) S sonnei in MSM in Belgium and the United Kingdom.
"Our results suggest that we are dealing with a high-risk clone of S. sonnei in continuous evolution," the study authors wrote. "The differences in terms of plasmid structures as well as the number of plasmids harboured by the seven S. sonnei isolates seems to indicate that this outbreak was produced by the transmission of one clone that is able to evolve and disseminate rapidly."
A report in February from the European Centre for Disease Prevention and Control noted an increase in XDR S sonnei infections in the United Kingdom and elsewhere in Europe and warned that the risk of spread among networks of MSM who engage in high-risk sexual practices, such as oral-anal contact, could be high in the coming months.
The authors say tracking the spread of successful epidemic clones of MDR S sonnei and understanding their evolution will be important for monitoring and control of outbreaks.
Sep 5 JAC-Antimicrob Resist study
High rate of antibiotic use found in people with dementia
Originally published by CIDRAP News Sep 7
A study of Veterans Health Administration data found that antibiotic prescribing was prevalent among a national cohort of persons living with dementia (PLWD), and inappropriate use appeared high, researchers reported late last week in Open Forum Infectious Diseases.
For the study, the researchers identified patients who received home-based personal care (HBPC) through the Veterans Affairs healthcare system from 2014 through 2018, focusing on patients aged 65 and older who received two or more in-person home visits by a physician and had a diagnosis of dementia. Antibiotics prescribed within 3 days of an HBPC visit were assessed from the initial HBPC visit through death or the end of the study period, and prescription fills and days of therapy (DOT) per 1,000 days of home care (DOHC) were calculated.
Among 39,861 PLWD (median age 85, 97% male, 15% Black), 16,956 (42.5%) received 45,122 antibiotic prescription fills, 67% of which were associated with diagnoses for conditions for which antibiotics are not indicated—mainly non-infectious noninformative diagnoses, such as chronic or other conditions. The antibiotic use rate was 20.7 DOT per 1,000 DOHC.
The most common antibiotic classes filled were quinolones (24.3%), aminopenicillins (16.6%), and sulfonamides/related agents (12.3%). The median length of antibiotic therapy was 7 days. Nearly one third (30.9%) of antibiotic fills were associated with HBPC telephone visits, and 42% were associated with advanced practice providers.
The study authors note that the findings suggest that the rate of antibiotic prescribing in HBPC is similar to that in nursing homes. Particularly concerning is the use of quinolones, which are classified as potentially inappropriate medications for older adults.
"Collectively, these findings underscore the need for further investigation regarding the scope, appropriateness, and harms of antibiotic use in home care settings," the study authors wrote. "It is necessary to better understand the clinical reasoning and documentation practices among HBPC providers."
Sep 3 Open Forum Infect Dis abstract
Early-life antibiotics for respiratory infections may establish pattern
Originally published by CIDRAP News Sep 7
A prospective study in Toronto, Canada, found that children who received antibiotics for upper respiratory tract infections (URTIs) early in childhood were more likely to receive them for URTIs later in childhood, researchers reported yesterday in the Journal of the Pediatric Infectious Diseases Society.
To evaluate the relationship between antibiotic prescriptions for URTI prior to age 2 and antibiotic prescriptions for URTI after age 2, the investigators followed children ages 0 through 5 from nine primary care practices in Toronto over an 8-year period (December 2008 through March 2016). Children were included in the study if they had at least one sick visit with their primary care physician prior to 2 years of age and one sick visit after. Diagnoses of pharyngitis, unspecified viral infection, cold, acute otitis media (AOM, or ear infection), and influenza were considered URTIs.
A total of 2,380 children were included in the final analysis, and the average duration of follow-up from the first visit was 4.6 years. Of 12,695 visits before age 2, 1,968 (15.5%) resulted in an antibiotic prescription (50.9% for AOM, 15.2 % for non-AOM URTI, and 33.9% for other conditions). Of 13,295 sick visits after age 2, 10,719 (24%) resulted in an antibiotic prescription (41.3% for AOM, 27.9% for non-AOM URTI, and 30.8% for other conditions).
In an adjusted analysis, antibiotic prescription for URTI prior to age 2 was associated with a 39% increased likelihood of an antibiotic prescription for a URTI after age 2 (adjusted odds ratio [aOR], 1.39; 95% CI, 1.19 to 1.63). A secondary analysis found that children prescribed an antibiotic for AOM prior to age 2 were more likely to receive antibiotics for URTI after age 2 (aOR, 1.44; 95% CI, 1.00 to 2.05).
The study authors speculate that antibiotic prescriptions early in life may reinforce parental expectations for antibiotics for URTIs, making withholding antibiotics for URTIs later in life more difficult.
"Results from the present study suggest that antibiotic prescription for URTI in early life may establish a pattern for antibiotic prescription for URTI in later childhood," the study authors wrote. "Reducing early life antibiotic prescription for URTI may result in reduction in antibiotic prescription for URTI in later life."
Sep 6 J Pediatric Infect Dis Soc abstract
