Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans
Study shows global rise in macrolide-resistant Mycoplasma pneumoniae
Antibiotic resistance, one of the most common causes of community-acquired pneumonia (CAP) in children, has risen dramatically over the past two decades, according to a study published this week in JAMA Network Open.
To analyze global patterns, temporal trends, and regional variations in macrolide-resistant Mycoplasma pneumoniae (MRMP) infections, a team of South Korean researchers conducted a systematic review and meta-analysis of 153 studies from 150 articles published prior to Sep 10, 2021.
They found the worldwide proportion of MRMP infections rose from 18.2% in 2000 to 41% in 2010 to 76.5% in 2019. When the proportion of MRMP infections was classified by World Health Organization (WHO) region, a significant increasing trend was observed in the Western Pacific region (from 17.1% in 2000 to 71.2% in 2011 to 76.5% in 2019), but trends did not change significantly over time in other WHO regions.
The highest proportion of MRMP infections was observed in the Western Pacific region (53.4%), followed by the South East Asian region (9.8%), the region of the Americas (8.4%), the European region (5.1%), and the Eastern Mediterranean region (1.4%). Among the M pneumoniae variants associated with resistance to macrolides, A2063G was the most commonly identified (96.8%), followed by A2064G (4.8%).
When study populations were classified by children, the proportion of MRMP infections was highest in studies that comprised only children (37%).
M pneumoniae causes an estimated 30% to 40% of CAP cases in children globally. Macrolide resistance is one of the possible causes of refractory M pneumoniae infections, which are difficult to treat and have been associated with increased long-term complications and higher medical costs. The study authors say antibiotic overuse, especially of macrolides, may be behind the rise in MRMP infections.
"The results of the present study provide helpful information on the proportion of MRMP infections and may be used to overcome the disease burden of MRMP infections via the establishment of appropriate therapeutic strategies," they wrote.
Jul 11 JAMA Netw Open study
Report: Reforms could boost antibiotic access in emerging markets
A new report from the One Health Trust suggests more regulatory flexibility is needed to accelerate the approval of new antibiotics in emerging markets.
In their analysis of the regulatory framework for antibiotic approval in three middle-income countries—South Africa, India, and Brazil—researchers with the One Health Trust (formerly the Center for Disease Dynamics, Economics & Policy) found that the national regulatory bodies in the three countries have taken steps to expedite the registration of medicines, including, in some cases, granting flexibility in clinical trial requirements for drugs targeting unmet public health needs.
In South Africa, for example, a strategy for prioritizing regulatory review of new medicines for HIV, tuberculosis, and cancer has been introduced, and the COVID-19 pandemic has led to expedited assessments of clinical trials for COVID-19 treatments.
Likewise, officials in Brazil have introduced priority pathways for rapid approval of drugs relevant to public health, and Indian authorities have drafted a plan to reduce the time to drug approval. However, antibiotics and multidrug-resistant infections aren't explicitly included in the list of eligible drugs and indications in any of these accelerated approval frameworks.
Going forward, the report recommends that regulatory agencies in emerging markets create a specific category for antibiotics that target serious and life-threatening infections within the framework provided for accelerated approval pathways, leverage existing programs for expedited drug approval, and increase regulatory authorities' capacity to deal with the complexity of antimicrobial resistance (AMR) and novel clinical trials. They also call for more collaboration and harmonization with drug regulatory agencies in high-income nations.
The report argues that while it is crucial to create new financial incentives and reform the antibiotic development market to create a sustainable pipeline of new antibiotics, regulatory reforms to accelerate approval of new antibiotics can also help boost their development and improve access in the parts of the world where they are most needed.
"The growing burden of AMR will need to be addressed with new antibiotics," One Health Trust Director Ramanan Laxminarayan, PhD, MPH, writes in the report. "Unless we significantly rethink and revise current processes for regulatory approvals, the burden of AMR will keep increasing."
Jul 12 One Health Trust report
Prior antibiotic use, longer hospital stays increase risk of CRE infections
Originally published by CIDRAP News Jul 14
A study of patients at a large tertiary-care medical center found that antibiotic exposure and length of stay were associated with an increased risk of developing a carbapenem-resistant Enterobacterales (CRE) infection, researchers reported today in Antimicrobial Stewardship & Healthcare Epidemiology.
To identify risk factors for CRE infection, Ohio State researchers conducted a retrospective case-case-control study, comparing patients who had been diagnosed as having a CRE infection at the hospital from 2011 through 2016 with patients diagnosed as having carbapenem-susceptible Enterobacterales (CSE) infections and a random selection of control patients. Data collected from patient medical records included age at admission, sex, length of hospital stay, and prescription for antibiotics in the 90 days prior to admission.
A total of 81 unique CRE patients were identified during the study period, and they were compared with 87 CSE patients and 89 control patients. In the unadjusted analysis, CRE patients were more than 18 times more likely to have been prescribed any antibiotic in the previous 90 days than CSE patients (odds ratio [OR], 18.35; 95% confidence interval [CI], 5.37 to 62.8) and 51 times more likely than control patients (OR, 51.1; 95% CI, 14.9 to 176.0).
In multivariable models, prescription of a beta-lactam antibiotic was associated with a fivefold increase in odds for CRE infection (OR, 5.43; 95% CI, 1.95 to 15.1) and a more than twofold increase in odds for CSE infection (OR, 2.65; 95% CI, 1.18 to 5.95). Each additional day of hospital admission was associated with an increased odds of infection of about 13% for CRE patients (OR, 1.14; 95% CI, 1.08 to 1.19) and CSE patients (OR, 1.13; 95% CI, 1.08 to 1.18).
"Future studies of this type may consider conducting more thorough reviews of medical records to determine specific residence type prior to admission and whether patients are coming from common locations that have seen patients previously diagnosed with either CRE or CSE," the study authors wrote. "Long-term and other group care facilities may have increased incidence of infection in general and of resistant organisms specifically and determining where patients are being admitted from can be important factors in determining how to care for these patients upon admission to a medical facility."
Jul 14 Antimicrob Stewardship Healthc Epidemiol study
Stewardship interventions linked to reduce antibiotics in urgent care
Originally published by CIDRAP News Jul 14
A multifaceted quality-improvement program implemented at urgent care clinics in an integrated academic health system was associated with reductions in inappropriate and overall antibiotic prescribing, without negatively affecting patient satisfaction, researchers reported yesterday in Infection Control & Hospital Epidemiology.
The program implemented in 2019 at Northwestern Medicine was developed by an ambulatory antibiotic stewardship committee and focused on improving antibiotic prescribing for "stewardship target visits," which included non–antibiotic-appropriate conditions like upper respiratory tract infections. The program also targeted "diagnosis shifting visits," in which clinicians add antibiotic-appropriate diagnoses to evade stewardship measures, overall antibiotic prescribing, and patient satisfaction for acute respiratory infections (ARI) visits. Interventions included comparative feedback and clinician and patient education.
From 2019 through 2021, 576,609 patients made 1,358,816 visits to 17 urgent care clinics, including 105,781 visits for which stewardship measures were applied and 149,691 visits for which diagnosis shifting measures were applied.
The antibiotic prescribing rate decreased for stewardship-measure visits from 34% in 2019 to 12% in 2021 (absolute change, −22 percentage points; 95% CI, −23 to −22), for diagnosis-shifting visits from 63% to 35% (−28 percentage points; 95% CI, −28 to −27). The overall antibiotic prescribing rate declined from 30% to 10% (−20 percentage points; 95% CI, −20 to −20). The patient satisfaction rate increased from 83% in 2019 to 89% in 2020 and 2021. There was no significant association between antibiotic prescribing rates of individual clinicians and ARI visit patient satisfaction.
"In conclusion, it is possible to decrease antibiotic prescribing for presumed viral illnesses in the urgent-care setting and maintain patient satisfaction," the study authors wrote. "Key elements of success may have included an ambulatory antimicrobial stewardship committee, physician champions, having data for analysis and reporting, and educational resources for patients and prescribers."
They added that reducing antibiotic prescribing for non–antibiotic-appropriate diagnoses has the potential to start a "virtuous cycle" for patients, as non-receipt of antibiotics may be associated with less antibiotic seeking in the future.
Jul 13 Infect Control Hosp Epidemiol abstract