ASP Scan (Weekly) for Feb 17, 2017

Daptomycin for kids' MRSA
;
Antibiotics sans prescription
;
CRE source in the ICU
;
C diff cluster
;
ASP recommendations
;
MCR-1 in chicken meat
;
Patient hand hygiene
;
Handshake stewardship

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

Daptomycin shown to be safe, effective in kids with MRSA skin infections

Daptomycin is well-tolerated and effective in children with invasive methicillin-resistant Staphylococcus aureus (MRSA) skin infections, according to the results of a clinical trial published this week in Pediatrics.

Safe and effective alternative therapies are needed for children with skin infections caused by community-acquired MRSA because of concerns about current treatments. The high doses of vancomycin that are needed to treat MRSA infections can cause kidney damage in children, and clindamycin, while well-tolerated, has resistance rates that exceed 10% to 15%. Linezolid, the other alternative agent, carries concerns about myelosuppression and neurotoxicity. 

In the multicenter, evaluator-blinded clinical trial conducted at 23 children's hospitals in the United States and seven in India from July 2008 through October 2013, 389 patients from 1 to 17 years old who had complicated skin and skin structure infections (cSSSIs) were randomized 2:1 to receive intravenous (IV) daptomycin or standard-of-care (SOC) treatment (primarily clindamycin or vancomycin). The intent-to-treat population comprised 257 patients randomized to daptomycin and132 randomized to SOC. Over 40% of the infections with documented gram-positive pathogens were caused by MRSA.

The primary objective was to evaluate daptomycin safety. The secondary objective was to compare the efficacy of the treatments, but the study wasn't designed or powered to confirm non-inferiority.

The trial results showed that the proportion of treatment-related adverse events were similar between the two treatment groups, with 14% of patients experiencing adverse events in the daptomycin-treated group and 17% in the SOC-treated group. The most common adverse events were diarrhea and increased levels of the enzyme creatine phosphokinase (CPK) in the blood. Daptomycin was not associated with an increased risk of neurologic or muscular toxicity.

Clinical success rates were similar between the two groups, with 91% of the daptomycin patients and 87% of the SOC patients seeing complete or partial resolution of cSSSI symptoms 7 to 14 days after the end of treatment.

"Daptomycin should provide a safe and effective alternative to vancomycin, clindamycin or linezolid for IV treatment of invasive MRSA skin infections," first author John Bradley, MD, said in a press release from the University of California-San Diego (UCSD). Bradley is a professor of clinical pediatrics at UCSD School of Medicine. 

The Food and Drug Administration is considering whether to approve daptomycin for use in children, according to the press release.
Feb 15 Pediatrics abstract
Feb 16 UCSD press release


No prescription required: Study looks at online pharmacies, antibiotic use
A study today in the Journal of Antimicrobial Chemotherapy reports that nearly half of online pharmacies available to residents of the United Kingdom don't require a prescription for the purchase of antibiotics.

In the small study, researchers from Imperial College London entered the search term "buy antibiotics online" into Google and Yahoo, then selected the first 10 unique Web sites that appeared on each search engine, for a sample size of 20. Though the sample size was small, the researchers say they represent a broad range of relevant sites.

Of the 20 online pharmacy sites reviewed, 5 showed evidence of operating in Great Britain. All 5 of those sites were registered with the General Pharmaceutical Council and the Medicines and Healthcare products Regulatory Agency (MHRA)—two groups that monitor and regulate UK pharmacies—and all 5 required a prescription before an antibiotic would be delivered. Fifteen of the Web sites did not have evidence of appropriate registration, which is required by law.

Overall, nine of the online pharmacies (45%) did not require a prescription for purchase of an antibiotic. In addition, 16 of the online pharmacies (80%) surveyed let the consumers choose the type of antibiotic, the dose, and the duration, although one of the pharmacies required customers to fill out a questionnaire after payment that would be reviewed by a doctor to assess an individual's suitability for an antibiotic. Only six of the online pharmacies required customers to complete a health questionnaire prior to purchase.

The investigators also found that antibiotics were advertised on several of the Web sites, a practice they note "is not congruent with current MHRA regulations."

The authors of the study say the findings raise concerns about the effectiveness of legislation, licensing, and regulation of online pharmacies in the United Kingdom. In addition, they highlight the need for patient education to be included in antibiotic stewardship initiatives. 

"If the risks of inappropriate antibiotic use are not conveyed to patients there is concern that, as consumers, they may seek to obtain antibiotics from an alternative source," they write. "Education and public awareness campaigns should encourage prescribers to identify patients' ideas, concerns, and expectations, whilst fully explaining why they do not need an antibiotic."
Feb 17 J Antimicrob Chemother study 

 

Report implicates CRE-contaminated sinks in ICU outbreak

An outbreak of carbapenem-resistant Enterobacteriaceae (CRE) at a Belgian hospital in 2015 was traced to contaminated sinks in an intensive care unit (ICU), according to a report yesterday in Antimicrobial Resistance & Infection Control.

Investigators at the University Hospital of Brussels noted that the incidence of CRE rose from 1 case in 2010 to 35 in 2015. They also reported that 5 of those patients became infected or colonized during their stay in the same ICU room from January to August of that year. Because of the timetable and the fact that the strains belonged to different species and had varied mechanisms of resistance, the team suspected environmental contamination.

Sampling revealed that seven of the eight sinks in the ICU were contaminated with CRE. The most frequently isolated strain from both the sinks and the patients was Citrobacter freundii type OXA-48, and genetic analysis showed a close relationship between the sinks and patients, pointing to source contamination. No positive samples were obtained from any of the other three ICUs in the hospital, each of which also house eight sinks.

After the sinks and plumbing were replaced, the sinks were flushed every morning with a glucoprotamin solution, and sink hygiene practices improved, no further cases were reported.
Feb 17 Antimicrob Resist Infect Control report

 

Study: Stewardship helps reduce C diff incidence in German hospital

Originally published by CIDRAP News Feb 16

A study yesterday in Antimicrobial Resistance and Infection Control describes a cluster of hospital-acquired Clostridium difficile infections (CDIs) in 26 patients with osteoarticular (bone and joint) infections.

The study was initiated after an increase in CDI incidence was observed in early 2015 in patients on the septic ward of a German hospital who experienced mostly implant-associated osteoarticular infections. Retrospective analysis showed that the rise in incidence on the ward had begun in 2014. The aim of the study was to define the source of the infections and evaluate the impact of measures taken by the hospital after the increase in CDIs.

From June 2014 through December 2015, 63 patients with gastrointestinal disorders were tested for C difficile, and CDI was confirmed by polymerase chain reaction testing in 26 patients. Multilocus sequence typing showed that 15 of the CDIs (58%) were caused by C difficile ribotype RT027. But molecular epidemiologic analysis, environmental sampling, and analysis of inpatient contacts could not identify a common source of the RT027 isolates. The only shared risk factor among the patients with RT027 was their stay on the septic ward.

Evaluation of the infection control and antibiotic stewardship measures undertaken by the hospital in response indicated that the incidence of CDI was reduced only after implementation of an intensified antibiotic stewardship program that lowered the use of three high-risk antibiotics on the septic ward: fluoroquinolones, third-generation cephalosporins, and clindamycin. Use of those antibiotics on the septic ward was double to triple the use of unaffected orthopedic wards. The intervention shifted antibiotic therapy toward the use of narrow-spectrum penicillins, linezolid, and rifampicin.

"The successful reduction of the CDI incidence demonstrates the importance of antibiotic stewardship programs focused on patients treated for osteoarticular infections," the authors conclude.
Feb 15 Antimicrob Resist Infect Control study

        

Experts recommend strategies for successful stewardship

Originally published by CIDRAP News Feb 15

An article yesterday in Clinical Infectious Diseases aims to help healthcare institutions comply with newly mandated antimicrobial stewardship standards by highlighting the habits of successful antimicrobial stewardship programs.

The article, which borrows its title from the popular self-help book "The 7 Habits of Highly Effective People," reviews the eight elements of performance that make up the New Antimicrobial Stewardship Standard, a set of guidelines developed by The Joint Commission for hospitals, critical access hospitals, nursing homes, ambulatory care organizations, and office-based surgery practices. The standard requires these institutions to have an antimicrobial stewardship program (ASP) based on current scientific literature as of Jan 1, 2017.

As the article notes, there is little guidance for hospital administrators on how to comply with the standard. Using real-world experience from established ASPs, the authors reviewed the eight elements of performance and recommended strategies that will help institutions implement each of those elements, reduce inappropriate antibiotic usage, and improve patient outcomes. Among the strategies they recommend are endorsement of an institution's ASP policy by hospital administration, mandated educational ASP competencies for all healthcare providers involved in antibiotic ordering and dispensing, use of various communication venues to educate patients about appropriate antibiotic use, and regular collection and analysis of data on antibiotic use and outcomes.

"Simply asking clinicians to do a better job at prescribing antimicrobials has not and does not work," the authors write. "Unraveling years of overprescribing antimicrobials will require behavior change."
Jan 14 Clin Infect Dis abstract 

 

MCR-1-carrying E coli found in Brazilian chicken meat

Originally published by CIDRAP News Feb 15

A new study in Antimicrobial Agents and Chemotherapy reports that colistin-resistant Escherichia coli isolates carrying the MCR-1 gene have been identified in commercial chicken meat in Brazil.

As part of a local investigation into the presence of colistin-resistant bacteria, researchers collected 41 chicken samples from markets in Sao Paulo and tested them for susceptibility to polymixin B and colistin and for the presence of the MCR-1 gene, which confers resistance to the last-resort antibiotic. They found eight clonally unrelated colistin-resistant E coli isolates carrying MCR-1.

The authors report that most of the E coli isolates exhibited a multidrug-resistant phenotype and carried additional genes conferring resistance to aminoglycosides, quinolones, sulphonamide, and tetracyclines. In addition, they found the presence of IncX4-type plasmids, which have been implicated in global dissemination of the gene, in five of the isolates.

Since it was first identified in China in 2015, the MCR-1 gene has been identified in food-producing animals, foods, aquatic environments, and humans in more than 30 countries. But studies reporting its presence in Enterobacteriaceae from foods have been infrequent, the authors note. They suggest it could be linked to widespread use of colistin in Brazilian pigs and poultry. Use of colistin in animal feed was banned by Brazil in 2016.

"In summary, these results highlight that commercial chicken meat can be an important reservoir of mcr-1-carrying E coli, which is a cause for public health concern, since this could contribute to the acceleration of the spread of the mcr-1 gene," the authors write.

Brazil is the third largest producer of chicken meat, according to the study.
Feb 13 Antimicrob Agents Chemother study

 

Educational intervention can improve patient hand hygiene

Originally published by CIDRAP News Feb 14

A study yesterday in the American Journal of Infection Control indicates that a simple educational intervention can improve hand hygiene in hospital patients.

Hand hygiene by patients and healthcare workers has been advocated as a measure to prevent the transmission and spread of pathogens that cause healthcare-associated infections and promote the emergence of antibiotic resistance. In the randomized trial, 54 patients on four medical-surgical wards at a Veterans Affairs hospital in Ohio received a bottle of hand sanitizer that was placed on their bedside table. In the intervention group, patients received education on hand hygiene from a member of the study team. The control group received no education.

The education was based on a patient hand hygiene model that directs patients to use hand sanitizer at five specific moments:

  1. Before and after touching wounds/devices
  2. Before eating
  3. After using the restroom
  4. When entering or leaving your room
  5. When healthcare personnel enter your room

The fifth moment was added as a nonverbal reminder to healthcare personal of the importance of hand hygiene.

To determine the impact of the intervention, the investigators measured patient hand sanitizer use by weighing the hand sanitizer bottles every day for 3 days. They also assessed the frequency of hand sanitizer use by patients when healthcare personnel entered the room.

Based on the grams of hand sanitizer used per day, the investigators found that the intervention group used significantly more hand sanitizer than the control group overall and for each of the 3 days of monitoring. In addition, the intervention group performed hand hygiene when healthcare personnel entered the room more often than the control group, although the difference was only statistically significant on day 1 of the trial.  

"These results suggest that the 5 moments for patient hand hygiene model can be an effective means to increase patient hand hygiene performance," the authors write.
Feb 13 Am J Infect Control study

 

Unique stewardship strategy increases ID consultations, study finds

Originally published by CIDRAP News Feb 13

The implementation of a "handshake stewardship" program at a children's hospital led to a significant increase in infectious disease (ID) consultations, according to a new study in Clinical Infectious Diseases.

In the quasi-experimental retrospective cohort study conducted at Children's Hospital Colorado in Denver, researchers compared rates of initial ID consultations before and after implementing a unique type of antibiotic stewardship program (ASP)—called "handshake stewardship"—that expands on the prospective audit and feedback approach. Handshake stewardship involves daily review of prescribed antimicrobials at 24 and 72 hours, real-time decision support for rapid diagnostic test reporting, and in-person communication between the stewardship team and attending physicians, regardless of whether there are ASP interventions.

A comparison of the pre-implementation phase (October 2010-September 2011) to the post-implementation period (October 2013-September 2015) showed that mean monthly ID consultations rose from 31 per 1,000 admissions to 42, an increase of 35%.

The authors of the study note the findings run contrary to the concern—expressed by ID providers in a recent survey—that ASPs would lead to a decrease on ID consultations and a loss of income. In addition, they note that ASP-recommended ID consultations only accounted for just over half of the additional ID consultations per month observed after implementation of the program. They argue that this could be an indirect benefit of the handshake stewardship approach.

"Daily in-person rounds leads to visibility and familiarity among the inpatient medical teams, breaking down barriers to units that may previously have little interaction with infectious disease providers," the authors write. "The 'Handshake Stewardship' approach provides a unique opportunity for a bi-directional exchange of information and education, often resulting in consultation."          
Feb 10 Clin Infect Dis abstract

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