Stewardship / Resistance Scan for Apr 04, 2017

Stewardship in Israel
Hospital stewardship barriers
States' FSMA, drug resistance funds
MCR-1 in France

Israeli stewardship programs lead to reduced antibiotic use in hospitals

A nationwide antibiotic stewardship program (ASP) in Israel led to a reduction in antibiotic use in acute and long-term care hospitals, according to research presented at the spring conference of the Society for Healthcare Epidemiology of America (SHEA).

The program, implemented in 2012 by the Israel Ministry of Health (MOH), required all general and post-acute care hospitals, along with the ambulatory care sector of the country's health maintenance organizations (HMOs), to establish ASP committees, develop treatment guidelines and methods to control prescribing, and report antibiotic consumption annually to MOH. Institutions used computerized databases to report all systemic antibiotics dispensed to patients.

The investigators calculated antibiotic consumption as defined daily doses (DDD) per 100 patient-days for the hospitals and DDD per 1,000 insured patients per day for the HMOs. In general hospitals, comparisons were reported for intensive care units (ICUs), internal medicine, and general surgery wards

Looking at dispensing data from 2012 through 2015, the investigators observed a decline in antibiotic use of 3.7 DDD/100 patient-days, with use declining by 7% in ICUs, by 11% in general surgery wards, and by 8% in internal medicine. In post-acute care hospitals, there was a decline of 3.4 DDD/100 patient-days—a 32% reduction in antibiotic use. But in the HMO outpatient settings, the data showed only a 4% decline in antibiotic use (0.3 DDD/1000 insured patients per day).

"The reporting requirement and annual feedback provided by the MOH have led to a reduction in use in acute and long-term care hospitals nationwide, but little effect as yet in the outpatient setting," the authors concluded.
SHEA spring 2017 conference

Report notes distrust in guidelines, other barriers to stewardship

Pulmonary physicians and nurses cite various obstacles to promoting antimicrobial stewardship, including doctors' distrust of clinical guidelines for pulmonary infections, according to a small study yesterday in the American Journal of Infection Control.

Australian researchers conducted semi-structured interviews with 28 pulmonary physicians and nurses from two hospitals. They identified both clinical and social barriers.

The clinical barriers were differentiating pneumonia from chronic obstructive pulmonary disease (challenges often lead to overtreatment), differentiating viral from bacterial infections, and differentiating colonization from infection, which could lead to either under- or overprescribing.

Social barriers included perceptions of antibiotic resistance as not an immediate threat, a mistrust of antibiotic guidelines, and hospital hierarchies, which were said to have a significant influence on prescribing practices.

The authors said hospitals must understand these dynamics in order to implement effective antibiotic stewardship programs.
Apr 3 Am J Infect Control study


States need $100M for FSMA, $47M for antibiotic resistance, group says

State agencies need about $100 million for implementing the Food Safety Modernization Act (FSMA) and $47 million for antimicrobial resistance efforts, among other public health spending initiatives, according to a letter to Congress yesterday from the National Association of State Departments of Agriculture (NASDA).

NASDA, in the appropriations request for fiscal year 2018, asked for $40 million a year for produce safety, $40 million a year for disease prevention in human food, and $20 million a year disease prevention in animal food as part of FSMA steps.

"NASDA requests the committee to continue to increase funding for the state implementation activities that are required by FSMA," the letter states. "While FDA [the Food and Drug Administraion] is charged with writing the rules, significant implementation and enforcement activities under FSMA are the primary responsibilities of state agencies."

The group also advocates for $63 million for state food safety and inspection services.

"NASDA strongly supports the continuation of the National Antimicrobial Resistance Monitoring System (NARMS) presently funded at $10.8 million," the letter says, while thanking Congress for increasing NARMS funding for meat testing by $3 million in previous years. The group also called for $36 million for the National Action Plan for Combating Antibiotic Resistant Bacteria (CARB).

Other requests affecting infectious disease funding include at least $195 million for animal and plant health inspections, fully funding the National Animal Health Monitoring System (NAHMS) for antibiotic research, and $15 million for the National Animal Health Laboratory Network (NAHLN), an early warning system for emerging and foreign animal diseases.
Apr 3 NASDA letter


MCR-1 identified in French surgical patient

French investigators yesterday confirmed the colistin-resistance MCR-1 gene in a Klebsiella pneumoniae isolate in a man who had been hospitalized for fungal meningitis, according to a report yesterday in Emerging Infectious Diseases.

MCR-1 was first identified in China in November 2015 in Escherichia coli samples from pigs, pork products, humans. It has since been detected in more than 30 countries and is especially worrisome because it resides on small gene segments called plasmids that can transfer among different pathogens.

The newly reported patient is a 38-year-old man who had chronic granulomatous disease that was diagnosed when he was a baby. Since then, he has had several minor and major diseases and conditions that required treatment with antimicrobial drugs—but he was never prescribed colistin, a drug of last resort for resistant infections.

In April 2016 he was hospitalized for removal of a thyroid abscess, which harbored Aspergillus fumigatus. During the course of his treatment he received multiple antifungals and antibiotics.

MCR-1 was confirmed at a national lab, and the K pneumoniae isolate also harbored seven other resistance genes. The authors say the source of MCR-1 remains unknown, and screening of 39 contacts revealed no further MCR-1 samples.
Apr 3 Emerg Infect Dis report

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