Stewardship / Resistance Scan for Jul 13, 2017

MDR-TB in Georgia
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Stewardship in the ED

Study finds high resistance to first-line MDR-TB drug in Georgia

More than half of the multidrug-resistant tuberculosis (MDR-TB) isolates tested in the Republic of Georgia were resistant to one of the first-line treatments for the disease, researchers reported yesterday in BMC Infectious Diseases.

In the study, researchers tested a collection of TB isolates to assess their resistance to the fluoroquinolone antibiotic pyrazinamide (PZA), one of the drugs recommended for first-line treatment of TB and MDR-TB. The isolates were collected as part of a larger study on TB in Georgia, which is recognized as one of the high-burden MDR-TB countries. According to the study, 16.6% of all laboratory-confirmed pulmonary TB patients in Georgia in 2014 were diagnosed with MDR-TB.

Of the 57 isolates tested for PZA susceptibility, 33 (57.9%) were resistant to PZA and 24 (42.1%) were susceptible. All 33 PZA-resistant isolates were MDR-TB strains, and 4 of the 57 isolates were identified as extensively drug-resistant (XDR)-TB. Mutations in the pncA gene, which are largely responsible for conferring resistance to PZA, were found in all 33 PZA-resistant isolates.

Molecular typing identified two major MDR-TB clusters (94-32 and 100-32) in which 67% and 93% of isolates, respectively, were PZA-resistant. Researchers also identified a member of the potentially highly transmissible clade A strain, along with a strain that was distantly related to the clade A strain, suggesting that different branches of the lineage have been introduced to the region.

"Our data contribute to the rising pool of evidence showing the high incidence of PZA resistance among MDR-TB isolates," the authors write. "Health authorities and TB control programs should consider prospective genotyping and PZA testing to assure current effective MDR-TB treatment and to inform the design of new MDR-TB treatment trials."
Jul 12 BMC Infect Dis study

 

Barriers, solutions for antibiotic stewardship in emergency departments

A study yesterday in the American Journal of Infection Control suggests that antibiotic stewardship in emergency departments (EDs) is hampered by a combination of technological and social factors, but that these barriers could be minimized by using electronic health record–based clinical decision support (EHR CDS) guided by a set of principles and practices.

In the study, researchers conducted interviews and focus groups with hospital and ED leadership, attending ED physicians, nurse practitioners, physician assistants, and residents at Children's Hospital Colorado Health System. The purpose was to elicit a range of information on factors that influence antibiotic prescribing in the ED, provider experience with EHR CDS, and the potential barriers to implementing antibiotic stewardship in the ED using EHR CDS. Data were reviewed and coded using constant comparative analysis and framework analysis until a final set of themes emerged.

The answers from participants revealed that two dominant beliefs framed their perception of antibiotic stewardship in the ED. The first was that efficiency was a core principal guiding antibiotic prescribing practices, as the volume and pace of the ED necessitated that providers manage their time efficiently. The second was autonomy in antibiotic prescribing is often constrained by external influences, including parents or a family's primary care provider (PCP).

These beliefs were reflected in the barriers to stewardship identified by the participants: the rapid pace of the ED, the limited time to interact with the patient and the family, the need to manage parental expectations about antibiotic use, and the need to support the prescribing decisions of the family's PCP.

The participants identified three principles and practices to guide and support antibiotic stewardship in the ED using EHR CDS. The principles included integrating EHR CDS into the existing workflow to support efficiency, maintaining a balance between provider autonomy and standardization, and using antibiotic prescribing data to communicate the scope of the issue to providers. Practices included designing a simple yet flexible EHR CDS user interface, providing performance data to providers regularly, and developing brief communications scripts about antibiotics that providers can use with patients.
Jun 24 Am J Infect Control abstract

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