Stewardship / Resistance Scan for Aug 01, 2017

Diagnostic stewardship
Animal antibiotics in Denmark
Key role for vaccines

Doctors call for diagnostic stewardship to improve antibiotic use

A commentary yesterday in JAMA argues for diagnostic stewardship as an additional strategy to reduce inappropriate use of antibiotics.

While culture and non-culture–based diagnostic tests are necessary for helping establish the presence or absence of infection, the authors write, the process of ordering and interpreting those tests is complex. In addition, clinicians often order common tests for patients who aren't exhibiting symptoms specific for the disease process. For example, they order Clostridium difficile tests for patients who don't have diarrhea and urine cultures for patients without symptoms of urinary tract infection.

The authors argue that the problem with these tests, especially the increasingly sensitive molecular tests, is that they frequently produce false-positive results or fail to distinguish colonization from infection. The end result is overtreatment and inappropriate antibiotic use.

As a result, some hospitals have launched efforts to improve diagnostic stewardship by modifying the process of ordering, performing, and reporting diagnostic tests. Examples of diagnostic stewardship interventions include educational campaigns to teach clinicians appropriate indications and sampling for tests, removal of specific tests from electronic health records, and laboratory policies that include refusing to process specimens that are collected and handled inappropriately.

The authors go on to write that while the most beneficial form of diagnostic stewardship has not yet been defined, and thoughtful application of diagnostic stewardship principles should be applied to mitigate any potential unintended consequences and maintain clinician autonomy, implementing diagnostic stewardship can improve clinical care by reducing inappropriate testing, false-positive test results, and over-diagnosis. And they say that stewardship will be even more important with the expanding array of molecular diagnostic tests.
Jul 31 JAMA viewpoint


Commentary details success of antibiotic stewardship in Danish animals

Two Danish experts detailed the initiatives behind Denmark's successful antimicrobial stewardship efforts in food animals, highlighting a farmer overuse identification program, an antibiotic tax, and lab verification for antibiotic prescriptions as playing key roles.

Their analysis appeared yesterday in a National Academy of Medicine (NAM) commentary.

The two scientists noted that the use of antimicrobials in food-producing animals increased in Denmark from 2003 to 2009, partly as a result of more pigs in production. As a result of increased antimicrobial use, the Danish Veterinary and Food Administration established the "Yellow Card" intervention in 2011, designed to target pig farmers using high amounts of antimicrobials. It set national threshold limits for the use of antimicrobials in weaners, grower pigs, and adult pigs and could result in an injunction for farmers using too many drugs.

In addition, Danish officials adopted two measures in 2013: (1) a tax on antimicrobials that favored narrow-spectrum antimicrobials and vaccines compared with broad-spectrum compounds and (2) mandated annual lab verification of intestinal and respiratory infections for prescriptions written for group treatments.

"Together, these interventions, particularly those implemented [after] 2010, appear to have ended the otherwise increasing trend in antimicrobial usage observed since 1999," the authors wrote. "The antimicrobial resistance levels in Denmark continue to be lower than in most EU countries, which is most likely because of the detailed research and monitoring of antimicrobial use and resistance in food animals and in humans."
Jul 31 NAM commentary


US expert underscores vaccines as key element to fight drug resistance

Bruce Gellin, MD, MPH, former director of the US National Vaccine Program Office in the Department of Health and Human Services, in a commentary today underscored the important role that vaccines can play in combating antimicrobial resistance.

Writing for Stat, Gellin, now president of global immunization for the Sabin Vaccine Institute, outlined key steps to addressing the problem, such as developing new antibiotics and stewardship measures. He added, "Preventing infections in the first place will also reduce the need for antibiotics. That's where vaccines come in as an important part of the solution."

Gellin also noted, "In the context of the global trend in antibiotic resistance, we have been undervaluing all that vaccines offer to both individuals and communities."

He noted that vaccines help prevent the rise of antimicrobial resistance by preventing bacterial diseases such as pneumococcal infections, bacterial meningitis, and pneumonia, but their use against viral diseases can also reduce antibiotic use by preventing influenza and other viral infections that are often mistreated with antibiotics.
Aug 1 Stat commentary

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