Stewardship / Resistance Scan for Aug 18, 2017

Antifungal susceptibility testing
Bacteriophage therapy
Expanded AMR monitoring

Data show gaps in antifungal susceptibility testing at US hospitals

A new study by researchers with the US Centers for Disease Control and Prevention indicates that availability of antifungal susceptibility testing (AFST) at US hospitals has improved in recent years, but substantial gaps remain.

The study, published Aug 16 in Open Forum Infectious Diseases, analyzed data for 2011 and 2015 from the Patient Safety Component Annual Hospital Survey, completion of which is required for all hospitals participating in the National Healthcare Safety Network. Hospital characteristics were examined in a multivariate analysis that included medical school affiliation, bed size, availability of AFST in the hospital's own laboratory or an affiliated medical center, and rates of Candida central-line associated bloodstream infections (CLABSIs).

Of the 4,690 acute care hospitals that participated in the survey in 2015, 95.5% offered AFST of any type, but only 28.4% offered AFST at their own laboratory or at an affiliated medical center, and 32.5% offered reflexive AFST. Pediatric (55.3%) and oncology (64.7%) hospitals more commonly offered AFST at their own laboratory or an affiliated medical center compared with general hospitals (28.0%), and more commonly offered reflexive testing (pediatric, 57.6%; oncology, 70.6%; and general hospitals, 33.0%). Of the general hospitals with a non-zero Candida CLABSI rate, 37.5% offered AFST at their own lab or an affiliated medical center, and 42.2% offered reflexive AFST.

Comparison of the 3,947 hospitals that completed surveys in 2011 and 2015 showed that the proportion of hospitals offering any AFST increased from 91.9% to 95.3%, while the proportion of hospitals offering AFST at their own laboratory or an affiliated medical center increased from 26.2% to 28.4%, and the proportion of hospitals offering reflexive AFST rose from 25.5% to 33.1%.

Factors associated with offering AFST at the hospital's own laboratory or an affiliated medical center included having a medical school affiliation (adjusted odds ratio [aOR], 1.46), having a non-zero Candida CLABSI rate (aOR, 1.41), and having a higher number of hospital beds (up to aOR of 3.23 for hospitals with 500 beds or more compared with hospitals with fewer than 100 beds). Factors associated with offering reflexive AFST included having AFST available at a hospital's own laboratory or an affiliated medical center (aOR, 9.61), medical school affiliation (aOR, 1.24), a non-zero CLABSI rate (aOR, 1.24), and higher number of hospital beds (aOR, 1.73).

The authors say that with the rise in drug-resistant Candida species, including multidrug-resistant Candida auris and echinocandin-resistant C glabrata, it's important that clinicians have access to AFST to make optimal treatment decisions.
Aug 16 Open Forum Infect Dis abstract


Case study: Phage therapy successfully treats multidrug-resistant infection

A case study in Antimicrobial Agents and Chemotherapy describes the successful use of a personalized bacteriophage-based therapeutic treatment in a patient with a life-threatening multidrug-resistant (MDR) infection.

The patient, a 68-year-old diabetic man, developed necrotizing pancreatitis that was complicated by an MDR Acinetobacter baumannii infection. Despite treatment with courses of vancomycin, meropenem, colisitin, tigecycline, and rifampin, the patient's condition continued to deteriorate for 4 months, and he became unresponsive. Because of the availability of any additional effective antimicrobial agents to treat the infection, an application was submitted to the Food and Drug Administration to request authorization to treat the infection with a combination of phages.

Using a cocktail of nine different phages that showed lytic activity against A baumannii, physicians initiated phage therapy intravenously and percutaneously into abscess cavities on day 109 of the infection, and a clear turning point was observed within 48 hours. Over the ensuing 11 weeks, the patient continued to receive bacteriophage therapy along with an antibiotic regimen of meropenem, fluconazole, and minocycline, during which time he showed steady clinical improvement. On day 245, the patient was discharged, and he subsequently returned to work.

"This case supports further study of the use of phage therapy in treating patients suffering from MDR bacterial infections with limited therapeutic options," the authors write. They add that future clinical trials focusing on delineating the extent to which bacteriophage-based therapeutics can be used as a last resort, either on their own or as an adjunct to traditional antibiotics, are warranted.
Aug 14 Antimicrob Agents Chemother study


Global health experts call for expanded AMR monitoring

A collection of infectious disease and global health experts says expanded national and subnational monitoring of countries' efforts to limit antimicrobial resistance (AMR) is needed to help governments maintain their commitments to tackle the problem.

In a commentary yesterday in PLoS Medicine, the group writes that while knowledge about the causes, consequences, and magnitude of AMR has improved in recent years, large information gaps about how nations are attempting to limit AMR remain. Surveillance data for low- and middle-income countries is lacking, variety in methodology and data collection hampers comparability across regions, the understanding of the clinical and public health burden of AMR is limited, and few data exist on how countries are responding to the problem. 

For successful implementation of the World Health Organization's (WHO's) Global Action Plan on AMR to occur, the group argues, these gaps need to be addressed. Expanded monitoring and harmonized data collection will enable countries to benchmark their national and subnational performance against other countries and use the best scientific evidence to shape policy, and it could result in greater involvement of health professionals and the public. In addition, the experts suggest regular data collection across countries could serve as a basis for a longitudinal assessment of AMR control that guides implementation of national and subnational policies.

"Ultimately, the goal of expanded monitoring is to trigger a virtuous circle in which the collection of data constantly improves our understanding and capacity to tackle AMR, which in turn calls for new evidence," the authors write.

The authors argue that the goal of expanded monitoring should be to "measure the problem and progress across its multiple dimensions while at the same time making it more tractable to policy makers and the public." Although there are many challenges to expanding monitoring programs, they suggest the focus should be on choosing an appropriate scientific approach to conceptualizing AMR and related control efforts; defining what to measure; selecting appropriate measurements from human, animal, and planetary health; developing surveillance capabilities; and creating an online platform that employs data visualization methods to communicate findings. 

The authors say the WHO should lead the process but also call for a broad coalition of global health actors to assist in the effort.
Aug 17 PLoS Med commentary

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