Stewardship / Resistance Scan for Aug 24, 2017

Severe C diff and fecal transplant
Gonorrhea resistance trends
MRSA, VRE contact precautions

Study shows strong promise for fecal transplants for severe C difficile

A study today involving 111 patients found that early fecal microbiota transplantation (FMT) dramatically improves survival in severe Clostridium difficile infections (CDIs).

Writing in Clinical Infectious Diseases, French researchers noted that they included 66 patients with severe CDI in an FMT group and 45 in an antibiotic-only group. The FMT group received vancomycin for 2 to 4 days before and after transplant, while the non-FMT group received one of several antibiotic therapy options, depending on their clinical status, but the vast majority were prescribed vancomycin. Patients were a median of 82 years old, and follow-up was conducted at 3, 6, and 12 months.

Three-month mortality was 42.2% (19/45) in the antibiotic group and 12.1% (8/66) in the FMT group, a 71% reduction. The investigators estimated that only four patients needed to be treated with FMT to save one life at 3 months. Thirty (45.5%) FMTs were performed using fresh stools and 36 (54.5%) with frozen stools, but the researchers found no significant difference between the two.

The authors concluded, "Risk of bias was low because baseline characteristics were similar and multivariate survival models were used."

In response to a perceived need by some to wait to change C difficile treatment recommendations until randomized, double-blind, controlled trials can be launched, the authors pointed to the expense of such studies, among other factors. They said that, given the promising results of their study, "waiting for double-blind randomized controlled trials to update the recommendations and management of the most vulnerable and severely ill C. difficile-infected patients who are at very high risk of mortality . . . does not seem ethical."

In a related commentary, however, Antoine Andremont, MD, PhD, who was not involved in the study, disagreed. Andremont, from the University Paris-Diderot Medical School, cited several reasons for not changing practice standards just yet, including concerns over stalling other key research of C difficile treatment and prevention (including antibiotic stewardship approaches) and the complex nature of the fecal microbiota.
Aug 24 Clin Infect Dis study
Aug 24 Clin Infect Dis commentary


European data show declining resistance for some gonorrhea antibiotics

New data reported today by the European Centre for Disease Prevention and Control (ECDC) shows antibiotic resistance levels declining for cefixime and ceftriaxone when used to treat gonorrhea. Resistance to azithromycin, however, is on the rise.

The data were gathered from a 2015 antimicrobial susceptibility survey conducted in 24 European Union member states. A total of 2,134 isolates were collected and tested, covering 3% of the gonorrhea cases reported by routine surveillance.

Compared to data from 2014, there was a slightly lower proportion of cefixime resistance in nine member states (1.7% compared to 2.0%), and only one isolate was found to be resistant to ceftriaxone (five were found in 2014). However, five isolates displayed high-level resistance to azithromycin, compared with one in 2014.

The ECDC said the declining resistance levels were partly due to the dual-therapy regimen (ceftriaxone plus azithromycin) currently recommended to treat gonorrhea in the EU. The rising resistance to azithromycin threatens this treatment strategy.

Last year the US Centers for Disease Control and Prevention (CDC) warned of rising azithromycin resistance rates among US gonorrhea cases. Both the CDC and ECDC said that approximately 25% of gonorrhea isolates are now resistant to tetracycline and ciprofloxacin, former first-line treatments for the sexually transmitted disease.
Aug 24 ECDC report
Jul 15, 2016, CIDRAP News story
"Gonorrhea growing more resistant to standard treatment"


Forgoing contact precautions not tied to increased MRSA, VRE

Discontinuing contact precautions did not affect the rates of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), according to the results of a retrospective study at a large Detroit hospital published yesterday in the American Journal of Infection Control.

Researchers assessed healthcare-related MRSA and VRE infection rates in the 12 months before and the 12 months after contact precautions were discontinued at an 800-bed teaching hospital in 2013. The study included 36,907 patients treated with contact precautions and 40,439 treated without. Contact precautions include infection-prevention measures in addition to standard precautions, such as gloves, gowns, and private rooms, for serious, easily transmitted diseases.

MRSA and VRE rates for the following infections did not differ significantly in the two study periods: catheter-associated urinary tract infections, ventilator-associated pneumonia, central line–associated bloodstream infections, surgical-site infections, and hospital-acquired MRSA bacteremia.
Aug 23 Am J Infect Control study

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