ASP Scan (Weekly) for Nov 24, 2017

C diff and stewardship
Clinical decision support
EMR protocol and C diff rates
Rise in Candida auris cases
Stewardship via telemedicine

Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans

Hospital stewardship tied to some Clostridium difficile reductions

Originally published by CIDRAP News Nov 22

Implementing an antimicrobial stewardship program was associated with lower use of antimicrobials deemed high risk and some reduction in Clostridium difficile infection (CDI), according to a single-center study yesterday in the Journal of Antimicrobial Chemotherapy.

UK investigators sought to evaluate the effect of an antimicrobial stewardship intervention targeting high-risk antimicrobials (HRAs) that was implemented in October 2008 and to compare their findings with those from similar previously published studies. They analyzed data on all medical and surgical patients at Ninewells Hospital—a large teaching hospital in Dundee, Scotland—from October 2006 to September 2010.

Six months after the program was implemented, medical wards saw a 33% HRA reduction, while surgery patients were prescribed 32% fewer HRAs. After a year, CDIs dropped 24% among medical patients (reduction of 7 cases per 1,000 admissions), but there was no change in disease rate among surgery patients. The authors noted that HRA use was also reduced significantly in six comparable studies, but only two reported reductions in CDI rates.

The researchers conclude, "Despite large reductions in HRA prescribing and reductions in CDI, demonstrating real-world impact of stewardship interventions remains challenging."
Nov 21 J Antimicrob Chemother study


Study shows clinical decision support may help cut antibiotic use

Originally published by CIDRAP News Nov 22

California investigators demonstrated that clinical decision support (CDS) integrated in an electronic health record can discourage inappropriate antibiotic prescribing, but provider education is unlikely to have a sustained effect on antibiotic prescribing, according to their study published yesterday in the American Journal of Managed Care.

The researchers used a stepped-wedge cluster randomized design to evaluate antibiotic use for acute sinusitis (sinus infection) at 127 Kaiser Permanente South California clinics from September 2014 through April 2015.

Their analysis of 21,949 visits (10,491 before and 11,458 after CDS intervention) showed a 22% reduction in antibiotic use after CDS implementation, but the absolute drop in use—from 85.9% to 83.9%—was small. They also found that the effect varied by a statistically significant amount by clinic. Education of healthcare providers, the investigators found, led to a 49% reduction in antibiotic use initially, but the difference did not persist.

The authors conclude, "Provider education and CDS improved antibiotic stewardship and changed diagnosis patterns. The benefits of education were brief, and CDS effectiveness varied by medical center."
Nov 21 Am J Manag Care study


EMR protocol tied to lower incidence of C diff infections

Originally published by CIDRAP News Nov 22

Researchers who conducted a single-center study in St. Louis reported yesterday in the American Journal of Infection Control that implementation of an automated electronic health record (EMR) protocol for targeted testing of high-risk patients for C difficile led to reduced rates of hospital-onset CDI by improving the timing and appropriateness of testing.

The scientists included patients in the study who had two or more of the following CDI risk factors: (1) admission to a medical institution in the preceding 90 days, (2) administration of antibiotics in the preceding 90 days, or (3) a history of CDI. The protocol involves identifying in the EMR high-risk patients who have diarrhea in the first 3 days of admission and promptly testing them for C difficile. After day 3, if diarrhea develops, providers ask a series of questions to help identify the appropriate patients for C difficile diagnostic testing.

The researchers found that the standardized infection ratio for C difficile dropped from 1.276 before the protocol to 0.645 afterward, a 49% statistically significant decrease. They note thathospital leadership commitment and buy-in from nurses and physicians was essential for the success of the intervention.
Nov 21 Am J Infect Control study


US cases of Candida auris continue to climb

Originally published by CIDRAP News Nov 21

The number of reported Candida auris infections in the United States has risen to 157, according to the most recent case count from the Centers for Disease Control and Prevention (CDC).

As of Oct 31, the multidrug-resistant (MDR) fungus has been identified in healthcare facilities in 10 states, with New York (102) and New Jersey (33) reporting the most cases. Cases have also been reported in California (1), Connecticut (1), Florida (2), Illinois (9), Indiana (1), Maryland (1), Massachusetts (6), and Oklahoma (1).

The case count, which rose from 126 in September, reflects the number of laboratory-confirmed C auris infections. The CDC also reports that 29 patients have probable infections and 212 people have been found to be colonized with the pathogen. Colonized patients were identified by targeted screening in four states with clinical cases.

In patients with compromised immune systems, C auris can cause serious invasive infections affecting the bloodstream, heart, brain, ear, and bones. The CDC estimates that more than 1 in 3 patients with an invasive C auris infection die, and reports from other countries estimate mortality rates as high as 50%.
Nov 17 CDC case count update


Italian telemedicine consultation reduces antibiotic use, MDR bacteria

Originally published by CIDRAP News Nov 21

A telemedicine-based infectious disease consultation service at an Italian pediatric cardiac hospital helped reduce antibiotic use, overall antibiotic costs, and the selection of MDR bacteria, researchers report in the Italian Journal of Pediatrics.

The remote stewardship program, which was started in January 2015 after a cluster of pneumonia patients were admitted to the intensive care unit (ICU), consisted of a biweekly videoconference discussion of all clinical cases admitted to the hospital and a review of antibiotic strategies for each patient. Additional consultation with specialists was also available via telemedicine. The main topics discussed during the meetings were monitoring and managing of MDR Enterobacteriaceae, antibiotic prophylaxis protocols in surgery, and the difference between empirical and definitive therapy.

To measure the impact of the program on antibiotic appropriateness, costs, incidence of nosocomial infections, and incidence of isolation of MDR bacteria, the researchers compared the period immediately before the intervention (January 2014 through March 2015) to the post-intervention period (March 2015 through March 2016).

There were 683 patients in the pre-intervention period and 531 patients in the post-intervention period. The rate of hospital infections in the ICU per 1,000/person days decreased from 9.5 in the pre-intervention period to 6.1 in the post-intervention period, a difference that was not statistically significant. The rate of MDR isolation decreased from 104 to 79 per 1,000/person days, a reduction of 25%. In addition, the overall cost of antibiotics fell from €25,000 to €15,000, and average antibiotic packages consumed per admission fell from 9 to 6.7.

"In conclusion, the infectious disease meeting via telemedicine has been an effective tool for economic and professional development and multidisciplinary management of complex patients," the authors write. "The appropriate use of antibiotics reduced the multi-drug resistant bacteria selection, thus improving patient safety."
Nov 17 Ital J Pediatr letter to the editor

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