Stewardship / Resistance Scan for Nov 08, 2017

Community-related C diff
;
Antibiotic sparing for UTIs

VHA study notes rise in community-associated C diff infections

A study of Veterans Health Administration (VHA) hospitals has found that cases of community-associated Clostridium difficile infection (CA-CDI) are on the rise, researchers from the University of Texas at Austin reported yesterday in the American Journal of Infection Control.

In the retrospective cohort study of all adult VHA beneficiaries with CDI from October 2002 through September 2014, the researchers identified 30,326 patients with a first CDI episode during the 12-year period. Health care facility–onset CDI (HCFO-CDI) accounted for 60.2% of cases and was the predominant type. Among cases linked to the community, 20.6% were classified as community-onset HCFO-CDI (CO-HCFA-CDI), and 19.2% were classified as CA-CDI.

There was a shift from HCFO-CDI to CA-CDI over the study period. The proportion of patients with HCFO-CDI decreased from 73.5% during fiscal year (FY) 2003 to 53.2% during FY 2014, while CA-CDI increased from 8.3% to 26.7%.

HCFO-CDI patients, however, had worse outcomes. In multivariable models, HCFO-CDI was a positive predictor of severe CDI (odds ratio [OR], 1.71) 30-day mortality (OR, 1.46), 60-day mortality (OR, 1.48), and 90-day mortality (OR, 1.54), but was not predictive of 30-day recurrence (OR, 0.41), 60-day recurrence (OR, 0.40), and 90-day recurrence (OR, 0.41).

The authors of the study suggest the shift from HCFO-CDI to CA-CDI over the 12-year period could be caused by increasing use of high-risk antibiotics, such as fluoroquinolones, in the community, as well as increasing use of proton-pump inhibitors. They also cite an increase in the number of elderly patients admitted to long-term care facilities, which have been identified as reservoirs of CDI.
Nov 7 Am J Infect Control study

 

Swiss study finds NSAIDS inferior to antibiotics for treating UTIs

A randomized controlled trial by Swiss researchers has found that symptomatic treatment with non-steroidal anti-inflammatory drugs (NSAIDs) as a potential antibiotic stewardship step is inferior to antibiotic treatment in women who have uncomplicated urinary tract infections (UTIs) and is likely to be associated with increased risk of pyelonephritis.

In a study today in BMJ, the researchers randomly assigned 253 women with uncomplicated lower UTI 1:1 to treatment with diclofenac or norfloxacin. Both patients and assessors were blinded to allocation. Participants started treatment immediately after randomization and were advised to take two capsules per day. The primary outcome was symptom resolution on day 3, and the secondary outcome was the use of any antibiotic up to day 30. All participants were given a package of fosfomycin to take as a rescue antibiotic if symptoms persisted past day 3.

Resolution of symptoms at day 3 was observed in 72 (54%) of 133 women assigned to diclofenac and 96 (80%) of 120 of women assigned to norfloxacin (risk difference, 27%, P = 0.98 for non-inferiority). The median time until resolution of symptoms was 4 days in the diclofenac group and 2 days in the norfloxacin group. A total of 82 women (62%) in the diclofenac group and 118 (98%) in the norfloxacin group (98%) used antibiotics up to day 30 (risk difference, 37%, P < 0.001 for superiority). Six women in the diclofenac group received a diagnosis of pyelonephritis—a bacterial infection of the kidneys—compared with none in the norfloxacin group (P = 0.03).

Although the results show that symptomatic treatment with NSAIDs is inferior to antibiotic treatment for UTI symptom relief, the authors of the study say the fact that fewer women in the diclofenac group were on antibiotics until day 30 is important. "The observed clinically relevant reduction in antibiotic use, which would likely contribute directly to decreasing resistance rates in the affected population, suggests that alternative approaches of combining symptomatic treatment with deferred, selective antibiotic use should be developed and tested in future trials," they write.
Nov 8 BMJ study

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