Stewardship / Resistance Scan for Dec 15, 2017

Rifampicin for Staph bacteremia
VRE in the ICU
ICU antibiotic stewardship

Study: No benefit from adding rifampicin to S aureus bacteremia treatment

The results of a large randomized trial show that adjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with Staphylococcus aureus bacteremia, UK researchers reported yesterday in The Lancet.

For many years, the researchers explain, it's been hypothesized that adding rifampicin to the standard treatment for S aureus bacteremia (either an anti-staphylococcal penicillin or a glycopeptide if the bacteria are resistant to methicillin) might improve outcomes for the infection, which is one of the most common and serious community- and hospital-acquired infections worldwide. That belief has led to widespread use of rifampicin for treatment of S aureus bacteremia, even though the evidence to support the benefit is weak.

To test the hypothesis that adjunctive rifampicin is beneficial for S aureus bacteremia patients, the researchers conducted a multicenter, randomized, double-blind, placebo-controlled trial of adults with S aureus bacteremia treated at 29 UK hospitals from December 2012 through October 2016. The participants were randomized 1:1 to receive either rifampicin or a placebo for 2 weeks, plus standard antibiotic therapy as chosen by the attending physician. The primary outcome was bacteriologically confirmed treatment failure or disease recurrence, or death (all-cause), from randomization to 12 weeks.

Of the 758 eligible participants, 370 received rifampicin and 388 received a placebo in addition to standard therapy. Standard antibiotics were given for a median duration of 29 days, and 619 participants (82%) received flucloxacillin. By week 12, bacteriologically confirmed treatment failure or disease recurrence, or death, had occurred in 62 participants (17%) in the rifampicin group compared with 71 patients (18%) in the placebo group (absolute risk difference -1.4%, hazard ratio 0.96). While there was a small but significant reduction in disease recurrence associated with rifampicin, that effect had no impact on short-term or long-term mortality. In addition, patients treated with rifampicin had more adverse events than those treated with placebo (17% vs. 10%) and were more likely to have drug interactions that complicated their treatment (6% vs. 2%)

"In summary, adjunctive rifampicin did not improve outcomes from S aureus bacteraemia, with the exception of a modest reduction in disease recurrence," the authors conclude. 
Dec 14 Lancet study
Dec 14 Lancet commentary


Irish study finds VRE contamination common in the ICU

Irish researchers report that intensive care unit (ICU) environmental contamination with vancomycin-resistant enterococci (VRE) in areas near patients is common, even in non-outbreak settings, according to a study yesterday in Infection Control and Hospital Epidemiology.

In the single-center study, conducted in the ICU of an 820-bed teaching hospital in Dublin, investigators took samples from the ICU environment and patients during seven sampling periods from October 2012 through June 2014. The aim of the study was to identify potential reservoirs of VRE, investigate the clinical and molecular epidemiology of VRE outside of outbreaks, and assess the role of active surveillance cultures (ASCs) in identifying VRE patients in this setting. Ireland has the highest rate of VRE bloodstream infections in Europe at 45.8%.

Of 289 sampling occasions involving 157 patients and their bed spaces, VRE isolates were recovered from patient bed spaces, clinical samples, or both on 114 of 289 sampling occasions (39.4%). The patient and their bed space were positive for VRE on 34 of 114 VRE-associated sampling occasions (29.8%). Thirty of the 157 patients (19%) were VRE-colonized.

Of 1,647 environment samples, 107 sites (6.5%) were VRE positive, with significantly greater VRE recovery from isolation rooms than from the open-plan area (9.1% vs 4.1%). The most frequently VRE-contaminated sites were the drip stand, bed control panel, and chart holders, which together accounted for 61% of contaminated sites. The use of ASCs resulted in a 172% increase in identification of VRE-colonized patients. Molecular typing revealed two environmental clusters, one involving three patients and generally greater heterogeneity of patient isolates compared to environmental isolates.

The authors conclude that better infection control policies that limit environmental transmission of VRE in the ICU are needed.
Dec 14 Infect Control Hosp Epidemiol study

Palestinian study finds good response to ICU stewardship intervention

A prospective audit-and-feedback antimicrobial stewardship program (ASP) in a Palestinian ICU found a high acceptance rate for the ASP team's recommendations, according to a study this week in the British Journal of Clinical Pharmacology.

The ASP program was begun at the Palestinian Medical Complex in September 2015. The investigators analyzed data from the 4 months before and the 4 months after implementation.

They found that, of 176 recommendations made by the ASP team, 78.4% were accepted. The most often accepted interventions were dose optimization (87%) and de-escalation based on culture results (84.4%). In addition, interventions were associated with a 24.3% reduction in antimicrobial use, shorter length of stay, and significantly reduced duration of therapy.
Dec 13 Br J Clin Pharmacol study

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