VHA papers propose research agendas in 4 areas of antibiotic resistance
A series of papers yesterday in Infection Control and Hospital Epidemiology by researchers and clinicians with the Veterans Health Administration (VHA) identifies key knowledge gaps and lays out research agendas to address the spread of drug-resistant pathogens in healthcare settings.
The papers are products of a conference convened by the VHA in September 2016 to identify the gaps in existing knowledge about multidrug-resistant organisms (MDROs) and targets for future investigation. The conference was divided into four subgroups that examined the following topics: disrupting transmission of MDROs in hospitals, strategies to reduce and improve the use of antibiotics, ways to manipulate the human microbiome to prevent colonization with resistant pathogens, and infection control and prevention in settings outside of acute care.
Four of the articles summarize the subgroup discussions and present a research agenda to address these specific issues. The article on transmission dynamics, for example, recommends further research into hand hygiene, active surveillance, isolation measures, and environmental cleaning, while the subgroup on antibiotic stewardship calls for identifying optimal stewardship strategies and developing stewardship strategies that work in the absence of infectious disease specialists.
The microbiome subgroup recommends establishing a comprehensive framework for microbiota research and further research into the efficacy of fecal microbiota transplantation. The special population subgroup identifies long-term care, spinal cord injury/disorder, ambulatory care, mental health care, and home-based care patients as the populations in need of tailored infection control and prevention policies.
"The Veteran's Health Administration is uniquely positioned to be a leader in this area and has the ability to make a real impact," Eli Perencevich, MD, director of the Center for Comprehensive Access and Delivery Research at the Iowa City Veteran's Affairs Health Care System, said in a press release from the Society for Healthcare Epidemiology of America (publisher of the journal). "These four articles will help set the research agenda and provide a starting point for other healthcare systems to implement, or improve upon, in their own approaches."
Feb 8 Infect Control Hosp Epidemiol paper #1
Feb 8 Infect Control Hosp Epidemiol paper #2
Feb 8 Infect Control Hosp Epidemiol paper #3
Feb 8 Infect Control Hosp Epidemiol paper #4
Feb 8 Infect Control Hosp Epidemiol paper #5
Feb 8 SHEA press release
Study: No benefit from prophylactic antibiotics for aspiration pneumonitis
Prophylactic antimicrobial therapy for patients with acute aspiration pneumonitis does not provide clinical benefit and is associated with escalation of antibiotic therapy among those who develop aspiration pneumonia, Canadian researchers report today in Clinical Infectious Diseases.
In the retrospective cohort study of patients with aspiration pneumonitis, an acute chemical lung injury caused by inhalation of sterile gastric contents that can quickly lead to respiratory failure, the researchers were looking to compare patients receiving prophylactic antibiotics with those receiving supportive care. While prophylactic antimicrobial therapy is frequently prescribed, it has not been demonstrated to prevent the development of aspiration pneumonia or reduce mortality.
A total of 200 patients met the case definition for acute aspiration pneumonitis; 76 (38%) received prophylactic antimicrobial therapy and 124 (62%) received supportive management only. Unadjusted in-hospital mortality was similar between both groups (25% vs. 25%). Patients receiving antimicrobial prophylaxis were no less likely than those receiving supportive management to require transfer to critical care (5% vs. 6%), but they received more frequent escalation of antibiotic therapy (8% vs. 1%) and fewer antibiotic-free days (7.5 vs. 10.9). After adjusting for patient-level predictors, antimicrobial prophylaxis was not associated with any improvement of mortality (odds ratio 0.9).
"Our study found that antimicrobial therapy upfront for the management of acute aspiration pneumonitis gives rise to the need for more antibiotics later, frequently with broader spectrum antibiotics," the authors write. "These findings support our hypothesis that prescribing post-aspiration prophylaxis simply generates antibiotic selective pressures resulting in the need for escalation of antimicrobial therapy in the event of development of aspiration pneumonia."
Feb 9 Clin Infect Dis study
Research supports reducing IV antibiotic therapy in kids with CAP
Decreasing a hospital's average intravenous-to-oral antimicrobial therapy transition time by 1 day in pediatric patients with community-acquired pneumonia (CAP) reduced length of stay and hospital costs without sacrificing patient outcomes, researchers reported yesterday in the Journal of Pediatric Infectious Diseases.
The retrospective study 78,673 pediatric patients hospitalized for CAP from 2007 to 2016 was conducted by researchers from Children's Minnesota using discharge data from 48 freestanding children's hospitals. High incidence of and substantial hospital costs for treatment of pediatric CAP impose a considerable resource burden, and the researchers wanted to explore how the transition from intravenous to oral antibiotics in these patients would alter length of stay, costs, and readmission rates.
The researchers found that a 1-day decrease in the average last day of service on which the hospital administered antibiotics intravenously was associated with a mean 0.58-day reduction in length of stay and a $1,332 reduction in the mean cost of stay. Results were similar using a 1-day decrease in the average first day of service on which the hospital administered antibiotics orally. The results showed no effect on the 30-day hospital readmission rate
Based on these findings, and similar results in studies of adult patients with CAP, the authors conclude, "Antimicrobial stewardship programs could strategically target methods for reducing the duration of intravenous antibiotic therapy, such as provider education and institution of intravenous-to-oral administration policies that could improve patient outcomes and reduce costs."
Feb 8 J Pediatr Infect Dis abstract
Study indicates yaws elimination strategy needs modification
Originally published by CIDRAP News Feb 8
A longitudinal study in Papua New Guinea has found that mass administration of antibiotics followed by targeted treatment did not eliminate yaws, researchers reported yesterday in The Lancet. The study also discovered the first signs of resistance in the tropical infection, which causes chronic disfiguring skin ulcers in children in at least 14 countries.
The World Health Organization's strategy to eliminate yaws, an infectious disease caused by Treponema pallidum subspecies pertenue (T p pertenue), is the mass administration of a single dose of azithromycin aiming for a population coverage of more than 90%, followed by active case detection surveys every 3 to 6 months. Previous studies had found that mass treatment with azithromycin was associated with a nearly 90% reduction of serologically-confirmed active yaws from 2.4% to 0.3%, but long-term efficacy has not been determined.
From April 2013 through October 2016, the researchers studied the population of Lihir, an island of Papua New Guinea where yaws is endemic. They found that mass azithromycin treatment followed by targeted treatment programs reduced the prevalence of active yaws from 1.8% to 0.1% at 18 months, but the infection began to re-emerge at 24 months and the prevalence climbed to 0.4% at 42 months. Most of the cases were latent infections in individuals who were absent at the time of mass treatment, but some were imported.
In addition, the researchers found five cases of yaws at months 36 and 42 that were resistant to azithromycin. Polymerase chain reaction testing indicated that the resistance was caused by mutations in the 23S ribosomal RNA gene. All the cases were from the same village, indicating infection with the same strain.
"Our study underlines the need to treat every individual living in an endemic zone, in order to cure latent infections," lead author Oriol Mitja, MD, said in a press release from the Barcelona Institute for Global Health. Mitja and his colleagues conclude that a distribution of a second or third round of azithromycin at 6 to 12 months might be of substantial benefit.
Feb 7 Lancet abstract
Feb 7 Barcelona Institute for Global Health press release
Antibiotic-resistant Campylobacter implicated in 2016 raw milk outbreak
Originally published by CIDRAP News Feb 8
A 17-case Campylobacter outbreak linked to raw milk in Colorado in August 2016 has been confirmed to be caused by C jejuni bacteria resistant to fluoroquinolones, a class of antibiotics often used to treat campylobacteriosis, scientists from Colorado and the Centers for Disease Control and Prevention reported today in Morbidity and Mortality Weekly Report (MMWR).
Health officials confirmed 12 cases, and 5 other were deemed probable. Patients ranged in age from 12 to 68, with a median age of 58, and 9 were male. Illnesses lasted from 3 to 10 days, and one person required hospitalization. Testing of samples from patients and unpasteurized milk from the source dairy revealed matching C jejuni pathogens.
The National Antimicrobial Resistance Monitoring System performed antimicrobial susceptibility tests on five representative isolates, and all were resistant to ciprofloxacin, tetracycline, and nalidixic acid.
The authors concluded, "All tested isolates' resistance to three antibiotics was concerning, particularly as fluoroquinolones are frequently used to treat Campylobacter infections in those cases where treatment is indicated. Treatment of antibiotic-resistant Campylobacter infections might be more difficult, of longer duration, and possibly lead to more severe illness than treatment of nonresistant Campylobacter infections." The noted that, in 2015, 25.3% of US C jejuni isolates were resistant to ciprofloxacin, an increase from 21.6% 10 years earlier.
Feb 9 MMWR report
Survey finds knowledge and practice gaps among antibiotic prescribers
Originally published by CIDRAP News Feb 7
An online survey of frontline prescribers found mostly positive attitudes toward antimicrobial stewardship programs (ASPs) but also identified several specific deficiencies related to knowledge, prescribing practices, and awareness of available resources, according to a study yesterday in Infection Control and Hospital Epidemiology.
The anonymous online survey of antimicrobial prescribers was administered in 2015 at five acute care hospitals within a hospital network in New York. The 49-item survey included questions to assess the knowledge, attitudes, and practices of prescribers related to different aspects of antimicrobial prescribing. The objective of the survey was to identify opportunities for education and other interventions to optimize prescribing practices.
A total of 402 respondents completed the survey. The vast majority of respondents (89%) agreed that antimicrobial resistance is a problem, and almost all agreed that ASPs can reduce resistance (96%) and improve patient care and safety (94%). Yet 32% felt that their hospital's ASP delayed care.
In addition, several knowledge and practice gaps were identified. Nearly one third (32%) of respondents "usually" or "always" liked to use the most broad-spectrum antibiotics possible, and 29% chose an unnecessarily broad-spectrum antibiotic for treating Escherichia coli urinary tract infection with susceptibilities that were provided in the survey. Some respondents lacked confidence in selecting empiric therapy using hospital antibiograms (30%), interpreting susceptibility results (24%), de-escalating therapy (18%), and determining duration of therapy (31%). Only 55% reported always reviewing antimicrobial appropriateness at 48 to 72 hours.
Nearly half (45%) of respondents believed they had not received adequate training regarding antimicrobial prescribing, and 23% said they were unaware of local web-based empiric treatment guidelines.
"The results of this survey demonstrate that prescriber education is an important role of the ASP team and that there is no 'one size fits all' approach to education," the authors write. "Understanding the facilitators of and barriers to appropriate antimicrobial prescribing within a healthcare facility and among prescribers is critical to the successful implementation of ASPs."
Feb 6 Infect Control Hosp Epidemiol study
Chinese surveillance data show substantial gonorrhea resistance levels
Originally published by CIDRAP News Feb 7
An analysis of gonorrhea isolates from seven provinces across China found substantial resistance to azithromycin and decreased susceptibility to ceftriaxone, the two drugs recommended as first-line treatment for the disease in many countries but not as yet in China.
Chinese scientists conducted antibiotic susceptibility and resistance testing on 3,849 clinical Neisseria gonorrhoeae isolates from patients from 2013 to 2016. Defining resistance to azithromycin as a mean inhibitory concentration (MIC) of 1.0 milligrams per liter (mg/L) or higher and decreased susceptibility to ceftriaxone as an MIC of 0.125 mg/L or higher, they found an 18.6% resistance rate to azithromycin and a 10.8% prevalence of decreased susceptibility to ceftriaxone.
Overall prevalence of both qualities was 2.3% but increased from 1.9% to 3.3% over the study period, as reported yesterday in PLoS Medicine.
The authors conclude, "To our knowledge, this is the first national study on susceptibility of N. gonorrhoeae to azithromycin and ceftriaxone in China. . . . Although dual therapy with azithromycin and ceftriaxone has been recommended by [the World Health Organization] and many countries to treat gonorrhea, reevaluation of this therapy is needed prior to its introduction in China."
Monotherapy with ceftriaxone for uncomplicated gonorrhea is still the recommended regimen in China, the study authors say.
Feb 6 PLoS Med study
Aetna highlights its efforts to fight antimicrobial resistance
Originally published by CIDRAP News Feb 7
Healthcare benefits provider Aetna International has released a new white paper on the antimicrobial resistance crisis that highlights some of the strategies the company is using to address the problem.
One of the initiatives the company has undertaken with US healthcare providers focuses on acute bronchitis in adults. Using claims data, Aetna identified more than 1,000 providers who were overprescribing for the condition, which is generally viral in nature and doesn't benefit from antibiotics. Aetna researchers then sent letters to these providers that detailed their position relative to their peers and included information on antibiotic resistance from the Centers for Disease Control and Prevention.
In India, the company is taking a three-stage approach that emphasizes antimicrobial stewardship in clinical training, auditing of medical consultations and prescribing practices, and counseling patients about appropriate antibiotic use. Aetna says it's also supporting efforts by accrediting bodies to make antimicrobial stewardship a standard in hospitals and outpatient settings alike.
According to the paper, these and other efforts helped reduce antibiotic use across Aetna's membership population from 27% in 2014 to 18% in 2016.
"We at Aetna International are doing our part through proactive education, early intervention, data analysis, and an emphasis on value-based care," the company says in the paper. "We invite our members, customers, providers, and everyone else who is affected by this crisis—in other words, everyone on the planet—to join us."
Feb 1 Aetna International white paper
Congress urged to provide incentives for antibiotic development
Originally published by CIDRAP News Feb 6
The Infectious Diseases Society of America (IDSA) today released a letter urging Congress to provide new economic incentives for the development of new antimicrobial drugs.
The letter calls on Congress to include antimicrobial research and development incentives in the reauthorization of the Pandemic and All-Hazards Preparedness Act (PAHPA). The purpose of PAHPA is to improve the nation's public health and medical preparedness and response capabilities in the event of a major public health emergency.
The letter warns that, beyond the well-documented public health threat posed by the emergence of bacterial infections that are difficult and sometimes impossible to treat, antimicrobial resistance (AMR) also poses a serious national security health threat. "Studies have concluded that the aerosolized release of a weaponized pathogen in just a single incident of bioterrorism in the Washington, DC area would result in a death toll of over 3 million," the letter states. "The death toll from a coordinated bioterrorist attack using a weaponized resistant pathogen would be many magnitudes higher."
Furthermore, the letter goes on, an outbreak of an untreatable bacterial infection "could overwhelm health systems, harm economies, and even destabilize communities or entire countries."
The letter, which was signed by more than 50 public health organizations, medical societies, and patient and industry groups, argues that including antimicrobial research and development incentives in PAHPA reauthorization will help ensure that the nation is prepared to respond to the AMR threat.
Feb 6 IDSA letter (scroll to bottom)
PAHO: cephalosporin-resistant gonorrhea present in 4 Americas countries
Originally published by CIDRAP News Feb 5
The United States, Brazil, Argentina, and now Canada, have all reported cases of cephalosporin-resistant gonorrhea, according to the latest situation report published by the Pan American Health organization (PAHO).
Gonorrhea has the ability to develop resistance to nearly all major antibiotics used for first-line empiric treatment of sexually transmitted infection, and extended-spectrum cephalosporins are the last available monotherapy used to treat infections caused by N gonorrhoeae.
In 2017, an asymptomatic Canadian woman was found to be infected with cephalosporin-resistant gonorrhea that was also resistant to ceftriaxone, cefixime, ciprofloxacin, and tetracycline. Her infection was susceptible to azithromycin.
PAHO said clinicians should be aware of any local resistance patterns when choosing an antibiotic to treat gonorrhea. So far, the bacterium is still susceptible to dual treatment with ceftriaxone and azithromycin.
Feb 2 PAHO report
Chinese study finds 45% cure rate for second-line MDR-TB treatment
Originally published by CIDRAP News Feb 5
A large Chinese study determined that less than half of patients with multidrug-resistant tuberculosis (MDR-TB) were cured with second-line treatment, according to a report in the Journal of Infection.
Of 2,322 MDR-TB patients identified in 2008 through 2010, 1,542 received standardized second-line TB drugs. Of those patients, 688 (44.6%) were cured. The researchers also reported that the percentage of patients who had a favorable outcome was 57.6% in previously untreated patients and 46.1% in patients who had received previous TB therapy. And women had a higher rate of favorable outcome (52.0%) than did men (45.8%). Favorable outcomes were also significantly decreased in elderly patients.
The authors concluded, "More attention should be paid to the MDR-TB population at high-risk of poor clinical outcome, including male, elderly age, and those who have received prior treatment."
Feb 2 J Infect study