Stewardship / Resistance Scan for Feb 09, 2018

Research agenda for antibiotic resistance
Antibiotics for aspiration pneumonitis
Stewardship in kids' pneumonia

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

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