ASP Scan (Weekly) for Mar 02, 2018

Resident prescribing savvy
Monitoring animal antibiotics
C diff treatment failure predictors
Senate antimicrobial resistance bill
Latest CARB-X funding
Pathways to lower antibiotics
Spread of resistant Pseudomonas

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

Survey finds low use of antibiograms among medical residents

A survey of medical residents found that 28% to 51% could not accurately identify pathogens to target with empiric therapy or select therapy with an appropriate spectrum of activity, and only 12% of respondents identified antibiograms as a prescribing resource, according to a study yesterday in Infection Control & Hospital Epidemiology.

Investigators with Oregon Health and Science University surveyed 106 residents, 69% of them in internal medicine and the rest in family medicine (18%) and pediatrics (13%). The response rate was 87%. The respondents were asked questions about two prescribing vignettes, one involving post-appendectomy fever, chills, purulent drainage, and other symptoms and one involving recurrent urinary tract infection. Respondents were asked to identify pathogens to cover with antimicrobial therapy, name resources they would use for clinical decision-making, and recommend specific empiric antibiotics.

In the first vignette, 71.7% correctly identified target pathogens and 49.0% correctly recommended empiric antibiotics. In the second vignette, the rates were 55.8% and 77.0%, respectively.

In response to resources they would use, only 12.3% of respondents identified antibiograms as a resource in prescribing empiric antibiotics with the most common choices being The Sanford Guide(chosen by 71.7%) and UpToDate (58.5%). When directly questioned, 89.6% of residents reported awareness of institutional antibiograms, but only 69.8% felt comfortable using them and 44.3% knew how to access them. Antibiograms are profiles of antimicrobial susceptibility testing results of a pathogen to a battery of antimicrobial drugs.

The authors conclude, "Efforts to improve antibiotic use may benefit from residents being given additional education on both infectious diseases pharmacotherapy and antibiogram utilization."
Mar 1 Infect Control Hosp Epidemiol study


Phased approach touted for monitoring ag antibiotics in low-resource nations

In a policy forum in PLoS Medicine, four international experts propose establishing an internationally endorsed phased approach to monitoring antimicrobial consumption in food animals that will be responsive and adaptive to low- and middle-income countries (LMICs).

The experts—two from Thailand and one each from the United Kingdom and the United States—note that antimicrobial use in animal production is climbing in LMICs but remains largely undocumented. They say that establishing a standardized framework for antimicrobial surveillance will track consumption trends; allow drug-consumption comparisons across countries, species, and farms, as well as with human consumption; and build a platform for studying the association between animal antimicrobial consumption and antimicrobial resistance (AMR) surveillance data.

They write that a phased approach "enables implementation of systems yielding standardized, globally comparable antimicrobial consumption data, which could inform policies to optimize antimicrobial usage in food animal production.

"The approach should be complemented by efforts to strengthen animal production systems, eliminate medically important antimicrobial growth promoters, and reduce reliance upon prophylactic antimicrobial use."

The authors also outline challenges specific to LMICs, such as low rates of AMR awareness, and they detail a case study framework that is being used in Thailand.
Mar 1 PLoS Medicine policy forum


Study finds treatment failure predictors in C diff patients on metronidazole

A 2-year study of hospital patients in South Korea who received metronidazole, a drug commonly used to treat mild-to-moderate Clostridium difficile (C diff) infection, found that certain factors were treatment failure predictors. Researchers reported their findings yesterday in an early online edition of Epidemiology and Infection.

Managing C diff infections often poses tough challenges, because it requires stopping the problematic antibiotic as soon as possible, but ongoing infection doesn't allow it.

The study took place at an academic hospital from Jan 2013 to Dec 2014. Of 314 C diff patients who got metronidazole during that time, 62 (19.7%) showed treatment failure, and 105 (33.4%) received additional antibiotics.

A review of the clinical records found that four factors were independent predictors of treatment failure among C diff patients on metronidazole: dialysis treatment, fever higher than 38.3 Celsius (100.9 Fahrenheit), low median serum albumin levels, and use of other antibiotics. The team found that concomitant antibiotic use increased the treatment failure rate and 30-day mortality in patients who were on metronidazole.

They concluded that findings suggest metronidazole should be used in mild cases of C diff only after offending antibiotics are discontinued.
Mar 1 Epidemiol Infect abstract


Two groups laud Senate bill to combat antimicrobial resistance

Originally published by CIDRAP News Mar 1

Two major infectious disease groups voiced strong support of a bill introduced yesterday to strengthen the US government's response to the growing threat of antimicrobial resistance (AMR).

The Infectious Diseases Society of American (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) applaud the Strategies to Address Antimicrobial Resistance (STAAR) Act, introduced by Senator Sherrod Brown, D-Ohio.

The STAAR Act would reauthorize the Interagency Antimicrobial Resistance Task Force and codify sections of the National Action Plan for Combating Antibiotic-Resistant Bacteria to promote prevention and tracking, enact Centers for Disease Control and Prevention (CDC) recommendations to bolster federal AMR efforts, provide research grants to healthcare facilities, and foster partnerships between the CDC and state health departments, among other steps, according to a news release from Brown's office.

"Senator Brown's important bill builds upon bipartisan investments in addressing AMR by reinforcing our public health capacity for prevention, detection, and tracking antibiotic resistance threats," the IDSA said in a news release. "The STAAR Act would also drive the implementation of antimicrobial stewardship programs in health care facilities that have proven to improve patient outcomes while lowering inappropriate antibiotic use that causes the development of resistance. The legislation would also strengthen research on AMR to help ensure the availability of evidence-based techniques and innovative tools to combat AMR."

In a SHEA press release, SHEA President Keith Kaye, MD, MPH, said, "Currently, health care systems in the United States face significant challenges in addressing antibiotic resistant bacteria, which threaten the lives and well-being of millions of people each year." He added that the act "addresses this complex public health issue head-on by providing much needed resources support for developing innovative approaches towards infection surveillance, antimicrobial stewardship, and research that can have a meaningful impact on prevention of antimicrobial resistance and patient safety."
Feb 28 IDSA news release
Mar 1 SHEA 
press release
Feb 28 Sen. Brown 
news release


CARB-X awards $2.4 million for antibiotic candidate to treat serious UTIs

Originally published by CIDRAP News Mar 1

CARB-X, a public-private initiative that supports companies in early-stage antibiotic discovery and development, today announced its latest grant: $2.44 million to Macrolide Pharmaceuticals of Watertown, Mass., to support the development of a novel fully synthetic macrolide antibiotic with gram-negative activity, according to a CARB-X news release. The drug is geared toward treating serious infections, including drug-resistant complicated urinary tract infections (cUTIs).

As an antibiotic class, macrolides are known to be effective against various gram-positive but not gram-negative pathogens. Macrolide is using its proprietary chemistry platform to re-engineer the macrolide scaffold with the aim of developing a fully synthetic macrolide to treat drug-resistant cUTI infections that can be administered intravenously and orally, CARB-X said.

If certain milestones are met, the Macrolide award could grow to $6.81 million, according to the release.

Kevin Outterson, JD, Executive Director of CARB-X, said, "The world urgently needs new antibiotics, rapid diagnostics, vaccines, and entirely new approaches to protect us against drug-resistant bacteria. The projects in the Powered by CARB-X portfolio are in the early stages of development, and there is always a risk of failure. But if successful, these innovative projects, like the Macrolide project, hold great potential to treat life-threatening infections and fight against drug-resistant bacteria."

Since the beginning of last year, CARB-X has announced awards totaling $64.64 million, plus an additional $81.42 million if project milestones are met.
Mar 1 CARB-X news release


Clinical pathways tied to lower antibiotic use in Italian pediatric hospital

Originally published by CIDRAP News Mar 1

The introduction of multidisciplinary patient management plans called clinical pathways (CPs) for pneumonia in an Italian pediatric emergency department was associated with impressive reductions in antibiotic prescribing, according to a study yesterday in PLoS One.

Italian pediatric antimicrobial prescription rates are among the highest in Europe, the authors of the study said. As a first step in an antimicrobial stewardship program, on Oct 1, 2015, they implemented a CP for community-acquired pneumonia (CAP) to lower overall prescribing of antibiotics, especially broad-spectrum options.

The researchers analyzed outcomes data on children 3 months to 15 years old who had CAP from Oct 15, 2014, to Apr 15, 2015 (pre-CP) or from Oct 15, 2015, to Apr 15, 2016 (post-CP). They assessed antibiotic prescribing during the two periods, including rates, breadth of spectrum, and duration of therapy. They also compared length of hospital stay.

Based on data from 120 pre-CP and 86 post-CP visits, the investigators determined that broad spectrum regimens for particular macrolides decreased from 50.0% to 26.8% after CP, with an associated increase in amoxicillin prescriptions. Median doses of antibiotics dropped from 10 to 8, and duration of therapy declined from 10 to 8 days.

Among inpatients they found a decrease in broad-spectrum regimens (100% pre-CP vs 66.7% post-CP) and the introduction of narrow-spectrum regimens (0% vs 33.3%). Hospitalized patients received antibiotics for 10 days post-CP compared with 18.5 days pre-CP, but inpatients had no statistical difference in length of therapy after the intervention.

In addition, the researchers reported no difference in treatment failure between the two periods.
Feb 28 PLoS One study


Study: Drug-resistant Pseudomonas aeruginosa spreads on hospital wards

Originally published by CIDRAP News Feb 27

A new single-center study shows that most antibiotic-resistant Pseudomonas aeruginosa infections were transmitted on hospital wards, but researchers failed to identify a persistent source for the bacteria. The study was published today in Antimicrobial Resistance & Infection Control. 

In 2003, multidrug-resistant strains of P aeruginosa emerged as a growing concern in the Dutch hospital studied, as they led to high rates of morbidity and mortality in hospitalized patients, especially those being treated in intensive care units (ICUs). This study aimed to identify epidemiologic relationships between patients infected with this strain and common transmission routes.

The researchers retrospectively matched cases at the Erasmus MC University Medical Centre in Rotterdam from 2003 to 2015. Of the 144 case-patients identified, 87 (60.4%) acquired their infection in general adult ICUs. But no relationship was identified between infection and room sharing, patient admission date, or medical staff.

"Our hypothesis is that persistent sources in the innate environment play an important role in the route of transmission of this pathogen," the authors said. "This is in agreement with current knowledge on the behaviour of this bacterium, as well as previous outbreak reports that identified the environment as source/reservoir."
Feb 27 Antimicrob Resist Infect Control study

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