Stewardship / Resistance Scan for Mar 02, 2018

Resident prescribing savvy
Monitoring animal antibiotics
C diff treatment failure predictors

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

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