Telemedicine study finds antibiotic Rx linked with shorter encounters
Researchers from the Cleveland Clinic have observed that telemedicine encounters in which antibiotics were prescribed for a respiratory tract infection (RTI) were shorter than encounters where a non-antibiotic or nothing were prescribed.
In a study today in the Annals of Internal Medicine, the researchers reviewed 13,438 US telemedicine encounters from January 2013 through August 2016 to assess the association between prescription outcome and length of encounters for patients diagnosed as having RTIs, including sinusitis, pharyngitis, and bronchitis. Encounter length was defined as the time the patient was connected to and interacted with the physician. The adjusted difference in encounter length was determined using a mixed-effects linear regression model that controlled for patient characteristics, physician characteristics, and geographic concordance between patient and physician.
Physicians prescribed antibiotics in 67% of encounters, non-antibiotics in 13%, and nothing in 20%. The mean unadjusted encounter length was 6.6 minutes when antibiotics were prescribed, 8 minutes when non-antibiotics were prescribed, and 7.5 minutes when nothing was prescribed. In the adjusted model, encounters that resulted in nothing being prescribed were 33 seconds longer than those resulting in antibiotic prescriptions; those resulting in prescription of a non-antibiotic were 1.12 minutes longer than those in which an antibiotic was prescribed.
In addition, encounters for sinusitis and pharyngitis were found to be shorter than those for bronchitis and other RTIs, encounters with older patients were longer than those with younger patients, and encounters with physicians in the West took longer than those with physicians in the Northeast. The researchers were not able to determine the appropriateness of antibiotic prescribing.
The authors suggest the findings are noteworthy because prescribing non-antibiotics has been suggested as a way to improve patient satisfaction while avoiding unnecessary antibiotics. But the longer time needed to explain why an antibiotic isn't necessary could be an impediment, especially with telemedicine. They conclude, "Because telemedicine encounters are short and physicians are often reimbursed by encounter volume, antibiotic stewardship efforts that lengthen visits even slightly may be challenging to implement."
Oct 2 Ann Intern Med abstract
FDA approves new antibiotic under limited population pathway
The US Food and Drug Administration (FDA) has approved a new antibiotic for the treatment of lung disease caused by Mycobacterium avium complex (MAC), a nontuberculosis mycobacterium commonly found in water and soil.
The agency approved Arikayce (amikacin liposome inhalation suspension) for use in a limited population of patients who don't respond to conventional treatment. It's the first drug to be approved under the Limited Population Pathway for Antibacterial and Antifungal Drugs (LPAD), which was established by Congress as part of the 21st Century Cures Act to streamline development and approval of drugs to treat serious or life-threatening infections in a small population of patients who have no other treatment options.
"This pathway, advanced by Congress, aims to spur development of drugs targeting infections that lack effective therapies," FDA Commissioner Scott Gottlieb, MD, said in an FDA news release. "We're seeing a lot of early interest among sponsors in using this new pathway, and it's our hope that it'll spur more development and approval of antibacterial drugs for treating serious or life-threatening infections in limited populations of patients with unmet medical needs."
The safety and efficacy of Arikayce were demonstrated in a randomized, controlled clinical trial where one group of patients received the drug plus a background multidrug antibacterial regimen, and a second group received the multidrug antibacterial regimen alone. By the sixth month of treatment, 29% of patients who received Arikayce had no growth of mycobacteria in their sputum cultures for 3 consecutive months, compared with 9% of the patients who were not treated with Arikayce.
As required for drugs approved under LPAD, labeling for Arikayce will include statements conveying that the drug has been shown to be safe and effective for use only in a limited population of patients.
Sep 28 FDA news release
Linezolid resistance genes found in cattle, swine enterococci
A study today by FDA and US Department of Agriculture (USDA) researchers is reporting the first known identification of linezolid resistance in bacteria from food-producing animals in the United States. The findings appear in the Journal of Antimicrobial Chemotherapy.
In an analysis of 500 bacterial isolates from food-animal cecal samples collected by the National Antimicrobial Resistance Monitoring System (NARMS) from 2013 through 2016, the researchers identified three isolates that were non-susceptible to linezolid, an oxazolidinone antibiotic that's used to treat vancomycin-resistant enterococci(VRE) infections in humans but is not used in animals. Two of the isolates were from cattle, including one each of Enterococcus faecium and E faecalis, and one E faecalis isolate was from a swine sample.
Whole-genome sequencing to determine the mechanisms underlying the resistant phenotypes revealed that all three isolates carried the linezolid resistance gene optrA, with one also carrying the cfr resistance gene. The genes were present on plasmids in all three isolates, and the E faecium isolate that possessed both optrA and cfr had them both on the same plasmid. In addition, the plasmid in the E faecium isolate also contained genes conferring resistance to aminoglycosides, macrolides, and phenicols.
The researchers note that while only three linezolid-resistant isolates were identified, the fact that they came from different sources and were genetically diverse suggests that linezolid-resistance plasmids are not limited to a distinct lineage of Enterococcus, and that resistant strains could independently emerge from different environments, including the food-animal environment. If these strains spread into humans, that could potentially threaten a critical antibiotic in human medicine.
"Although the presence of linezolid-resistant strains in food animals may not directly increase the risk of limiting the efficacy oxazolidinones in human therapy, people may become exposed to these bacteria through animal contact or contamination of food," the authors of the study write. "Now that we have identified linezolid resistance genes on plasmids that also carry other resistance genes, it remains to be seen whether these genes spread further through co-selection, clonal expansion, or other mechanisms."
The authors say investigators will continue to use NARMS to perform surveillance of linezolid resistance among enterococci from food animals and foods to identify any notable trends.
Oct 1 J Antimicrob Chemother abstract
Study: Drinking more water might prevent urinary tract infections
Women who drank more water were less likely to get urinary tract infections (UTIs) than controls and may be a way to reduce antibiotics, according to a study today in JAMA Internal Medicine.
The study involved 140 women who reported three or more UTIs in the previous year. Half of the women were encouraged to drink 1.5 liters of water daily for 12 months in addition to their normal beverages, and half were not. The women who drank more water saw a 50% reduction in UTIs.
The mean number of cystitis (UTI) episodes was 1.7 (95% confidence interval [CI], 1.5-1.8) in the water group, compared with 3.2 (95% CI, 3.0-3.4) in the control group, with a difference in means of 1.5 (95% CI, 1.2-1.8; P < .001), the authors said. Overall, there were 327 cystitis episodes, 111 in the water group and 216 in the control group. The authors concluded by saying that increased water consumption is a useful tool for UTI prevention that limits antibiotic use.
In an accompanying editorial, JAMA editor Deborah Grady, MD, PhD, notes that the study was not blinded, and the results were self-reported. She also emphasized that the study was sponsored by Danone, a company that supplied bottled water to study participants.
Despite those caveats, Grady said, "The research question is important and the intervention was safe, easy, and effective (and it would be impossible to blind a trial in which drinking water is the intervention)."
Oct 1 JAMA Intern Med study
Oct 1 JAMA Intern Med editorial