Stewardship / Resistance Scan for Dec 03, 2018

Procalcitonin-guided antibiotic therapy
'Expected Practice' and short-course antibiotics
UTI management bundle

Procalcitonin-guided therapy reduces antibiotic duration, study finds

The use of an algorithm that recommends stopping antibiotics for lower respiratory tract infections (LRTIs) based on procalcitonin (PCT) levels was associated with reduced antibiotic duration without increasing adverse outcomes, researchers at an academic tertiary care hospital report today in Open Forum Infectious Diseases.

The single-center clinical trial, conducted at Johns Hopkins Bayview Medical Center, evaluated PCT-guided antibiotic therapy for LRTI by comparing antibiotic duration in a control group of 200 patients admitted prior to the intervention with antibiotic duration in a post-intervention group of 174 patients. The intervention involved daily measurements of PCT values with a rapid sensitive assay and review by an infectious disease (ID) pharmacist and an ID physician; antibiotic discontinuation was recommended if serial PCT values fell 80%.

The primary and secondary end points were total antibiotic duration per LRTI episode and antibiotic days of therapy (DOT) per 1,000 patient-days present. Overall adverse outcomes at 30 days included death, transfer to an intensive care unit, Clostridioides difficile infection, and post-discharge antibiotic prescription for LRTI.

Providers complied with the PCT algorithm in 70% of encounters. Overall, the median antibiotic duration in the PCT group was lower than in the control group (5 days vs 6 days, P = 0.052), and total days of antibiotic therapy were significantly lower (1,883 vs 2,039 DOT/1,000 patient-days present).

When stratified by admitting diagnosis, median antibiotic durations were significantly shorter in the PCT group for pneumonia (6 vs 7 days, P = 0.045) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD, 4 days vs 3 days, P < 0.001). Total antibiotic use was significantly shorter in the PCT group for AECOPD (788 vs. 1,513 DOT), but not for pneumonia (2,259 vs 2,360 DOT). There were no significant differences between the two groups in rates of adverse outcomes at 30 days.

The authors of the study conclude, "Overall, our study demonstrates that PCT-guided cessation of antibiotic therapy, when undertaken as a stewardship intervention, is a safe and effective strategy to reduce antibiotic use in patients with LRTI."
Dec 3 Open Forum Infect Dis abstract


'Expected Practice' may decrease antibiotic use for common infections

In another study today in Open Forum Infectious Diseases, researchers at the Los Angeles County + University of Southern California Medical Center report that an intervention requiring clinicians to adhere to "Expected Practice" around short-course antibiotic therapy was tied to decreased antibiotic use for common infections.

As the authors of the study explain, Expected Practice is a mechanism that educates providers about evidence-based medicine practice while also establishing an institutional requirement for standard practice. "Expected Practices set an institution's expectation for how its providers practice medicine, and hence set stronger standards of care compared to clinical guidelines, which are typically viewed more as literature-based suggestions or expert consensus," they write.

The Expected Practice around short-course antibiotic therapy was developed by a workgroup of primary and specialty care experts at the hospital and based on multiple randomized clinical trials that have demonstrated that shorter courses of antibiotics are as effective as longer courses for many common bacterial infections. Under the intervention, providers were expected to adhere to shorter antibiotic courses for common infections unless deviations could be clinically justified. The authors say one of the benefits of Expected Practice is that it alleviates provider concerns that they could be individually exposed to blame if they prescribed short-course antibiotic therapy and the clinical outcome was bad.

In a quasi-experimental pre-/post- quality improvement study, the researchers compared average antibiotic DOT and total antibiotic exposure in the 12 months prior to implementation of the intervention and the 12 months post-intervention, focusing on patients diagnosed as having urinary tract infections (UTIs), skin and other soft-tissue infections (SSTIs), pneumonia, and ventilator-associated pneumonia (VAP). When adjusted for all covariates of interest, average antibiotic DOTs decreased 10%, 11%, 11%, and 27% for UTIs, SSTIs, pneumonia, and VAP, respectively, after the introduction of Expected Practice.

Decreases for antibiotic exposure were even larger, falling by 17%, 13%, 29%, and 35% for UTIs, SSTIs, pneumonia, and VAP, respectively. An assessment of in-house mortality found no changes post-intervention.

The authors conclude that Expected Practice is a promising new psychological tool to promote effective antibiotic stewardship.
Dec 3 Open Forum Infect Dis abstract

Study: UTI management bundle cuts inappropriate antibiotics, treatment

Implementation of a UTI management bundle at a Canadian hospital was associated with a 75% reduction in antibiotic treatment for asymptomatic bacteriuria (AB) and improved management of UTIs, researchers reported today in Infection Control and Hospital Epidemiology.

The UTI management bundle instituted at Moncton Hospital in New Brunswick consisted of four components: nursing education, prescriber education, laboratory intervention, and pharmacy prospective audit and feedback. The intervention concentrated on appropriate indications for urine culture, UTI diagnosis, and appropriate treatment according to institutional guidelines. To determine the potential effectiveness of the bundle, researchers at the hospital conducted a retrospective chart review of consecutive inpatients with positive urinary cultures before and after implementation. Primary outcome measures included overall adherence to institutional UTI management, appropriate antibiotic use and duration of therapy, and rates of inappropriate therapy for AB.

Chart review found that, within the pre-intervention study population of 276 patients, 165 (59.8%) were found to have AB, of whom 111 (67.3%) were treated with antimicrobials. Of the 268 patients reviewed post-intervention, 133 (49.6%) were found to have AB, and 22 of the 133 (16.5%) were treated with antimicrobials. Thus, a 75.5% reduction of inappropriate AB treatment was achieved. The absolute risk reduction in AB treated after implementation of the UTI bundle was 50.8% (95% confidence interval, 40.3% to 59.3%), with a number needed to treat of two. Total days of avoidable antibiotic therapy decreased from 781 to 138 from the pre- to post-intervention periods.

In addition, educational components of the bundle were linked to a substantial decrease in nonphysician-directed urine sample submission, and adherence to a UTI management algorithm improved substantially in the intervention period, with a notable decrease in fluoroquinolone prescription for empiric UTI treatment.

"Our study has shown that the laboratory-based intervention, in both noncatheterized and catheterized patients as part of a UTI management bundle, is effective in reducing the inappropriate treatment of AB and improving overall adherence to best practice," the authors of the study conclude.
Dec 3 Infect Control Hosp Epidemiol study

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