Stewardship / Resistance Scan for Jan 14, 2019

Stewardship in English hospitals
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Whiff of C diff in pets
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Fecal microbiota transplant trial

Study evaluates stewardship uptake, antimicrobial usage in England

Researchers with Public Health England (PHE) report that a survey of England's National Health Service (NHS) hospitals found that the vast majority have made progress in establishing antimicrobial stewardship programs (ASPs), but many lack senior leadership and dedicated funding, and there was no significant correlation between stewardship scores and antimicrobial usage.

In an article published in the Journal of Antimicrobial Chemotherapy, the researchers evaluated ASP structures and processes through an online survey of 152 NHS hospitals. Scores were assigned to quality indicators based on resource- and labor-intensiveness, and the investigators analyzed the association between stewardship scores and prescribing, with a particular focus on World Health Organization–categorized Access, Watch, and Reserve (AWaRe) antibiotics.

Overall, 148 of 152 hospitals responded to the survey, and over 80% had high scores on antimicrobial policies, stewardship team structure, designated stewardship leads and antimicrobial pharmacists, and policies and access to outpatient parenteral antimicrobial therapy. But less than 50% had senior clinical leadership support and dedicated program funding. High-process performance (above 80%) was observed for antimicrobial pre-authorization, prescribing review and feedback, restricted susceptibility reporting, antimicrobial consumption monitoring, adherence to guidelines, and junior doctor training, while less than 50% of hospitals distributed resistance surveillance data and educated senior clinicians on appropriate prescribing.

From 2016 through 2017, there was no significant change in mean total antimicrobial prescribing (incidence rate ratio [IRR], 1.02; 95% confidence interval [CI], 1.00 to 1.05, P = 0.116) for all participating hospitals, and there were no major changes in the prescribing of antimicrobials from the AWaRe categories. But there were some noteworthy associations. While carbapenem prescribing fell by 7% (IRR, 0.93; 95% CI, 0.88 to 0.98) in non-teaching hospitals, prescribing of Watch antibiotics increased for specialist hospitals (odds ratio [OR], 1.10; 95% CI, 1.01 to 1.20), as did Reserve category prescribing for teaching (OR, 1.58; 95% CI 1.23 to 3.02) and specialist hospitals (OR 3.09; 95% CI, 2.02 to 4.74). A higher process score was associated with lower baseline prescribing of Reserve antimicrobials (OR, 0.82; 95% CI, 0.67 to 1.01).

The authors of the study say further studies are needed with better defined primary outcomes such as burden of disease or attributable mortality due to antimicrobial resistance to assess the true impact of ASP interventions over time.
Jan 11 J Antimicrob Chemother study

 

Chinese study identifies cats, dogs as potential C diff sources

A new study by Chinese scientists suggests that companion animals could be a source of pathogenic Clostridioides difficile. The findings appear in BMC Infectious Diseases.

To assess the burden of C difficile carriage and shedding by household pets, researchers from Xuzhou Medical University collected fecal samples of adult pets in pet shops in Xuzhou City in China's Jiangsu province, then identified and isolated C difficile strains. They used multilocus sequence typing (MLST) to identify sequence types and assess the possibility of transmission between pets and humans, employed multiplex polymerase chain reaction to detect toxin genes, and performed antimicrobial susceptibility testing.

A total of 175 fecal samples were collected from 146 healthy dogs and 29 cats, and C difficile was isolated from only 3 samples (1.7%)—2/29 cat samples (7.0%) and 1/146 (0.7%) dog samples.

The isolates were categorized into three MLST sequence types that have been identified in patients in eastern China and belong to the clade that contains most human C difficile sequence types. They were susceptible to chloramphenicol, tetracycline, metronidazole, and moxifloxacin and resistant to ampicillin, clindamycin, and cefoxitin. Notably, one strain recovered in the feces of a healthy dog, D141–1, carried toxin genes, implying a potential association between pets and pathogenic C difficile infections in humans.

"Since there is intimate contact between humans and their pets, the isolation of C. difficile from pets in this study suggests a possibility that humans may be colonized by C. difficile carried by pets, although faecal shedding of pathogenic C. difficile was not common among healthy dogs and cats," the authors write.
Jan 11 BMC Infect Dis study

 

Trial will evaluate safety, efficacy of fecal transplant for recurrent C diff

The National Institute of Allergy and Infectious Diseases announced today that a research consortium has begun enrolling patients in a clinical trial to determine whether fecal microbiota transplantation (FMT) delivered by enema is a safe and effective treatment for recurrent C difficile infection (CDI).

FMT for recurrent CDI has produced strong results in several small clinical trials in recent years, with cure rates as high as 90%, but the long-term safety has not been established. Although the US Food and Drug Administration still considers FMT an investigational treatment, physicians are allowed to perform the procedure using screened stool if recurrent CDI patients aren't responding to antibiotic treatments. According to the Centers for Disease Control and Prevention, roughly 20% of CDI patients treated with antibiotics experience a recurrence of symptoms.

The multicenter randomized controlled trial will enroll 162 adult volunteers who've had at least two episodes of CDI within the previous 6 months. One group of patients will take anti-diarrheal medication and receive FMT via enema, while the other group will take anti-diarrheal medication and receive a placebo solution via enema. The trial is part of a larger effort to gather data on how to standardize FMT, which can be delivered by several methods, including enema, upper gastrointestinal endoscopy, colonoscopy, or pill.

Trial sites include Emory University, Duke University Medical Center, and Vanderbilt University Medical Center.
Jan 14 NIAID news release

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