Stewardship / Resistance Scan for Feb 28, 2019

Resistant gonorrhea in Europe
Antibiotic treatment for UTIs
XDR infection deaths
Asia-Pacific stewardship grants

Surveillance data show gonorrhea resistance levels stable in Europe

The latest data from the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP) reveal stable levels of resistance to the currently recommended antibiotics for Neisseria gonorrhoeae, according to a report today from the European Centre for Disease Prevention and Control (ECDC). But high resistance to azithromycin threatens the effectiveness of the treatment regimen, ECDC officials warn.

Testing of 3,248 N gonorrhoeae isolates collected from 27 European Union/European Economic Area countries in 2017 shows that resistance to cefixime and azithromycin (1.9% and 7.5%, respectively) remained stable compared with 2016 (2.1% and 7.5%). In addition, no isolates with resistance to ceftriaxone were detected for the second year in a row. But the number of countries reporting resistant isolates for both antibiotics increased, with the number of countries reporting cefixime-resistant isolates climbing to 15 (from 14 in 2016 and 9 in 2015) and the number of countries reporting azithromycin-resistant isolates rising to 23 (from 21 in 2016 and 18 in 2015).

"The fact that we have not seen ceftriaxone resistance among the tested isolates for two consecutive years is promising," ECDC expert Gianfranco Spinaldi, MD, MPH, said in a press release. "But at the same time, the persistent level of resistance to azithromycin across Europe is a major concern for us because it compromises the recommended dual therapy with ceftriaxone and azithromycin."

The ECDC also notes that the recent reports of extensively drug-resistant gonorrhea strains, particularly the cases with ceftriaxone resistance and high-level azithromycin resistance identified in the United Kingdom and Australia in 2018, highlight the need to understand what is driving changes in resistance prevalence.

The ECDC will publish a revised version of its multidrug-resistant gonorrhea response plan later this year.
Feb 28 ECDC Euro-GASP report
Feb 28 ECDC press release


UTI study ties risks of infection, death to no or delayed antibiotics in seniors

A study yesterday in the British Medical Journal (BMJ) found that, in elderly patients with a diagnosed urinary tract infection (UTI), receiving no antibiotics or delayed antibiotics was associated with an increased risk of bloodstream infection or death within 60 days

The retrospective study looked at primary care records from 157,264 adults aged 65 years and older in England who presented to a general practitioner with at least one UTI symptom from November 2007 to June 2015. The main outcome measures were bloodstream infection, hospital admission, and all-cause mortality within 60 days after the index UTI diagnosis.

Among the 312,896 UTI episodes recorded, 7.2% did not have a record of antibiotics being prescribed, and 6.2% showed a delay in prescribing. Overall, 1,539 episodes of bloodstream infection were recorded after the initial UTI. The rate of bloodstream infection significantly increased when patients were not prescribed an antibiotic (2.9% vs 0.2% for immediate antibiotics) and when antibiotics were deferred (2.2% vs 0.2%). After adjusting for covariates, patients were significantly more likely to experience a bloodstream infection in the no antibiotics group (adjusted odds ratio [aOR], 8.08; 95% confidence interval [CI], 7.12 to 9.16) and the deferred antibiotics group (aOR, 7.12; 95% CI, 6.22 to 8.14).

In addition, the results showed that the proportion of patients admitted to the hospital was nearly two times higher for those in the no antibiotics group (27%) and the deferred antibiotics group (26.8%) compared with the immediate antibiotics group (14.8%), and the risk of all-cause mortality within 60 days was significantly higher with no antibiotics (aOR, 2.18; 95% CI, 2.04 to 2.33) and deferred antibiotics (aOR, 1.16; 95% CI, 1.06 to 1.27). Men older than 85 were particularly at risk for both bloodstream infection and 60-day all-cause mortality.

The authors of the study say the findings are particularly noteworthy given the rising incidence of gram-negative bloodstream infections in England.

"Our study suggests the early initiation of antibiotics for UTI in older high risk adult populations (especially men over aged >85 years) should be recommended to prevent serious complications," they conclude.
Feb 27 BMJ study


Study examines deaths from XDR gram-negative infections

A study from a large healthcare database estimated that deaths from extensively drug-resistant (XDR) gram-negative infections was 12.6% and that hospitalization for an XDR infection costs more than $35,000. A team led by the National Institutes of Health (NIH) reported their findings yesterday in the American Journal of Infection Control.

The database they used from Vizent, Inc., contained clinical information, including claim codes and specific medication charges, from 120 academic medical centers and 300 affiliated hospitals. For the study, researchers looked at inpatient encounters between January of 2010 and December of 2013. And they used a tracer antibiotic algorithm as a surrogate marker to investigate and estimate mortality related to XDR gram-negative infections.

Over the study period, 232,834 gram-negative infections were reported from 79 hospitals, of which 1,023 per 3,350 (30.5%) who were prescribed colistin died and 9,188 per 105,641 (8.7%) who were on beta lactams died. Patients who received 4 or more consecutive days of intravenous colistin or died within 4 days of starting the treatment had an excess mortality of 12.6% compared to those who received noncarbapenem beta-lactams that targeted gram-negative bacteria.

The team also found that mortality for the XDR gram-negative infections varied by infection site, onset, and severity. For example, infections coded for sepsis had 3-fold higher mortality and severe sepsis or septic shock had 9-fold higher mortality, which the authors said could suggest that a higher baseline risk of death could amplify the impact of XDR on clinical outcome.

They noted that the healthcare cost of the infections falls within earlier estimates for multi-drug resistant infections, but may be a conservative estimate, because discharge factors such as rehabilitation costs and productivity loss weren't factored in.

Though the prevalence of XDR phenotypes among gram-negative infections is relatively now, documenting their high mortality, role in outbreaks, and global spread are important for raising awareness, the group wrote, adding that new tools for analyzing information from large databases and electronic medical record repositories will help guide antibiotic use and development, as well as other control measures, such as new rapid diagnostics.
Feb 27 Am J Infect Control abstract


Joint Commission, Pfizer fund grants to boost stewardship in Asia-Pacific

The Joint Commission and drug company Pfizer this week announced the selection of six quality improvement projects to receive funding as part of a 2-year grant to improve antimicrobial stewardship in the Asia-Pacific region, according to a Joint Commission news release.

Grant recipients range from establishing a unit-based safety program in India to developing a primary care stewardship model in China to building an international network in India, Micronesia, Nepal, and the Philippines. The projects are anticipated to be completed by early 2022.

Scott Williams, PsyD, director of research with the Joint Commission, said, "We believe the projects can help accelerate the development and adoption of evidence-based approaches that have the capacity to prevent or contain antimicrobial resistance and support the appropriate use of antimicrobial agents."

The Joint Commission did not specify a dollar amount for the grants.
Feb 26 Joint Commission news release

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