Stewardship / Resistance Scan for Mar 07, 2019

Outpatient surgery overprescribing
Resistance prevalence and sepsis
Resistant gonorrhea strain

VA study finds 5% rate of prolonged antibiotics after outpatient surgery

A 2-year multicenter Veterans Administration (VA) retrospective cohort study published yesterday discovered that 5% of patients having outpatient surgeries received antimicrobial prophylaxis longer than 24 hours after surgery, with rates varying by procedure, facility type, and surgical specialty.

Writing in Antimicrobial Resistance & Infection Control, VA researchers said they analyzed data from Oct 1, 2015, through Sep 30, 2017, on any veteran undergoing an outpatient surgical procedure in any of five specialties: general surgery; urology; ophthalmology; ears, nose, and throat (ENT); or orthopedics. Guidelines recommend postoperative preventive antimicrobials for no longer than 24 hours after incision closure.

Among 153,097 outpatient surgeries, 7,712 patients (5.0%) received antimicrobial prophylaxis lasting longer than 24 hours. Rates ranged from 0.4% for eye surgeries to 13.7% for genitourinary procedures. Cystoscopies (16%) and cystoureteroscopy with lithotripsy (20%) had the highest rates, while hernia repair, cataract surgeries, and laparoscopic cholecystectomies had the lowest rates, at 0.2% to 0.3.

The investigators also found that lower-complexity ambulatory surgical centers and hospital outpatient departments had about a 30% higher incidence of prolonged antimicrobial prophylaxis compared with complex hospitals.

The authors conclude, "Increasing pharmacy, antimicrobial stewardship and/or infection prevention resources to promote more evidence-based care may support surgical providers in lower complexity ambulatory surgery centers and hospital outpatient departments in their efforts to improve this facet of patient safety." They add that genitourinary and ENT specialists may especially benefit from stewardship interventions.
Mar 6 Antimicrob Resist Infect Control study


Study links antibiotic resistance prevalence to sepsis-related outcomes

A paper published yesterday in the International Journal of Antimicrobial Agents suggests an association between the prevalence of antibiotic resistance and rates of hospitalization and mortality for sepsis in the United States, with a particularly strong association observed for fluoroquinolone-resistant Escherichia coli.

While antibiotic resistance is known to contribute to rates of septicemia and associated mortality, which have risen significantly over the past 2 decades, less is known about the relationship between the prevalence of resistance to various antibiotics and rates of sepsis-related outcomes.

Using data from the Centers for Disease Control and Prevention's Antibiotic Resistance Patient  Safety Atlas, researchers from Harvard, the US Department of Health and Human Services, and the National Institutes of Health explored the issue by looking at the relationship between state-specific percentage of resistant bacteria samples in patients with catheter-associated urinary tract infections and rates of hospitalization and mortality for sepsis. They evaluated the associations for different age-roups and different combinations of antibiotics and bacteria.

Many positive correlations between prevalence of antibiotic resistance and rates of septicemia hospitalization and mortality were found in the study, particularly for older adults. But among the different combinations of antibiotics and bacteria, resistance to fluoroquinolones in E coli had the strongest association with septicemia hospitalization rates for patients over 50, and with sepsis mortality rates for patients between 18 and 84 years old. The authors note that E coli is a major source of gram-negative septicemia in the United States, and that the prevalence of fluoroquinolone-resistant E coli isolates in urinary tract and bloodstream infections is high.

The authors say the results support the need to enhance antibiotic stewardship, step up efforts to prevent infection with antibiotic-resistant bacteria, and examine whether replacing certain antibiotics with other agents in the treatment of different syndromes could reduce the rate of severe outcomes associated with bacterial infections.
Mar 6 Int J Antimicrob Agents abstract


Resistant gonorrhea clone identified in two UK women

A team of British scientists reported today that a Neisseria gonorrhoeae clone with ceftriaxone resistance and intermediate resistance to azithromycin has been detected in the United Kingdom.

Writing in Eurosurveillance, the investigators describe a cluster of cases involving the N gonorrhoeae FC428 clone, which was first reported in Japan in 2015 and has since been detected in Australia, Canada, Denmark, Ireland, and France. The clone was detected in two women (Case 1 and Case 2) from the United Kingdom who tested positive for gonorrhea in October and November 2018 after having unprotected sex with men from the UK while in Ibiza, Spain.

The two sexual contacts of Case 1 could not be contacted for testing but are suspected of also being infected. The contact of Case 2, who was also linked to the sexual network of Case 1, was asymptomatic when tested in November 2018, but the investigators believe he may have been the source of Case 2's infection.

Case 1 was treated empirically with ceftriaxone and azithromycin and was cured; Case 2 failed the first two treatments but cleared the infection after treatment with intravenous ertapenem.

Whole-genome sequencing revealed that the genomes of the isolates from the two cases were indistinguishable, and comparison with previously sequenced ceftriaxone-resistant isolates demonstrated that the isolates belonged to the FC428 clone. Except for one other case, all previous FC428 cases had been linked to sexual contact in Southeast Asia, which is believed to be the reservoir for the clone.

"There is growing evidence that the FC428 clone has the potential to spread globally, which is of concern given it is resistant and intermediate resistant to the only two remaining empirical treatment options for N. gonorrhoeae, ceftriaxone and azithromycin," the authors of the report write. "As the transmission between our cases is likely to have occurred between UK residents visiting Ibiza, a well-known European party destination, there is a risk that further undetected transmission has occurred."
Mar 7 Eurosurveill rapid communication

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