Stewardship / Resistance Scan for Mar 08, 2019

Home therapy for kids' cellulitis
Antibiotics and UTI relapse

Australian study shows promise for home IV antibiotics for peds cellulitis

A non-inferiority trial in Australia has determined that intravenous (IV) ceftriaxone at home may be an alternative to IV flucloxacillin in the hospital for children who have cellulitis, according to a study yesterday in The Lancet Infectious Diseases.

An area of increased focus in antimicrobial stewardship has been outpatient parenteral antimicrobial therapy (OPAT), which involves IV antibiotic administration in the home rather than at the hospital. OPAT can reduce costs, but the authors of the new study also wanted to ensure it provided good outcomes. They write that their study is the first randomized controlled trial of any acute infection requiring IV antibiotic therapy in children comparing efficacy and safety of home or ambulatory treatment with standard hospital management.

One hundred ninety children 6 months to 18 years old were randomly assigned to receive either 50 milligrams per kilogram (mg/kg) of ceftriaxone once daily at home or 50 mg/kg of flucloxacillin every 6 hours in the hospital.

Overall, treatment failure occurred in 2 (2%) children in the home group and in 7 (7%) children in the hospital group, and, in the per-protocol analysis, it occurred in 1 (1%) of 89 children in the home group and in 7 (8%) of 91 children in the hospital group. In addition, only 2 children in the home group compared with 10 in the hospital group had an adverse event. And there was no difference between the groups in the rates of nasal acquisition of methicillin-resistant Staphylococcus aureus or gastrointestinal acquisition of extended-spectrum beta-lactamase-producing bacteria or Clostridioides difficile after 3 months.

The authors conclude, "Findings from our study provide robust evidence that children with moderate to severe cellulitis can be effectively treated at home without the need for hospital admission. Additionally, we have shown that this management pathway is highly acceptable to families and has cost-saving benefits for the hospital."

An accompanying commentary noted, "Although OPAT has several benefits compared with hospitalisation, the burden of OPAT is still substantial for both patients and caregivers, especially compared with oral therapy. A growing body of evidence suggests that intravenous antibiotics are overused in place of equally effective oral therapy across a variety of serious infections in children that might require hospitalisation."
Mar 7 Lancet Infect Dis abstract
Mar 7 Lancet Infect Dis commentary


Study finds link between antibiotic therapy, urinary infection relapse

The results of a study today in Epidemiology and Infection on urinary tract infections (UTIs) among college-aged women suggest that initial treatment with trimethoprim-sulfamethoxazole may increase the risk of UTI relapse.

In the study, researchers from the University of Florida sought to understand the relationship between empiric antibiotic treatment for uncomplicated UTI and the likelihood of recurrent infections, theorizing that women who received treatment with antibiotics associated with higher rates of antibiotic resistance (trimethoprim-sulfamethoxazole and fluoroquinolones) would be more likely to have a recurrent UTI.

They also looked at the associations between empiric therapy and UTI recurrence within 2 weeks, which was defined as a potential infection relapse rather than a recurrent infection. In addition, baseline patient characteristics, including age, race, and region of origin, were analyzed for association with recurrence and relapse.

The retrospective study analyzed electronic medical record data on 6,620 women who were diagnosed with a UTI at the University of Florida Student Health Care Center from 2006 through 2014. Of those women, 1,051 (15.9%) developed a recurrent UTI and 215 (3.2%) experienced relapse. In the multivariate analysis, Asian women were found to have greater odds of experiencing a recurrent UTI than Caucasian women, while African-American women had lower odds. But there was no association between initial antibiotic treatment and recurrent UTI.

However, multivariate analysis of women who suffered a relapse found that women treated with trimethoprim-sulfamethoxazole had more than twice the increased risk of UTI relapse compared with women treated with combination therapy (adjusted odds ratio [aOR], 2.14; 95% confidence interval [CI], 1.23 to 4.09). Women born outside the United States also had increased odds of UTI relapse compared with those born in the United States (aOR, 2.12; 95% CI, 1.30 to 3.31).

The authors of the study say that the link between UTI relapse and trimethoprim-sulfamethoxazole may be related to increasing rates of resistance to the drug, and that further study of this link is warranted. They also call for more research on how race and region of origin contribute to recurrence and relapse.
Mar 8 Epidemiol Infect abstract

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