Stewardship / Resistance Scan for Mar 15, 2019

Penicillin allergy de-labeling
;
Antibiotic misuse in Irish long-term care
;
Resistant bacteria in imported shrimp

Penicillin allergy intervention cuts down on restricted antibiotic use

Australian researchers reported yesterday in the Journal of Antimicrobial Chemotherapy that a novel, pharmacist-led penicillin allergy de-labeling intervention at a tertiary hospital led to a significant decrease in the prescribing of restricted antibiotics.

The single-center study evaluated the impact of a weekly ward round that was implemented at the hospital in March 2018 and was led by an infectious disease physician, an allergy nurse, and an antimicrobial stewardship (AMS) pharmacist. Using electronic health records, the team identified patients with a documented penicillin allergy who were receiving an antibiotic, then reviewed their allergy history and phenotype to determine whether the allergy label was a type A (non-immune-mediated) reaction or the patient required a direct oral rechallenge or skin test, and whether he or she could be transitioned from a restricted antibiotic. The 5-month audit looked at how many penicillin allergies were de-labeled, and the resulting impact on restricted antibiotics.

Over the 5-month period, 309 patients were identified during 19 ward rounds, and 106 met the inclusion criteria for the study. Of those 106 patients, 40 (37.7%) had their penicillin allergy de-labeled. The highest rate of penicillin allergy de-labeling was among patients who were referred for a direct oral rechallenge, with 95.2% (20 of 21) having their allergy label removed. Of the 22 patients with a type A reaction, 14 (63.6%) were de-labeled, and 4 of 4 patients who underwent a skin test were found to tolerate penicillin. Prescribing of restricted antibiotics in the 106 patients fell from 42.5% pre–ward round to 17.9% post–ward round.

The authors of the study conclude, "We have illustrated a successful model for a pharmacist-led AMS, a penicillin allergy de-labelling ward round, targeting non-immune-mediated and low-risk allergy phenotypes. Similar models should be encouraged in other hospitals with established AMS programmes."
Mar 14 J Antimicrob Chemother study

 

Survey finds significant prophylactic antibiotic use in Irish long-term care

Point-prevalence surveys conducted in Irish long-term care facilities (LTCFs) have a found a high rate of prophylactic antibiotic prescribing, according to a paper yesterday in Eurosurveillance.

The Healthcare-Associated Infections in Long-Term Care Facilities (HALT) surveys were conducted in 2013 and 2016. Researchers collected and analyzed data on the type of facility, resident characteristics, and systemic antimicrobial prescriptions for healthcare-associated infections, including whether the antimicrobial was for prophylactic or therapeutic purposes.

A total of 190 LTCFs participated in the 2013 HALT survey, and 224 participated in the 2016 survey; 119 participated in both surveys. Most were nursing homes and mixed care, intellectual disability, and psychiatric LTCFs. The overall prevalence of antimicrobial prescribing was similar in both surveys (9% to 10%). The proportion of prophylactic prescribing was higher in 2016 (42.5%) than it was in 2013 (38.3%), but among the 119 LTCFs that took both surveys, prophylactic prescribing was the same (40%). In both surveys, urinary tract infections (UTIs) accounted for most of the prophylactic antibiotics prescribed, followed by respiratory tract infections (RTIs), skin or wound infections, and infections at other sites.

The analysis of all the LTCFs in both surveys found that the main prophylactic agents were nitrofurantoin (39%) and trimethoprim (41%) for UTIs; macrolides (47%) for RTIs, and macrolides and tetracycline (56%) for skin or wounds. More than 50% of the prophylactic antibiotics were prescribed in intellectual disability facilities and around 40% in nursing homes. Prophylaxis was recorded more often for female patients, residents living in LTCFs for more than 1 year, and residents with a urinary catheter.

The authors of the study note that while antimicrobial prophylaxis is appropriate for selected indications—such as surgery—much of the prophylactic prescribing they identified does not appear to follow guidelines or be evidence-based.

"The high prevalence of antimicrobial use in Irish LTCFs, particularly antimicrobial prophylaxis, indicates an urgent need to develop and implement education and stewardship programmes specifically targeted towards residential care settings," the authors write. "While participation in repeated HALT surveys is a valuable surveillance method, it must be supplemented by local quality improvement initiatives, based on each LTCF's survey results."
Mar 14 Eurosurveill study

 

Canadian investigation finds resistant bacteria in imported shrimp

An investigation by CBC News has found troubling levels of antibiotic-resistant bacteria in imported shrimp bought at Canadian grocery chains.

In a report today, CBC News Marketplace found that 9 of 51 frozen shrimp products (17%) bought from major grocery stores in Calgary, Toronto, Saskatoon, and Montreal were carrying bacteria—including Escherichia coli and Staphylococcus aureus—that were resistant to at least one antibiotic, and bacteria in three of the shrimp products were harboring extended-spectrum beta-lactamase (ESBL) genes. Two of the shrimp products were carrying methicillin-resistant Staphylococcus aureus.

According to the report, Canada imports about $700 million worth of shrimp each year, mainly from India, Vietnam, China, and Thailand, and much of it from shrimp farms that commonly use antibiotics. Five of the contaminated products were from India. Marketplace notes that while the Canadian Food Inspection Agency inspects 5% of imported shrimp for antibiotic residues, it does not test for antibiotic-resistant bacteria.

Gerry Wright, PhD, an infectious disease expert at McMaster University, told Marketplace that the lack of testing for resistant bacteria in imported food is a gap that needs to be addressed.

"Once these organisms are here, once these genes are in Canada, then there's no good way to keep them from spreading around. So what would be a really good idea is to prevent them from getting in in the first place," he said.
Mar 15 CBC News story

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