Stewardship / Resistance Scan for Mar 27, 2019

Physician AMR disconnect
Oral vs IV antibiotics for UTI bacteremia
Ineffective molecular diagnostics

Study finds disconnect in clinic docs' antimicrobial resistance knowledge

A survey of physician attitudes about antibiotic use in clinic settings found that nearly all agree that antimicrobial resistance (AMR) is a national problem, but only 63% thought the issue is a problem at their own facilities. A group based at Wayne State University reported its findings yesterday in the American Journal of Infection Control.

The researchers focus on clinic settings because of the high volume of antibiotic prescribing at physician discretion. The cross-sectional survey consisted of a self-administered 34-item questionnaire to eligible US physicians from May 2018 to August 2018. The voluntary anonymous survey was delivered through email and online forums such as Facebook. The most common ambulatory settings were hospital outpatient clinics and emergency departments, urgent care centers, surgical centers, oncology clinics, mental health clinics, and hospice.

Of 323 doctors who completed the survey, 271 (84%) were attending physicians, with 62% in primary care and the rest residents or fellows. The survey revealed that 99% agreed that AMR is a national problem and 99% reported that overprescribing or use of antibiotics for self-limiting nonbacterial infections are important causes of AMR. However, respondents voiced less agreement on other factors perceived to play a role in AMR, such as overuse of broad-spectrum medications and patients' expectations.

Only 63% of respondents reported AMR as a problem in their facilities, and 23% still believe aggressive prescribing is needed to avoid clinical failures. Prescribing guidelines had a low to moderate impact on antibiotic choice, and measures that respondents say reduce AMR include education, institution guidelines, and regular audits.

Aside from underestimating the significance of the problem in their own clinics, respondents seem to have significant knowledge gaps and ambivalence about resistance mechanisms, the authors concluded. "Global and national AMR awareness campaigns and antibiotic stewardships that incorporate interactive education and feedback, along with input of local experts are critically needed to successfully address the mounting problem of AMR in both inpatient and ambulatory settings," they wrote.
Mar 26 Am J Infect Control abstract


No treatment failure difference noted in IV vs oral meds for UTI bacteremia

A comparison of intravenous (IV) and IV-transitioned-to-oral antibiotic treatment in hospital patients with gram-negative bacteremia from a urinary tract infection (UTI) found no difference in treatment failure, researchers based at the Mayo Clinic in Rochester, Minnesota, reported yesterday in the Journal of Global Antimicrobial Resistance.

The single-center retrospective cohort study included hospitalized noncritically ill adults patients who received culture-susceptible antibiotic therapy for 7 to 12 days. The most common treatments were ciprofloxacin and levofloxacin.

Of 346 patients enrolled in the study, 82 (23.7%) were in the IV group and 264 (76.3%) were in the group transitioned from IV to oral medication. The researchers said the transition from IV to oral antibiotics has been a successful strategy for battling several infections, but there is little data on outcomes in patients with bacteremia from UTIs.

Of six treatment failures, two (2.4%) occurred in the IV group and four (1.5%) occurred in the oral treatment group. All failures were linked to recurrence of the index organism.

When the team looked at secondary outcomes, they found that the IV group had significantly higher rates of IV line-associated complications, with shorter hospital stays for the patients in the oral cohort.
Mar 26 J Glob Antimicrob Resist abstract


Scientists note low clinical yield of molecular diagnostic panels for diarrhea

A study today in Open Forum Infectious Diseases found a low clinical yield for molecular diagnostic panels as an antimicrobial stewardship tool for outpatients with diarrhea.

Molecular diagnostic panels for enteric pathogens offer increased sensitivity and reduced turnaround time, the authors of the study, primarily from the University of Virginia, write. But they come at a steep price, and often pathogen detections do not change clinical management and enteric disease is self-limited.

To explore the panels more in depth, the researchers analyzed 629 tests from adult outpatients with diarrhea in 2015 and 2016, among which a pathogen was detected in 127 tests, or 20.2%.The most common pathogens were enteropathogenic Escherichia coli (7.5%), norovirus (3.8%), enteroaggregative E coli (2.2%), Campylobacter (1.4%), and Salmonella (1.4%).

The investigators noted that the clinical yield of diagnostic panels was low, with antimicrobial treatment clearly indicated for only 18 subjects (2.9%) and any change in clinical management indicated for 33 subjects (5.2%). In contrast, following the clinical criteria for diagnostic testing from 2017 guidelines from the Infectious Diseases Society of America would have reduced testing by 32.3% without significantly reducing the clinical yield.
Mar 27 Open Forum Infect Dis study

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