Stewardship / Resistance Scan for May 17, 2019

Northern Ireland AMR plan
Rapid susceptibility tests
Unneeded antibiotics for respiratory infections

Northern Ireland announces One Health AMR plan

The government of Northern Ireland yesterday announced a 5-year, One Health action plan to fight antimicrobial resistance (AMR).

The plan, developed by Northern Ireland's Department of Health and Department of Agriculture, Environment and Rural Affairs in collaboration with the United Kingdom's Food Standards Agency (FSA), aims to address the growing threat of drug-resistant pathogens by lowering the burden of infection in humans and animals, optimizing antibiotic use on farms and in human medicine, strengthening AMR surveillance, minimizing the spread of AMR in the environment, and investing in research into new therapeutics and diagnostics.

Among the specific goals laid out in the plan are a 10% reduction in the incidence of specific drug-resistant infections in people, a 50% reduction in healthcare-associated gram-negative bloodstream infections, and a 15% reduction in human antimicrobial use by 2023-2024.

"This issue affects more than just human health and healthcare. Whenever we make an environment favourable for infectious bugs, then they take advantage," Maria Jennings, FSA director in Northern Ireland, said in a press release. "This affects farming, the environment and ultimately the food we eat.  Taking a One Health approach and working with partners across government is the most effective way to address AMR."

The plan was developed in conjunction with the United Kingdom's 20-year vision and 5-year national action plan for addressing AMR, released in January.
May 16 Northern Ireland 5-year action plan
May 16 Northern Ireland Executive press release
Jan 24 CIDRAP News story, "UK aims to cut antibiotics 15% in 5-year plan"


Rapid susceptibility test produces mixed results in German study

Introduction of a novel, rapid antimicrobial susceptibility test at a German hospital significantly reduced time for species identification (ID) and antimicrobial susceptibility testing (AST) in patients with bloodstream infections, as well as time to optimal antimicrobial therapy, researchers at University of Cologne Hospital reported yesterday in Clinical Infectious Diseases. But the test did not affect antimicrobial consumption or clinical outcomes.

In the quasi-experimental study, researchers investigated the impact of The Accelerate Pheno system (ADX), a new technology that identifies microorganisms from a positive blood culture within 90 minutes and provides phenotypic AST results within 7 hours, by analyzing three different groups of patients with a positive blood culture. One group was evaluated and treated with conventional diagnostics, a second with conventional diagnostics and antimicrobial stewardship program (ASP) intervention, and a third with ADX and ASP intervention. The goal was to see whether use of ADX leads to earlier therapeutic decision-making, decreased use of broad-spectrum antimicrobials, decreased length of hospitalization, and better clinical outcomes.

Overall, 204 patients were evaluated; 64 in the conventional diagnostics group, 68 in the conventional diagnostics plus ASP group, and 72 rapid diagnostics plus ASP group. Compared with the two groups using conventional diagnostics, the use of ADX significantly decreased time from Gram stain to ID (median: 23 vs 2.2 hours, P < 0.001) and time to AST results (median: 23 vs 7.4 hours, P < 0.001) and shortened time from Gram stain to optimal antimicrobial therapy (median: 11 vs 7 hours, p < 0.024) and to step-down antimicrobial therapy (median: 27.8 vs 12 hours, P < 0.019). But no significant differences were found in the duration of antimicrobial treatment, total antimicrobial consumption, length of hospital stay, or 7-day and 28-day in-hospital mortality.

"In conclusion, the use of ADX significantly reduced time to ID and AST as well as time to optimal antimicrobial therapy but did not affect clinical outcome parameters," the authors of the study write. "It remains to be determined if a larger study in a high resistance setting or in a setting with 24/7 microbiology service or with less active ASP involvement can show lower mortality rates and antimicrobial consumption when rapid susceptibilities are provided."
May 16 Clin Infect Dis abstract


Study: Antibiotics for respiratory infections common in cancer patients

In another study yesterday in Clinical Infectious Diseases, researchers with Fred Hutchinson Cancer Research Center found that nearly one-third of hematology-oncology patients were prescribed antibiotics for a respiratory tract infection. But viral causes were identified in 75% of patients tested, and viral testing was associated with reduced prescribing.

The retrospective study looked at the electronic medical records of patients who presented for care at Seattle Cancer Care Alliance and had received a diagnosis for acute upper respiratory tract infection (URI) or acute bronchitis from October 2015 through September 2016. The researchers obtained antibiotic prescribing, viral testing, and other clinical data from the first clinical encounter for the URI through day 14 to characterize antibiotic prescribing patterns, use of respiratory viral diagnostic tests, and clinical outcomes associated with URI in an immunocompromised population.

Of the 251 patients included in the final analysis, 81 (32%) were prescribed an antibiotic for URI symptoms, with 52 (64%) receiving prescriptions on day 0, 11 (14%) on days 1-2, and 18 (22%) on days 3-14. Viral testing was performed in 113 patients (45%), and at least one virus was detected in 85 (75%). Antibiotic prescribing and viral testing varied substantially by clinical service.

On univariate analysis, sputum production or chest congestion were associated with higher risk of antibiotic prescribing (relative risk [RR], 2.3; 95% confidence interval [CI], 1.4 to 3.8, P < 0.001), while viral testing on day 0 was associated with lower risk of antibiotic prescribing (RR=0.4, 95% CI 0.2 to 0.8, P = 0.01), though collinearity between viral testing and clinical service limited the ability to separate these effects on prescribing. Antibiotic prescribing was not associated with subsequent URI-related healthcare visits (P = 0.89).

The authors of the study conclude, "These findings highlight the need for further research to explore the role and cost-effectiveness of molecular respiratory viral testing in limiting unnecessary antibiotic use among hematology-oncology patients."
May 16 Clin Infect Dis abstract

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