Stewardship / Resistance Scan for Jul 22, 2019

Stewardship at the end of life
;
Strep test and overprescribing

Survey: Antibiotic stewardship often lacking for end-of-life care

A survey of 36 hospitals discovered that about two-thirds had antimicrobial stewardship programs (ASPs) that monitored antimicrobial use in patients during end-of-life care, but only a third had ASPs that offered guidance for patients receiving comfort care only, according to a study today in Infection Control & Hospital Epidemiology.

Yale University investigators conducted an electronic survey of ASPs from the Society for Healthcare Epidemiology of America (SHEA) Research Network, a consortium of hospitals collaborating on multicenter projects in healthcare epidemiology. Members of 36 of the 94 hospitals completed the survey in May and June of 2018.

In addition to finding that 23 hospitals (64%) had ASPs that monitored antimicrobial use during end-of-life care and 13 (36%) had ASPs offering comfort-care antimicrobial use guidance for patients, the survey results showed that recommendations for intravenous antimicrobials were more common than recommendations for oral antimicrobials in 86% of programs.

The researchers also found that approval of antimicrobials in the ASPs was often influenced by patients' goals, with 15 ASPs (42%) having antimicrobials restrictions affected by comfort measures only, 9 (25%) having them affected by no-escalation-of-care status, and 4 (11%) affected by do-not-resuscitate/intubate orders.

Free-text responses indicated that ASPs should support end-of-life clinical decisions in four ways: (1) discerning adverse events, (2) supporting palliative care providers, (3) refining guidelines specific to end-of-care issues, and (4) educating physicians.
Jul 22 Infect Control Hosp Epidemiol study

 

Study: Molecular test for group A strep could lead to overprescribing

Researchers in Chicago report today that the illumigene test, a molecular-based assay for group A Streptococcus (GAS), is significantly more likely than throat culture to yield positive results in patients without GAS pharyngitis, a finding they say could have an impact on outpatient antimicrobial stewardship efforts.

In a study published in The Pediatric Infectious Disease Journal, researchers from Northwestern University Feinberg School of Medicine and Lurie Children's Hospital of Chicago enrolled children between the ages of 3 and 17 who visited the hospital's pediatric clinic for health supervision or follow-up of a non-infectious condition and had no signs or symptoms of pharyngitis. They then performed the illumigene test and blood agar plate throat cultures on duplicate throat swabs to compare the proportion of positive tests.

The illumigene test replaced throat cultures at the hospitals for diagnosis of GAS pharyngitis in 2014, and since then hospital records have detected an increase in positive GAS tests. The researchers hypothesized that asymptomatic carriers may be testing positive and receiving unnecessary antibiotics.

Among the 385 enrolled children, significantly more illumigene tests (78/385, 20.3%) than throat cultures (48/385, 12.5%) were positive. Three swabs yielded an "indeterminate" illumigene test result (all 3 paired swabs were culture-negative), leaving 382 pairs for analysis. Results were discordant for 32 of 382 pairs (8.4%), of which 31 of 32 (97%) were illumigene-positive/culture-negative. A positive result was significantly more likely with the swab chosen for the illumigene test than with the one used for culture. In a small subset of 13 illumigene-positive lysates tested by polymerase chain reaction, 4 (31%) were negative, and the paired cultures were negative in all four.

"The results of the present study are consistent with the hypothesis that the sensitivity of the illumigene test is such that it can identify GAS more readily than occurs with standard throat culture, especially in patients with very low streptococcal burden," the authors of the study write.

They conclude that additional studies of GAS molecular tests are needed, and that new clinical guidelines are needed to define the role of these tests in clinical care.
Jul 22 Pediatr Infect Dis J study

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