Stewardship / Resistance Scan for Aug 13, 2019

Combo therapy for MRSA infections
EMR-driven stewardship

Adding beta-lactam to daptomycin improves MRSA outcomes, study finds

The addition of a beta-lactam antibiotic to daptomycin is associated with improved clinical outcomes in patients with methicillin-resistant Staphylococcus aureus bloodstream infections (MRSA BSIs), researchers reported yesterday in Clinical Infectious Diseases.

In the retrospective observational study, conducted at two academic medical centers in Detroit from 2008 through 2018, researchers from Wayne State University compared two groups of adults who had MRSA BSIs; one group was treated with daptomycin plus a beta-lactam (DAP+BL), and the other group received daptomycin monotherapy. The primary outcome was composite clinical failure (60-day all-cause mortality and/or 60-day recurrence).

A total of 229 patients were included in the study, with 72 receiving DAP+BL and 157 receiving daptomycin monotherapy. Overall, 52 patients (22.7%) experienced clinical failure, including 43 (27.4%) in the daptomycin group and 9 (12.5%) in the DAP+BL group. In unadjusted and inverse probability of treatment weighted (IPTW)-adjusted analyses, DAP+BL was associated with significantly reduced odds of clinical failure (odds ratio [OR], 0.362; 95% confidence interval [CI], 0.164 to 0.801; adjusted OR, 0.386; 95% CI, 0.175 to 0.853). Lower clinical failure was also consistently demonstrated in all pre-specified subgroups across the spectrum of host and infection characteristics.

The authors of the study say the findings add to a growing body of evidence that beta-lactams, which are ineffective on their own against MRSA, can enhance the bactericidal activity of daptomycin against invasive MRSA infections.
Aug 12 Clin Infect Dis abstract


Study: Electronic medical records aid ICU stewardship program

The integration of electronic medical record (EMR) data with an intensive care unit antimicrobial stewardship (ICU-AMS) program was associated with high clinician compliance with recommendations and improved antibiotic appropriateness, Australian researchers reported today in Infection Control and Hospital Epidemiology.

The primary objective of the study was to examine the impact of an EMR-driven ICU-AMS program at Austin Health, a tertiary care referral hospital in Australia, on clinician compliance with a range of AMS recommendations. The service utilized EMR data coupled with face-to-face consultations with an infectious disease (ID) physician, an ID fellow, and an AMS pharmacist. The recommendations were defined by an internally developed "5 Moments of Antimicrobial Prescribing" metric: (1) escalation, (2) de-escalation, (3) discontinuation, (4) switch, and (5) optimization. The secondary objectives included measuring the impact of this service on antibiotic appropriateness and use of high-priority target antimicrobials.  The impact of the ICU-AMS round on antimicrobial appropriateness was evaluated using point-prevalence survey data.

For the 202 patients reviewed over 5 months (from implementation in August 2017 through December 2017), 412 recommendations were made in accordance with the "5 Moments" metric. The most common recommendation made by the ICU-AMS team was moment 3 (discontinuation), which comprised 173 of 412 recommendations (42.0%), with an acceptance rate of 83.8% (145 of 173). Data collected for point-prevalence surveys showed an increase in prescribing appropriateness from 21 of 45 (46.7%) recommendations pre-intervention (October 2016) to 30 of 39 (76.9%) during the study period (September 2017).

The ICU-AMS service was also associated with an immediate reduction in the use of several key target antibiotics, including meropenem (−40.5%; 95% CI, −52.9% to −24.8%), piperacillin-tazobactam (−39.8%; 95% CI, −50.8% to −26.6%), and vancomycin (−36.6%; 95% CI, −48.3% to −22.4%), and with a significant reduction in the monthly trend in use of vancomycin (−13.2%; 95% CI, −17.9%, −8.4%]).

"In conclusion, the use of an EMR-driven ICU-AMS model demonstrated a decrease in target antibiotic utilization as well as an increase in the appropriateness of antimicrobials," the authors of the study write. "ICU-AMS models that integrate the EMR should be encouraged in centers with appropriate digital resources to achieve subsequent positive impacts on antibiotic prescribing."
Aug 13 Infect Control Hosp Epidemiol abstract

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