Stewardship / Resistance Scan for Dec 09, 2019

News brief

Stewardship intervention at VA clinics shows durable success, study finds

A multifaceted outpatient stewardship intervention at Veterans Affairs primary care clinics in Pennsylvania was associated with sustained reductions in overall, unnecessary, and suboptimal antibiotic prescription rates for up to a year after some components were discontinued, researchers reported today in Clinical Infectious Diseases.

The intervention at seven primary care clinics in the Veterans Affairs Pittsburgh Healthcare System (VAPHS), implemented in response to high rates of inappropriate antibiotic use, involved clinician education, peer comparisons of overall antibiotic prescribing rates (provided to prescribers in monthly emails), and a clinical decision support electronic order set, and was directed against all antibiotic prescribing.

The intervention was tied to a significant reduction in total and unnecessary antibiotic prescribing, but after 6 months, peer comparisons were discontinued. To evaluate whether benefits of the intervention were sustained after ending peer comparisons, researchers from VAPHS, the University of Pittsburgh, and Allegheny Health Network analyzed overall, unnecessary, and suboptimal antibiotic prescribing during the baseline period (January to June 2016), the intervention period (January to June 2017), and the post-intervention period (January to June 2018).

When adjusted for seasonality, the results showed that the mean antibiotic prescribing rate fell from 76.9 prescriptions per 1,000 office visits during the baseline period to 49.5 per 1,000 office visits (a 35.6% reduction) and remained significantly lower during the post-intervention period (56.3 per 1,000 office visits, 26.8% lower than the baseline). The rate of unnecessary antibiotic prescribing fell from 58.8% during baseline to 37.8% during the intervention and 44.3% post-intervention. Overall, 19.9% of antibiotics were prescribed optimally during the baseline period, compared with 36.6% during the intervention and 34.9% during the post-intervention period.

Although the results show the intervention achieved durable success, the authors note that roughly 40% of antibiotic prescriptions were still not indicated and 65% were suboptimal. In response to the data, they have reinstituted an ongoing education and peer-comparison based approach.

"While we observed long-term benefits after withdrawing peer comparison, our experience suggests that best results will be attained with sustained rather than time-limited interventions," they write.
Dec 9 Clin Infect Dis abstract

Hospital stewardship program linked to lower antibiotic use, AMR

In another study published today in Clinical Infectious Diseases, Canadian researchers reported that implementation of a comprehensive hospital-based antibiotic stewardship program (ASP) at a Toronto hospital resulted in reduced antibiotic use and was associated with a significant decline in institutional antimicrobial resistance (AMR).

The controlled interrupted time series study by researchers from the University of Toronto and Sunnybrook Health Sciences Centre looked at 14 years (October 2002 to September 2016) of data from Sunnybrook's Bayview Campus, a 627-bed teaching hospital where an ASP was implemented in 2009. The ASP involved dedicated infectious diseases physicians and pharmacists providing regular service-specific education, hospital-wide antibiotic guidelines, formulary restrictions, and pharmacist-led prospective audit-and-feedback for targeted antibiotics. The primary outcome analyzed in the study was the change in incidence of hospital-acquired antibiotic-resistant organisms (HA-AROs) and multidrug-resistant organisms (HA-MDROs) among clinical isolates.

The analysis found statistically significant shifts in consumption of targeted antibiotics (incidence rate ratio [IRR], 0.98; 90% confidence interval [CI], 0.87 to 1.10), non-targeted antibiotics (IRR, 0.93; 95% CI, 0.83 to 1.04), and total antibiotics (IRR, 0.94; 95% CI, 0.85 to 1.04) during the intervention period, corresponding with a 9% reduction in HA-ARO burden (IRR, 0.91; 95% CI, 0.83 to 0.99) and 13% reduction in HA-MDRO burden (IRR, 0.87; 95% CI, 0.73 to 1.04).

This occurred despite an upward trajectory in community associated (CA) antibiotic resistance rates throughout the baseline and intervention periods, during which CA-ARO burden rose by 40% (IRR, 1.40; 95% CI, 1.28 to 1.54) and CA-MDRO burden rose by 68% (IRR, 1.68; 95% CI, 1.57 to 1.82).
Dec 9 Clin Infect Dis abstract

Review of penicillin allergy may lower use of non–beta-lactams

More than two thirds of patients with reported penicillin allergies at a Miami hospital were able to take other beta-lactam antibiotics, according to research presented today at the midyear clinical meeting of the American Society of Health System Pharmacists (ASHP).

In the study, pharmacists from Baptist Hospital of Miami interviewed 63 patients with reported penicillin allergies and then reviewed their medication histories prior to verifying orders for alternative antibiotics. The reviews revealed that 43 of the 63 patients (68%) had previously and successfully used other beta-lactam antibiotics, most often cephalosporins, and that aztreonam and levofloxacin were the most commonly prescribed non–beta-lactam antibiotics before the assessment. The pharmacists recommended switching these patients to a beta-lactam antibiotic, and the substitution saved the hospital $21,500 over 3 months.

Penicillin allergies are reported by up to 10% of the population, but research has shown that more than 95% of patients reporting penicillin allergy are not truly allergic. Non–beta-lactam substitutions are frequently more expensive, broader spectrum, and associated with more side effects.

"The prevalence of this perceived allergy makes our study particularly useful to hospitals and healthcare systems as they look at better patient care and cost reductions," Rita Chamoun, PharmD, clinical staff pharmacist at Baptist Hospital of Miami and lead author of the study, said in an ASHP press release. "Working together, pharmacists and other medical professionals can find alternatives that work for some patients. A multi-disciplinary approach is key to optimizing therapy in patients with a reported penicillin allergy."

Chamoun said the study also illustrates the importance of evaluating and improving antibiotic allergy documentation.
Dec 9 ASHP press release

News Scan for Dec 09, 2019

News brief

Malaysia reports vaccine-derived polio case

Malaysia's health ministry yesterday announced a vaccine-derived poliovirus type 1 (cVDPV1) case, marking the country's first polio case in 27 years, according to a statement.

The patient is a 3-year-old boy from the city of Tuaran in Sabah state who was hospitalized for fever followed by a weak limb, which required admission to the intensive care unit. Tests confirmed his cVDPV1 infection on Dec 6.

Tests conducted by the World Health Organization (WHO) polio regional lab in Australia found that the virus was linked to that of an acute flaccid paralysis case in the Philippines, which is battling a cVDPV2 outbreak and has also reported cVDPV1.

A survey of children ages 2 months to 15 years in Sabah found that 23 of 199 did not receive polio vaccine. As of Dec 5, surveillance of 646 people near the infected child's residence found no other acute flaccid paralysis cases. Further investigation is still under way, including tests on stool samples from close contacts and on environmental samples.

Polio immunization activities will continue in residential areas and will be expanded in high-risk areas, the ministry said, adding that the efforts are designed to ensure immunization coverage of over 95%.

Malaysia's last polio case occurred in 1992 and the country was declared free of the disease in October 2000. It switched from oral polio vaccine to inactivated polio vaccine in 2008.
Dec 8 Malaysian health ministry statement

Sanofi awarded $226 million to expand pandemic flu vaccine capacity

The US Department of Health and Human Services (HHS) today announced that it awarded a 6-year contract worth $226 million to Sanofi Pasteur to boost its capacity to produce recombinant flu vaccine in the United States as part of pandemic preparedness. In a statement, HHS said the contract aligns with the Sep 19 presidential executive order to modernize flu vaccines and technologies.

HHS said the work will take place through a partnership between Sanofi and the HHS Biomedical Advanced Research and Development Authority (BARDA), part of the Assistant Secretary for Preparedness and Response.

Rick Bright, PhD, BARDA director, said in the statement that flu virus can spread rapidly across the globe in a matter of weeks, making technologies that quickly and safety produce flu vaccines fundamental to outbreak response. "Keeping vaccine manufacturing in the United States is essential to protect Americans from pandemic influenza and to save lives. Better, faster vaccine technologies, produced in the U.S. will improve access, protect more people and, ultimately, strengthen our nation's health security," he said.

HHS said Sanofi is the only company with a seasonal recombinant flu vaccine licensed in the United States that has resources to leverage the technology for pandemic preparedness. According to the contract, Sanofi will retrofit its vaccine manufacturing facilities in Swiftwater, Pennsylvania, which will double its US recombinant protein-based flu vaccine capacity. Agreement options include retrofitting an additional facility at the site to produce adjuvant, development and licensing an adjuvanted recombinant pandemic vaccine, and HHS access to vaccine production capacity for up to 25 years after the manufacturing facilities are completed. The agreement projects that Sanofi could provide nearly 100 million doses of recombinant flu vaccine for use during a pandemic.

Sanofi said today in a press release that the investigational pandemic vaccine will use the same recombinant technology as its Flublok quadrivalent vaccine. It also notes that the contract will expand the site's role as a center for excellence for pandemic preparedness by adding both recombinant and adjuvant alongside current egg-based manufacturing.
Dec 9 HHS press release
Dec 9 Sanofi Pasteur press release

2018's romaine-linked E coli outbreak largest in decades

According to a study today in Clinical Infectious Diseases, a multistate outbreak of Escherichia coli O157:H7–tainted romaine lettuce in 2018 was the largest American outbreak in decades, eventually sickening 240 people in 37 states. That's 30 more case-patients than the Centers for Disease Control and Prevention (CDC) noted in a final update on the outbreak.

Of the 240 cases, 104 people were hospitalized, 28 developed hemolytic uremic syndrome, and 5 patients died, according to the study authors, led by CDC scientists. Of 179 people who were interviewed, 152 (85%) reported consuming romaine lettuce in the week before illness onset, the authors said, and eventually 20 sub-clusters of cases were identified. All romaine lettuce implicated in the outbreak was grown in Yuma, Arizona.

The New Jersey Department of Health first notified the CDC of two E coli outbreaks in April of 2018, with clusters of patients having eaten at the same restaurant chain. Eventually 20 more clusters of patients were identified across the country, many having eaten chopped salads at the same restaurant chains.

"This outbreak was the largest multistate STEC O157 outbreak in several decades, eclipsing in magnitude a 2006 outbreak linked to fresh spinach," the authors said. "The true size of this outbreak was likely much larger than the 240 illnesses reported through PulseNet, suggesting that thousands of people were actually sickened in this outbreak."

Though a single source of contamination was not identified, the E coli strain was found at multiple points along a 3.5-mile irrigation canal that ran along 36 romaine fields.
Dec 9 Clin Infect Dis study
Jun 28, 2018, CDC final outbreak update

Health officials confirm 3 yellow fever cases in Mali, Ivory Coast

The Ministry of Health in Mali has confirmed three cases of yellow fever in that country and Ivory Coasst as of Dec 3, according to a post late last week on ProMED Mail, the online reporting system of the International Society for Infectious Diseases.

The three cases are in different locations: Kati (Bamako region), Manankoro in the health district of Bougouni (Sikasso region) and the village of Keregouana in Ivory Coast.

The Ministry of Health is sending extra surveillance teams to the villages. The outbreak has also been reported to the WHO.

Yellow fever is a viral hemorrhagic disease primarily spread by Aedes aegypti mosquitoes. One dose of the yellow fever vaccine offers lifelong protection against the virus.
Dec 5 ProMed Mail post