Stewardship / Resistance Scan for Mar 04, 2020

News brief

Study: Inappropriate presurgical antibiotic use common in children

A point-prevalence study of 32 US children's hospitals found that prophylactic (preventive) antibiotics were inappropriately given in 33.0% of pediatric surgical patients. The study, published today in Infection Control & Hospital Epidemiology, was led by members of the SHARPS Collaborative based at Washington University in St. Louis.

The researchers collected chart data from the hospitals' electronic medical records from September 2016 to December 2017, identifying 1,324 children receiving antibiotics (cefazolin, clindamycin, vancomycin, cefoxitin, and piperacillin/tazobactam) for surgical prophylaxis.

Overall, 485 prophylactic antibiotics were classified as inappropriate because of administration longer than 24 hours (n = 387, 79.8%), no indication for prophylaxis (32, 6.6%), and the use of antibiotics that were too broad spectrum (29, 6.0%).

National guidelines give procedure-specific recommendations for antibiotic prophylaxis, including drug and dosing, to prevent surgical-site infections. "The 2017 Centers for Disease Control and Prevention (CDC) guideline recommends only a single dose of perioperative prophylaxis for clean and clean-contaminated cases," the authors wrote. "Despite these guidelines, inappropriate surgical prophylaxis use continues to be common."

Inappropriate surgical prophylaxis was highest in otolaryngologic patients (62.7%; 95% confidence interval [CI], 52.6% to 72.1%), cosmetic or reconstructive surgery patients (40.7%; 95% CI, 30.0–52.2), and neurosurgery patients (40.3%; 95% CI, 34.2% to 46.6%).

Of the 485 prescriptions deemed inappropriate, 258 (53.2%) would not have been routinely reviewed by the hospitals' antimicrobial surgical programs, according to the authors. The hospitals' use of inappropriate prophylaxis varied significantly, from 0.0% to 62.8%.

The study likely underestimated the percentages of inappropriate use, considering the new CDC recommendation of no antibiotics for low-risk procedures, the investigators said. They called for more studies to better estimate the inappropriate prophylaxis rate, identify contributing factors, and determine the best ways to optimize prophylactic use of antibiotics.
Mar 4 Infect Control Hosp Epidemiol study

Study: De-escalation rates low in hospitalized pneumonia patients

An analysis of adults with pneumonia at 164 US hospitals has found that less than 15% of those treated with broad-spectrum antibiotics had their coverage de-escalated by day 4, researchers reported today in Clinical Infectious Diseases.

The study, conducted by researchers with Cleveland Clinic and the University of Massachusetts Medical School, aimed to assess de-escalation practices in a cohort of hospitalized pneumonia patients after negative cultures for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa.

New guidelines from the American Thoracic Society and the Infectious Disease Society of America recommend switching from broad-spectrum to narrower-spectrum antibiotics at 48 hours if microbial cultures do not reveal these multidrug-resistant pathogens and the patient is improving. The researchers wanted to know to what degree hospitals will have to change their practices to adhere to this recommendation.

The study’s primary outcome was de-escalation on hospital day 4. The researchers also looked at the association of de-escalation with all-cause mortality, transfer to an intensive care unit (ICU), length of hospital stay, and costs.

Of the 14,170 pneumonia patients treated with one anti-MRSA and at least one anti-pseudomonal antibiotic from 2010 through 2015, both antibiotics were de-escalated in 1,924 patients (13%) by day 4. Hospital de-escalation rates ranged from 2% to 35% and varied across regions, but de-escalation was more common in large teaching hospitals.

At hospitals in the top quartile of de-escalation, rates of de-escalation were less than 50%—even in patients at lowest risk for death. In propensity-adjusted analysis, patients with de-escalation had lower odds of subsequent transfer to the ICU (adjusted odds ratio, 0.38; 95% CI, 0.18 to 0.79), shorter hospital stays (adjusted ratio of means, 0.76; 95% CI, 0.75 to 0.78), and costs (adjusted ratio of means, 0.74; 95% CI, 0.72 to 0.76).

The authors of the study concluded that, in order to adhere to the new guidelines, physicians will need to substantially change their response to negative cultures for most non-critically ill patients. "Since antibiotics are not benign, and antimicrobial stewardship is an important priority, hospital antibiotic stewardship programs should emphasize de-escalation following negative cultures as an opportunity to reduce exposure to broad-spectrum antibiotics, improving both antimicrobial stewardship and medication safety by substitution of lower-toxicity agents," they wrote.
Mar 4 Clin Infect Dis abstract

News Scan for Mar 04, 2020

News brief

Saudi health ministry reports another MERS case

Today Saudi Arabia's Ministry of Health (MOH) reported a new MERS-CoV case in Najran, bringing the March tally to three infections, after the ministry reported 18 in February.

The MERS-CoV (Middle East respiratory syndrome coronavirus) case involves a 42-year-old man with unknown exposure to camels, a known MERS risk factor. The MOH listed the case as primary, meaning he is unlikely to have contracted the virus from another person. The patient is not a healthcare worker.

Infection with MERS-CoV can cause severe illness and death. The virus can transmit between humans but has done so mainly in healthcare settings, according to the World Health Organization (WHO).

As of Jan 31, 2020, the WHO said that it had received reports of 2,519 laboratory-conﬁrmed MERS infections, including 866 associated deaths. The vast majority of these cases occurred in Saudi Arabia.
Mar 4 Saudi MOH report

Avian flu outbreaks strike poultry in Taiwan and Bulgaria

Two countries reported more avian flu outbreaks in poultry: Taiwan, involving three different subtypes, and Bulgaria with a pair of new highly pathogenic H5N8 outbreaks, according to the latest reports from the World Organization for Animal Health (OIE).

In Taiwan, animal health officials reported two more highly pathogenic H5N2 outbreaks in native chickens, which began in the middle of February in Kaohsiung City and Pingtung County. Taken together, the virus killed 9,193 of 39,367 susceptible birds, and the rest were culled as part of the outbreak response. The region has been battling high-path H5N2 outbreaks since 2015. Also, authorities reported one more low-pathogenic H5N2 outbreak, which struck a poultry farm in Chiayi County and began on Feb 1, killing 1,500 of 20,000 chickens, with culling slated for the survivors.

Also, in a separate development, Taiwan reported four more outbreaks involving highly pathogenic H5N5 avian flu, part of activity that began in September 2019. The outbreaks began from Feb 7 to Feb 21, and two were detected at slaughterhouses. Combined, the outbreaks killed 361 of 12,123 susceptible birds. The rest were destroyed to slow the spread of the virus.

Bulgaria, meanwhile, reported two more outbreaks involving H5N8, both on farms in the city of Plovdiv. The events started on Mar 2, killing a total of 40 of 8,620 susceptible birds. The surviving poultry were culled.
Mar 3 OIE report on high-path H5N2 in Taiwan
Mar 3 OIE report on low-path H5N2 in Taiwan
Mar 3 OIE report on high-path H5N5 in Taiwan