New York study finds need for stewardship programs in outpatient clinics

Few outpatient clinics in New York City—one of the nation's most densely populated cities—have antibiotic stewardship programs, according to a study that focused on prescriptions written for acute respiratory infections. A team from several facilities in the city published its findings today in Infection Control & Hospital Epidemiology.

The goal of the study was to determine baseline data for clinic-based antibiotic stewardship programs, an initial step in improving outpatient prescribing practices as part of the United Hospital Fund's efforts to improve the city's healthcare system.

The team surveyed 31 hospital-owned clinics from nine hospitals and health systems about their current stewardship practices and performed chart reviews of 30 randomly selected adult acute respiratory illness (ARI) patients, collecting their data from June to August 2016.

Few sites had outpatient stewardship activities. Though 68% of practices had stewardship programs in their health systems, only 25% of the clinics had institutional guidelines for antibiotic use and selection and only 11% had ambulatory-specific guidance.

A review of 1,004 patient charts found that 37.3% overall had received antibiotics for ARIs, but sites varied from 17.4% to 71%. Antibiotic prescriptions for bronchitis and sinusitis was also high—doctors prescribed the drugs for nearly 67% of patients who had acute bronchitis and more than 80% with acute sinusitis.

Macrolides were the most commonly prescribed antibiotics. Most of the 302 respondents acknowledged the need for tools to help guide prescribing. "It remains unclear whether the pervasive reliance on macrolides results from gaps in knowledge of [the] antibiotic spectrum and the common causes of ARIs or the convenience of macrolides," the authors wrote.

The authors said the second stage of the United Hospital Fund's initiative will use the baseline findings to help form site-specific plans to improve outpatient prescribing practices.
Sep 18 Infect Control Hosp Epidemiol abstract

Study finds outpatient antibiotic prescribing in US seniors remains steady

A new study by researchers from the US Centers for Disease Control and Prevention (CDC) has found that outpatient antibiotic prescribing among older adults did not change much from 2011 to 2014, though significant regional variations were noted. The findings appeared yesterday in the Journal of the American Geriatrics Society.

Using a database that collects information on outpatient prescribing from US pharmacies, the researchers conducted a chi-square trend analysis to assess annual changes in antibiotic prescribing among US adults aged 65 and older. They also calculated prescribing rates by antibiotic, age-group, sex, state, census region, and provider specialty.

The results showed that prescribing rates remained stable overall (P = 0.89) during the study period, with adults aged 65 and over receiving 46 million outpatient antibiotic prescriptions in 2011 (1,113 prescriptions per 1,000 persons) and 51.6 million in 2014 (1,115 prescriptions/1,000 persons). In 2014, the prescribing rate was higher in women than in men (1,225 vs. 974 prescriptions/1,000 persons) and in patients older than 75 compared with those aged 65 to 74 (1,157 vs. 1,084 prescriptions/1,000 persons). The highest prescribing rate was in the South census region (1,228 prescriptions/1,000 persons), which was 44% higher than the rate in the West (854 prescriptions/1,000 persons).

Quinolones were the most widely prescribed antibiotic class, followed by penicillins and macrolides, and azithromycin was the most commonly prescribed antibiotic drug, followed by amoxicillin and ciprofloxacin. Internists and family physicians prescribed 43% of antibiotic courses.

The researchers conclude that future efforts to optimize outpatient prescribing in US seniors should focus on reducing quinolone and azithromycin use and targeting primary care providers in the South.
Sep 17 J Am Geriatr Soc abstract

High levels of resistant gut bacteria tied to bloodstream infection risk

New research from Rush University and the University of Michigan shows that patients with higher levels of Klebsiella pneumonia–carbapenemase-producing K pneumoniae (KPC-Kp) within the gut microbiota had a higher risk of bloodstream infection in the long-term acute care hospital (LTACH) setting. The research is published in Clinical Infectious Diseases.

The study is based on weekly rectal swabs collected from 506 patients of an LTACH in Chicago from May of 2015 through May of 2016. The swab samples were cultured and tested for KPC-Kp.

Almost half the patients (255, or 45.4%) provided samples that were colonized with KPC-Kp, and 11 (4.3%) had KPC-Kp bacteremia. In an analysis, the researchers concluded that a relative abundance cutoff of 22% predicted KPC-Kp bacteremia with sensitivity of 73%, specificity of 72%, and relative risk of 4.2 (95% confidence interval [CI], 1.3-14.0, P = 0.01).

"Among antibiotics analyzed, only preceding carbapenem use was associated with a relative abundance of KPC-Kp ≥22% (HR [hazard ratio], 2.19; 95% CI, 1.06-4.55; P = 0.036)," the authors said.  
Sep 18 Clin Infect Dis study