Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans
New metric aims to capture antibiotic prescribing among pediatricians
Originally published by CIDRAP News Dec 22
A team of pediatricians in Massachusetts has developed a new metric for capturing the range of antibiotic prescribing among pediatricians for common clinical scenarios.
The Antibiotics Likelihood Index (ALI), described in a paper last week in the Journal of the Pediatric Infectious Diseases Society, was developed using data from 2018 and 2019 for children ages 3 months to 17 years from 53 practices in a large pediatric network in Massachusetts. Based on those data, the clinicians grouped encounters into Reason for Visit categories and then analyzed the proportion of encounters with an antibiotic prescription within each category.
The ALI was defined as the proportion of encounters with an antibiotic prescribed among categories that accounted for more than 80% of encounters with an antibiotic prescribed.
Analysis of the 2018 data showed that six Reason for Visit categories—cough, ear complaints, fever, sore throat, rash, and congestion/upper respiratory infection—accounted for 82.4% of all antibiotics prescribed. Among the 222,682 encounters for the top 6 categories combined, 30.3% had an antibiotic prescribed, defined as the ALI for the entire sample. The authors repeated the analysis for the 2019 data and found similar results, with an overall ALI of 30.8%. The index among individual prescribers for 2018 ranged from 7.5% to 57.2%, and for 2019 it ranged from 9.9% to 60.2%.
The authors say the strengths of the ALI compared to other proposed metrics of antibiotic prescribing are that it varies very little according to patient demographic factors such as age, sex, and insurance type, and it allows for a fair comparison of one pediatrician's overall antibiotic prescribing to another.
"Further research to validate the ALI construct within other pediatric primary care networks would be helpful to establish the generalizability of this approach," they wrote.
Dec 18 J Pediatric Infect Dis Soc abstract
Sepsis management bundle not tied to more antibiotics or fewer deaths
Originally published by CIDRAP News Dec 22
An analysis of data on sepsis patients found that adherence to a federally mandated sepsis management bundle in US hospitals was not associated with a change in already increasing rates of broad-spectrum antibiotic use or with improved mortality rates, researchers reported this week in JAMA Network Open.
The retrospective study, conducted among 117,510 adults admitted to 114 hospitals with suspected sepsis from October 2013 to December 2017, aimed to analyze the impact of implementing the 2015 Centers for Medicare and Medicaid (CMS) Severe Sepsis and Septic Shock Early Management Bundle (SEP-1).
While SEP-1 has catalyzed widespread sepsis quality improvement efforts, the study authors note, concerns have been raised that the bundle, which requires clinicians to administer broad-spectrum antibiotics to suspected sepsis patients within 3 hours, would lead to inappropriate use of broad-spectrum antibiotics. There have also been concerns that the bundle has increased detection of milder sepsis cases, which may affect mortality rates.
The primary outcome of the interrupted time series and logistic regression analysis was quarterly rates of risk-adjusted short-term mortality. Secondary outcomes included administration of anti–methicillin-resistant Staphylococcus aureus (MRSA) or antipseudomonal beta-lactam antibiotics within 24 hours of hospital arrival.
While there were increases in the use of anti-MRSA antibiotics (19.8% in Quarter 4 of 2013 to 26.3% in Q4 of 2017) and antipseudomonal antibiotics (27.7% in Q4 of 2013 to 40.5% in Q4 of 2017), these trends preceded SEP-1 and did not change with SEP-1 implementation. Unadjusted short-term mortality rates were similar in the pre–SEP-1 period (Q4 of 2013 through Q3 of 2015) versus the post–SEP-1 period (Q1 of 2016 through Q4 of 2017) (20.3% vs 20.4%), and SEP-1 implementation was not associated with changes in level (OR, 0.94; 95% confidence interval [CI], 0.68 to 1.29) or trend (OR, 1.00; 95% CI, 0.97 to 1.04) for risk-adjusted short-term mortality rates.
"These findings suggest that alternate approaches to improving mortality for patients with sepsis are warranted," the authors wrote.
Dec 20 JAMA Netw Open study
Stewardship steps tied to reduced antibiotics, C diff at community hospital
Originally published by CIDRAP News Dec 20
Implementation of a multifaceted antimicrobial stewardship program (ASP) in a large community hospital in New Jersey was associated with significant, sustained reductions in unnecessary antibiotic use, Clostridioides difficile infection (CDI) rates, and antimicrobial acquisition costs, researchers reported late last week in Infection Control & Hospital Epidemiology.
In early 2013, the 413-bed acute care non-teaching hospital implemented two processes to address overuse of broad-spectrum intravenous antibiotics: reduction in the computerized antibiotic ordering duration from 14 days to 7 days, and a pharmacist-driven ASP that had authority to discontinue unnecessary antibiotic use. In addition, the hospital changed its CDI testing protocol in 2016 to reduce unnecessary testing.
Comparison of the baseline period (October 2012 to March 2013) to the period following implementation of the ASP showed that average antibiotic days of therapy (DOT) fell by more than 10% initially, and over the study period fell from 860 per 1,000 patient-days to 400 to 500 per 1,000 patient-days in 2021. Reductions were consistent among all antibiotic classes. No concordant rise in complications, such as increased intensive care unit admissions or 30-day sepsis readmission rates, were observed.
The hospital's CDI rate fell by more than 90%, with the most significant reduction occurring after the test protocol was changed, and antibiotic acquisition costs declined by more than 50%. The analysis also found that Pseudomonas aeruginosa susceptibilities to piperacillin and imipenem increased by statistically significant levels.
The study authors note that the findings are significant because most literature on ASPs has been published from large academic medical centers, where physicians are employed by the health system, and very little research has been published on ASPs in non-academic settings that use private practice infectious diseases physicians. They say the results indicate that antibiotic prescribing can be improved even in settings where many physicians are in private practice.
"Safely averting the administration of thousands of doses of unnecessary and potentially harmful therapeutics exemplifies high-value care," they wrote. "We believe that these results could potentially serve as a benchmark for appropriate utilization, particularly in community hospitals."
Dec 17 Infect Control Hosp Epidemiol abstract
New C diff drug substantially reduces recurrence in phase 3 trial
Originally published by CIDRAP News Dec 20
Summit Therapeutics, of Cambridge, Massachusetts, announced promising results today from a phase 3 trial of its investigational precision CDI drug, ridinilazole.
The results of the phase 3 Ri-CoDiFy trial, which included 759 patients at hospitals in the United States and several other countries, showed that patients treated with ridinilazole experienced substantially less recurrence of CDI compared with patients treated with vancomycin. That finding resulted in a higher sustained clinical response (SCR) for ridinilazole than for vancomycin, but the drug did not meet the study's primary end point for superiority. SCR is defined as clinical response of the treated episode of CDI and no recurrence of infection 30 days after the end of treatment.
The company says the results, which have not yet been peer-reviewed or published, were particularly promising in patients considered high-risk.
While vancomycin is the standard of care for CDI, treatment with broad-spectrum antibiotics, which eliminate both good and bad gut bacteria, can put patients at risk of recurring infections. A phase 2 study of ridinilazole showed that the drug specifically targets C difficile, sparing commensal bacteria.
"Although Ri-CoDIFy did not meet the primary endpoint for the design of this study, we did see a meaningful reduction in recurrence in the ridinilazole arm, which we believe is tied to the precision properties of ridinilazole and its associated relative sparing of the gut microbiome," Fong Clow, DSc, head of biometrics at Summit, said in a company press release. "We believe this is a viable measurement of the effect of this drug and has biological significance as to the potential value of the drug."
Dec 20 Summit Therapeutics press release
