Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans
Danish study supports shorter antibiotics course for pneumonia
A study of hospitalized pneumonia patients in Denmark found similar outcomes between short-course and prolonged-course antibiotic therapy, Danish researchers reported yesterday in Clinical Microbiology and Infection.
For the study, researchers with University of Copenhagen Hospital prospectively followed patients admitted to four hospitals with community-acquired pneumonia (CAP) from November 2017 through February 2019. They included patients who had achieved clinical stability within 3 days of treatment and measured outcomes among those treated—as decided by the attending physician—with 8 to 14 days of antibiotic therapy (prolonged-course) and those treated with 4 to 7 days of therapy (short-course). The primary outcome was post-treatment mortality within 30 days, and secondary outcomes included readmissions or new antibiotics.
The study cohort included 1,151 patients with a median age of 74, with an equal distribution of men and women. The median treatment duration was 6 days in the short-course group and 9 days in the prolonged-course group.
The 30-day post-treatment mortality was 3.36% (11/327) in the short-course group and 3.40% (28/824) in the prolonged-course group (adjusted odds ratio [aOR], 1.05; 95% confidence interval [CI], 0.38 to 1.88). Readmission occurred in 15.6% (42/269) of short-course patient vs 14.0% (102/727) of prolonged-course patients (aOR, 1.07; 95% CI, 0.75 to 1.69) and new prescription of antibiotics in 11.9% (32/269) vs 12.1% (88/727) (aOR, 0.99; 95% CI, 0.61 to 1.49).
"Our findings support the increasing evidence on the effectiveness of short-course therapy in patients hospitalised with CAP," the study authors wrote, citing recent randomized controlled trials (RCTs) that have found short antibiotic courses for CAP to be non-inferior to longer courses. "These results could serve as an important adjunct to RCTs by enabling their findings to be more applicable in routine clinical settings."
Aug 18 Clin Microbiol Infect study
Long antibiotic durations noted for kids with pneumonia, urinary infections
Originally published by CIDRAP News Aug 17
Prescribing data from a children's hospital network in Chicago showed considerable variation in antibiotic durations for children treated for CAP and urinary tract infections (UTIs) in ambulatory settings, with the variability largely unrelated to the severity of symptoms, researchers reported late last week in the Journal of the Pediatric Infectious Diseases Society.
The retrospective study used outpatient prescribing data from 2016 through 2019 to determine antibiotic durations for CAP and UTIs in pediatric populations and the influence of non-clinical predictors of long antibiotic duration. While some medical society guidelines suggest 10 days of antibiotics for pediatric CAP, and 7 to 14 days of antibiotics for UTIs in children ages 2 to 24 months, recent studies have suggested shorter antibiotic durations for both conditions may be just as effective in children. Guidelines at the hospital and its 14 outpatient centers recommend 7 days of antibiotics for treatment of both CAP and UTIs in children.
Overall, 2,124 prescriptions for CAP and 1,116 prescriptions for UTI were included in the study. Prescriptions were longer than 10 days in 59.9% and 47.6% of children treated for CAP and UTI, respectively. Long durations were more common in the emergency department (ED) than in clinics for UTIs, and more common in convenient care for CAP. Younger children had greater odds of long antibiotic duration for both diagnoses, with children younger than 1 year old having much higher odds of a longer antibiotic duration for CAP (odds ratio [OR], 8.64; 95% CI, 5.01 to 14.89) and for UTIs (OR, 4.24; 95% CI, 2.33 to 7.72) compared with older children.
Medicaid insurance was also associated with long therapy for UTI (OR, 1.66; 95% CI, 1.17 to 2.35) and CAP (OR, 1.43; 95% CI, 1.o9 to 1.86). Residents and fellows were less likely to give long durations than attending physicians, while advanced practice nurses were more likely to administer long therapies in CAP. Subsequent hospitalizations were uncommon for UTI (n = 10) and CAP (n = 20).
"Future stewardship interventions should address non-clinical predictors of antibiotic duration including addressing potential provider biases that can influence the decision-making process," the study authors concluded. "Reducing the unnecessarily long duration of therapy is an important quality intervention to reduce the risk of antimicrobial resistance and adverse events."
Aug 14 J Pediatric Infect Dis Soc abstract
Higher antibiotic use found in young, White, rural children in Kentucky
Originally published by CIDRAP News Aug 17
In another study published late last week in the same journal, an analysis of statewide Medicaid data in Kentucky showed that antibiotic fills were higher among young, White children in rural areas and those with chronic conditions.
To evaluate patient-level antibiotic use among children in Kentucky, which consistently ranks as one of the highest prescribing states for antibiotic use in adults and children, researchers from the University of Tennessee, the University of Louisville, and Duke University examined pharmacy data from a cohort of children enrolled in Medicaid from 2012 through 2017. The cohort followed the same children, who were ages 0 to 14 in 2012, over the 6-year study period, looking at outpatient antibiotic prescriptions, age, sex, race, zip code, and chronic conditions.
A total of 169,724 children were included in the study, and they received 1,478,484 antibiotic prescriptions over the study period. Of these children, there were 10,804 (6.4%) children with no antibiotic prescription claims during the study period; 43, 473 (25.6%) had 1 to 3 antibiotic prescriptions; 34,318 (20.2%) had 4 to 6 antibiotic prescriptions; 30, 994 (18.3%) had 7 to 10; 35, 018 (20.6%) had 11 to 20; and 15, 117 (8.9%) children had more than 20 antibiotic prescriptions.
Overall, the population had a median total of six antibiotic prescriptions during the study period, but use was higher in children ages 0 to 5 (median of 8 antibiotic fills, compared with 5 for older children), White children (median of 7 antibiotic fills, compared with 3 for Black children), children in rural settings (median of 9 antibiotic fills, compared with 7 for suburban children and 4 for urban children), and children with chronic conditions (median of 8 antibiotic fills, compared with 6 for children without chronic conditions).
The study authors say the findings support studies in other states that have found racial and urban-rural disparities in antibiotic prescribing for children, and that further research is needed to better understand whether these disparities reflect variations in family expectations, care-seeking behavior, and/or clinician bias.
"Eliminating racial and rural differences in antibiotic prescribing should be a priority for outpatient antibiotic stewardship," they wrote.
Aug 14 J Pediatric Infect Dis Soc study
BD, Accelerate announce collaboration on rapid ID, susceptibility tests
Originally published by CIDRAP News Aug 16
Becton, Dickinson and Company (BD) and Accelerate Diagnostics yesterday announced a commercial collaboration agreement to bring rapid identification and antibiotic susceptibility tests to more clinicians and patients worldwide.
Under the agreement, BD will market and sell through its global sales network the Food and Drug Administration–approved Accelerate Pheno system, which delivers rapid pathogen identification and antibiotic susceptibility test results from blood cultures 1 to 2 days faster than traditional laboratory methods. The agreement also covers the Accelerate Arc module.
The companies say the two testing systems will help clinicians determine faster whether a patient needs an antibiotic, and if so, which one they need.
"When a patient is very sick, every minute matters," Brooke Story, MBA, president of Integrated Diagnostic Solutions for BD, said in a press release. "Through our collaboration with Accelerate Diagnostics, we can help clinicians more quickly, efficiently and effectively treat patients, which may lead to a reduction in health care costs and help slow the spread of antimicrobial resistance."
Aug 15 Accelerate Diagnostics press release
Survey reveals low antibiotic knowledge, improper antibiotic use in China
Originally published by CIDRAP News Aug 16
The overall level of antibiotic knowledge in China is low, and inappropriate use of antibiotics is high, according to the results of a survey published last week in BMC Infectious Diseases.
The online survey, conducted from July through September 2018, was used to collect data from respondents in China on antibiotic use and related knowledge. While non-prescription antibiotic sales are illegal in China, the practice is common, and inappropriate antibiotic use has long been widespread. The survey focused on three aspects of inappropriate antibiotic use: self-medication with antibiotics (SMA), self-storage with antibiotics (SSA), and non-adherence to antibiotic treatment (NAAT). Logistic regression was used to determine factors associated with these inappropriate behaviors.
Of the 15,526 respondents, more than 55% could not correctly identify whether antibiotics were used to treat bacterial or viral infections, and 57.6% could not distinguish antibiotics from anti-inflammatory agents. Overall, 26.0%, 46.6% and 27.4% of the participants had high, medium, and low levels of antibiotic knowledge, respectively.
Regarding inappropriate use, 37.1% reported SMA, 67.9% reported SSA, and 53.3% reported NAAT in the past 6 months. A breakdown of the four types of non-adherence behaviors showed that 48.3%, 15.2%, 25.5%, and 78.0% of respondents said that they had missed antibiotics, increased antibiotic dosage, decreased antibiotic dosage, and discontinued antibiotics once symptoms disappeared, respectively.
After adjusting for other variables, multivariate logistic regression analyses showed that respondents aged 30 to 44 years (aOR, 1.36; 95% CI, 1.26 to 1.47), with higher levels of education (aOR, 1.16; 95% CI, 1.05 to 1.29), poor status of self-perceived health (aOR, 1.57; 95% CI, 1.38 to 1.80), and medium (aOR, 1.08; 95% CI, 1.02 to 1.15) or low (aOR, 1.40; 95% CI, 1.28 to 1.54) levels of antibiotic knowledge were more likely to report SMA, SSA, and NAAT.
The study authors say the results indicate an urgent need for a national action plan and effective public health strategies to address the widespread inappropriate use of antibiotics in China.
Aug 13 BMC Infect Dis study
VHA program tied to improved antibiotic use for respiratory infections
Originally published by CIDRAP News Aug 15
A clinician-directed intervention implemented at facilities in the Veterans' Healthcare Administration (VHA) was associated with better management of, and reduced antibiotic prescribing for, acute respiratory infections (ARIs), researchers reported today in Infection Control & Hospital Epidemiology.
The ARI Campaign, implemented in 2017 by the VHA's Antimicrobial Stewardship Taskforce to reduce unnecessary antibiotic prescribing for ARIs, encourages Veterans' Affairs (VA) hospitals to engage high-prescribing physicians with two strategies: audit and feedback with peer comparison of ARI antibiotic prescribing rates, and individualized academic detailing of ARI management. To evaluate the effectiveness of the ARI Campaign, researchers with the VA and the Centers for Disease Control and Prevention (CDC) calculated the probability of receiving antibiotics for an ARI before and after implementation (October 2012 through March 2019). Secondary outcomes included probability of a return clinic visit or infection-related hospitalization.
Comparing 1,003,509 and 323,023 uncomplicated ARI visits before and after implementation, respectively, the researchers found the probability of receiving antibiotics for ARI decreased 18% after implementation (OR, 0.82; 95% CI, 0.78 to 0.86). Facilities with the highest quartile of intervention intensity demonstrated larger reductions in antibiotic prescribing (OR, 0.69; 95% CI, 0.59 to 0.80) compared to nonparticipating facilities (OR, 0.89; 95% CI, 0.73 to 1.09).
Return visits (OR, 1.00; 95% CI, 0.94 to 1.07) and infection-related hospitalizations (OR, 1.21; 95% CI, 0.92 to 1.59) were not different before and after implementation within facilities that performed intensive implementation.
"The findings suggest that implementation of the clinician-directed intervention was associated with improvements in guideline-concordant ARI management," the study authors concluded.
Aug 15 Infect Control Hosp Epidemiol abstract
Antibiotic stewardship education linked to improved dental antibiotic use
Originally published by CIDRAP News Aug 15
The first US antibiotic stewardship intervention for private practice dentists was associated with fewer antibiotic prescriptions and significant improvements in appropriate antibiotic prescribing, researchers reported last month in Open Forum Infectious Diseases.
In a prospective multipractice cohort study, a team led by Ohio State pharmacists and clinicians recruited private practice dentists for a four-phase dental antibiotic stewardship initiative. The four phases included collection of baseline antibiotic use data and a pre-education survey to establish the level of knowledge about antibiotic stewardship, three interactive education sessions conducted by infectious disease and antibiotic stewardship program (ID ASP) experts, 3 months of audit and weekly feedback with 1-on-1 consults for dentists who prescribed antibiotics inappropriately, and a post-education survey.
Outcomes assessed included overall antibiotic prescribing, antibiotic appropriateness, and antibiotic duration before and after education.
Fifteen dentists participated, 10 of whom had practiced for more than 20 years. The pre-education survey found 14 were unfamiliar with dental antibiotic stewardship. While procedures over the study period increased from 8,526 to 9,203, the number of antibiotic prescriptions pre/post-education decreased 14.5%, from 2,124 to 1,816. Overall, the proportion of appropriate antibiotic use (both for treatment and prevention) increased from 19% to 87.9% pre/post-education, with appropriate prophylactic antibiotic use improving from 46.6% to 76.6% and appropriate use of treatment antibiotics improving from 15% to 90.2%.
In addition, antibiotic duration pre/post-education decreased from 7.7 days to 5.1 days, and use of clindamycin declined 90%. The post-education survey responses recommended making antibiotic stewardship a required annual continuing education component.
"Similar to antibiotic stewardship in hospitals, simply asking physicians or dentists to do a better job at prescribing antibiotics does not work," the study authors wrote. "After learning dental antibiotic stewardship from ID ASP experts, dentists rapidly optimized antibiotic use."
The authors also note that they have since been invited to speak about dental antibiotic stewardship at local and national study clubs and dental societies.
Jul 25 Open Forum Infect Dis study