Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans
Co-infections with COVID-19, Candida auris confirmed in India
Scientists in New Delhi, India, report infections with worrisome multidrug-resistant Candida auris in 10 of 15 critically ill COVID-19 patients who also had candidemia over a span of several months, according to a report yesterday in Emerging Infectious Diseases.
After the authors predicted in June that C auris would be a problem during this pandemic, they analyzed samples from 596 intensive care unit patients, 420 of whom (70.5%) required mechanical ventilation. They detected Candida in the blood of 15 patients (2.5%), and C auris was the predominant pathogen in 10 of them.
Eight of the patients were 66 or older, and seven were men. The younger patients were 25 and 52. They required hospital stays of 20 to 60 days, but with a median of 21 days. Six patients died, underscoring the danger of both COVID-19 and this deadly fungal infection. The authors say the patients were probably infected during hospitalization.
Three of the C auris isolates were multi-azole resistant and 7 were multidrug resistant, including 3 that were resistant to three classes of antifungal drugs and 4 that were resistant to two classes. All isolates were resistant to fluconazole but susceptible to echinocandins.
The authors conclude, "Critically ill COVID-19 patients with C. auris infection tend to have concurrent conditions (e.g., diabetes mellitus, chronic kidney disease) and risk factors (e.g., need for mechanical ventilation, receipt of steroids). To reduce complications, admission times in overburdened hospitals, and death rates among COVID-19 patients, identifying and treating C. auris infections is vital."
Aug 27 Emerg Infect Dis study
Study: Feedback, education reduced antibiotic prescribing in telemedicine
Originally published by CIDRAP News Aug 27
Individualized prescribing feedback and education in a telemedicine practice significantly decreased antibiotic prescribing rates for upper respiratory infection (URI) and bronchitis compared with education alone, US researchers reported yesterday in the Journal of General Internal Medicine.
In a randomized controlled trial conducted at Doctor on Demand, a US telemedicine practice, from Jan 1 to Nov 30, 2018, a team lead by researchers from the Antibiotic Resistance Action Center at the George Washington Milken Institute of Public Health examined the effect of two antibiotic stewardship interventions on antibiotic prescribing for upper respiratory infection, bronchitis, sinusitis, and pharyngitis—four conditions for which antibiotics are inappropriately prescribed or overprescribed. One group of clinicians at the practice (the control group) received education (treatment guideline presentation and an online course), and the intervention group received education plus individualized feedback via an online dashboard with monthly rates of personal and practice-wide prescribing rates.
The primary outcome of the trial was the antibiotic prescription rates for each of the four diagnostic categories.
In the pre-intervention period, the control and intervention groups had different baseline antibiotic prescribing rates for URI (18.4% vs 15.0%), bronchitis (46.8% vs 64%), sinusitis (84.1% vs 87.2%), and pharyngitis (81.3% vs 74.9%). Antibiotic prescriptions for all conditions decreased in the post-intervention period compared with those in the pre-intervention period. Compared with the control group, however, the reduction in antibiotic prescriptions for URI and bronchitis was greater in the group that received education plus individual feedback (interaction term ratio, 0.60; 95% confidence interval [CI], 0.47 to 0.77 for URI and 0.42; 95% CI, 0.32 to 0.55 for bronchitis). There was no significant difference between the two groups for sinusitis and pharyngitis.
The authors of the study note that in December 2018 Doctor on Demand expanded the intervention to provide feedback dashboards to all clinicians at the practice.
"These findings should be used to promote antibiotic stewardship across telemedicine and other ambulatory medical practices," the authors wrote. "Future studies should examine the long-term impact of education and feedback interventions, and maintenance of antibiotic prescription reductions."
Aug 26 J Gen Intern Med study
Study highlights impact of fluoroquinolone restriction initiative
Originally published by CIDRAP News Aug 26
A quality improvement initiative to restrict fluoroquinolone prescribing in high-risk patients reduced fluoroquinolone use without negative impacts, researchers from the University of Wisconsin School of Medicine and Public Health reported yesterday in PLOS One.
The initiative was implemented in the intensive care unit (ICU) and solid-organ transplant unit at the University of Wisconsin Hospital in July 2016 in an attempt to decrease the rate of hospital-onset Clostridioides difficile infection (HO-CDI), which is associated with fluoroquinolone use. The restriction required antimicrobial stewardship pre-approval for fluoroquinolone prescribing. In the study, the researchers compared rates of HO-CDI in the 24 months before and after the initiative, along with fluoroquinolone and alternative antibiotic days of therapy (DOT), length of hospital stay, readmissions, and mortality.
The results showed that HO-CDI rates did not decrease significantly after the initiative, but fluoroquinolone use fell from 111.6 to 19.8 DOT per 1,000 patient-days without negatively impacting length of stay, readmissions, or mortality.
In contrast, use of third-generation cephalosporins, aminoglycosides, and piperacillin-tazobactam increased post-intervention. Interviews with hospital staff (residents, attending physicians, advanced practice providers, and pharmacists) identified the strength of the hospital's antimicrobial stewardship program (ASP) and pharmacy involvement as key facilitators of the restriction program, and patient complexity and lack of provider education as barriers.
"Lessons from our initiative, particularly those learned from exploring the perspectives of front line providers, can be applied to larger-scale ASP interventions," the authors of the study wrote. "Future studies should confirm safety and efficacy of restriction policies among critically ill and immunocompromised patients with particular attention to the impact on prescribing of alternative agents and explore other opportunities for optimization of antimicrobial prescribing, such as at the time of hospital discharge."
Aug 25 PLOS One study
New AVMA report highlights resistant bacteria in animals
Originally published by CIDRAP New Aug 25
The American Veterinary Medical Association (AVMA) yesterday released a new report on the antibiotic-resistant pathogens affecting animal health in the United States.
Like the Centers for Disease Control and Prevention's 2019 report on antibiotic resistance threats, which highlighted the impact of antibiotic-resistant bacteria on human medicine, the AVMA report summarizes the issue for veterinary medicine. It highlights the bacterial pathogens that cause disease in food-producing and companion animals, with a focus on pathogens identified as a concern for elevated antibiotic resistance.
The report provides a host-species–specific breakdown of pathogens of concern, with summary reports for dogs and cats, cattle, chicken and turkeys, horses, fish and shrimp, sheep and goats, and swine, and detailed report cards for each specific bacterial pathogen identified as a potential resistance threat. The information is intended to help veterinarians evaluate the potential for resistance in clinical cases and inform antibiotic therapy and other treatment approaches.
The AVMA report also provides guidance for veterinarians on how they can combat antibiotic resistance, encouraging appropriate antibiotic prescribing, use of diagnostic testing to inform treatment, infection prevention and control strategies, and collaboration with producers to develop comprehensive herd health programs.
"Slowing and limiting the emergence and spread of antimicrobial resistance can only be achieved with widespread engagement, especially among leaders in veterinary medicine, animal agriculture, and public health," the report states. "Only through concerted commitment and action will those caring for the health and welfare of animals be able to succeed in reducing this threat."
Aug 24 AVMA report
Policy at VHA hospitals lowers unnecessary urine cultures
Originally published by CIDRAP News Aug 25
Policies that limit unnecessary urine culturing were associated with a decrease in urine cultures without negative consequences at Veterans Health Administration (VHA) hospitals, US researchers reported today in Infection Control & Hospital Epidemiology.
The retrospective, quasi-experimental study compared rates of urine cultures at six VHA hospitals from August 2013 through January 2018. Three of the hospitals implemented conditional urine reflex testing policies under which urine cultures are performed only if a preceding urinalysis met prespecified criteria, and three of the hospitals served as control sites.
Participants included all adult patients with at least one urinalysis ordered. The primary outcome was the rate of urine cultures performed per 1,000 patient-days, and the secondary outcome was the rate of gram-negative bloodstream infections—the most common severe outcome of untreated urinary tract infections (UTIs)—per 1,000 patient-days.
During the study period, there were 50,901 patient admissions from 24,759 unique patients, and a total of 224,573 urine cultures were performed. At the intervention sites, the overall average number of urine cultures performed did not significantly decrease relative to the pre-intervention period (5.9% decrease, P = 0.8), but the researchers observed a 21% decrease in the rate of urine cultures performed compared to the control hospitals. Analysis of gram-negative bloodstream infection rates found no significant difference between infection and control sites (P = .49)
The findings are noteworthy because asymptomatic bacteriuria—defined as a positive urine culture in the absence of symptoms of a UTI—is a significant driver of inappropriate antibiotic prescribing.
"Conditional urine reflex testing policies in the acute-care setting was associated with reduced unnecessary urine culturing without adverse effects," the authors of the study concluded.
Aug 25 Infect Control Hosp Epidemiol abstract
CMS sepsis bundle linked to increased use of broad-spectrum antibiotics
Originally published by CIDRAP News Aug 24
Implementation of a core measure sepsis bundle by the Centers for Medicare and Medicaid Services (CMS) was associated with an immediate and long-term increase in the use of broad-spectrum antibiotics for hospital-onset multidrug-resistant (MDR) organisms, researchers reported late last week in Clinical Infectious Diseases.
In the study, a team led by researchers from Virginia Commonwealth University evaluated monthly antibiotic data for four categories of antibiotics at 111 US hospitals before and after the 2015 implementation of the Sepsis Bundle Core Performance Measure for hospitals participating in Inpatient Quality Reporting (SEP-1). One element of the bundle is initiation of broad-spectrum antibiotics within 3 hours of sepsis diagnosis. The four antibiotic categories evaluated included antibiotics for surgical prophylaxis, broad-spectrum agents for community-acquired infections, broad-spectrum antibiotics for hospital-onset/MDR organisms, and anti–methicillin resistant Staphylococcus aureus agents.
Using interrupted time series and negative binomial regression analyses, the researchers observed an immediate increase in the level of broad-spectrum agents for hospital-onset/MDR organisms (+ 2.3%, P = .0375) and a smaller long-term increase in trend (+ 0.4%, P = .0273) after the SEP-1 bundle was implemented. Overall antibiotic use also increased immediately following SEP-1 implementation (+ 1.4%, P = .0293). There was also an unexpected decrease of 7.3% in Clostridioides difficile infection (CDI) rates immediately following implementation.
When the analyses was limited to sepsis patients, there was a significant increase in the use of all antibiotic categories at the time of SEP-1 implementation.
The authors of the study say the findings are noteworthy because correctly diagnosing sepsis is challenging, and there are concerns that the aggressive timelines for antibiotic therapy in SEP-1 may result in overdiagnosis and inappropriate use of broad-spectrum agents, which could promote development of antibiotic resistance.
"These data suggest that antimicrobial stewardship programs should apply postprescription audit and feedback strategies among sepsis patients to ensure that antibiotic de-escalation is occurring appropriately," the authors wrote. "Further investigations regarding higher use of broad-spectrum antibiotics and impact on CDI and antibiotic resistance development are warranted."
Aug 22 Clin Infect Dis abstract
Antibiotic resistance likely not a major driver of gonorrhea spread in NYC
Originally published by CIDRAP News Aug 24
In a study yesterday in the same journal, an analysis of gonococcal isolates collected in New York City in 2012 and 2013 showed that all large transmission clusters were susceptible to current gonorrhea therapies.
In their analysis of genome sequences, antibiotic susceptibility, and patient data from 897 gonococcal isolates cultured by the New York City Public Health Laboratory from January 2012 through June 2014—a convenience sample that represents 1.5% of total gonorrhea infections in New York City during the period—the researchers found that the New York City gonococcal phylogeny reflected global diversity, with isolates from 22 of the 23 global Neisseria gonorrhea lineages.
They also observed that the isolates clustered on the phylogeny by sexual behavior (P < 0.001), with one lineage significantly associated with isolates from men who have sex with men (MSM) and another associated with isolates from heterosexuals. They also clustered based on race and ethnicity (P < 0.001).
Analysis of antibiotic susceptibility showed that 24.3% of isolates were resistant to ciprofloxacin, 0.9% had reduced susceptibility to azithromycin, and 0.3% had reduced susceptibility to ceftriaxione. Minimum inhibitory concentrations were higher across antibiotics in isolates from MSM compared with heterosexuals (P < 0.001) and white heterosexuals compared with black heterosexuals (P < 0.01). The largest transmission clusters were all susceptible to azithromycin, ceftriaxone, and ciprofloxacin and included isolates from across patient demographic groups.
The authors of the study say the findings indicate that antibiotic resistance was not a major driver of gonorrhea transmission in New York City during the study period, but note that, nationally, reduced susceptibility to azithromycin has increased from 0.6% in 2013 to 4.6% in 2018—after the study period.
"While resistance remains a major public health concern, strategies to reduce overall gonorrhea transmission are also needed as pre-existing transmission networks may present opportunities for rapid spread of resistant lineages," they wrote. "Greater understanding of the transmission dynamics of both susceptible and resistant infections can aid the design of effective intervention strategies for controlling gonorrhea, and further investment in sexual health services and interventions are critical."
Aug 23 Clin Infect Dis abstract