Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans
First US case of gonorrhea with resistance-conferring mutation identified
Originally published by CIDRAP News Dec 10
A paper today in Morbidity and Mortality Weekly Reports (MMWR) describes the first US case of Neisseria gonorrhoeae harboring a genetic element that confers resistance to a first-line antibiotic.
The N gonorrhoeae isolate, collected from an HIV-negative heterosexual man in Nevada, was identified by investigators from the Southern Nevada Health District (SNHD) in November 2019, when testing revealed reduced susceptibility to ceftriaxone and cefixime, but not to azithromycin. An intramuscular shot of ceftriaxone and an oral dose of azithromycin is the current recommended regimen for gonorrhea.
Molecular testing of the isolate by the Centers for Disease Control and Prevention (CDC) revealed the emerging mosaic penA60 allele, which was first identified in Japan in 2016 and confers resistance to cephalosporins and increases the risk of treatment failure. Despite the reduced susceptibility to ceftriaxone, the patient reported at the end of November 2019 that his symptoms had resolved, and further testing returned negative results.
The CDC subsequently tested 257 N gonorrhoeae isolates collected from the Southern Nevada area by SNHD from September 2019 through November 2019 to look for the presence of the penA60 allele but found no additional isolates carrying it. Additional testing of 5,500 gonococcal isolates from the Gonococcal Isolate Surveillance Project (GISP) found none with reduced susceptibility to ceftriaxone or cefixime. The investigation was stopped in February.
The origin of the isolate remains unclear, the investigators said.
"This case highlights the utility and importance of surveillance programs like GISP as effective tools in identifying emerging antimicrobial-resistant pathogens that can negatively impact patient outcomes and threaten public health," they wrote.
Dec 10 MMWR Notes from the Field
Primary care stewardship cuts antibiotics, costs for respiratory infections
Originally published by CIDRAP News Dec 8
A cluster-randomized controlled trial conducted in Spanish primary care settings suggests a multifaceted stewardship intervention helped reduce antibiotic prescribing for acute respiratory infections (ARIs) and was cost-effective, Spanish researchers reported yesterday in Antimicrobial Resistance and Infection Control.
The intervention was introduced among primary care providers in Galicia, a region of northwest Spain where at least one third of all antibiotic prescriptions are for ARIs but only half are thought to be appropriate. It included a one-hour educational outreach visit tailored to physician knowledge gaps identified in a previous study, an online course integrated in practiced accreditation, and a clinical decision support system.
To evaluate the intervention, after a median of 19 months, researchers looked at antibiotic prescribing among 1,217 physicians recruited from seven intervention clusters and 1,393 from control clusters. The main outcomes measured were overall antibiotic prescribing for ARIs, antibiotic use by class, the ratio of consumption of broad- to narrow-spectrum antibiotics, and the savings attributed to the intervention.
The results showed a 4.23% decline in overall antibiotic prescribing in the intervention group compared with the control group, highlighted by a 6.51% reduction in penicillin use. The ratio of consumption of broad- to narrow-spectrum penicillins, cephalosporins, and macrolides fell by 8.97%. Because of the reduction in antibiotic prescriptions, Spain's National Health Service directly saved €311 (USD $377) per physician and patients directly saved €573 ($694).
"The results of this study indicate that low-cost interventions based on the previously identified gaps can be effective and, in addition, have a positive cost-benefit relationship over a short time horizon, something that could be highly relevant for their application by healthcare systems," the authors wrote.
Dec 7 Antimicrob Resist Infect Control study
VA stewardship interventions linked to reduced antibiotic use for ARIs
Originally published by CIDRAP News Dec 8
Implementation of the Centers for Disease Control and Prevention's Core Elements of Outpatient Antibiotic Stewardship at Veterans Affairs (VA) emergency departments and primary care clinics was associated with reduced antibiotic prescribing for uncomplicated ARIs and a drop in hospitalizations, US researchers reported today in Clinical Infectious Diseases.
Key elements of the intervention included physician education and diagnosis-based audit and feedback reports.
The quasi-experimental, controlled study compared the effects of Core Elements implementation at 10 VA sites—four emergency departments and six primary care clinics—with prescribing data from 40 control sites over a 5-year period.
There were 16,712 and 51,275 uncomplicated ARI visits at the intervention and control sites, respectively, from 2014 through 2019. Antibiotic prescribing rates fell from 59.7% pre-intervention to 41.5% post-intervention, compared with 73.5% to 67.2% at the control sites. The proportion of visits with appropriate therapy increased from 53.8% to 69.1% at the intervention sites (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.31 to 2.14), but was unchanged at the control sites (OR, 1.04; 95% CI, 0.91 to 1.19).
There was no statistical difference in ARI-related return visits post-implementation (-1.3% vs -2.0%), but all-cause hospitalization was lower within the intervention sites (-0.5% vs -0.2%). The OR to diagnose upper respiratory tract infection not otherwise specified compared to other non-ARI diagnosis increased post-implementation for intervention sites (1.27) but not control sites (0.97).
The authors conclude that healthcare systems interested in improving antibiotic prescribing should embrace the Core Elements framework and consider implementation of similar interventions.
Dec 8 Clin Infect Dis abstract
More improper antibiotics noted for ARIs in rural vs city Tennessee kids
Originally published by CIDRAP News Dec 8
In another study on antibiotic prescribing for respiratory infections, researchers in Tennessee reported today in Open Forum Infectious Diseases that inappropriate antibiotic use for ARIs was significantly higher in children from rural counties compared with urban counties.
The study cohort consisted of children aged 2 months to 5 years who were enrolled in Tennessee Medicaid from 2007 through 2012 and diagnosed with an ARI in the outpatient setting during that period. Using electronic medical record and pharmacy data, researchers from Vanderbilt University Medical Center and Atrium Health compared rates of ARI and related antibiotic use among children in completely rural, mostly rural, and mostly urban counties. Multivariable regression models were used to measure associations between rurality of residence and the rate of study outcomes.
Compared with children from mostly urban areas, children from mostly rural and completely rural counties had higher rates of ARIs (adjusted incidence rate ratio [aIRR], 1.07 1.07, respectively), ARI-related antibiotic use (aIRR, 1.15 and 1.17), and ARI-related inappropriate antibiotic use (aIRR, 1.34 and 1.33).
Although the proportion of ARIs associated with overall and inappropriate antibiotic use decreased over time, they remained higher in children living in rural counties compared to urban counties throughout the study period. The strength of the association between rurality and rate of antibiotic use was higher among black children and those from households with lower median incomes.
"These findings should inform targeted outpatient stewardship efforts to reduce inappropriate antibiotic use and its consequences," the authors concluded.
Dec 8 Open Forum Infect Dis abstract
CDC report shows declines in healthcare-associated infections
Originally published by CIDRAP News Dec 7
A new report from the CDC shows some encouraging declines in healthcare-associated infections (HAIs) across four US healthcare settings, including one linked to antibiotic use.
The 2019 National and State HAI Progress Report, which covers data from acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, and long-term acute care hospitals, shows a 7% decrease in central line-associated bloodstreams infections from 2018 to 2019 and an 8% reduction in catheter-associated urinary tract infections. Compared with the 2015 baseline standardized infection ratio, 51 states performed better on at least two infection types in 2019, 40 states performed better on three infection types, and 30 states improved on at least four infection types.
The report also showed an 18% decline in Clostridioides difficile infections from 2018 to 2019. C difficile is the leading cause of hospital- and antibiotic-associated diarrhea in the United States.
But there remains room for improvement. The data showed a 2% increase in ventilator-associated events, no significant change in surgical-site infections related to 10 select procedures, and no significant change in methicillin-resistant Staphylococcus aureus bacteremia.
The CDC estimates that, on any given day, 1 in 31 US hospital patients has an HAI, a growing number of which are caused by antibiotic-resistant bacteria. The agency has placed an increased focus on reducing HAIs in US hospitals recent years, but it says more work on HAI surveillance and prevention is needed.
"While much progress has been made, more needs to be done to prevent healthcare-associated infections in a variety of settings," the report stated.
Dec 2 CDC HAI Progress Report