Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans
Tennessee data highlight small group of high antibiotic prescribers
An analysis of outpatient antibiotic prescriptions in Tennessee in 2016 shows that a small number of prescribers were responsible for a "dramatically disproportionate" number of prescriptions, researchers reported today in Infection Control and Hospital Epidemiology.
The retrospective analysis of nearly 8 million prescriptions for outpatient oral antibiotics dispensed at retail pharmacies across the state in 2016 found that there were 1,195 prescriptions per 1,000 total population, and that 50% of the state's total antibiotic prescriptions were written by just 9.3% of prescribers. Of all medical specialties, nurse practitioners wrote the most antibiotic prescriptions (30.6% of all prescriptions), followed by family medicine physicians (15.6%). Urologists had the highest average prescriptions per provider, with 571.
Diving deeper into the high-prescribing group, the researchers found that the specialist groups most likely to be associated with high prescribing were urologists (odds ratio [OR], 3.249; 95% confidence interval [CI], 3.208 to 3.289), nurse practitioners (OR, 2.675; 95% CI, 2.658 to 2.692), dermatologists (OR, 2.396; 95% CI, 2.365 to 2.428), physician assistants (OR, 2.382; 95% CI, 2.364 to 2.400), and pediatricians (OR, 2.340; 95% CI, 2.320 to 2.361). High prescribers were also more likely to have been born in the 1960s (OR, 2.574; 95% CI, 2.531 to 2.618), practice in rural areas, and prescribe more broad-spectrum antibiotics than non-high-prescribing counterparts, including third-generation cephalosporins, macrolides, and extended-spectrum penicillins.
The authors of the study say the data suggest that a stewardship strategy targeting a "small but impactful" group of high prescribers, regardless of specialty, practice location, experience, or gender could significantly reduce outpatient antibiotic prescribing and is potentially a more efficient use of limited resources. But they acknowledge that developing a universal set of interventions deployed easily and relevant to a diverse prescriber group will be a challenge.
"Although we recognize the challenges inherent in this approach, we are hopeful that with continued support and creativity, we can develop and implement successful antimicrobial stewardship interventions for all high prescribers across Tennessee," they write.
Nov 22 Infect Control Hosp Epidemiol abstract
UNICEF warns of children's vulnerability to antibiotic resistance
The United Nations Children's Fund (UNICEF) published a technical note today on the threat of antimicrobial resistance (AMR) to child survival, growth, and development.
Calling AMR "perhaps the greatest threat to child survival and health of this generation," the document notes that children are particularly susceptible to diseases caused by drug-resistant microbes because their immune systems aren't fully developed, and that children in low-resource settings with poor sanitation and limited access to healthcare are at even greater risk. As a result, UNICEF warns, AMR has the potential to undo gains in child health achieved by the global health community in recent years.
The technical note identifies three priority areas where UNICEF is currently implementing activities in response to AMR: 1) reducing the incidence of infection; 2) promoting access to, and optimal use of, antimicrobial agents; and 3) increasing awareness and understanding of AMR. It also outlines how different divisions within the agency can strengthen these ongoing efforts to protect children against drug-resistant infections. Among the highlighted efforts are the water, sanitation and hygiene (WASH) program, financial support for increased immunization, the communication for development (C4D) strategy, and support for programs that promote access to diagnostics and appropriate antibiotics while also preventing excessive use.
UNICEF says that because it is a leading voice and advocate for children in 192 countries and territories, and has a reputation as a trusted partner with expertise across sectors and disciplines, it can add significant value to the global AMR response.
Nov 22 UNICEF technical note
Study on CRE in US military health system notes high risk of death
Originally published by CIDRAP News Nov 21
A study of hospitalized patients in the US military health system database shows that carbapenem-resistant Enterobacteriaceae (CRE) infections are associated with longer and more costly hospitalizations and a significant increase in the risk of in-hospital death, researchers reported yesterday in the American Journal of Infection Control.
For the retrospective study, the researchers with the Uniformed Services University analyzed data on patients admitted to one of the many US military treatment facilities for at least 2 days with a CRE infection from October 2008 through September 2015. The aim of the study was to analyze risk factors for CRE infection and evaluate important healthcare outcomes in this patient population. Multivariable logistics regression was used to identify comorbid conditions associated with CRE infections, and a high-dimensional propensity score was used to evaluate CRE-associated in-hospital mortality, length of stay, and hospitalization costs.
Of 1,162,686 hospitalized patients, the researchers identified 143 with a CRE infection over the 7-year study period. Compared with patients without CRE infection, most were older men admitted to large hospitals. Analysis of cultures from the patients showed that most CRE isolates were highly resistant to other antibiotic classes. The conditions associated with CRE infection included manipulation of the gastrointestinal tract, musculoskeletal trauma, orthopedic procedures, septicemia, and exposure to broad-spectrum beta-lactam antibiotics. The in-hospital mortality rate for patients with CRE infection was 9.1%, compared with 0.46% for those without.
After propensity score adjustment, CRE infection was associated with a triple increase in the odds of in-hospital death (adjusted odds ratio, 3.34; 95% confidence interval [CI], 1.82 to 6.12), significantly higher hospitalization costs (attributable difference, $206,664; P < .001), and longer hospital stays (attributable difference, 28.8 days; P < .001).
The authors say their study "highlights the importance of initiatives aimed at curbing the spread of these costly infections."
Nov 20 Am J Infect Control abstract
New international group to monitor antibiotic resistance in the environment
Originally published by CIDRAP News Nov 21
An international team of scientists this week launched a new effort to track antibiotic resistance in the environment.
The primary goal of the international collaboration, dubbed EMBARK (Establishing a Monitoring Baseline for Antimicrobial Resistance in Key environments), is to understand how common antibiotic resistance is in the environment, and what type of resistance mechanisms are most frequently found in different settings. The data will then be used to standardize different methods of resistance surveillance and identify high-priority targets for monitoring.
The group, which includes scientists from Sweden, Germany, France, China, and Pakistan, also aims to create an early-warning system by developing and evaluating methods to detect new and emerging resistance mechanisms that could spread from the environment to humans.
EMBARK leaders say they hope to develop monitoring tools and methods that are affordable, easy to use, and modular.
"This is crucial, since effective antibiotic resistance monitoring may be most urgent and important in countries that may not be able to afford it," EMBARK coordinator Johan Bengtsson-Palme, PhD, said in a video on the group's website. "Our long-term goal is to develop a monitoring protocol that can be adapted to the available budget and still be relevant and comparable between countries and different situations."
EMBARK has received €1.4 million ($1.5 million US) in funding from the Joint Programming Initiative on Antimicrobial Resistance.
Nov 18 EMBARK launch announcement
European health group releases 'roadmap' to address antibiotic resistance
Originally published by CIDRAP News Nov 20
The European Public Health Alliance's Stakeholder Network on AMR has released a roadmap outlining the path European leaders should take in their efforts to fight drug-resistant infections.
Emphasizing the need for a multidisciplinary, "One Health" approach, the roadmap calls for European Union (EU) member states and institutions to pursue five strategies against AMR:
- Set targets and performance indicators for progress in reducing antibiotic use and antibiotic-resistance in human and veterinary medicine
- Help countries mobilize resources for better implementation of national AMR policies
- Close the collaboration gap between civil society and EU policy makers
- Focus EU policy-making on infection control and prevention and antibiotic stewardship programs
- Tackle the environmental dimension of AMR in the framework of the European green deal
The strategies are aimed at what the Stakeholder Network on AMR sees as some of the current gaps in the EU's response to rising antibiotic resistance. To date, according to the group, the European Commission has not set any targets or performance indicators for antibiotic use, several EU countries have no national action plan in place, and civil society groups have not been formally brought into the policy-making process.
"For Europe to become a global leader and best practice region on AMR the EU must demonstrate ambition, leadership and policy coherence between all AMR-related areas, ensuring that political and policy priorities are translated into action and have a lasting impact," the roadmap signatories write.
Nov 18 AMR Stakeholder Network roadmap
EU regulators approve new rapid diagnostic test for clinical use
Originally published by CIDRAP News Nov 20
European regulators today granted CE-mark certification for the T2 Resistance Panel, a rapid diagnostic test that can detect antibiotic resistance genes associated with sepsis-causing pathogens from whole-blood samples.
Developed by T2 Biosystems of Lexington, Massachusetts, with support from CARB-X (the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator), the T2 Resistance Panel can detect 13 of the most serious antibiotic-resistance genes identified by the Centers for Disease Control and Prevention, directly from blood and within 3 to 5 hours. It's the first diagnostic test that can detect all of these resistance markers from blood samples, and the first to graduate from the CARB-X portfolio.
"This represents a huge step forward for patients, and a critical milestone for CARB-X," Kevin Outterson, JD, executive director of CARB-X, said in a CARB-X press release. "Rapid diagnosis of drug-resistant infections is essential to improve appropriate treatment for patients, and to save lives."
The CE-mark indicates conformity with the health, safety, and environmental protection standards that govern products sold within European Economic Activity countries, and is legally required to place a medical device on the market in Europe. The certification means that the test can now be used on patients in Europe.
The T2 Resistance Panel was granted Breakthrough Device designation by the US Food and Drug Administration earlier this year, but is not yet available for clinical use in US hospitals.
Nov 20 CARB-X press release
Paper calls for short-term, long-term strategies on antibiotic development
Originally published by CIDRAP News Nov 20
A new paper in The Lancet Infectious Diseases calls for a two-pronged strategy to address the weakness of the antibiotic research and development (R&D) pipeline.
In their assessment of current efforts to stimulate antibiotic R&D, researchers from the United Kingdom note that a combination of push incentives from public-private partnerships like CARB-X and the Global Antibiotic Research and Development Partnership (GARDP) and pull incentives, such as the antibiotic subscription model recently announced by the UK National Health Service, are currently keeping the antibiotic pipeline from completely running dry.
But just barely, they argue. Even with these efforts, a combination of high development costs, low public investment, and low profit margin for new antibiotics is causing many pharmaceutical companies to abandon the market. And companies that do produce new antibiotics are facing financial difficulties.
In the short term, the authors of the paper argue, this model needs to be maintained, because the pharmaceutical industry is still the best equipped to undertake antibiotic innovation. Therefore, strengthening current push and pull incentives and creating new ones, like market-entry rewards, is the best course of action for the immediate future. But because the long-term viability of the for-profit antibiotic development model is unclear and antibiotics are a global resource that needs to be distributed equitably, the authors propose the creation of an international, publicly funded, non-profit antibiotic R&D institute to transform how new antibiotics are discovered and developed.
"The formation of such an institute would create a permanent, integrated, open, and transparent home for the two key resources produced during pharmaceutical R&D: knowledge and skill," the authors write. "Novel antibiotics would be a public commodity that could be developed according to a prioritisation process determined by greatest need rather than greatest profit, and disseminated according to a principle of what could be termed shared burden."
The authors suggest the institute could be financed through a variety of mechanisms, including government funding, taxation, antibiotic usage fees, insurance payments, and contributions from the pharmaceutical industry.
Nov 18 Lancet Infect Dis paper
FAO manual helps guide prudent antibiotic use for pigs, poultry
Originally published by CIDRAP News Nov 20
Yesterday the United Nations Food and Agriculture Organization (FAO) and the Swedish University of Agricultural Sciences (abbreviated SLU) launched a manual on the prudent use of antibiotics in pigs and poultry targeted especially to farmers, pharmacists, and veterinarians in non-EU Eastern European and Balkan countries, the Caucasus, and central Asia.
"The manual is about how to reduce the use of antibiotics in livestock through disease prevention. We have focused on poultry and pig breeding since it is where most antibiotics are used globally," Ulf Magnusson, DVM, PhD, SLU professor and lead author of the manual, said in an SLU news release. SLU experts wrote the manual with a working group of international experts, including additional Swedish scientists. Sweden is a world leader in keeping food animals healthy while using minimal antibiotics, according to the release.
The manual covers the prevention of infectious diseases without antibiotics, how to use the drugs prudently and effectively, and practical recommendations on combining prudent use with preventive measures for good productivity. Non-drug measures to prevent disease include good animal husbandry and welfare, effective external and internal farm biosecurity, and appropriate vaccine use.
The authors detail how to phase out the use of antibiotics for growth promotion, avoid the use of highest-priority antibiotics that are critical for human medicine, use antibiotics only after a veterinarian has diagnosed a disease, strive for individual treatment of animals, and dispose of unused antibiotics, among other stewardship steps.
The authors write, "The recommendations are highly relevant for those who have larger, more commercial and professional production systems. However, the principles for disease prevention and use of antibiotics may be applied by all categories of farmers." The FAO also notes that, although the manual focuses on a specific geographical region, its principles may be applied elsewhere, as well.
Nov 19 FAO/SLU report
Nov 19 SLU news release
Audit finds EU efforts to fight antibiotic resistance are lacking
Originally published by CIDRAP News Nov 18
A new report from the European Court of Auditors (ECA) argues that while some progress has been made, EU leaders need to do more to address the health burden of antibiotic resistance.
In their assessment of the European Commission and European Centre for Disease Prevention and Control's management of key antibiotic resistance activities and resources, the auditors found that support for the "one health" approach was having some positive impacts, including more prudent use of veterinary antibiotics in most member states. But they also noted that there are big differences between the member states, that veterinary antibiotics use overall is still too high, and that gaps in collecting data and monitoring resistance in food animals and food remain. Incomplete surveillance data on hospital infections and insufficient knowledge of antibiotic-resistant pathogens in the environment were also cited as issues.
In addition, the auditors pointed out that while 99% of the EU's antibiotic-resistance budget is devoted to research, there has not yet been any breakthrough in the development of new antibiotic classes, and the specific market challenges for new antibiotics have not been addressed.
"Antimicrobial resistance is a serious threat to public health," ECA member Nikolaos Milionis said in a press release. "While there has been some progress on veterinary issues, the European Commission, together with the Member States, need to further step up their efforts to tackle this growing threat."
The report calls on the European Commission to provide more support for member state national action plans, promote better monitoring and use of veterinary antibiotics, and strengthen strategies for boosting antibiotic-resistance research.
Nov 15 ECA report
Nov 15 ECA press release
New guidance on drug-resistant TB prioritizes oral antibiotics
Originally published by CIDRAP News Nov 18
The American Thoracic Society (ATS), US Centers for Disease Control and Prevention (CDC), European Respiratory Society, and Infectious Diseases Society of America have published a practice guideline on treating drug-resistant tuberculosis (TB) that includes new recommendations for the choice and number of drugs in a regimen and duration of therapy, as well as the role of injectable drugs in multidrug-resistant TB (MDR-TB).
Writing in the American Journal of Respiratory and Critical Care Medicine, experts from the four organizations note that they analyzed data from 50 studies involving 12,030 patients total across 25 countries to develop the guideline.
The guideline makes clear that treatment should be tailored based on drug-susceptibility testing, and that patients should not receive medicines to which the Mycobacterium tuberculosis strain is resistant. It also prioritizes the use of oral medications.
The guideline recommends treatment with a later-generation fluoroquinolone for all infected contacts of patients who have MDR-TB, rather than watchful observation, and it provides evidence-based guidance for treating pregnant women who have MDR-TB. The experts also spell out the role of surgery in treating MDR-TB and advice for treating isoniazid-resistant TB.
"Having the participation of committee members from multiple medical societies and the CDC, as well as patient advocate perspectives, was absolutely critical to discussing the balance between desirable and undesirable health effects of interventions, making certain they were favorable for MDR-TB patients, including for children and pregnant women," said Payam Nahid, MD, MPH, chair of the guideline committee, in an ATS news release.
Nov 15 Am J Respir Crit Care Med guideline
Nov 18 ATS news release
