Stewardship / Resistance Scan for Dec 05, 2016

Antibiotic prescribing in kids
MDR-TB in China

Study documents country variations in pediatric antibiotic prescribing

An analysis of antibiotic prescribing in outpatient pediatric settings in three European countries—Italy, the Netherlands, and the United Kingdom—showed varied usage patterns that might be helpful for evaluating and modifying current antibiotic stewardship programs, according to a study in the latest issue of the Pediatric Infectious Disease Journal.

Researchers based their retrospective cohort study on prescribing information from electronic health records from 2001 to 2010, covering more than 2 million children. The databases include records for Italian children up to age 14 and for the Netherlands and the United Kingdom up to age 18. The team also looked at two newly proposed pediatric-specific quality indicators: the proportion of amoxicillin users (amoxicillin index) and the ratio between amoxicillin and broad-spectrum antibiotics (A/B ratio).

For all three countries, antibiotic use was highest in the first years of life.

Prevalence of antibiotic prescribing was highest in Italy at 52.0%, followed by the United Kingdom at 36.2%, and the Netherlands at 18.0%. UK clinicians showed a slight reduction in global and amoxicillin use over time, with low prescribing of broad-spectrum antibiotics. In the Netherlands, antibiotic prescribing is low and stable, but levels of broad-spectrum antibiotics are progressively increasing. Meanwhile, in Italian pediatric settings, patterns were dominated by broad-spectrum antibiotics.

The investigators noted that two pediatric quality indicators easily showed the patterns and that the total antibiotic prevalence indicators may both be useful for gauging national programs and making future improvements.
December Pediatr Infect Dis J abstract


Study: MDR-TB in Shanghai gaining resistance as it spreads

A study in The Lancet Infectious Diseases indicates that multidrug-resistant tuberculosis (MDR-TB) strains in the largest city in China are largely being transmitted from person to person, and that many of those strains are becoming more resistant during transmission.

In the population-based, retrospective observational study,  Chinese researchers performed genotyping and whole-genome sequencing of isolates from 7,892 patients in Shanghai who tested positive for TB from 2009 to 2012. They also measured strain diversity within and between genomically clustered isolates. The authors of the study say it's the first population-based study to combine genomics with detailed epidemiologic data to identify MDR-TB transmission pathways in a region in China, the country with the second-most MDR-TB cases worldwide.

It is commonly believed, the authors note, that most cases of MDR-TB result from inadequate treatment. But while many cases of MDR-TB strains are due to person-to-person transmission of MDR strains, few studies have provided evidence of transmission of MDR-TB at the population level. Understanding the causes and transmission patterns of MDR-TB is considered crucial for efforts to reduce the disease.

The findings suggest that transmission is common. Overall, the researchers found that 367 of the 7,892 patients (5%) had MDR-TB. They also found that nearly a third of the 324 MDR strains identified were in 38 genomic clusters that differed by 12 or fewer single nucleotide polymorphisms, which indicates recent transmission, and that transmission of MDR strains accounted for 73% of MDR-TB cases overall. Residential communities and related public facilities were the most common transmission settings.

Furthermore, transmission network analysis showed that 87% of the clusters acquired additional drug-resistance mutations during transmission.

"Transmission of MDR strains of tuberculosis has a substantial role in the burden of MDR tuberculosis in China," the authors write. "Interventions, such as early detection of cases, infection control, and evidence-based treatment, are urgently needed to stem the epidemic."
Dec 2 Lancet Infect Dis study

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