Stewardship / Resistance Scan for Apr 04, 2018

Defensive prescribing
C diff drop with diagnostic stewardship
AMR levels in Cambodian kids

Defensive medicine found common when prescribing antibiotics

A study group with the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) reports that 45% of specialists in infectious diseases and clinical microbiology sometimes worried and 29% often worried about malpractice implications when prescribing or advising on antibiotic prescriptions, and 85% reported defensive behaviors when prescribing, according to a study today in the Journal of Antimicrobial Chemotherapy.

The experts report on their experience with AntibioLegalMap, an international Internet-based survey targeting those two specialties. The survey included 830 professionals in 74 countries.

When asked about the fear of liability, 164 of 774 respondents (21.2%) said they never worried, 349 of 774 (45.1%) sometimes worried, and 221 of 774 (28.6%) frequently worried when prescribing or advising on antibiotic prescriptions. Being female, 35 years or younger, and aware of previous cases of litigation were independently associated with such concerns.

In addition, 525 of 618 respondents (85.0%) reported some defensive behavior in antibiotic prescribing and 505 of 661 (76.4%) reported defensive behaviors in advising. The preferred measures to reduce fear and defensive behaviors were having local guidelines and sharing decisions through teamwork, the scientists reported.
Apr 4 J Antimicrob Chemother abstract


Diagnostic stewardship tied to lower hospital rates of Clostridium difficile

A new study in Infection Control and Hospital Epidemiology describes how University of California-Los Angeles researchers achieved a two-fold reduction of Clostridium difficile rates after implementing diagnostic stewardship and provider education programs.

The study took place over a 12-month period at the Los Angeles County and University of Southern California Medical Center. The stewardship program began with provider education on how to properly collect and include stool samples as diagnostic criteria.

Before the program was implemented, researchers found that more than 50% of admitted patients with positive C difficile tests lacked symptoms of colitis and had at least one confounding factor at the time of stool collection, such as laxative use. The rate of false-positives was estimated to be 70%. This is because a positive C difficile NAAT does not distinguish between infection and colonization, the authors said.

The hospital implemented a two-step C difficile testing program that required a confirmatory test with a toxin-specific enzyme-linked immunosorbent assay (ELISA) assay after a positive C difficile nucleic acid amplification tests (NAAT).

"Starting in January 2017, after implementing the diagnostic and education interventions, the average number of tests ordered fell to 85 per month (a 43% reduction), of which 7 per month were positive (36% reduction)," the authors said.

C difficile infections are the most common healthcare-associated infections in the United States, resulting in 44,500 deaths and $5.4 billion in healthcare expenses.
Apr 3 Infect Control Hosp Epidemiol study


Study finds high antimicrobial resistance levels in Cambodian kids

A 9-year analysis of bacteria samples from hospitalized children in Cambodia found high rates of antibiotic resistance, especially among gram-negative organisms, an international research group reported yesterday in Emerging Infectious Diseases.

The samples were from Angkor Hospital for Children in Siem Reap. From 39,050 bacterial cultures collected from 2007 to 2016, they identified 1,371 target pathogens. Multidrug-resistance rates were 82% each for Escherichia coli and Klebsiella pneumoniae. In addition, 62.1% of K pneumoniae isolates and 47.2% of E coli isolates were resistant to ampicillin and gentamicin. Third-generation cephalosporin resistance was seen in 78.8% of K pneumoniae, 49.5% of E coli, and 93.3% of Acinetobacter baumannii isolates.

For Salmonella, the team found that resistance patterns varied by subtype, with the proportion highest for Salmonella Typhi—85% of them fluoroquinolone and multidrug resistant—and lowest for Salmonella Paratyphi A, of which only 22.7% were resistant to fluoroquinolone or other drugs.

The researchers found that resistant K pneumoniae was more common in infants, which they said might be the result of acquisition of gram-negative organisms from hospital surfaces. And Salmonella Typhi was more often resistant in kids younger than age 5, which the team said could be related to their exposure to more antimicrobial drugs.

In patients who had community-associated gram-negative bacteremia, resistance to third-generation cephalosporins was associated with more deaths, intensive care unit admissions, and a 2.26-fold greater healthcare costs in survivors.

The team concluded that the surveillance findings fill a gap in the understanding of antimicrobial resistance in Cambodian kids and shows that tracking the patterns is feasible in similar low-resource settings.
Apr 3 Emerg Infect Dis study

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