ASP Scan (Weekly) for Jun 15, 2018

Nurses' role in stewardship
Antibiotics for nursing home residents
Less common CRE pathogens
Pharmacists' role in stewardship
Canadian stewardship success
Stand-by antibiotics
Individualized risk assessment
Carbapenem-focused stewardship
Colistin-resistant E coli in Vietnam
Influenza-MRSA coinfection in kids
Combo therapy for resistant Klebsiella

Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans

Study finds nurses are overlooked in stewardship programs

Research presented at the 45th annual conference of the Association for Professionals in Infection Control (APIC) suggests that nurses should play a bigger role in antimicrobial stewardship programs (ASPs).

The research, conducted at Jefferson Health (a regional health system in New Jersey and Pennsylvania), aimed to examine how the role of nursing in the system's ASP could be strengthened. Nursing buy-in was achieved by opening up participation in the ASP at three of Jefferson Health's New Jersey hospitals to nursing leadership, educators, performance improvement, and infection control. In addition, a computer-based learning module, with materials written in "nurse speak," was shared across the three hospitals.

To gauge comprehension of stewardship principles, nurses at the hospitals were given a 10-question baseline-assessment quiz on antibiotic use. The results showed that more intensive care unit (ICU) nurses recognized how to interpret antibiotic susceptibility results than non-ICU nurses (92.3% vs. 87.6%), and more ICU nurses knew how to interpret non-susceptibility results as well (82.7% vs. 78.6%). Overall, most nurses (93.8%) incorporated microbiology results during sign-out reporting. But only 50% of clinical nurses checked susceptibility results of cultures prior to administering antibiotics. If cultures showed resistance, only 65.1% of clinical nurses notified the physician.   

"Our findings show that nurses have been overlooked and under-utilized in ASPs," Jefferson Health - New Jersey Infection Control Officer Cindy Hou, DO, the study's lead author, said in an APIC press release. "Changing the culture and empowering nurses to speak up about antimicrobial stewardship leads to closer team coordination and cross-discipline collaboration, which ultimately saves lives."
Jun 13 APIC 2018 abstract (search for ASR-46) 
Jun 13 APIC press release


Study highlights antibiotic prescribing outside nursing homes

A study yesterday in Antimicrobial Resistance and Infection Control found that 13% of antibiotic prescriptions for nursing home residents were initiated in settings outside the nursing home, and that inappropriate use was higher in these settings.

For the study, researchers from the University of Wisconsin-Madison conducted a cross-sectional, multi-center investigation of five nursing homes in southern Wisconsin. The aim of the study was to characterize antibiotic therapy in the five nursing homes and compare the appropriateness based on the setting where the prescription was initiated.

The investigators identified antibiotic prescribing events from nursing home facility records, looking specifically at antibiotics prescribed for suspected lower respiratory infections, skin and soft-tissue infections, and urinary tract infections (UTIs) in the nursing home, in an emergency department, or at an outpatient clinic, then compared appropriateness by setting and infection type.

Among 735 antibiotic starts, 640 (87.1%) were initiated in the nursing home, 61 (8.3%) in the outpatient clinic, and 34 (4.6%) in the emergency department. UTI was the most commonly treated type of infection (49.7%). Overall, inappropriate antibiotic prescribing varied by setting: Nursing home (47.5%), emergency department (47.1%), and outpatient clinics (63.9%). Variation in inappropriate prescribing for UTI was even wider: Nursing home (55.9%), emergency department (73.3%), and outpatient clinic (80.8%). In multivariate analysis, regardless of infection type, patients who had an antibiotic initiated in an outpatient clinic had 2.98 times increased odds of inappropriate use.

Although the generalizability of the findings are limited, the authors conclude that antibiotic prescribing initiated outside of the nursing home, particularly in outpatient clinics, is an important area for additional investigation and should be considered in efforts to improve antibiotic stewardship in nursing homes.
Jun 14 Antimicrob Resist Infect Control study


Minnesota officials describe CRE caused by uncommon pathogens

Originally published by CIDRAP News Jun 14

Although carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) involving Escherichia coliKlebsiella, and Enterobacter cause the most mortality and other clinical impact, CRE associated with less common genera may also cause detrimental infections, researchers with the Minnesota Department of Health (MDH) reported today in Morbidity and Mortality Weekly Report(MMWR).

CRE from less common genera have generally not been targeted for carbapenemase testing, the authors note, in part because some of them have intrinsic resistance to the carbapenem imipenem (IMP) and others express species-specific chromosomal carbapenemases. But the less common CRE organisms can also harbor plasmid-mediated carbapenemases.

The investigators found that 149 (12.0%) of 1,241 CRE isolates tested at the MDH Public Health Laboratory from Jan 1, 2014, through Sep 30, 2017, were CP-CRE. All were from different patients. Of the 149 CRE, 20 (13.4%) were from less common genera. The most common species were IMP-producing Providencia rettgeri (7 isolates) and Klebsiella pneumoniae carbapenemase (KPC)-producing Citrobacter freundii (6).

Among the 20 patients, median age was 56.5 years (range, 14 to 75 years), and 15 patients were hospitalized at the time of culture collection. Two patients were hospitalized internationally—one in Kenya, one in Kuwait—in the year before they tested positive.

The authors concluded, "Less common Enterobacteriaceae genera appear to be a small but potentially important subset of CP-CRE; however, estimates of the true proportion of CP-CRE from these less common genera are limited by the lack of systematic testing. Of note, many of the carbapenemases in the less common CRE genera were not KPC."
Jun 15 MMWR report


Advocates say hospital pharmacists strengthen stewardship programs

Originally published by CIDRAP News Jun 14

The European Association of Hospital Pharmacists (EAHP) is calling for a greater role for pharmacists in antibiotic stewardship programs.

In a position paper on antimicrobial resistance (AMR) issued yesterday, the group calls on national governments and health system managers to "utilise the specialized background and knowledge of the hospital pharmacists in multi-professional antibiotic stewardship teams," arguing that pharmacists can help enforce stewardship and promote prudent use of antimicrobial drugs.

Among the ways that pharmacists can strengthen stewardship programs, the group says, is through reviewing antibiotic duration, advising on the cessation of appropriate antibiotic treatment, and educating other healthcare professionals on restricted use of certain antibiotics.

Other recommendations in the position paper include universal application of infection and prevention control measures, regulatory oversight of antibiotic use in the livestock and agriculture sector, and increased investment to support the development of new antibiotics and new fields of infectious disease control. The EAHP also urges governments to make arrangements to maintain essential antibiotics on the market and prevent shortages.
Jun 13 EAHP position paper


Study links lower hospital antibiotic use with ASP components

Originally published by CIDRAP News Jun 13

An observational study of Canadian hospitals found that certain structural and strategic components of antimicrobial stewardship programs (ASPs) are associated with lower antibiotic use, a team of Canadian researchers reported yesterday in Infection Control and Hospital Epidemiology.

The study used a survey and data on antibiotic use to determine the relationship between ASP components and antibiotic use. The Ontario ASP Landscape Survey, developed by Public Health Ontario and sent to hospitals across the country, asked the clinicians most responsible for stewardship at their institution about eight structural and 32 strategic components of their ASP. Researchers used hospital purchasing data from 2014 to determine the crude and adjusted defined daily doses (DDD) of antibiotics per 1,000 patient-days across facilities. They then compared the rate ratios (RRs) of DDD per 1,000 patient-days for hospitals with and without each ASP component of interest.

Of 127 eligible hospitals, 73 (57%) participated in the study. A sevenfold difference in antibiotic use across hospitals was observed, ranging from 253 to 1,872 DDD per 1,000 patient-days. After adjustment for hospital and patient characteristics, the only structural component associated with lower risk-adjusted antibiotic use was the presence of designated ASP funding or resources (adjusted RR 0.87).

Of the strategic components on the survey, only prospective audit and feedback (adjusted RR, 0.80) and intravenous-to-oral conversion policies (adjusted RR, 0.79) were associated with lower risk-adjusted antibiotic use. No association between the overall number of ASP components and antibiotic use was found.

The authors say the study offers important considerations for ASPs in hospital settings.
Jun 12 Infect Control Hosp Epidemiol study


'Stand-by' antibiotics encourage unwarranted use, study finds

Originally published by CIDRAP News Jun 13

Finnish researchers report that carriage of "stand-by" antibiotics for travelers' diarrhea (TD) encouraged less cautious use of antibiotics, according to a new study in Travel Medicine and Infectious Disease.

The researchers reviewed questionnaires and health diaries filled out by 316 Finnish volunteers who had traveled to subtropical locations and acquired TD on their trip. The questionnaires included 103 multiple-choice or open-ended questions, and the health diaries collected information on symptoms, severity of illness, duration of symptoms, and antibiotic use. Multivariable analysis was applied to identify factors associated with antibiotic use.

Of the 316 travelers, 53 (17%) were carrying stand-by antibiotics. Antibiotic use was more frequent in the stand-by antibiotic carriers (34%) than non-carriers (11%). While antibiotics were taken equally for severe and incapacitating TD, more stand-by antibiotic carriers resorted to medication for mild/moderate symptoms (38% vs. 4%) and non-incapacitating disease (29% vs. 5%). All travelers with stand-by antibiotics had been advised to use them only for TD symptoms they considered severe.

Multivariable analysis showed that antibiotic use was associated with stand-by antibiotic carriage (odds ratio [OR], 7.2), vomiting (OR, 3.5), incapacitating diarrhea (OR, 3.6), age (OR, 1.03), and healthcare visits for diarrhea (OR, 465.3). The rate of travelers' diarrhea–related healthcare did not differ significantly between stand-by antibiotic carriers and non-carriers (3.8% vs. 6.1%)

The authors say the results are significant because stand-by antibiotics have long been prescribed for travel, with the assumption that it would decrease the rate of seeking healthcare abroad. But carrying stand-by antibiotics did not appear to significantly discourage medical visits. In addition, stand-by antibiotic carriers were less cautious with their antibiotic use, using the drugs mainly in cases of non-severe and non-incapacitating diarrhea.

They conclude, "To cut back on unwarranted use of antibiotics for TD, new approaches need to be explored." 
Jun 9 Travel Med Infect Dis abstract


Individualized risk assessment tied to lower antibiotic use

Originally published by CIDRAP News Jun 13

A single center study found that an individualized risk assessment strategy for multidrug-resistant (MDR) organisms that uses a clinical prediction score for pneumonia can decrease the use of broad-spectrum antibiotics without an increase in adverse outcomes, researchers reported in the Journal of Antimicrobial Chemotherapy.

Researchers at Mount Sinai West in New York City reviewed the records of 102 patients admitted for community-onset pneumonia before and after the implementation of a risk assessment program for MDR organisms that uses the drug resistance in pneumonia (DRIP) score. The primary aim was to identify the effects of this intervention on antibiotic days of therapy (DOT), and secondary outcomes included all-cause readmissions and time to clinical improvement.

The investigators found that the program was associated with a decrease in broad-spectrum antimicrobials for treating methicillin-related Staphylococcus aureus (MRSA) and for pseudomonads, without an increase in adverse outcomes. It was not, however, tied to significantly lower odds of readmission or time to clinical improvement.
Jun 11 J Antimicrob Chemother abstract


Requiring carbapenem justification may lower its use, study finds

Originally published by CIDRAP News Jun 13

A stewardship-targeted justification requirement for computerized physician order entry reduced days of carbapenem use by 34% in 23 hospitals, according to a new study in the Clinical Pharmacy Research Report.

Researchers with Sanford Medical Center in Fargo, N.D., measured carbapenem days of therapy (DOT) after the stewardship intervention was implemented in the 23 medical centers. The program required physicians to justify carbapenem use in the electronic health record. The team compared periods from Dec 1, 2015, to Mar 31, 2016, and from Dec 1, 2016, to Mar 31, 2017.

They found that carbapenem use dropped from 35.8 DOT per 1,000 patient-days to 23.7 DOT per 1,000 patient-days, a 33.8% reduction. Morbidity, mortality, and resistance rates remained unchanged.

The authors conclude, "This study suggests that a stewardship-targeted justification requirement in computerized physician order entry is an effective approach to reducing carbapenem utilization."
Jun 11 Clin Pharm Res Rep study


Study finds high prevalence of colistin-resistant E coli in Vietnamese village

Originally published by CIDRAP News Jun 12

A study examining the prevalence of colistin-resistant bacteria in healthy people from a rural Vietnamese village found that more than 70% were carrying colistin-resistant E coli, a team of Japanese scientists reported at the annual meeting of the American Society for Microbiology (ASM).

The investigators enrolled 98 healthy participants from 36 households Nguyen Xa village, a representative rural community in Vietnam. Microbiological analysis of stool specimens obtained from each participant detected colistin-resistant bacteria in 70 of 98 residents (71.4%) and 29 of 36 households (80.6%). All of the colistin-resistant isolates were identified as E coli, and 69 of the 70 isolates possessed either MCR1 and/or MCR3, the mobile colistin-resistance genes. In addition, the rate of multidrug-resistance in the MCR-positive E coli isolates was 91.4%.

"It is a remarkable finding from a public health viewpoint that most households that participated in the study had colistin-resistant E. coli carriers," presenting author Yoshimasa Yamamoto, PhD, of Osaka University said in an ASM press release. "Thus, this requires urgent public health attention."

Colistin, considered a last resort antibiotic in human medicine, is one of the most commonly used antimicrobials in food-animal production in Vietnam.
Jun 9 ASM Microbe 2018 abstract
Jun 9 ASM press release


Study: Vancomycin alone insufficient for pediatric influenza-MRSA

Originally published by CIDRAP News Jun 11

A small study in Clinical Infectious Diseases has found that coinfection with influenza and MRSA is associated with high mortality in critically ill children, and that mortality was more than five times higher in children who received vancomycin monotherapy, a finding the authors say supports treatment with additional antibiotics in severe cases.

For the study, the investigators prospectively enrolled 170 children with influenza infection and acute respiratory failure treated at 34 pediatric intensive care units from November 2008 through May 2016. They compared baseline characteristics, clinical courses, and therapies in children with MRSA coinfection, non-MRSA bacterial coinfection, and no bacterial coinfection. In addition to assessing clinical outcomes, they wanted to examine the use of antibiotic therapy in children with influenza-MRSA coinfection, hypothesizing that variability would be high and would be associated with mortality.

Thirty of the children were diagnosed as having MRSA respiratory coinfection, while 61 had a diagnosis of non-MRSA bacterial coinfection and 79 had no clinical diagnosis of bacterial coinfection. Influenza-MRSA was associated with more frequent leukopenia, acute lung injury, vasopresser use, extracorporeal life support, and mortality compared with either non-MRSA group. Influenza-related mortality was 40% with MRSA compared with 4.3% without MRSA (relative risk [RR], 9.3).

Overall, 29 of 30 children with MRSA coinfection received vancomycin within 24 hours of hospitalization, but mortality was 69.2% in those who received vancomycin only; in the children who received vancomycin and a second anti-MRSA agent within the first 24 hours, mortality was 12.5% (RR, 5.5).

"Although limited, this 'real-world evidence' on antibiotic efficacy in pediatric influenza-MRSA coinfection, a sporadic and fulminant disease with high fatality, indicates that vancomycin alone is insufficient for children in the PICU with acute respiratory failure," the authors write.

An accompanying commentary notes that while the study is small, "a potential mortality signal of this magnitude should give providers pause before treating severe disease with vancomycin alone." 
Jun 9 Clin Infect Dis study
Jun 9 Clin Infect Dis commentary


Ceftazidime-avibactam therapy shows promise against resistant Klebsiella

Originally published by CIDRAP News Jun 11

Italian scientists have determined that ceftazidime-avibactam salvage therapy is effective in patients with severe infections caused by carbapenemase-producing K pneumoniae, especially those involving the bloodstream, according to a separate new study in Clinical Infectious Diseases.

Ceftazidime-avibactam has been approved in Europe for treating complicated intra-abdominal and urinary-tract infections, as well as for hospital-acquired pneumonia and gram-negative infections with limited treatment options. The researchers analyzed data on 138 patients who were started on ceftazidime-avibactam salvage therapy after a median of 7 days on first-line antimicrobial treatment.

Thirty-day mortality among the 104 patients who had bacteremic carbapenemase-producing K pneumoniae infections was significantly lower in ceftazidime-avibactam patients than in a matched cohort treated with other second-line drugs (36.5% vs. 55.7%, P = 0.005).

Multivariate analysis of the 208 cases of carbapenemase-producing K pneumoniae bacteremia identified septic shock, neutropenia, Charlson comorbidity index of 3 or higher, and recent mechanical ventilation as independent predictors of mortality, whereas receipt of ceftazidime-avibactam was the sole independent predictor of survival.
Jun 9 Clin Infect Dis abstract

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