Stewardship / Resistance Scan for Jul 02, 2018

Clinical decision support tool aids stewardship
Dutch animal antibiotic use

Study: Stewardship module increases antimicrobial reviews, interventions

A new study by researchers with the University of Chicago Medical Center has found that use of a clinical decision support system at the hospital significantly increased the number of antimicrobial reviews and interventions while maintaining a sustained impact on antimicrobial utilization.

The single-center retrospective cohort study, published in Infection Control and Hospital Epidemiology, assessed the impact of the Epic Antimicrobial Stewardship Module (EAM) on antibiotic stewardship program (ASP) interventions by comparing the total number of interventions during the preimplementation period (February 2014 through January 2015) versus the postimplementation period (May 2016 through April 2017). EAM uses specific criteria to generate a list of alerts for the ASP team to review, including new start restricted antimicrobials, intravenous to oral administration, azole therapeutic drug monitoring, anti-retrovirals, pathogen-drug mismatch, and Staphylococcus aureus or yeast in blood culture. The EAM also provides a list of patients with specific pathogens, such as multidrug-resistant organisms or organisms with elevated minimum inhibitory concentrations to certain antibiotics.

Results of the analysis showed that prior to EAM implementation, the ASP team documented 5,433 antimicrobial reviews and made 1,436 interventions (119.7 interventions per month). After EAM implementation, the ASP team documented 8,288 reviews and made 7,444 interventions (620.3 interventions per month). A marked increase in the rate of all types of interventions was observed, with optimization and monitoring of antimicrobial therapy constituting most interventions pre-EAM and post-EAM (46.8% and 54.3%), followed by safety/monitoring (37.2% and 28.2%). Interventions were accepted more than 96% of the time.

Analysis of secondary outcomes showed that days of therapy (DOT) for all target antimicrobials per 1,000 patient-days per group decreased from 5,338.5 pre-EAM to 4,753.2 post-EAM (P = 0.4), while the percentage of antimicrobial drug expenditures relative to overall drug expenditures did not change significantly (7.14% pre-EAM and 8.32% post-EAM, P > .05). The average length of stay was similar between both groups (9.2 days vs. 9.0 days, P > .05), but the overall inpatient all-cause mortality rate was higher in the pre-EAM group (0.39 vs. 0.20, P < .01).

"The improved process for identification of patients requiring ASP review and/or intervention as well as streamlined documentation resulting from the EAM have broadened our ability to ensure optimal, safe, and judicious use of antimicrobials," the authors write. "Based on our experience, hospitals looking to establish or improve upon existing ASP practices should consider investing in a comprehensive clinical decision support system to improve efficiency and document value."
Jun 28 Infect Control Hosp Epidemiol abstract


Dutch report shows small increase in animal antibiotic use

A new report by Dutch public health, veterinary, and food safety officials shows that sales of antibiotics for animals in the Netherlands in 2017 rose slightly compared to 2016, while the presence of antibiotic-resistant bacteria in chickens fell.

The MARAN 2018 report (Monitoring of Antimicrobial Resistance and Antibiotic Usage in Animals in the Netherlands) shows an increase of 3% in sales of antimicrobial veterinary medicinal products in 2017 (181 tonnes) compared to 2016 (176 tonnes), with significant reductions in antibiotic use observed in broilers and turkeys, smaller reductions observed in pigs, and veal calves, and a small increase observed in dairy cattle. The use of antibiotics of critical importance to human healthcare (fluoroquinolones, 3rd and 4th generation cephalosporins, polymixins, and trimethoprim/sulfonamides) continued to drop, with steep declines noted in comparison with 2011 sales.

Analysis of antimicrobial resistance data found that resistance in indicator Escherichia coli from fecal samples to most antibiotics tested decreased in broilers from 2016 to 2017, stabilized in pigs, and showed a slight increase in veal calves. The proportion of resistant E coli remained low in dairy cattle. As in previous years, levels of resistant E coli were substantially higher in chicken and turkey meat than in pork and beef. The proportion of E coli isolates resistant to 3rd generation cephalosporins was low in fecal samples from broilers and pigs and not detected in dairy cattle and veal calves.

Selective culturing of fecal samples found that 22.6% were positive for ESBL/AmpC-producing E coli, with a sharp decrease noted in broilers (from 56.5-50.3% in 2015-2016 to 32.6% in 2017); the prevalence in pigs and dairy cows also decreased and stabilized at around 10%. For the second year in a row, an increase was observed in white and rose veal calves carrying ESBL/AmpC-producing E coli, and 2017 was the first year a higher prevalence was recorded in veal calves than in broilers (36.7% vs. 32.6%). The overall presence of ESBL/AmpC-producing E coli in meat samples in 2017 was 9.6%.

No carbapenemase-producing Enterobacteriaceae were detected in active surveillance of livestock, and the colistin-resistance gene MCR-1 was detected in 1.2% of E coli from livestock 7.7% of E coli from chicken meat. The authors of the report say the higher prevalence of MCR-1 in chicken meat compared to fecal broiler samples could be explained by the fact that some retail chicken meat in Dutch supermarkets comes from countries where colistin is used in livestock production.
Jun 27 MARAN 2018 report

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