Stewardship / Resistance Scan for Jul 12, 2018

Stewardship nudge
MDR-TB in kids
Mycoplasma genitalium guidelines

Study: Intervention reduces unnecessary antibiotic use for pneumonia

A new study by researchers with a health system in Detroit indicates that a small, behavioral "nudge" in microbiology reporting increased de-escalation and discontinuation of unnecessary broad-spectrum antibiotics in pneumonia patients. The results were reported in Open Forum Infectious Diseases.

In the study, researchers with the Henry Ford Health System evaluated antibiotic de-escalation and discontinuation in 210 patients treated with anti–methicillin-resistant Staphylococcus aureus (MRSA) and antipseudomonal antibiotics for respiratory infections. The quasi-experimental study was conducted over two periods: a 6-month period before implementation of an intervention to improve the clarity of microbiology results, and a corresponding 6-month period following the intervention.

In the intervention, respiratory cultures with no dominant organism growth and no Pseudomonas or S aureus were reported as "commensal respiratory flora only: No S aureus/MRSA or P. Aeruginosa." Prior to the intervention, these were reported as "commensal respiratory flora."

The researchers found that de-escalation/discontinuation was more commonly found in the intervention group than in the pre-intervention group (73% vs. 39%, P < 0.001). After adjusting for severity of illness and comorbidities, the intervention comment was associated with a 5.5-fold increased odds of de-escalation. Acute kidney injury was also reduced in the intervention group (14% vs. 31%, P = 0.003). No statistically significant difference in all-cause mortality was detected between the two groups (18% vs. 30%, P = 0.052).

"Our study demonstrates that a simple behavioral intervention to more clearly communicate respiratory culture results for normal flora can impact prescribing, and may reduce patient harm," the authors write.
Jul 10 Open Forum Infect Dis abstract


Meta-analysis finds 2nd-line therapy effective against MDR-TB in children

A meta-analysis of 28 studies involving children with multidrug-resistant tuberculosis (MDR-TB) determined that, in general, second-line MDR-TB antibiotics work well in this age-group, despite a high burden of severe disease, according to a study yesterday in PLoS Medicine.

The researchers analyzed data on 975 children from 18 countries; 731 (75%) had bacteriologically confirmed and 244 (25%) had clinically diagnosed MDR-TB. The median age was 7.1 years, and 39% were infected with HIV. When compared with clinically diagnosed patients, children with confirmed MDR-TB were more likely to be older, to be infected with HIV, to be malnourished, and to have severe TB on chest radiograph (P < 0.001 for all traits).

Overall, 764 of 975 (78%) had a successful treatment outcome at the conclusion of second-line therapy—75% among confirmed and 89% among clinically diagnosed children. Success dropped to 56%, however, among HIV-positive children who had bacteriologically confirmed TB and did not receive any antiretroviral treatment during MDR-TB therapy, compared with 82% in those who received ART.

In children with confirmed MDR-TB, the use of second-line injectable agents and high-dose isoniazid were associated with treatment success (adjusted odds ratio, 2.9 and 5.9, respectively), but the authors say the findings for high-dose isoniazid may have been skewed by site effect, as most of these patients came from Cape Town.
Jul 11 PLoS Med study


British group offers guidance to combat resistant Mycoplasma genitalium

The British Association for Sexual Health and HIV (BASHH) this week released new guidelines for managing infections with Mycoplasma genitalium, which is becoming increasingly antibiotic-resistant. The guidelines emphasize comprehensive testing, including for macrolide-resistance mutations, and point out that many clinics don't have such tests but should.

M genitalium infection is most often asymptomatic, but when they do occur they can mimic other sexually transmitted diseases like chlamydia and gonorrhea.

The highest-level recommendations in the guidance including testing all male patients who have non-gonococcal urinary tract infections, as well as all patients who have signs and symptoms of pelvic inflammatory disease. "Nucleic acid amplification tests (NAATs) that detect M. genitalium specific DNA or RNA in clinical specimens are the only useful diagnostic method," the guidelines state. "Several CE marked commercial tests are available, although none are currently FDA approved."

The authors also advise that, when possible, all M genitalium–positive specimens be tested for macrolide-resistance mediating mutations.

They state, "Whilst the guideline sets out recommendations for best practice according to current evidence, it is acknowledged that not all clinics will have access to M. genitalium testing at the time of guideline publication. The objective of this guideline is therefore also to assist clinics and laboratories in making the case for funding towards M. genitalium testing by underlining the importance of testing in relevant populations."

BASHH has opened the guidelines to feedback until Sep 1.
Jul 8 BASHH guidelines 

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