ASP Scan (Weekly) for Oct 26, 2018

Stewardship to reduce C diff
Declining ear infections, antibiotics
Antibiotic overuse with RSV
Financial incentives for antibiotic stewardship
Costs of ESBL surveillance

Cephalosporin-sparing stewardship tied to lower hospital C diff rates

A Swedish study has found that a hospital stewardship program that restricted cephalosporin use was tied to reduced rates of Clostridioides difficile infection (CDI).

The retrospective study, published yesterday in the Journal of Antimicrobial Chemotherapy, compared two similar hospitals in the country—which has a high incidence of healthcare facility–associated CDI (HCF-CDI) in spite of relatively low in-hospital use of antibiotics. One of the hospitals instituted a cephalosporin-sparing antimicrobial stewardship program (ASP) after 2007, while the other had no such program.

The researchers found that, at the ASP hospital, cephalosporin use declined by 87% from 2007 to 2015, and the number of CDIs dropped from 2.25 per 1,000 hospital admissions to 1.16 (P = 0.0014). The non-ASP hospital, in contrast, had a slight (but not statistically significant) increase, from 2.09 to 2.38 CDIs per 1,000 hospital admissions. The authors said an increased use at the ASP hospital of other broad-spectrum antibiotics, such as piperacillin/tazobactam, was not associated with offsetting increases in CDI cases.

The investigators conclude, "Decreased use of cephalosporins is an effective strategy to decrease HCF-CDI incidence over time in a setting with high incidence and low antibiotic use."
Oct 25 J Antimicrob Chemother abstract


Ear infections—and antibiotics for them—both show decline

Scientists from the drug maker Pfizer report that US pediatric cases of acute otitis media (AOM, or middle ear infection) and antibiotic prescriptions for AOM declined substantially from 2011 to 2016, but the average number of antimicrobial prescriptions written per AOM visit remained stable, according to a study in Vaccine.

The investigators used various data sources to measure outpatient visits, incidence, antimicrobial prescriptions, and medical expenditures for AOM during the study period. They focused on children 9 years old and younger.

The researchers report an estimated 11.5 million AOM episodes in children in that age-group in 2011, with by far the highest incidence rate (IR) in children aged 2 years and younger. All subsequent years had lower IRs, and by 2016, IR was 25.1% lower than in 2011 across the age-group studied. The team also estimated that, from 2012 to 2016, 10.8 million fewer AOM cases and 9.2 million fewer cumulative AOM antimicrobial prescriptions were reported compared with 2011 estimates, which represents about a $5.6 billion drop in direct medical expenses.

The average number of antibiotic prescriptions per AOM visit, however, remained stable, with 0.89 and 0.86 prescriptions per visit in 2011 and 2016, respectively, indicating no change in prescribing practice.
Oct 24 Vaccine abstract


Dutch, Israeli study finds antibiotic overuse in children with viral infections

Originally published by CIDRAP News Oct 25

A team of Dutch and Israeli researchers report in The Pediatric Infectious Disease Journal that nearly a third of children hospitalized with a lower respiratory tract infection (LRTI) caused by a virus were treated unnecessarily with antibiotics.

The patient population in the prospective study included children 1 month of age and over with an LRTI or fever without source from hospitals in the Netherlands and Israel. The researchers were looking to determine the incidence of bacterial coinfections and the amount of antibiotic overuse in children with respiratory syncytial virus (RSV), a common viral LRTI that is a risk factor for bacterial coinfection. In winter seasons, 20% of hospitalizations and 18% of emergency department visits for acute respiratory infections in young children are associated with RSV.

A total of 784 children were recruited from October 2013 through May 2016, and 188 children (24%) were positive for RSV. Of the 188 RSV-positive children, 92 (49%) were treated with antibiotics, including 27 (14%) who had bacterial coinfections and were treated appropriately and 8 in whom an expert panel could not distinguish simple viral infection from bacterial coinfection. That left 57 children (30%) treated unnecessarily with antibiotics. Antibiotic overuse was similar among Dutch and Israeli children.

"In conclusion, our data show that although bacterial coinfections in children with RSV infections are relatively rare, high percentages of antibiotic prescriptions are common," the authors of the study wrote. "Further research is need to develop accurate and practical tools to help physicians recognizing bacterial coinfections in children infected with RSV."
Nov 2018 Pediatr Infect Dis J abstract


Financial incentives may cut antibiotic prescribing, with few unintended results

Originally published by CIDRAP News Oct 22

The antibiotic prescribing component of a financial incentive program to improve services at UK National Health Service (NHS) clinics found a significant reduction in both total and broad-spectrum antibiotic prescribing in primary care settings, with no link to unintended consequences, except for a few specific conditions.

A research team from Imperial College London reported its findings on Oct 18 in two separate reports in Clinical Infectious Diseases: one on the impact of the antimicrobial stewardship component of the Quality Premium (QP) program and the other on possible unintended consequences.

UK officials introduced the QP program in 2015, which included financial incentives for meeting different criteria, including reducing antibiotic prescribing by 1% and reducing broad-spectrum antibiotic prescriptions by 10%.

To gauge the impact of the program, the researchers analyzed national antibiotic prescribing data from April 2013 till February 2017 using a segmented regression analysis of interrupted time series data. They looked at the total number of items prescribed, the number prescribed per STAR-PU (specific therapeutic group age-sex related prescribing units), and number and percentage of broad-spectrum antibiotics prescribed.

More than 140 million antibiotic items were prescribed during the study period. After the quality premium was introduced, antibiotic prescribing decreased by 8.2%, reflecting more than 5.9 million fewer antibiotics prescribed in the 23 months after the QP went into effect compared with expected numbers based on trends found in the months before the intervention. The investigators also saw a relative decrease in antibiotics prescribed per STAR-PU, as well as a similar effect for broad-spectrum antibiotics, which were reduced by 18.9%.
Oct 18 Clin Infect Dis abstract

In the second study, which focused on potential unintended consequences of the reduced prescribing part of the quality premium incentive, the team looked at databases of general practitioner consultations and emergency department (ED) admissions for a set of pre-defined conditions. Their analysis covered 27,334 clinic visits and more than 5 million ED admissions.

Overall, the researchers didn't see any changes in rates for either measure. When they considered each condition separately, however, they found a significant increase in hospital admission for quinsy (peritonsillar abscess) and significant decreases for hospital-acquired pneumonia, scarlet fever, pyelonephritis, and complicated urinary tract infections. For clinic visits, the team focuses on empyema and scarlet fever and didn't observe any significant changes for either.
Oct 18 Clin Infect Dis abstract


Active surveillance for ESBL-E in neonatal intensive care found costly 

Originally published by CIDRAP News Oct 22

A single-center study today in Infection Control and Hospital Epidemiology found that active surveillance to prevent extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) transmission may have contributed to a decline in incidence in a neonatal intensive care unit (NICU), but was too costly to continue.

The retrospective observational study was conducted at Children's National Health System in Washington, DC, where active surveillance for ESBL-E colonization has been performed in the NICU since the early 1990s, when a point prevalence study revealed a colonization rate of 30%. Researchers from the hospital and George Washington University School of Medicine and Health Sciences reviewed 19 years of data to evaluate the efficacy and financial impact of active surveillance on ESBL colonization and infection in the NICU and to assess the need for continuing the practice.

The study included patients admitted to the NICU from January 1999 through March 2018. Active surveillance using rectal swabs was conducted on all patients admitted to the unit until March 2017. Overall, 171 patients were found to have ESBL-E colonization or infection, and 150 of those patients (87.7%) were detected by active surveillance. The overall incidence rate of ESBL-E colonization or infection was estimated to be 1.4 per 100 patient admissions. The hospital-acquired incidence rate was 0.41 per 1,000 patient-days; this rate had declined since 2002, with an average of six cases detected annually, and declined significantly after the unit moved into a single-bed unit featuring private rooms in 2009. Of the 150 colonized patients, 14 (9.3%) subsequently developed an infection.

The researchers estimated that active surveillance resulted in a total of 50,950 specimens being collected and that the total direct cost of processing those specimens was $127,187—an average of $848 to detect one patient colonized with ESBL-E.

"Active surveillance for ESBL-E in this setting might have contributed to the prevention of ESBL-E transmission when used in conjunction with contact precautions and private rooms, but it became increasingly costly when incidence continued to decrease," the authors of the study write. "Thus, we have decided to discontinue the active surveillance, and we continue to emphasize the use of fundamental infection control strategies, including proper hand hygiene, contact precautions, and appropriate antibiotic use, to combat antimicrobial resistance, including that of ESBL-E pathogens, in our NICU."
Oct 22 Infect Control Hosp Epidemiol abstract

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