ASP Scan (Weekly) for Nov 09, 2018

Antibiotics in long-term care facilities
C diff and adverse outcomes
Stewardship in India
Drug-resistant Shigella in Vermont
Deadly MDR infections in India
MCR-1 prevalence in Bolivia
MRSA in refugees
Economic report on AMR interventions
Pioneering efforts against resistance
Poor public antibiotic knowledge
AMR prevalence in Canadian hospitals
Antibiotic dispensing in Spanish pharmacies

Study: Antibiotics commonly prescribed upon discharge to long-term care

A study today in Infection Control and Hospital Epidemiology reports that 23% of patients at an Oregon hospital were prescribed antibiotics upon discharge to a long-term care facility (LTCF).

In the single-center study, researchers analyzed pharmacy data on all adult patients at Oregon Health and Science University Hospital who were discharged to an LTCF from January 2012 through June 2016. They wanted to quantify the prevalence and characteristics of patients prescribed antibiotics upon discharge to an LTCF and examine the association between receiving an antibiotic prescription upon discharge and healthcare use, including 30-day hospital readmission, 30-day emergency department (ED) visits, and Clostridioides difficile-associated hospital readmission or 60-day ED visit.

Among the 6,107 discharges to an LTCF, 22.9% were prescribed antibiotics upon discharge, of whom 24.7% had more than one antibiotic prescription. The most frequently prescribed antibiotics were cephalosporins (20.4%), fluoroquinolones (19.1%), and penicillins (16.7%). Most records of discharged patients (82.1%) had a diagnosis code for a bacterial infection, with the most prevalent diagnosis being urinary tract infections (35.9%).

Among the patients who received an antibiotic prescription upon discharge, the incidence of 30-day hospital readmission to the index facility was 15.9%, the incidence of 30-day ED visit at the index facility was 11.0%, and the incidence of C difficile infection (CDI) on a readmission or ED visit within 60 days of discharge was 1.6%. Following adjustments for confounding, receiving an antibiotic prescription upon discharge was significantly associated with 30-day ED visits (adjusted odds ratio [aOR], 1.2; 95% confidence interval [CI], 1.02 to 1.5) and with CDI within 60 days (aOR, 1.7; 95% CI, 1.02 to 2.8) but not with 30-day readmissions (aOR, 1.01; 95% CI, 0.9 to 1.2).

The authors conclude, "Our observation that nearly one-quarter of discharges to LTCFs were prescribed antibiotics upon discharge may inform interventions to improve antibiotic prescribing and stewardship efforts in both acute-care and LTCFs."
Nov 9 Infect Control Hosp Epidemiol abstract


Study finds increased risk of adverse outcomes in elderly C diff patients

In another study today in Infection Control and Hospital Epidemiology, researchers with Washington University School of Medicine and Sanofi Pasteur found that CDI in elderly patients is associated with increased risk of short- and long-term adverse outcomes, including all-cause mortality, and the risk exists even for those considered at low risk.

Using 2011 Medicare claims data on all elderly patients coded for CDI and a random sample of uninfected patients, the researchers performed two different analyses to understand the impact of CDI on all-cause mortality and short- and long-term morbidity among elderly patients, and to estimate the differential risk of outcomes on CDI compared to uninfected persons. They wanted to determine whether there is heterogeneity in risk of poor outcomes, as that could affect how CDI prevention efforts are targeted.

The investigators compared claims records of 174,903 patients coded for CDI with those of 1,318,538 control patients. In matched-pairs analyses, CDI was associated with increased risk of death (odds ratio [OR], 1.77; 95% CI, 1.74 to 1.81; attributable mortality, 10.9%), new LTCF transfer (OR, 1.74; 95% CI, 1.67 to 1.82), and new skilled nursing facility transfer (OR, 2.52; 95% CI, 2.46 to 2.58) within 30 days. In a stratified analysis, CDI was associated with greatest risk of 30-day all-cause mortality in people with the lowest baseline probability of CDI (hazard ratio, 3.04; 95% CI, 2.83 to 3.26), with the risk progressively decreasing as the baseline probability of CDI increased. CDI was also associated with increased risk of subsequent 30-day, 90-day, and 1-year hospitalization.

"Our findings suggest that CDI prevention strategies should not be limited to just high-risk populations; lower-risk elderly populations may have the greatest benefit," the authors write. "New strategies to prevent CDI focused on the elderly need to be developed to reduce mortality, morbidity, and decline resulting in loss of independence and institutionalization."
Nov 9 Infect Control Hosp Epidemiol abstract 


Indian antimicrobial stewardship program shows promising results

Researchers report that an antimicrobial stewardship program (ASP) at a large Indian hospital appeared to help reduce prescribing of restricted antibiotics and save money. The study appeared yesterday in Open Forum Infectious Diseases.

The ASP at the 1,300-bed hospital in the state of Kerala was established in February 2016 and included a physician/hospitalist, an intensivist, microbiologists, clinical pharmacists, and an administrative champion. The ASP created a list of restricted antibiotics and tracked appropriate antibiotic selection, including loading dose, maintenance dose, frequency and route, duration of therapy, de-escalation, and compliance with ASP recommendations. Appropriate use was encouraged with positive feedback to providers.

To assess the performance of the ASP, the researchers compared defined daily doses (DDD) and cost of antimicrobials during the pre-implementation period (February 2015 to January 2016) and the post-implementation period (February 2016 to January 2017).

Of the 48,555 patients admitted during the post-implementation phase, 4,613 (10%) received at least one antibiotic, and 1,020 received 1,326 prescriptions for restricted antibiotics. Antibiotic therapy was determined to be appropriate for 56% of the total patient prescriptions. A total of 2,776 instances of inappropriate therapy were noted by the ASP team, with inappropriate duration (29%) the most common reason. Compliance with ASP recommendations was 54%. For all major restricted antibiotics (except carbapenems), DDD per 100 patient-days declined and the mean monthly cost dropped by 14.4%.

The authors of the study say the preliminary results are encouraging, given that ASPs are rare and generally unstructured in India, and suggest that mandating multidisciplinary ASPs in acute care hospitals would be a "wise next step" for policy in India. 
Nov 8 Open Forum Infect Dis abstract


Vermont tracks XDR Shigella outbreak in retirement community

Originally published by CIDRAP News Nov 8

The Vermont Department of Health (VDH) is investigating an outbreak involving an extensively drug-resistant (XDR) Shigella sonnei strain at a retirement community in Wake Robin. The outbreak involves 22 confirmed and 44 probable cases.

Vermont health officials began investigating the outbreak on Oct 18 and alerted the Centers for Disease Control and Prevention (CDC) of the outbreak on Oct 22. The CDC is assisting Vermont officials with the investigation because of the highly resistant nature of the bacteria.

"Antibiotic resistance means that the bacteria have developed the ability to prevent antibiotics from working. When bacteria are resistant to antibiotics, the treatment we would normally use may not work, and the bacteria can continue to multiply," said Vermont Health Commissioner Mark Levine, MD, in a VDH press release. "Fortunately, most people who get this will recover in five to seven days without the need for treatment."

Shigella infections commonly cause stomach cramps, diarrhea, and fever. Shigella is best prevented by washing hands thoroughly several times per day.

Levine said the most recent onset of illness was Nov 1.
Nov 6 VDH press release


Indian study links multidrug-resistant infections to higher mortality risk

Originally published by CIDRAP News Nov 8

A new study by researchers with the Center for Disease Dynamics, Economics and Policy has found a significant relationship between multidrug-resistant (MDR) bacterial infections and mortality in India.

In the retrospective study, published today in Clinical Infectious Diseases, researchers analyzed patient-level antimicrobial susceptibility tests (ASTs) results and patient mortality outcomes from 10 Indian hospitals. They focused on resistance patterns for drugs commonly used to treat ESKAPE pathogens—Enterococcus spp., Staphylococcus aureusKlebsiella pneumoniaeAcinetobacter baumanniii, Pseudomonas aeruginosa, and Enterobacter spp—and resistance to Escherichia coli. To evaluate patient mortality in relation to MDR bacteria, they conducted multivariate regression analyses, adjusting for age, sex, hospital location, and specimen source.

The researchers analyzed data on 5,103 AST results. The overall mortality rate of patients was 13.1%, with increased odds of mortality among patients with MDR infections (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.14 to 2.16) and XDR infections (OR, 2.65; 95% CI, 1.81 to 3.88). Infections with MDR and XDR E coli, XDR K pneumoniae, and MDR A baumannii were associated with 2-3 times higher mortality. Mortality in patients with methicillin-resistant S aureus (MRSA) infections that were also non-susceptible to aminoglycosides was significantly higher when compared with susceptible strains.

"While data were observational, preventing establishment of causality, our results provide strong quantification of the association between mortality and multidrug resistant patterns in a representative LMIC [low- and middle-income country], and highlight the significant threat MDR and XDR pathogens pose to human health in developing countries," the authors write. 
Nov 8 Clin Infect Dis abstract


High MCR-1 prevalence found in Bolivian children not exposed to antibiotics

Originally published by CIDRAP News Nov 8

Scientists have found an almost 40% carriage rate of the colistin-resistance gene MCR-1 in children in the Chaco region of Bolivia, according to a report today in Eurosurveillance.

The study involved 337 children from eight villages in the semi-arid, sparsely populated region in eastern Bolivia. The children ranged in age from 7 to 11 years, with an average age of 9.2 years.

The researchers analyzed fecal samples and found that 129 of the children (38.3%) harbored pathogens that contained MCR-1. Some children had more than one positive sample, yielding a total of 173 MCR-1–positive isolates, 171 of which were E coli. All of those 171 isolates were susceptible to carbapenems and tigecycline.

Only 4 of the MCR-1 carriers had previous antibiotic exposure. Colistin is considered an antibiotic of last resort for MDR bacterial infections.

The authors conclude, "This high prevalence of mcr-1-like carriage, in absence of professional exposure, is unexpected. Its extent at the national level should be investigated with priority."
Nov 8 Eurosurveillance report


Study: Almost half of refugees to Finland harbor MDR bacteria

Originally published by CIDRAP News Nov 8

University of Helsinki researchers determined that 45% of asylum seekers and refugees treated at their hospital harbored MDR bacteria, including 21% who had MRSA, according to a separate study today in Eurosurveillance.

The investigators analyzed microbiological and clinical data from 447 refugees who were treated from January 2010 to August 2017. Iraq was the most common country of origin (46.5%), followed by Afghanistan (10.3%), Syria (9.6%), and Somalia (6.9%).

The authors found that 45.0% were colonized by MDR bacteria, 32.9% had extended-spectrum beta-lactamase-producing Enterobacteriaceae, 21.3% had MRSA, and 0.7% harbored carbapenemase-producing Enterobacteriaceae. As well, 12.5% had two or more MDR bacterial strains. Multivariable analysis revealed geographic region and previous surgery outside Nordic countries as risk factors for MRSA colonization.

The authors conclude, "The data suggest that these patients should be considered a risk group that requires both screening of MDR bacteria and infection control measures at entry to hospitals in low-prevalence countries."
Nov 8 Eurosurveillance study


OECD: Interventions to reduce resistant bacteria could save lives, money

Originally published by CIDRAP News Nov 7

A report today from the Organization for Economic Co-operation and Development (OECD) suggests that investment in a package of measures to reduce antimicrobial resistance (AMR) could avert thousands of deaths each year and save money in the long run.

According to the OECD analysis, the proportion of infections caused by antibiotic-resistant bacteria could increase from 17% in 2015 to 18% in 2030 across the 33 OECD countries, with resistance to second- and third-line antibiotics expected to be 70% higher by 2030. In countries outside the OECD, resistance rates are higher and projected to grow even faster. If no effective action is taken, the report warns, an estimated 2.4 million people in Europe, North America, and Australia could die between 2015 and 2050, and OECD countries could spend up to $3.5 billion a year on AMR-related complications.

The report suggests, however, that governments could counter the problem with a combination of five affordable public health interventions: (1) improved environmental hygiene in healthcare facilities, including better hand hygiene; (2) stewardship programs to promote more prudent use of antibiotics; (3) use of rapid diagnostic tests to differentiate between bacterial and viral infections; (4) delayed antibiotic prescribing; (5) and public awareness campaigns.

"All the assessed interventions are 'best buys' to tackle AMR in the assessed countries given their high impact on population health, affordability to implement, and excellent cost-effectiveness ratio," write the authors of the report. "Savings from delayed prescriptions, improved hand hygiene, and, in most cases, from stewardship programmes exceed the cost of implementation."

The OECD analyzed three different packages of interventions and estimated that a mixed intervention package that includes stewardship programs, use of rapid diagnostic tests, mass media campaigns, and enhanced hospital hygiene could avert up to 47,000 deaths and save around $3 per person a year in OECD countries.
Nov 7 OECD report


'Pioneering' AMR initiatives to be highlighted at upcoming conference

Originally published by CIDRAP News Nov 7

The Wellcome Trust announced today that it has chosen two projects that are taking "pioneering" action to combat AMR to present their work at the upcoming Call to Action conference in Ghana on Nov 18-19.

One of the projects is based in Bangladesh and involves a community dialogues approach to helping prevent the growth of AMR. Led by the University of Leeds in collaboration with the Malaria Consortium and ARK Foundation, the project trains volunteers to facilitate dialogues with community members about the rational use of antibiotics. From April 2018 through July 2018, volunteers hosted more than 200 meetings in the Comilla district of Bangladesh.

The other project is Superheroes Against Superbugs, a program that teaches schoolchildren in India about bacteria, antibiotics, and resistance and encourages them to create a dialogue about AMR through comic books, short animated films, and other creative concepts.

The two initiatives will be highlighted on day one of the Call to Action conference, which will bring together health officials from national governments and agencies and representatives from the private and philanthropic sectors to address the most critical gaps in tackling the development and spread of drug-resistant infections. The conference is being co-hosted by Wellcome Trust, the United Nations Foundation, and the governments of Ghana and Thailand.
Nov 7 Wellcome Trust news release


Nationwide survey in Japan finds deep misconceptions about antibiotics

Originally published by CIDRAP News Nov 7

A nationwide survey in Japan has found that misconceptions about antimicrobials and antimicrobial resistance (AMR) abound, and many have taken antimicrobials inappropriately, with almost half having obtained antibiotics for the common cold, according to a study in PLOS One.

Researchers conducted the online survey in March 2017 and collected data from 3,390 participants. Questions focused on antibiotic use, knowledge about the drugs and AMR, sources of antibiotic information, and behavior and perception of antibiotics during visits with healthcare providers.

Almost half (46.2%) of the respondents had taken antibiotics, 45.5% of them for the common cold, which doesn't require antibiotics. The study also found that 11.7% of participants stored antibiotics at home and 23.6% said they had stopped or adjusted antibiotic doses by themselves; 1.9% of respondents had taken leftover antibiotics.

Regarding antibiotic and AMR knowledge, only 21.9% knew that antibiotics could not kill viruses, which compares with 43% in Europe, the authors said. In addition, only 24.6% of Japanese knew antibiotics were not effective against colds and influenza. Although 67.5% of participants knew that antibiotics would not work in the future unless used properly, only about 20% of them knew what kind of diseases or pathogens they target. Only 7.1% answered all four questions about antibiotics correctly.

During medical visits, 10.2% asked for antibiotic prescriptions from their physicians, and 30.2% believed that physicians who prescribed the drugs for the common cold were good.

The authors conclude, "Although information about antibiotics and AMR has not been adequately shared to the Japanese public, the majority of them who did have the correct information reported their wish for changes to improve the behaviour of people with regards to use of antibiotics."
Nov 5 PLOS One study


Rate of drug-resistant organisms in Canadian hospitals remains steady

Originally published by CIDRAP News Nov 5

A point prevalence survey conducted at Canadian hospitals shows that national prevalence rates for infection or colonization with antimicrobial-resistant organisms (AROs) saw little change from 2010 to 2016, according to a study today in Infection Control and Hospital Epidemiology.

The survey of adult inpatients in Canadian hospitals with more than 50 beds was conducted in February 2016. Patients colonized or infected with methicillin-resistant S aureus (MRSA), C difficile infection (CDI), vancomycin-resistant Enterococcus (VRE), extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae, and carbapenem-resistant Enterobacteriaceae (CREs) were included. Previous surveys had been conducted in 2010 and 2012.

In total, 160 hospitals from 9 of 10 provinces with 35,018 adults patients participated in the survey. Hospitals reported a total of 3,117 patients colonized or infected with at least one ARO, for a prevalence of 8.9 per 100 patients. Median prevalence per 100 patients was 4.1 for MRSA, 1.1 for CDI, 0.8 for VRE, 0.8 for ESBLs, and 0 for CREs. Hospitals in western Canada had the highest median prevalence of MRSA and VRE, while hospitals in central Canada had a higher median prevalence of CDI. Among the 106 hospitals that participated in all three surveys, no significant changes were detected in the prevalence of any of the AROs from 2012 to 2016.

Although CREs remained infrequently identified, they were reported from more hospitals in 2016 (15%) compared to 2012 (7%). The authors of the study also note that the true prevalence of VRE in Canadian hospitals is likely higher because routine screening for VRE on admission decreased from 94% in 2010 to 74% in 2016.

The authors say ongoing national surveillance for AROs will be important for evaluating potential changes in the epidemiology of diseases caused by these bacteria.
Nov 5 Infect Control Hosp Epidemiol study


Spanish study: Nearly 20% of pharmacies dispense antibiotics without  prescription

Originally published by CIDRAP News Nov 5

A study today in the Journal of Antimicrobial Chemotherapy reports that nearly 20% of pharmacies in a region of Spain dispense antibiotics without a prescription, especially under patient pressure.

In the cross-sectional "simulated patient" study, conducted in two provinces of northwestern Spain from December 2016 through January 2017, four actors visited 977 pharmacies simulating symptoms of a respiratory infection. Each visit began with a request for medication to relieve symptoms, then gradually escalated to a request for stronger medication than what was originally offered, followed by a request for an antibiotic and a specific request for amoxicillin. The result of the demand process was recorded, along with other data (including the area where the pharmacy was located and the sex and education level of the person dispensing the antibiotic).

An antibiotic was obtained in 18.83% (95% confidence interval [CI], 16.5% to 21.4%) of the visits, with the number of antibiotics dispensed increasing with the level of pressure. Analysis of the effect of independent variables showed that there was greater likelihood of antibiotic dispensing in rural areas (odd ratio [OR], 1.79; 95% CI, 1.20 to 2.68) or semi-rural areas (OR, 1.66; 95% CI 1.13 to 2.44) than in urban areas. No association was found with the sex or training of the person who dispensed the antibiotic. 

The authors of the study say the findings indicate that interventions aimed at reducing dispensing of non-prescribed antibiotics should be carried out, with a priority placed on rural pharmacies. Spain has one of the highest rates of antibiotic consumption in the European Union.
Nov 5 J Antimicrob Chemother study

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