ASP Scan (Weekly) for Nov 16, 2018

Improper prescribing in the ER
Hospital stewardship in China
Antibiotic use in Poland
Swiss AMR-related illness, deaths
Antibiotic use in Scotland
Drug-resistant malaria in India
Spread of resistant bacteria in hospitals
Health departments against antimicrobial resistance
Public concern over antibiotic resistance

Australian data show a third of emergency room antibiotics not needed

An observational study in Australia has found that a third of antibiotic prescriptions in an emergency department (ED) were deemed inappropriate, according to a study yesterday in the Journal of Antimicrobial Chemotherapy.

Researchers at Gold Coast University Hospital assessed 1,019 patient presentations that involved an antibiotic prescription in the ED during 4 separate weeks throughout 2016, one each in February, May, August, and November.

They determined that 640 antibiotic prescriptions (62.8%) were appropriate, 333 (32.7%) were inappropriate, and 46 (4.5%) were not assessable. Adults were more likely to receive an inappropriate antibiotic prescription than children (36.9% vs. 22.9%). Patients who likely had sepsis-related organ failure were also more likely to be prescribed improper antibiotics (56.7% vs. 36.1%).

The researchers found no difference in inappropriate prescribing rates in the ED based on patient gender, hospital admission status, reason for antibiotic administration (treatment vs. prophylaxis), or time of shift (day vs. night).

The authors conclude, "With over one in three antibiotic prescriptions in the ED being assessed as inappropriate, there is a pressing need to develop initiatives to improve antibiotic prescribing to prevent antibiotic-associated patient and community harms."
Nov 15 J Antimicrob Chemother study


Hospital in China cuts antibiotics markedly after stewardship initiation

A single-center study in China reports that, after instituting an antimicrobial stewardship program, the use of antibiotics was cut by almost two-thirds and rates of methicillin-resistant Staphylococcus aureus (MRSA) dropped dramatically, according to a study today in Epidemiology & Infection.

Scientists explored the trends and correlations between antibiotic consumption and resistance of S aureus in a tertiary hospital at Jiaotong University in northwest China from 2010 to 2016. They found that antibiotic use dropped from 951.9 to 346.5 defined daily doses per 1,000 patient-days, a 63.6% reduction. The decrease was statistically significant for several antibiotic classes, including cephalosporins, monobactams, aminoglycosides, imidazole derivatives, and macrolides.

The incidence of MRSA among S aureus isolates declined from 73.3% in 2010 to 41.4% in 2017, and the decrease was significantly correlated with lower consumption of several classes of antibiotics. The authors note that, since the end of the study, resistance rates of S aureus have remained significantly reduced, and MRSA rates have dropped even further.
Nov 16 Epidemiol Infect study


Decade-long study shows high antibiotic consumption in Poland

A 10-year study of antibiotic consumption in Poland published yesterday in Antimicrobial Resistance & Infection Control discovered high use of the drugs compared with the rest of Europe, and consumption has climbed 8% since 2007.

Study investigators used data from the Healthcare-Associated Infections Surveillance Network within the European Centre for Disease Prevention and Control (ECDC), combined with a literature review. They measured consumption in daily doses per 1,000 inhabitants per day (DIDs).

They found that antibiotic use nationwide rose from 22.2 DIDs in 2007 to 23.9 in 2016, an 8.3% increase, though down from a high of 26.2 in 2015. That compares with a low of 10 DIDs in the Netherlands and a high of 36 DIDs in Greece, according to ECDC data. The figure places Poland as having the 19th highest consumption rate among 23 European nations.

The report also notes that rates of broad-spectrum antibiotic prescribing are also high, at 25.8% of total antibiotics, placing Poland at 16 of the 23 countries. The rate of broad-spectrum prescribing, however, is falling in Poland.

The authors say that, although the high rate of antibiotic consumption does not bode well for antibiotic resistance, the 8% increase is much lower than the 36% global increase worldwide in the past decade.

The authors conclude, "Since the limited educational activities among physicians and dentists may play an important role in the current antibiotic consumption patterns, integrated actions focusing on appropriate antibiotic prescribing in the pre- and post-graduate training should be instigated and followed up at [the] national level."
Nov 15 Antimicrob Resist Infect Control study


Swiss researchers report 7,000 AMR cases, almost 300 AMR deaths a year

Swiss researchers estimate that antibiotic-resistant bacteria in the country cause more than 7,000 illnesses and almost 300 deaths a year, according to a letter in The Lancet Infectious Diseases.

To duplicate a study using ECDC data in 2015 for European Union nations, the researchers applied the same methodology to data from the ECDC and the Swiss Centre for Antibiotic Resistance for the same year.

They estimated that 7,156 cases of infections with antibiotic-resistant bacteria occurred in 2015, including 276 deaths and 7,400 disability-adjusted life-years (DALYs) lost. That corresponds to 85.0 cases, 3.3 deaths, and 87.8 DALYs per 100,000 people. The highest proportion of the infections was caused by third-generation cephalosporin-resistant Escherichia coli and Klebsiella pneumoniae.
Nov 15 Lancet Infect Dis letter


Scottish officials report human antibiotic use down slightly

Originally published by CIDRAP News Nov 15

Health Protection Scotland (HPS) this week released its One Health antimicrobial resistance (AMR) report, which found decreases in antibiotic use overall and in primary care but increases in acute care, with AMR levels in animals remaining fairly steady.

The report said the total use of antibiotics in people was 25.5 defined daily doses per day in 2017, a 3.0% decline since 2013. Antibiotic use in primary care declined 7.8% since 2013, but in acute hospitals it increased 18.0% in the same period.

Other findings in humans:

  • As part of Scotland's shift in healthcare roles, nurses are now responsible for the second-highest proportion of antibiotic prescribing in the community: 8.4%, up from 3.9% in 2013.
  • The proportion of Escherichia coli bacteremia isolates non-susceptible to commonly used antibiotics was generally stable in the last 5 years, but resistance to some antibiotics stayed high.
  • Officials reported 108 carbapenemase-producing organisms in 2017, a 39% increase since 2013.
  • The HPS recorded 2,610 gonorrhea cases in 2017. None were ceftriaxone non-susceptible, but high levels of azithromycin resistance were noted in 1.6%.

Professor Alistair Leanord, Director of Scottish Microbiology Reference Laboratories, said in an HPS news release, "It is reassuring that we have not seen any significant changes in resistance to antibiotics in the common organisms that cause the majority of infections."

In animals, data from veterinary clinics show that levels of non-susceptibility to antibiotics have remained stable from 2013 to 2017, though levels of non-susceptibility in E coli from poultry and pigs were greater than those from cattle and sheep.

Extended-spectrum beta-lactamases (ESBLs) were detected in an E coli isolate from a fecal sample from a single pig and also in the urine of a dog in 2017. That compares with five ESBLs detected from animal samples in 2016.

The report did not include antibiotic use data for animals.
Nov 13 HPS news release
Nov 13 HPS full report


Study shows evidence of artemisinin resistance in East India

Originally published by CIDRAP News Nov 15

A study today in the New England Journal of Medicine provides evidence of artemisinin-resistant Plasmodium falciparum malaria in Eastern India that may be spurred by a novel mutation.

The study was conducted in West Bengal, India, in 2013 and 2014, and involved 136 patients with uncomplicated malaria treated with artesunate-sulfadoxine-pyrimethamine. Therapeutic efficacy was monitored from day 1 to day 42, using thick blood smears that analyzed the clearance of the malaria parasite from the blood.

The authors followed World Health Organization (WHO) guidelines to define artemisinin resistance, which included the presence of parasitemia at 72 hours after treatment (with a parasite-clearance half-life of more than 5 hours), the persistence of a parasite survival rate greater than 10%, and the presence of a mutation in kelch13 distal to codon 440.

Increased parasite clearance half-lives longer than 5 hours were observed in 14% of the patients. 

"Among the 5 patients who were positive for parasites at day 3, the isolates from 4 patients had the kelch13 G625R mutation, and the isolate from the other patient had the R539T mutation. In accordance with the WHO criteria, these 5 isolates were thus identified as being artemisinin-resistant," the authors said. "We identified G625R as a potential novel mutation that, along with R539T, is associated with artemisinin resistance."

The authors concluded the study by calling for increased surveillance of drug resistance.
Nov 15 N Engl J Med 


Study examines transfer of bacteria between hospital surfaces, patients

Originally published by CIDRAP News Nov 14

In a study today in Infection Control and Hospital Epidemiology, researchers from Duke University and the University of North Carolina observed the transmission of multidrug-resistant organisms (MDROs) between the hospital environment and patients in nearly 20% of encounters.

In the prospective cohort study, which was conducted at two hospitals, the researchers sought to characterize the nature of bacterial transfer events between patients and environmental surfaces using four "marker" MDROs known for their propensity to contaminate and persist on hospital surfaces: (MRSA), vancomycin-resistant enterococci (VRE), Clostridioides difficile, and multidrug-resistant Acinetobacter baumannii. Although contaminated surfaces are thought to play a role in spreading healthcare-associated infections, the nature, direction, persistence, and quantity of bacterial transfer between surfaces and patients remains poorly understood.

The researchers collected data on 80 patient-room encounters in 68 general ward rooms. Environmental and patient microbiological samples were obtained on admission into a freshly disinfected inpatient room, and repeat samples from room surfaces and patients were taken on days 3 and 7 and each week the patient stayed in the same room. The two primary outcomes of interest were the baseline and subsequent patterns of patient colonization and hospital surface contamination, and the number of microbiologic and molecularly proven bacterial transfer events between hospital surfaces and patients.

In total, 9 patients (11.3%) were asymptomatically colonized with MDROs at study entry. Hospital rooms were contaminated with MDROs despite terminal disinfection in 44 of 80 patient rooms (55%) at the time of study enrollment. The researchers detected microbiologic bacterial transfer events in 12 of 65 patients (18.5%), with 4 occurring from the patient to the environment, 4 occurring from the environment to the patient, and 4 of indeterminate direction. In 2 of the encounters, the patient acquired the MDRO present in the environment at the time of admission.

The study authors conclude, "This study suggests that research on prevention methods beyond the standard practice of room disinfection at the end of a patient's stay is needed to better prevent acquisition of MDROs through the environment." 
Nov 14 Infect Control Hosp Epidemiol abstract


Local health departments join the AMR Challenge

Originally published by CIDRAP News Nov 13

To mark US Antibiotic Awareness Week, the National Association of County and City Health Officials (NACCHO) today announced a commitment to support the Antimicrobial Resistance (AMR) Challenge, a year-long initiative led by the US Department of Health and Human Services and the Centers for Disease Control and Prevention.

Organization officials say local health departments can help in the fight against AMR by investigating reportable diseases and unusual resistance, promoting containment strategies to reduce the spread of disease, and collecting and analyzing data to identify outbreaks, monitor trends, and target prevention efforts.

"As a partner of the AMR Challenge, NACCHO aims to increase awareness and engagement of local health departments in activities related to preventing and controlling antimicrobial resistance; promote the critical role of local health departments in protecting their communities from antimicrobial resistance-related threats; and facilitate opportunities for local health departments to identify local-level commitments in support of the AMR Challenge," NACCHO CEO Lori Tremmel Freeman said in a press release.

The challenge, launched in September, calls on public- and private-sector organizations around the world to make at least one commitment in one of five areas: improving antibiotic use in humans and animals; reducing antibiotics and resistant bacteria in the environment; developing new antibiotics, vaccines, and diagnostics; enhancing data collection and sharing; and improving infection prevention and control.

NACCHO represents the nation's nearly 3,000 local health departments.
Nov 13 NACCHO press release
Sep 26 CIDRAP News story "HHS, CDC issue AMR 'challenge' to public, private sectors"


Survey shows vast majority of Americans are concerned about resistance

Originally published by CIDRAP News Nov 12

A new public opinion survey shows that more than 8 in 10 Americans are concerned about the health threat posed by antibiotic resistance, and majorities across the political spectrum think the federal government should do more to address the issue.

In the survey of 1,004 US adults, commissioned by Research!America in collaboration with the Infectious Diseases Society of America (IDSA), 65% of respondents said antibiotic resistance is a public health problem and 81% said they're concerned that resistance will make infections more difficult or impossible to treat. Seventy-six percent of respondents—81% of Democrats, 76% of Republicans, and 70% of Independents—said the federal government should increase funding for research and public health initiatives, while 74% agreed that the government should provide incentives to encourage increased private sector investment in antibiotic development.

"Americans understand that antibiotic-resistant 'superbugs' are a public health threat, and they support putting the public and private sector research continuum to work to address this intensifying health threat," Mary Woolley, Research!America president and CEO, said in a press release.

The survey also revealed, however, that Americans may need more education on appropriate antibiotic use. While 91% of respondents said healthcare providers should only prescribe antibiotics when they're needed, more than a third (37%) said antibiotics are effective for treating viral infections, and 29% said they would be dissatisfied if their child did not receive an antibiotic for a viral infection. Only 57% were aware that even a single course of unnecessary antibiotics can contribute to antibiotic resistance.
Nov 12 Research!America press release

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