ASP Scan (Weekly) for May 24, 2019

WHA and antimicrobial resistance
Urgent sepsis antibiotics
Resistant Pseudomonas from Mexico
Antibiotic prescribing nudge
Unnecessary testing, treatment for kids' pneumonia
Fewer antibiotics for implant infections
Artificial intelligence for AMR

Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans

WHA adopts resolution to combat antimicrobial resistance

Yesterday member states at the World Health Assembly (WHA)—the annual meeting of the decision-making body of the World Health Organization (WHO)—adopted a resolution calling for continued high-level commitments to implement and adequately fund multisectoral national action plans addressing antimicrobial resistance, the WHO said in a news release.

The resolution urges countries to strengthen infection prevention and control measures, including water sanitation and hygiene; enhance participation in the Global Antimicrobial Surveillance System; ensure prudent use of antimicrobials; and support multisectoral annual self-assessment surveys.

The resolution acknowledges the work of the Interagency Coordination Group on Antimicrobial Resistance to provide practical guidance to enhance global action to address antimicrobial resistance, and stresses the importance of addressing antimicrobial resistance to the achievement of the 2030 Agenda for Sustainable Development. 

It requests the WHO director-general to significantly enhance support to countries in implementing their national action plans and help mobilize needed financial resources, in collaboration with other United Nations agencies and partners. It also calls on the WHO director-general to maintain the WHO list of critically important antimicrobials for human medicine.
May 23 WHO news release 


Study links lower triage scores to delayed sepsis antibiotics

Originally published by CIDRAP News May 23

Sepsis patients who received a slightly higher emergency department (ED) triage score received antibiotics faster, a crucial step for survival, researchers from Intermountain Medical Center reported yesterday at the American Thoracic Society annual meeting under way in Dallas.

For the study, the team looked at adult sepsis patients who were treated at four Intermountain EDs in Utah from July 2013 to January 2017, according to an Intermountain press release. The EDs use a common five-point acuity score, with one being most in need of immediate care and five the least. They focused on patients with mid-range scores of 2 (emergent) and 3 (urgent) who had abnormally low blood pressures. Of 799 patients, 591 has a score of 2 and 208 had a score of 3. Then they gauged how quickly the patients received antibiotics.

Those who had triage scores of 3 had door-to-antibiotic times that were 32 minutes longer than those assigned a score of 2.

Ithan D. Peltan, MD, MSc, the study's senior author and attending physician in the Intermountain Medical Center Shock Trauma Intensive Care Unit and Intermountain Healthcare Telecritical Care, said in the statement that federal and international standards encourage starting broad-spectrum antibiotics within 3 hours of a sepsis patient's ED arrival. "Those 32 minutes can make a major difference in a patient's chances for survival."
May 22 Intermountain Medical Center press release


Report on superbugs from Mexico highlights medical tourism dangers

Originally published by CIDRAP News May 23

Officials from the Centers for Disease Control and Prevention (CDC) and seven state health departments today provided new details on 12 US patients who contracted Verona integron–encoded metallo-beta-lactamase–producing carbapenem-resistant Pseudomonas aeruginosa (VIM-CRPA) tied to medical procedures in Mexico—and how the infections could pose a risk to US hospitals.

Reporting in Morbidity and Mortality Weekly Report (MMWR), the investigators say the CDC received 31 reports of VIM-CRPA through its Antibiotic Resistance Laboratory Network from Sep 18 through Nov 19, 2018. Six of those cases were tied to invasive medical procedures in Mexico. After the CDC alerted healthcare professionals about the risk, six more cases came to light.

The 12 patients were from seven states: Utah, Washington, Arizona, Arkansas, Oregon, Texas, and West Virginia. Specimen collection ranged from November 2015 through December 2018. Eleven of the patients were medical tourists—they had traveled to Mexico specifically for bariatric surgery—and the 12th underwent endoscopic cholangiopancreatography in September 2018 after falling ill while traveling. Six patients were hospitalized in the United States for their VIM-CRPA infections, and one who developed a bloodstream infection died. Previous reports have noted that the infections have been tied to Grand View Hospital in Tijuana.

"This investigation highlights the potential for acquiring infections with highly antibiotic-resistant organisms not commonly found in the United States when receiving health care abroad that, once imported into this country, can spread within U.S. health care facilities," the authors write.

They add, "Any patient with an overnight stay in a health care facility outside the United States in the preceding 6 months should undergo rectal screening for carbapenemases on admission to a U.S. health care facility."

On Mar 5, the WHO said 20 people in nine states were tied to the outbreak.
May 24 MMWR report
Mar 5 CIDRAP News scan


Letter to 'nudge' high antibiotic prescribers linked to drop in prescribing 

Originally published by CIDRAP News May 21

A letter sent to the highest antibiotic-prescribing General Practitioners (GPs) in Northern Ireland was tied to a nearly 5% reduction in prescribing in those practices over the course of a year, researchers reported yesterday in the Journal of Antimicrobial Chemotherapy.

The letter, signed by Northern Ireland's chief medical officer, was sent to 221 GPs in 67 practices in Northern Ireland in October 2017, on the basis of those practices being in the top 20% of highest prescribers by standardized total antibiotic prescribing rate. The idea behind the behavioral intervention was that providing a descriptive social norm feedback "nudge" could get prescribers to change their prescribing practices. A similar intervention conducted in England in 2014 was associated with 3.3% relative reduction in antibiotic prescribing in targeted practices.

The outcomes measured in the study were the standardized total antibiotic prescribing rates in the four calendar quarters following the intervention (October 2017 through September 2018).

The greatest change occurred in the first quarter following the intervention, when there was a change of – 25.7 (95% confidence interval [CI], – 42.5 to – 8.8) antibiotic items per 1,000 Specific Therapeutic group Age-sex Related Units (STAR-PU) associated with the intervention. But with each subsequent quarter, the coefficient increased by a diminishing amount, to – 58.7 antibiotic items per 1,000 STAR-PU (95% CI, – 116.7 to – 0.7) after 1 year. In the final three quarters of the intervention, none of the individual quarters showed a significant change in antibiotic prescribing from the pre-intervention period.

Still, approximately 18,900 fewer antibiotic items were prescribed than if the intervention had not been made, representing a 4.6% reduction in antibiotic prescribing in those practices and a 1% reduction in overall primary care antibiotic prescribing in Northern Ireland.

The authors of the study conclude, "This intervention is an example of a low-cost, simple behavioural 'nudge' that policymakers can use to effectively meet their goals without introducing new policies or rules."
May 20 J Antimicrob Chemother abstract 


Study finds diagnostic testing and antibiotic use is high in kids with CAP

Originally published by CIDRAP News May 21

A study by a team of US pediatric emergency medicine and infectious disease experts has found that diagnostic testing and antibiotic use in children with community-acquired pneumonia (CAP) in outpatient settings remain high, despite recommendations against their routine use. The findings appeared yesterday in the Journal of Pediatric Infectious Diseases.

Because CAP in most young children is viral, the 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America pediatric CAP guidelines recommend against routinely performing these diagnostic tests and prescribing antibiotics. To evaluate the use of diagnostic testing and antibiotics before and after publication of these guidelines, the researchers used data from the 2008-2015 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to determine the proportion of visits in which chest radiography (CXR) was performed, a complete blood count (CBC) or blood culture was obtained, and antibiotics were prescribed for children aged 1 to 6 years with CAP.

The results showed that in an estimated 6.3 million pediatric visits for CAP from 2008 through 2015, a CBC was obtained in 8.6% of visits, blood culture in 11.1%, CXR was performed in 43%, and antibiotics were prescribed in 73.9%. In addition, when antibiotics were prescribed, most of them were macrolides or cephalosporins, which is inconsistent with the guideline recommendations to use narrow-spectrum penicillins as first-line treatment. No difference was found in CBC, blood culture, CXR, and antibiotic orders overall between the pre-guideline and post-guideline periods. 

The authors of the paper suggest the high rates of testing and treatment in children with CAP could be attributable to diagnostic uncertainty and the lack of objective, easily obtained tests to determine CAP etiology. They conclude, "Effective interventions are needed to decrease potentially unnecessary diagnostic testing and treatment."
May 20 J Pediatric Infect Dis Soc abstract


Trial supports shorter antibiotic therapy for orthopedic implant infections

Originally published by CIDRAP News May 20

The results of a randomized clinical trial conducted by Swiss researchers suggest that 4 weeks of antibiotic therapy is non-inferior to 6 weeks in patients with orthopedic implant infections. The findings appear in the Journal of Antimicrobial Chemotherapy.

In the single-center trial, researchers with Geneva University Hospitals analyzed 123 patients who had an infected implant surgically removed. The patients were randomized 1:1 to receive either 4 or 6 weeks of systemic antibiotic therapy. The most common type of infection included orthopedic plate infection (44), prosthetic joint infection (38), and infected nail implants (11). The antibiotic regimen for each patient was selected by the treating surgeon in consultation with an infectious diseases expert.

The primary outcome was remission of infection at the operative site, and the secondary endpoint was the occurrence of any adverse events related to antibiotic therapy. The non-inferiority margin was 10%.

Of the 123 cases in the intention-to-treat population, 120 episodes (98%) were cured microbiologically and 116 (94%) clinically after a median follow-up period of 2.2 years. Recurrence of clinical infection occurred in four patients in the 4-week arm and three patients in the 6-week arm (Pearson X² test; P = 0.74); in all cases, this occurred at around 2 months following the end of antibiotic treatment. These results were formally in line with the non-inferiority hypothesis, as the two-tailed 95% confidence intervals [CIs] largely excluded the 10% margin (1.5%, 95% CI, −9.8% to 6.8%). The study could not meet the non-inferiority hypothesis in terms of adverse events, however.

The authors of the study conclude, "Our randomized trial confirms the opinion of several experts who have suggested that results are likely similar for patients with surgically debrided OM [osteomyelitis] treated with 4 versus 6 weeks of antibiotic therapy.As there are many advantages, and apparently no disadvantages, patients with orthopaedic implant infections might benefit from this shorter antibiotic treatment."
May 18 J Antimicrob Chemother study


Australian researchers to use artificial intelligence against AMR

Originally published by CIDRAP News May 20

A multidisciplinary team of scientists and medical researchers in Australia has launched a new project to put artificial intelligence (AI) to work against antimicrobial resistance (AMR).

Combining machine learning with data streams from people, animals, and the environment, the OUTBREAK (One-health Understanding Through Bacterial REsistance to Antibiotics Knowledge) project will create a spatial and temporal map of AMR in Australia, using a One Health approach. The ultimate aim of the technology is to predict possible AMR outbreaks, trace the origins of outbreaks, and evaluate the risks and cost-effectiveness of treatments and intervention strategies.

"Every city, town, region and country will have a different AMR fingerprint and therefore different risks," chief investigator Steven Djordjevic, PhD, said in a press release from the University of Technology Sydney (UTS), one of 14 institutions collaborating on the project. "Our vision, ultimately, is a worldwide AI-powered network for AMR surveillance and mitigation, led by Australian research and industry."

The team will include experts in genomics and metagenomics, microbiome and computational biology, zoonotic diseases, biosecurity, pharmacy, risk management, and machine learning.

The project is supported by a $1 million grant from the Medical Research Future Fund, with the possibility of $5 million in additional funding.
May 17 UTS press release

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