Stewardship / Resistance Scan for May 11, 2020

Nursing home stewardship for UTIs
Funds for rapid susceptibility test
Acid suppressors and C diff

Nursing home intervention associated with fewer antibiotics for UTIs

A low-intensity, multifaceted stewardship intervention implemented at nursing homes was associated with improved antibiotic prescribing for urinary tract infections (UTIs), US researchers reported today in JAMA Internal Medicine.

The intervention focused on antibiotic use in cases of uncomplicated and unlikely cystitis (inflammation of the bladder), which are significant drivers of inappropriate antibiotic prescribing in nursing homes. Specific interventions included a 1-hour introductory webinar, pocket-sized educational cards, web-based coaching sessions, routine audit-and-feedback regarding UTI rates, and educational clinical vignettes addressing the diagnosis and treatment of uncomplicated cystitis.

Twenty-five nursing homes were involved in the study, with 12 randomized to receive the intervention from May 1, 2017, to Apr 30, 2018, and 13 receiving standard care. The primary outcome was antibiotic treatment for unlikely cystitis, and secondary outcomes included overall antibiotic use for any UTI, rates of Clostridioides difficile infection (CDI), and rates of all-cause hospitalization and death.

The study period included 512,408 intervention facility resident-days and 443,912 control-facility resident days. Analysis of the results found that the incidence of antimicrobial use for unlikely cystitis was 27% less in the intervention facilities compared with control facilities (adjusted incident rate ratio [AIRR], 0.73; 95% confidence interval [CI], 0.59 to 0.91; P = .004), and overall antibiotic use for any type of UTI was 17% lower in the intervention facilities than in the control facilities (AIRR, 0.83; 95% CI, 0.70 to 0.99; P = .04).

The rate of CDI remained stable in the intervention group but increased in the control facilities, resulting in a baseline-adjusted reduction in the intervention group of 65% (AIRR, 0.35; 95% CI, 0.19 to 0.64; P < .001). In addition, there was no statistically significant difference in all-cause hospitalizations (AIRR, 0.95; 95% CI, 0.75 to 1.19; P = .63) or all-cause deaths (AIRR, 0.92; 95% CI, 0.73 to 1.16; P = .48) between the two groups.

"Nursing homes face many challenges in addressing antimicrobial stewardship," the authors wrote. "Pragmatic approaches to antimicrobial stewardship are thus important in such a setting. Our findings suggest that facilities can successfully improve antibiotic use and outcomes with such tools and an approach with a low level of onsite engagement."
May 11 JAMA Internal Med abstract


CARB-X to fund rapid diagnostic and antibiotic susceptibility test

CARB-X announced today an award of more than $6 million to Day Zero Diagnostics, of Boston, to develop a rapid diagnostic and antibiotic susceptibility test for bacterial infections that combines whole-genome sequencing and machine learning.

The $6.2 million in initial funding will support the development of a diagnostic system that extracts and sequences DNA from a patient sample, then analyzes the genomic data to identify the pathogen and determine its antibiotic susceptibility profile within hours. Traditional methods of identifying bacterial pathogens and their antibiotic susceptibility take 2 to 3 days to produce results. The system is designed to simultaneously test a broad range of bacteria and their antibiotic susceptibility.

"This is the first whole-genome sequencing and machine learning technology in the CARB-X portfolio, and an exciting new diagnostic approach," Erin Duffy, PhD, chief of research and development at CARB-X, said in a press release. "New technologies, like the diagnostic under development by Day Zero, if successful, could transform the way the way physicians diagnose and treat drug-resistant infections, and save lives."

Day Zero will be eligible for an additional $18.7 million from CARB-X if the project meets certain development milestones.

The project is the 60th to be funded by CARB-X (the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator) since it was established in 2016. The public-private partnership has awarded more than $220 million to support preclinical development of new antibiotics, diagnostics, and alternative therapies for antibiotic-resistant infections.
May 11 CARB-X press release


Review finds use of acid suppressors linked to recurrent C difficile

Use of acid-suppressing medication (ASM) during hospitalization for CDI was associated with a 64% increase in recurrent CDI, according to a systematic review and meta-analysis published in Clinical Infectious Diseases.

A literature search with no limitations on date and a primary focus on the risk of CDI recurrence in patients using any ASM—primarily histamine-2 receptor antagonists and proton pump inhibitors (PPIs)—identified nine studies involving 5,668 patients. Of these patients, 3,027 (53.4%) were on ASM, and 1,003 (17.7%) developed recurrent CDI. Meta-analysis of the studies demonstrated that patients on ASM were 64% more likely to develop recurrent CDI compared with patients not using ASM (odds ratio [OR], 1.64; 95% CI, 1.13 to 2.38; P = 0.009), while patients using PPIs had an 84% increased risk of recurrent CDI compared with patients on ASM (OR, 1.84; 95% CI, 1.18 to 2.85; P = 0.007).

The authors say the findings are limited by the heterogeneity of the studies, which defined CDI recurrence and ASM exposure in different ways, and add that additional research is needed to confirm the findings and understand the mechanism by which ASM increases the risk of recurrent CDI. But they suggest a reassessment of ASM is needed, and that clinicians should consider discontinuing use of these medications during treatment whenever possible, since ASMs are frequently overprescribed.

"During CDI treatment clinicians should carefully review the indication for ASM and if no clear indication is evident, ASM should be discontinued," they wrote. "Given the high risk of recurrence of CDI and the significant morbidity, mortality, and cost burden associated with CDI recurrence, this modifiable risk factor cannot be neglected."
May 9 Clin Infect Dis abstract

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