Stewardship / Resistance Scan for Sep 04, 2020

Urinary culture intervention
Antibiotic prescribing in Kenyan children

Urinary culture intervention linked to lower antibiotic prescribing

An intervention to reduce antibiotic treatment for asymptomatic bacteriuria (ASB) at a Toronto hospital was safe and associated with reduced exposure to unnecessary antibiotics, Canadian researchers reported this week in Infection Control and Hospital Epidemiology.

In a prospective observational study conducted at Mount Sinai Hospital in Toronto, which implemented an intervention in 2013 to stop processing midstream urine cultures (MSUs) from patients unless the laboratory was called, researchers interviewed 1,678 patients with an MSU order on days 0 and 4 to ask about urinary symptoms and any adverse events. From 2017 to 2019, day 30 follow-up was added.

The primary outcome was serious adverse events due to not processing MSUs. Secondary outcomes included nonserious adverse events, rates of cultures submitted and processed, proportion of patients prescribed urinary tract infection (UTI)-directed antibiotics, and laboratory workload.

Among 912 and 459 patients followed to days 4 and 30, respectively, no serious adverse events attributable to not processing MSU cultures were identified. However, 6 patients (0.7%) had prolonged urinary symptoms potentially associated with not processing MSU cultures.

The researchers estimated that 4 patients missed having empiric antibiotics stopped in response to negative MSU cultures, and 99 antibiotic courses for asymptomatic bacteriuria (ASB) and 8 antibiotic-associated adverse events were avoided. The rate of submitted MSU samples and proportion of patients receiving empiric UTI-directed antibiotics did not change. The proportion of MSU cultures processed declined from 59% to 49% (P < .0001), and total laboratory workload was reduced by 185 hours.

"In conclusion, not processing MSU cultures from medical and surgical inpatients is safe, and it reduces inappropriate ASB therapy and laboratory workload," the authors of the study wrote. "We believe that the benefits of reduced antibiotic use outweigh the harm of persistent symptoms in a very few patients."
Sep 2 Infect Control Hosp Epidemiol abstract


Antibiotic prescribing frequent in ill Kenyan children, study finds

US and Kenyan researchers reported yesterday in Clinical Infectious Diseases that antibiotic treatment was high in a cohort of Kenyan children with undifferentiated fever, despite a low prevalence of bacterial illness.

The researchers examined clinical presentation and management of Kenyan children with fever at five hospitals or clinics from 2014 through 2017. The aim of the study was to characterize which variables are associated with higher odds of antibiotic therapy in both malaria-negative and malaria-positive children and to evaluate the concordance of diagnosis of bacterial illness with antibiotic treatment. All five sites were in malaria-endemic regions of Kenya, and all children in the study were tested for malaria by blood smear microscopy.

Of the 5,737 children enrolled in the study, 68% (3,902) were prescribed antibiotic therapy, while 14% (812) received a primary diagnosis of bacterial illness. In 777 children (14%), bacterial illness was given as the differential diagnosis. Nearly two thirds of those given antibiotics (64%) had neither a primary nor differential diagnosis of bacterial illness.

On multivariate analysis, a negative malaria test was associated with a sevenfold increase in the odds of receiving an antibiotic (odds ratio, 7.1; 95% confidence interval [CI], 5.6 to 9.1). Other factors associated with increased odds of antibiotic therapy included age 1 to 4 years; reporting of head, ears, eyes, nose, and throat symptoms; and having a flush toilet in the home.

"Based on these results and given the degree of diagnostic uncertainty, providers seem highly reluctant to discharge febrile children without empiric antibiotic treatment," the authors of the study wrote.

They suggested that providers in these settings, lacking point-of-care tests beyond those for malaria, may benefit from improved clinical education and implementation of enhanced guidelines for clinical decision-making.
Sep 3 Clin Infect Dis abstract

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