Stewardship / Resistance Scan for Sep 14, 2020

Rapid diagnostics for bloodstream infections
Oral antibiotics for bone-joint infections
Antibiotic overuse after discharge

Rapid diagnostics, stewardship linked to quicker time to optimal antibiotics

The introduction of a rapid diagnostic test (RDT) in conjunction with antimicrobial stewardship (AMS) activities and infectious disease (ID) consultation at an academic tertiary medical center was associated with shortened time to optimal antibiotic therapy in patients with bloodstream infections, University of Maryland researchers reported in Open Forum Infectious Diseases.

In the retrospective quasi-experimental study, researchers with the University of Maryland's School of Medicine and School of Pharmacy compared time to optimal antibiotic therapy and clinical outcomes in patients with gram-negative bloodstream infection (GN BSI) during three different periods: pre-RDT/AMS, post-RDT/pre-AMS, and post-RDT/AMS.

Rapid testing was conducted with Verigene Blood-Culture Gram-Negative, a microarray RDT that detect eight key organisms and six genetic resistance determinants within 2.5 hours. Optimal therapy was defined as appropriate coverage with the narrowest spectrum, accounting for source and co-infections.

Altogether, 832 patients were included in the study; 237 pre-RDT/AMS, 308 post-RDT/pre-AMS, and 237 post-RDT/AMS. The proportion of patients on optimal antibiotic therapy increased with each intervention (66.5% vs 78.9% vs 83.2%, P < 0.0001), and the time to optimal therapy decreased with the introduction of RDT (47 hours vs 24.9 hours vs 26.5 hours, P = 0.09).

Using multivariable modeling, the researchers determined that ID consult was an effect modifier, and therefore the results were stratified by presence of ID consult. Within the ID consult stratum, controlling for source infection and for intensive care unit stay, both post-RDT/pre-AMS (adjusted hazard ratio [aHR], 1.34; 95% confidence interval [CI], 1.04 to 1.72) and post-RDT/AMS (aHR, 1.28; 95% CI, 1.01 to 1.64) improved time to optimal therapy compared with the pre-RDT/AMS period. The effect was not observed in the stratum without ID consult.

"In conclusion, introduction of RDT in GN BSI resulted in significant decrease in time to optimal antibiotic therapy, by a median of approximately 22 hours from blood culture draw," the study authors wrote. "Additionally, the overall proportion of patients placed on optimal antibiotic therapy increased."
Sep 12 Open Forum Infect Dis abstract


UK study supports oral antibiotics for patients with bone, joint infections

A study by UK researchers published today in Clinical Infectious Diseases indicates that findings of the Oral Versus Intravenous Antibiotics (OVIVA) trial can be implemented into clinical practice.

The OVIVA trial, conducted in the United Kingdom, found that oral antibiotic therapy was non-inferior to intravenous therapy when used during the first 6 weeks in patients with bone and joint infections (BJIs). The results of the trial were initially presented in 2017 and published in 2019, but to date there have been no reports describing their reproducibility in real-world settings.

To determine whether the OVIVA findings can be replicated, researchers with the Royal National Orthopaedic Hospital, which implemented changes in practice in 2017 based on the results, looked at all patients diagnosed as having BSI at the hospital in the 12 months pre- and post-implementation. Outcomes included treatment failure, adverse drug reactions (ADRs), ADR-related hospital readmission, hospital length of stay (LOS), and treatment costs. Patient follow-up was conducted by an outpatient parenteral antibiotic therapy (OPAT) service.

In their analysis of 328 patients (145 pre- and 183 post-implementation), the researchers found that 66.1% of patients were switched to a suitable oral antibiotic regimen post-implementation. The rate of treatment failure was more common post-implementation (18.6%) compared with pre-implementation (13.6%), but Kaplan-Meier analysis of infection-free survival at 12 months did not demonstrated any statistical difference between the two groups (P = .154). Subgroup analysis showed that in the post-implementation period, treatment failure was more common in patients who required IV antibiotics due to lack of suitable options (IV, 26.7% vs oral, 14.3%).

ADRs requiring close monitoring or change of treatment were more common post-implementation (37.1% vs 21% pre-implementation), but ADR-related hospital readmissions were similar in both groups (2.2% vs 2.1%). The post-implementation group showed a reduction in 4 days in the median LOS and a median cost reduction of £ 2,764.28 (US $3,558) per patient.

The authors of the study conclude, "These findings provide a useful guide for hospitals implementing the results of the OVIVA trial. Larger multicenter studies are required to better understand the differences in antibiotic regimens in varying patient groups and against specific pathogens."
Sep 14 Clin Infect Dis study


Antibiotic overuse noted after discharge in pneumonia, UTI patients

A study of patients diagnosed as having pneumonia and urinary tract infections (UTIs) at 46 hospitals in Michigan found that about half had antibiotic overuse after discharge, researchers reported late last week in Clinical Infectious Diseases.

The retrospective cohort study, led by researchers with Michigan Medicine, looked at patients treated for pneumonia or UTI at hospitals in the Michigan Hospital Medicine Safety Consortium from July 2017 through 2019 to quantify the proportion of patients discharged with antibiotic overuse, which was defined as unnecessary antibiotic use, excess antibiotic duration, or suboptimal fluoroquinolone use. The researchers used linear regression analysis to assess hospital-level association between antibiotic overuse after discharge in patients treated for pneumonia versus patients treated for UTI.

Of the 21,825 patients treated for infection (12,445 pneumonia, 9,380 UTI), 49.1% had antibiotic overuse after discharge, including 56.9% of patients treated for pneumonia and 38.7% of patients treated for UTI. The median duration of antibiotic overuse after discharge was 4 days. In patients treated for pneumonia, 63.1% of overuse days after discharge were due to excess antibiotic duration, while in patients treated for UTI, 43.9% of overuse days were due to unnecessary antibiotic treatment of asymptomatic bacteriuria.

The percentage of patients discharged with antibiotic overuse varied fivefold among hospitals, from 15.9% to 80.6%, and was strongly correlated between conditions. For every 10% increase in patients treated at a hospital for UTI who had overuse after discharge there was an 8.5% increase in patients treated for pneumonia who had overuse after discharge.

The authors of the study said the findings suggest prescribing culture, physician behavior, and organizational processes all play a role in overprescribing after discharge.

"Given the ubiquity of overuse after discharge, it is imperative that stewardship programs enact interventions to improve prescribing—which often means stopping antibiotics—at care transitions," they wrote, adding that easier methods of tracking antibiotics at discharge could enable more complete national measures of antibiotic use.
Sep 11 Clin Infect Dis abstract

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