Stewardship / Resistance Scan for Mar 23, 2021

Antibiotic stewardship in long-term care
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Amoxicillin for acute sinusitis

Audit and feedback tied to improved antibiotic use in long-term care

Audit and feedback with peer comparison was associated with small reductions in prolonged antibiotic treatment in a study involving physicians and long-term care (LTC) facility residents in Ontario, Canadian researchers reported today in Clinical Infectious Diseases.

In the province-wide difference-in-differences study, researchers assessed antibiotic prescribing among 1,238 physicians caring for 96,185 resident. They compared the prescribing of 343 physicians who received a voluntary audit and feedback report and quarterly information on antibiotic prescribing in relation to their peers with 895 physicians who received no feedback. The report was launched in January 2019, and the study evaluated antibiotic prescribing in LTC facilities from 2018 through 2019.

The primary outcomes were the proportion of residents initiated on an antibiotic and the proportion of antibiotic prescriptions that lasted longer than 7 days in the year before and after the report was introduced. The researchers also embedded a pragmatic randomized controlled trial (RCT) within the study to compare a novel, dynamic feedback report with a static report.

The researchers observed a temporal decline in antibiotic initiation and duration between the first quarter of 2018 and the last quarter of 2019, with the proportion of residents initiated on an antibiotic dropping from 28.4% to 21.3%, and the proportion of treatments lasting longer than 7 days falling from 34.4% to 29%. Difference-in-differences analysis indicated that the audit and feedback report was associated with a greater decline in use of prolonged antibiotics (adjusted absolute difference, -2.65%; 95% confidence interval [CI], -4.93% to -0.28%), for an estimated total reduction of 335,912 days of antibiotic treatment after the intervention.

Audit and feedback not associated with a greater decline in antibiotic initiation (adjusted difference 0.10%; 95% CI, -0.51% to 0.61%), and the embedded RCT found no difference in outcomes between the dynamic and static reports.

"Audit and feedback is a pragmatic, scalable intervention to improve antibiotic use, and when coupled with evaluation systems using administrative databases it could generate sustainable and large reductions in antibiotic use," the study authors conclude.
Mar 23 Clin Infect Dis abstract

 

Trial finds no benefit from additional amoxicillin for acute sinusitis

The results of a randomized clinical trial indicate additional amoxicillin did not benefit adults receiving amoxicillin and clavulanate for acute sinusitis, researchers reported today in JAMA Network Open.

In the double-blind, comparative effectiveness trial, adult patients at Albany Medical Center in New York who had symptoms of acute sinusitis were randomly allocated to two treatment groups: the standard treatment of 875 milligrams (mg) of amoxicillin and 125 mg of clavulanate plus a placebo tablet, or a high-dose treatment of 875 mg of amoxicillin and 125 mg of clavulanate plus 875 mg of amoxicillin twice a day for 7 days. The purpose was to replicate a previous trial in which an unplanned subgroup analysis had found that higher-dose amoxicillin might provide a benefit.

The primary efficacy outcome was the percentage of patients who reported a Global Rating of Improvement (GRI) score of 5 or 6 ("a lot better" or "no symptoms") after 3 days of treatment. The primary safety outcome was a score of 3 ("severe") for diarrhea at day 3 or 10. A total of 157 patients, out of a projected 240, were enrolled in the study, with 79 receiving the standard dose and 78 the high dose; 9 and 12 patients, respectively, withdrew or were lost to follow-up before assessment of the primary outcome.

An unplanned interim analysis prompted by COVID-19 restrictions found that at day 3, a total of 31 of 70 patients in the standard-dose group (44.3%) reported a score of 5 or 6, compared with 24 of 66 (36.4%) in the high-dose group, for a difference of -7.9% (95% CI, -24.4% to 8.5%). At that point, the study was stopped for futility. Evaluation of safety data showed diarrhea was common in both groups at day 3, with 40.8% in the standard-dose group and 43.1% in the high-dose group reporting any diarrhea. Severe diarrhea was reported in 7.0% of the standard-dose patients and 7.7% of the high-dose group.

The study authors say the finding is disappointing, since the standard treatment has been found to provide only minimal benefits for acute sinusitis.
Mar 23 JAMA Netw Open study

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