Stewardship / Resistance Scan for Jan 12, 2022

Improper antibiotics for respiratory infections
Shigella reduction in Niger

Study highlights inappropriate prescribing for respiratory infections

A study of 42 million US patient visits for antibiotic-inappropriate acute respiratory infections (ARIs) found that more than 10% received an antibiotic prescription, with providers in urgent care clinics and southern states among the most likely prescribers, US researchers reported this week in Infection Control & Hospital Epidemiology.

The study, conducted by researchers from the Centers for Disease Control and Prevention and IQVIA using IQVIA's medical claims and prescription databases, looked at 41.97 million patient visits from October 2018 through September 2019 with diagnosis codes for ARIs for which antibiotics are generally not indicated. These included asthma, allergy, bronchitis, bronchiolitis, flu, viral upper respiratory infection, and non-suppurative otitis media (earache).

The researchers calculated the Prescriber Inappropriate Antibiotic Prescribing Index (PIAPI) as the proportion of a clinician's visits for antibiotic-inappropriate ARIs that received an antibiotic, and used a machine-learning model to determine drivers of PIAPI.

The average PIAPI was 11%, meaning that clinicians prescribed antibiotics in 11% of visits for which the drugs were unnecessary. The machine-learning model identified outpatient setting, patient-age mix, and state as the strongest predictors of PIAPI. Among settings, average PIAPI ranged from 5% in outpatient hospital clinics to 21% in urgent care facilities. Clinicians who saw children predominantly had a lower average PIAPI (7%) than those who saw adults or balanced age mixes (11%–13%). The researchers also detected wide variation by state, with the highest average PIAPIs in southern states, including Mississippi (17%) and Alabama (18%).

"This project demonstrated that machine-learning may be valuable in targeting antibiotic stewardship interventions," the study authors wrote.
Jan 10 Infect Control Hosp Epidemiol abstract


Mass azithromycin distribution in Niger tied to reduction in Shigella in kids

A study of children in Niger who received biannual administration of azithromycin found a substantial reduction in Shigella carriage after 2 years, researchers reported this week in Clinical Infectious Diseases.

In the study, researchers from the United States and Niger analyzed rectal samples from children in 30 villages in Niger that had participated in the MORDOR I trial, which randomized children in Niger, Malawi, and Tanzania to receive biannual administration of azithromycin or placebo. Using polymerase chain reaction (PCR) assays, the researchers screened the samples for 29 enteropathogens at baseline and at 24 months.

At baseline, five pathogens had a baseline prevalence of greater than 2%: enteroaggregative Escherichia coli (21.7%), Shigella (14.1%), Campylobacter jejeuni or Campylobacter coli (12.9%), enterotoxigenic E coli (11.8%), and typical enteropathogenic E coli (3.8%). There were no differences in pathogen quantity by trial arm.

At 24 months, however, the prevalence of Shigella in samples from the villages randomized to azithromycin was 64% lower than those from placebo villages (prevalence ratio, 0.36; 95% confidence interval [CI], 0.17 to 0.97), corresponding to an absolute prevalence difference of –11.1% (95% CI, –19.4% to –2.8%). No other differences in pathogen quantity or prevalence were observed.

The study authors say the findings could partly account for the 18.1% reduction in mortality observed in the Niger cohort in the MORDOR I trial, which was the largest mortality reduction observed among the three countries in the study. In addition, they note that analysis of verbal autopsies conducted in Niger following MORDOR I have found reductions in incidence and deaths from dysentery, which can be caused by Shigella.

"In summary, we found a significant reduction in Shigella carriage from a high baseline among children 1-59 months of age in villages that received biannual azithromycin instead of placebo," they wrote. "Together with reports demonstrating a substantial decrease in dysentery incidence, these findings suggest that a reduction in Shigella infections may have contributed to the observed reduction in mortality."
Jan 10 Clin Infect Dis abstract
Apr 26, 2018 CIDRAP News scan on MORDOR trial

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