Stewardship / Resistance Scan for Jan 31, 2022

News brief

Stewardship bundle tied to better antibiotic prescribing for virtual visits

A multifaceted stewardship intervention aimed at virtual visits was tied to improvements in guideline-concordant antibiotic prescribing for upper respiratory tract infections (URTIs) and sinusitis, University of Michigan researchers reported today in Infection Control & Hospital Epidemiology.

The intervention at Michigan Medicine was aimed at improving antibiotic prescribing for URTIs within E-visits, an asynchronous care delivery system in which patients fill out a questionnaire related to symptoms and advanced practice providers (APPs) respond with a written treatment plan.

The intervention included modifications of the existing questionnaire, the addition of a nudge for guideline-concordant prescribing in the electronic medical record, and audit and feedback of APP prescribing. To study the impact of the intervention on appropriate antibiotic prescribing for URTIs, researchers looked at all adult patients who completed E-visits for "cough," "flu," or "sinus" symptoms at Michigan Medicine before and after the intervention was implemented.

From January 2018 through September 2020, there were 5,151 E-visits for the included symptoms. Prior to the intervention, 43.2% of E-visits resulted in antibiotic prescriptions, compared with 28.9% of post-intervention visits. The number of prescriptions with guideline-concordant antibiotic selection rose from 37.9% to 66.1% for amoxicillin-clavulanate and from 13.8% to 22.7% for doxycycline. In addition, median antibiotic duration fell from 10 days to 5 days.

An interrupted time series analysis showed that guideline-concordant antibiotic prescribing increased significantly after the intervention and continued along a similar upward trend over time.

"This approach can aid stewardship efforts in the ambulatory care setting with increases in telemedicine," the study authors write.
Jan 31 Infect Control Hosp Epidemiol abstract

Stewardship strategies to optimize pediatric outpatient antibiotics

In another study published today in the same journal, researchers in Tennessee found that a bundled stewardship intervention was associated with improved appropriate ambulatory antibiotic prescribing for children, despite the COVID-19 pandemic.

The before-and-after study looked at guideline-concordant antibiotic use during three periods at five community general pediatrics practices in Tennessee. Each practice chose two to four implementation strategies known to be effective at reducing outpatient antibiotic use and implemented them in their practice over the entire study period.

Researchers held quarterly meetings with all providers to review de-identified peer comparison feedback across practices. Interventions included antibiotic-use commitment posters, parent education, development of local clinical practice guidelines, and electronic health record template changes.

The three study periods assessed were May 2018 to September 2019 (baseline, P1), Nov 11, 2019, to Mar 20, 2020 (pre–COVID-19 pandemic, P2), and Mar 21, 2020, to Nov 10, 2020 (pandemic, P3).

Improvements in guideline-concordant antibiotic use were observed in the pre–COVID-19 intervention period (P2) and were sustained during the pandemic (P3) for several diagnoses. These included otitis media (P1 72.14% vs P2 81.42% vs P3 86.11%), group A streptococcal pharyngitis (P1 66.13% vs P2 81.56% vs P3 80.44%), pneumonia (P1 70.6% vs P2 76.2% vs P3 100%), sinusitis (P1 76.2% vs P2 83.78% vs P3 82.86%), and skin and soft-tissue infections (P1 97.18% vs P2 100% vs P3 100%).

Practices with higher fidelity to the implementation strategies demonstrated higher guideline-concordant prescribing than those with lower fidelity.

In a survey conducted after the study, more providers reported referring to guidelines to make decisions about prescribing antibiotics following the intervention (38.9%), compared with a pre-intervention survey (5.6%).

"In conclusion, despite the COVID-19 pandemic, this study demonstrates that outpatient antibiotic stewardship implementation strategies are feasible in community general pediatrics practices that are not affiliated with an academic institution, and it provides a framework for real-world implementation of outpatient antibiotic stewardship," the study authors write.
Jan 31 Infect Control Hosp Epidemiol abstract

Study finds drop in resistance gene after fecal microbiota transplantation

A small study of hospital patients colonized with multidrug-resistant organisms (MDROs) found a reduction in the expression of antibiotic resistance genes following fecal microbiota transplant (FMT), South Korean researchers reported late last week in Antimicrobial Resistance & Infection Control.

The single-center prospective study involved patients colonized with vancomycin-resistant Enterococcus (VRE), carbapenemase-producing Enterobacteriaceae (CRE), or both, who underwent FMT from healthy, unrelated donors from May 2018 through April 2019.

The primary endpoint was the complete elimination of antibiotic resistance genes 1 month after FMT, and the secondary endpoint included decreased expression of resistance genes. All patient fecal samples were tested via real-time reverse transcription polymerase chain reaction (PCR) on days 1, 7, 14, and 28 for the quantification of VanA, bla_KPC, bla_OXA, and bla_NDM genes.

Of the 29 patients who received FMT, 26 (59.3%) were infected with VRE, 5 (11.1%) with CPE, and 8 (29.6%) with VRE/CPE. The mean duration of MDRO carriage before FMT was 71 days. Sixteen patients (59.3%) received antibiotics before FMT, and 17 patients (63.0%) were treated with antibiotics after FMT. Median patient age was 51 years.

In a culture-dependent method, the expression of VanA and overall genes significantly decreased (P = 0.011 and P = 0.003, respectively) after FMT. In a culture-independent method, VanA, bla_NDM, and overall gene expression significantly decreased over time after FMT (P = 0.047, P = 0.048, P = 0.002, respectively). Similar results were confirmed following comparison between each time point in both the culture-dependent and -independent methods.

Regression analysis did not reveal important factors underlying the genetic response after FMT. No adverse events were observed.

The authors say that while the sample size was small and the study did not include a control group, the findings suggest FMT could be an effective way to reduce antibiotic resistance gene expression and facilitate MDRO decolonization.
Jan 29 Antimicrob Resist Infect Control study

News Scan for Jan 31, 2022

News brief

Medicare patient care-seeking for severe mental illness down in COVID-19

Significantly fewer adult Medicare beneficiaries with schizophrenia or bipolar 1 disorders had mental health-related outpatient, emergency department (ED), and hospital visits, as well as fills for antipsychotics and mood-stabilizing drugs in the first 8 months of the COVID-19 pandemic.

The findings, published late last week in JAMA Network Open, suggest that people with serious mental illness experienced substantial disruptions in care amid the pandemic, especially among the disadvantaged, the researchers said.

Led by Harvard Medical School investigators, the study included more than 650,000 Medicare beneficiaries diagnosed as having schizophrenia or bipolar 1 disorders. The researchers compared care patterns from January to September 2020 with those in the same period in 2019.

Relative to 2019, outpatient mental health visits during the first month of the pandemic fell from 265,169 (36.7%) to 200,590 (29.2%), a 20.3% decrease. In the same period, fills of antipsychotics and mood stabilizers dropped from 216,468 (29.9%) to 163,796 (23.9%), also a 20.3% decline. Similarly, ED visits fell from 12,383 (1.7%) to 8,503 (1.2%), a 27.7% decrease, and hospitalizations declined from 11,564 (1.6%) to 7,912 (1.2%), a 27.9% decrease.

From Aug 3 to 30, 2020, visits rebounded somewhat but were still lower than in 2019, ranging from a relative decline of 2.5% for outpatient visits to 12.9% for hospital admissions. From Mar 16 to Sep 27, 56.7% of outpatient mental health visits were provided via telemedicine.

Multivariable analyses showed that outpatient visits were slightly lower among those with a disability (odds ratio [OR], 0.95) from Mar 16 to Jun 21 and among Black versus White people (OR, 0.97) and those dual-eligible for Medicare and Medicaid (OR, 0.96) from Jun 22 to Sep 27.

The study authors noted that people with serious mental illness may be susceptible to care disruptions because they often have a disability, lack homes, live in poverty, are socially isolated, lack the ability to access telemedicine, have higher rates of chronic conditions, and may delay seeking in-person care because of their elevated risk of COVID-19 infection and death.

"Additionally, the pandemic may exacerbate preexisting disparities among individuals who belong to racial or ethnic minority groups or rural residents," they wrote.
Jan 28 JAMA Netw Open study

Denmark reports case of variant swine flu in slaughterhouse worker

A single case of variant swine flu was detected in a Danish slaughterhouse worker in November, authorities from the Statens Serum Institut (SSI) announced over the weekend. The case is isolated.

"It is estimated that the patient has been infected in connection with his work at a Danish pig slaughterhouse," the SSI said. "Furthermore, it is not estimated that there is no risk of further human-to-human transmission."

Last year an unrelated case of variant swine flu was detected in Denmark, and authorities said the most recent case is similar to a virus detected in three pig herds. The SSI did not share the subtype of the most recent swine flu case.

According to Avian Flu Diary, an infectious disease tracking blog, in 2021 variant swine influenza cases were detected in the United States (17), France, Taiwan, Canada (4), Brazil, Germany, Denmark (2) and the Netherlands.
Jan 29 SSI report
Jan 29 Avian Flu Diary post

H5N1 avian flu hits poultry in Ivory Coast and Nepal

Animal health officials in Ivory Coast and Nepal reported highly pathogenic H5N1 avian flu outbreaks in poultry, according to the latest notifications from the World Organisation for Animal Health (OIE).

Ivory Coast reported two separate events, both linked to the introduction of new poultry into flocks. One of the outbreaks began on Nov 10 at a layer farm in Grand-Bassam, about 25 miles east of Abidjan. The virus killed 174 of 11,000 susceptible birds. The other event started on Nov 21 at a poultry breeding farm in Abidjan, killing 5,000 of 32,000 susceptible birds.

Nepal reported an H5N1 outbreak that began on Jan 17 at a layer farm in Morang district in the eastern part of the country, killing 3,510 of 5,160 susceptible chickens. Officials said wild birds at an irrigation canal near the farm may have passed the virus to birds at the facility.
Jan 27 OIE report on H5N1 in Ivory Coast (Grand-Bassam)
Jan 27 OIE report on H5N1 in Ivory Coast (Abidjan)
Jan 28 OIE report on H5N1 in Nepal

In its latest situation update on avian flu, the United Nations Food and Agriculture Organization (FAO) said since its last report on Dec 23, 2021, a total of 1,050 avian flu outbreaks have been reported across Africa, the Americas, Asia, and Europe. A vast majority (998) involved H5N1, but other highly pathogenic subtypes were reported, as well, including H5N2, H5N3, H5N5, H5N8, and unsubtyped H5.
Jan 26 FAO situation update