ASP Scan (Weekly) for Apr 15, 2022

Vaccine hesitancy and poor antibiotic knowledge
Short-course antibiotics for BSI
C difficile on potatoes
Antibiotic-resistant Campylobacter
Household C diff spread
Shorter antimicrobial prophylaxis trial
Remote stewardship for rural areas
COVID-linked antibiotic use in Medicare patients
Fluoroquinolone stewardship

Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans

Survey data link suspicion of vaccines with low antibiotic knowledge

Data from the Wellcome Monitor survey of UK citizens reveal that negative views of vaccination are tied to having poor knowledge about the role of antibiotics for treating infections, according to a study today in Vaccine.

Alistair Anderson, PhD, of the University of Nottingham, analyzed data from 2,654 people polled in late 2018 as part of the Wellcome Trust Monitor Wave 4 survey. He found that, compared with people who ranked the risk of vaccines as "fairly low," those who said their risks are "very high" were almost three times more likely to provide incorrect information on the proper use of antibiotics (odds ratio [OR], 2.87; 95% confidence interval [CI], 1.71 to 4.89).

The key antibiotic question involved choosing which of a list of conditions (viral infections, fungal infections, bacterial infections, cold, flu, or allergic reactions) could be effectively treated with antibiotics.

Those who ranked vaccination risk as "fairly high" were 51% more likely to provide accurate antibiotic information (OR, 1.51; 95% CI, 1.21 to 1.88). Conversely, those who said vaccines have "no risk at all" were 31% less likely to provide antibiotic misinformation (OR, 0.69; 95% CI, 0.50 to 0.95).

In comparing views on vaccine effectiveness, Anderson found that, compared with those who said vaccines are almost always effective, only respondents who felt that vaccines were "sometimes effective" (OR, 1.26; 95% CI, 1.05 to 1.51) or "almost never or never effective" (OR, 2.32; 95% CI, 1.32 to 4.19) were more likely to provide incorrect responses about antibiotics' utility.

Anderson concludes, "More detailed qualitative research is needed to understand the nature of the connection suggested by this study."
Apr 15 Vaccine study


Analysis shows benefit of 7-day antibiotics for bloodstream infections

Both short and conventional durations of antibiotic therapy provide comparable clinical outcomes when assessed using desirability-of-outcome ranking (DOOR) to consider benefits and risks of treatment options for gram-negative bloodstream infections (GNB), US, Israeli, and Italian researchers reported late last week in Open Forum Infectious Diseases.

Although a 7-day antibiotics course has been demonstrated to be non-inferior to a conventional, 14-day course in terms of mortality and infectious complications for GNB, the researchers sought to explore whether the shorter treatment yields a better overall clinical outcome.

The investigators applied a DOOR analysis to the results of a previously completed randomized controlled trial (RCT) that compared short versus conventional antibiotic therapy for hospitalized patients with uncomplicated GNB. They determined the probability that a randomly selected patient receiving a short course would have a more desirable overall outcome than a participant in the other group.

For the 604 patients included in the original study (306 short course, 298 conventional), the probability of having a more desirable outcome with a short course compared with a conventional course was 51.1% (95% CI, 46.7% to 55.4%), indicating no significant difference.

The authors conclude, "DOOR can provide useful information regarding the totality of treatment effects on patient outcomes and provide clinicians with comprehensive analyses of the risks and benefits of an intervention to help guide therapeutic decision-making. We believe DOOR should be prospectively included in future RCTs."
Apr 9 Open Forum Infect Dis abstract


Study finds more than 1 in 5 European potatoes harbors C difficile

European scientists report a 22.4% Clostridioides difficile contamination rate on potatoes sampled from 12 European countries, according to a report yesterday in Eurosurveillance.

C difficile causes one of the most common healthcare-associated infections and is predominantly associated with hospital stays. It is considered an urgent antibiotic resistance threat.

The researchers chose to sample potatoes because of their wide availability, ease of sampling, and high positivity rates. They sampled tubers in Austria, France, Greece, Ireland, Italy, the Netherlands, Poland, Slovakia, Spain, Sweden, Romania, and the United Kingdom.

Of 147 samples, 33 (22.4%) tested positive, with rates ranging from 0 to 100% across the countries, but 9 nations had at least a 10% positivity rate. Whole-genome sequencing revealed several genetically related strain pairs.

The researchers conclude that the findings "indicate potatoes can serve as a vector for introducing C. difficile spores in the household environment, where the bacterium can then multiply in sensitive hosts."
Apr 14 Euro Surveill report


Study finds antibiotic resistance in US, UK Campylobacter holding steady

Originally published by CIDRAP News Apr 13

A large-scale analysis reveals that the prevalence of antimicrobial resistance (AMR) has remained stable for Campylobacter in the United States and United Kingdom in recent years, suggesting that antibiotic stewardship efforts have not made a large impact, according to a new study in Antimicrobial Agents and Chemotherapy.

UK and US scientists analyzed 32,256 Campylobacter jejuni and 8,776 Campylobacter coli genomes taken from people, poultry, and other farm animals, comparing trends in 2015 through 2018 with those in 2001 through 2014, a period that served as a baseline. UK samples were dominated by human isolates (about 70% for C coli, for example, versus 5% for US C coli), with farm animal samples poorly represented. In contrast, US samples showed a better representation of farm animal samples for both C jejuni and C coli.

The team founds that AMR markers were detected in 68% of C coli and 53% of C jejuni isolates, with 15% of C coli isolates being multidrug resistant, compared with only 2% of C jejuni isolates. The prevalence of aminoglycoside, macrolide, quinolone, and tetracycline resistance remained fairly stable from 2001 to 2018 in both pathogens, but statistically significant differences were observed between the two countries. For example, the proportion of aminoglycoside- and tetracycline-resistant isolates was significantly higher in the United States than in Britain from 2015 to 2018, while the prevalence of quinolone resistance was significantly lower in the United States.

The authors conclude, "Taken together, the data presented here strongly suggest that reduced usage of antibiotics has not resulted in a significant reduction of antimicrobial resistance in Campylobacter, which is of considerable public health and economic concern.

"Changes in agricultural practices, slaughter, and retail will need to be substantial to reduce the overall prevalence of Campylobacter. These efforts should lessen the need for antibiotic usage to achieve the goals of antimicrobial stewardship."
Apr 11 Antimicrob Agents Chemother study


Study highlights risk of discharged C diff patients spreading the disease

Originally published by CIDRAP News Apr 13

The incidence of C difficile infection (CDI) in household members exposed to a recently CDI-hospitalized family member was 73% greater than for those not exposed, and the incidence increased the longer the family member was in the hospital, University of Iowa researchers note today in a study in Emerging Infectious Diseases.

CDI is one of the most commonly occurring types of healthcare-associated infections and is predominantly associated with hospital stays. Occurring mainly in people who've had both recent medical care and antibiotic exposure, it is considered an urgent antibiotic resistance threat by the Centers for Disease Control and Prevention (CDC) and affects 223,000 US hospital patients a year.

The investigators analyzed US insurance claim data from 2001 through 2017 to compare monthly CDI incidence among people in households with and without a family member hospitalized in the previous 60 days. They found that CDI incidence among insurance enrollees exposed to a recently hospitalized family member was 73% greater than enrollees not exposed

The researchers also identified a relationship between the total days of hospital stay for the index patient and the CDI risk in family members. Compared with people whose family members were hospitalized less than a day, the incidence rate of CDI in household contacts increased from 1.30 (95% confidence interval [CI], 1.19 to 1.41) for 1 to 3 days of hospitalization to 2.45 (95% CI, 1.66 to 3.60) for more than 30 days of hospitalization.

The authors conclude, "Asymptomatic C. difficile carriers discharged from hospitals could be a major source of community-associated CDI cases."
Apr 13 Emerg Infect Dis abstract


Trial supports shorter antimicrobial prophylaxis for orthopedic surgery

Originally published by CIDRAP News Apr 12

A randomized clinical trial found that a shorter antimicrobial prophylaxis (AMP) duration for "clean" orthopedic surgery (scheduled procedures not involving complications like open wounds) was non-inferior to a longer duration in preventing healthcare-associated infections (HAIs), Japanese researchers reported today in JAMA Network Open.

In the multicenter, cluster randomized trial, 1,211 participants undergoing clean orthopedic surgery were divided into two groups: one had AMP discontinued within 24 hours of wound closure (group 24), and the other had AMP discontinued within 24 to 48 hours (group 48). Group allocation was switched every 2 to 4 months according to the facility-based cluster rule. The primary outcome was incidence of HAIs requiring antibiotic therapies within 30 days of surgery. The non-inferiority margin was 4%.

There were 633 participants (median age, 73; 60.5% women) in group 24 and 578 participants (median age, 74; 64.7% women) in group 48. HAIs occurred in 29 patients (4.6%) in group 24 and 38 patients (6.6%) in group 48. Intention-to-treat analyses showed a difference in the risk of HAIs of −1.99 percentage points (95% CI, −5.05 to 1.06 percentage points; P < .001 for non-inferiority) between groups, indicating non-inferiority. Results of adjusted intention-to-treat, per-protocol, and per designated procedure population analyses supported this result, without a risk of antibiotic resistance and prolonged hospitalization.

The findings are noteworthy because several studies have shown that AMP is still routinely continued for several days after orthopedic surgery, despite concerns that prolonged AMP may increase the risk of antimicrobial resistance.

"To our knowledge, this is the first large size clinical trial to elucidate the effect of AMP duration on postoperative HAI in the field of orthopedic surgery," the study authors wrote. "Our results support the global notion against antimicrobial resistance and may encourage surgeons to shorten AMP duration and reduce the antibiotic load in clean orthopedic surgeries."
Apr 12 JAMA Netw Open study


Remote stewardship in rural nurseries tied to fewer infant antibiotics

Originally published by CIDRAP News Apr 12

Implementation of a remote antibiotic stewardship program (ASP) in medically underserved newborn nurseries was associated with a decline in the number of infants exposed to antibiotics and total antibiotic use, researchers reported today in Pediatrics.

The remote ASP, implemented at eight rural nurseries in Texas, included 24/7 provider-to-provider phone consultation with a neonatal infectious diseases specialist, on-site and virtual education sessions on topics such as early-onset sepsis and the risks and benefits of antibiotic exposure in newborns, and prospective audit and feedback of prescribing practices. Using a cluster-randomized, stepped-wedge design, researchers evaluated the impact of the program over 3 years, including a 15-month baseline period, a 9-month step-in period using random nursery order, and a 12-month post-intervention period.

During the study period, there were 9,277 infants born, 4,586 of them preintervention and 4,691 postintervention. The proportion of infants exposed to antibiotics declined from 6.2% pre-ASP to 4.2% post-ASP (absolute risk reduction, 25%; relative risk 0.68; 95% CI, 0.63 to 0.75). Similarly, total antibiotic use declined from 117 to 84.1 days of therapy per 1,000 patient-days (-28%; 95% CI, −22% to −34%). No safety signals were observed; the mean length of stay was unchanged (1.84 days preintervention, 1.83 days postintervention), as was the frequency of infant transport to a higher level of care (0.26% preintervention, 0.23% postintervention).

The ASP also proved feasible for staff. There were 451 provider-to-provider phone consultations during the study period, and most were less than 5 minutes and occurred during normal business hours.

The study authors say that while the sample size is small, the findings suggest that remote ASPs could be a viable strategy for rural or medically underserved nurseries.

"A 2% absolute reduction in antibiotic exposure is a small decrease; however, if applied to the approximately 1.7 million births in rural or medically underserved areas in 2020, this reduction would equate to over 30,000 less antibiotic courses, which in turn could reduce the risk of obesity, asthma, eczema, diabetes, metabolic syndrome, multidrug resistant organisms, and other adverse consequences of early antibiotic exposure," they wrote.
Apr 12 Pediatrics abstract


Study: Medicare outpatients frequently received antibiotics for COVID-19

Originally published by CIDRAP News Apr 11

A review of data on Medicare beneficiaries during the first year of the COVID-19 pandemic found that nearly a third of outpatient COVID-19 visits were linked to an antibiotic prescription, mainly for azithromycin, CDC researchers reported late last week in JAMA.

The analysis of Medicare carrier claims and data from the Medicare Part D prescription drug plan from April 2020 to April 2021 found that 29.6% of more than 1.1 million COVID-19 outpatient visits were associated with an antibiotic prescription. The rate of prescribing varied by month, with higher rates of prescribing occurring during a wave of COVID-19 cases in the winter of 2020-21 (range, 17.5% in May 2020 to 33.3% in October 2020). Prescribing was highest in the emergency department (33.9%), followed by telehealth (28.4%), urgent care (25.8%), and office visits (23.9%).

Azithromycin was the most frequently prescribed antibiotic (50.7% of cases), followed by doxycycline (13%), amoxicillin (9.4%), and levofloxacin (6.7%). Urgent care had the highest percentage of azithromycin prescriptions (60.1%), followed by telehealth (55.7%), office visits (55.1%), and ED (47.4%).

Differences were observed by age, sex, and location, with non-Hispanic White beneficiaries receiving antibiotics for COVID-19 more frequently (30.6%) than other racial and ethnic groups, including American Indian/Alaska Native (24.1%), Asian/Pacific Islander (26.5%), Black (23.2%), and Hispanic (28.8%) patients.

Despite some early studies that indicated azithromycin might benefit COVID-19 patients, subsequent randomized clinical trials demonstrated no benefit.

"These observations reinforce the importance of improving appropriate antibiotic prescribing in outpatient settings and avoiding unnecessary antibiotic use for viral infections such as COVID-19 in older adult populations," the CDC researchers wrote.
Apr 8 JAMA research letter


Stewardship linked to drop in fluoroquinolones for urinary tract infections

Originally published by CIDRAP News Apr 11

A multifaceted antimicrobial stewardship intervention at a community health system dramatically reduced fluoroquinolone prescribing for urinary tract infections (UTIs), researchers reported today in Infection Control & Hospital Epidemiology.

The intervention implemented at Lee Health, a large community health system in Florida, included development of an antimicrobial stewardship team to oversee the intervention, dissemination of a system-specific UTI treatment pathway with an emphasis on the use of non-fluoroquinolone antibiotics, and modification of the electronic health record to incorporate treatment recommendations. A fluoroquinolone stewardship dashboard was also created, and prescribers received monthly reports on the percentage of UTI visits for which fluoroquinolones were prescribed.

Originally implemented in four urgent care locations in April 2019, the intervention was extended to the system's 19 primary care clinics in August 2019.

Comparison of prescribing data from the 6-month post-intervention period (September 2019 to February 2020) with the pre-intervention period (September 2018 to February 2019) showed that the percentage of fluoroquinolone prescribing for UTIs fell from 17.6% pre-intervention to 3.0% post-intervention in the four urgent care clinics, and from 23.8% to 6.8% in the 19 primary care clinics. Percentages of any primary care clinic visits at which a fluoroquinolone was prescribed fell from 1.3% to 0.5%.

Sustained decreases in fluoroquinolone prescribing for UTIs were observed in a third assessment period compared with the pre-intervention period for both urgent (3%) and primary care (7%).

"Our initiative demonstrated that a multifaceted antimicrobial stewardship bundle had a significant and sustained impact on fluoroquinolone utilization in urgent care and primary care clinics," the study authors wrote. "Although the emphasis of our intervention was on UTI-related visits, the impact potentially extended beyond UTI visits, given the large decrease in total fluoroquinolone prescriptions, which was not completely accounted for by visits with UTI-related diagnosis codes."
Apr 11 Infect Control Hosp Epidemiol study

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