Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans
Study finds antibiotics, other medications in urban streams
Screening of a network of urban streams in Baltimore revealed high concentrations of pharmaceuticals, including antibiotics, researchers reported this week in Environmental Science & Technology.
The analysis of 371 water samples collected weekly over the course of a year (November 2017 to November 2018) detected 37 unique compounds belonging to 11 pharmaceutical classes. The antibiotic trimethoprim was the most frequently detected compound (137 detections in 371 samples), while acetaminophen was the compound with the highest concentrations. Antidepressants were also frequently detected.
Among the sites tested, higher concentrations and more compounds were found in streams with higher population densities.
Using their weekly estimates to calculate the annual loads of pharmaceuticals at the outflow point (Baltimore's Inner Harbor), the researchers estimated that the equivalent of 30,000 tablets of acetaminophen, 1,700 doses of antibiotics, and 30,000 doses of antidepressants flow into the harbor each year.
The authors note that because the sewage produced by residents of this urban stream network is transplanted to a wastewater treatment plant outside the watershed, the source of the compounds is likely leaking sewer pipes rather than wastewater effluent.
"These results demonstrate the importance of developing, maintaining, and improving sewage infrastructure to protect water resources from pharmaceutical contamination," they wrote.
Aug 18 Environ Sci Technol abstract
COVID-19 restrictions in Australia linked to lower community antibiotic use
Originally published by CIDRAP News Aug 19
COVID-19 restrictions in Australia were associated with a substantial decline in community dispensing of antibiotics for respiratory infections, researchers reported this week in the British Journal of Clinical Pharmacology.
Using national claims data on antibiotic dispensing from November 2015 through October 2020, a team led by researchers at the University of New South Wales (UNSW) Sydney conducted an interrupted time series analysis to investigate monthly trends in antibiotic dispensing and face-to-face and telehealth consultations with general practitioners (GPs). COVID-19 restrictions began in Australia in January 2020 with restrictions on travel from high-risk countries, ramped up in March 2020 with school closure and limits on gatherings, then were relaxed in May 2020.
The researchers observed a 17% increase in the monthly rate of antibiotic dispensing in March 2020, but from April onward there was a sustained 36% decline in the monthly rate of antibiotic dispensing, adjusted for seasonality.
The mean monthly rate of antibiotic dispensing for April through October 2020 fell to 56.8 per 1,000 population, from 91.1 per 1,000 population for the corresponding period in 2019. Dispensing of antibiotics primarily used for respiratory infections (roxithromycin, amoxicillin, and clarithromycin) fell by 51% to 69%, while antibiotics used for non-respiratory infections (flucloxacillin, metronidazole, and trimethoprim) were unchanged.
Antibiotics dispensed by GPs decreased from 63.5 per 1,000 population from April through October 2019 to 37.0 per 1,000 population during the corresponding period in 2020. GP consultation rates remained stable overall, but telehealth consultations accounted for 31% of consultations from April 2020 onward.
The study authors say the findings could inform post-pandemic antimicrobial stewardship practices.
"The 'natural experiment' arising from the public health responses to the COVID-19 pandemic is a unique occasion to inform antimicrobial prescribing guidelines, highlighting the potential reduction in antibiotic prescribing by GPs and specialists for respiratory viral infections," the study authors wrote.
Aug 17 Br J Clin Pharmacol study
Study: Stopping, de-escalating antibiotics didn't worsen patient outcomes
Originally published by CIDRAP News Aug 19
A review of stewardship interventions at a Japanese hospital suggests that the use of carbapenems and anti–methicillin-resistant Staphylococcus aureus (MRSA) antibiotics can be safely reduced without worsening patient outcomes, researchers reported this week in the American Journal of Infection Control.
The antimicrobial stewardship program (ASP) at the hospital reviewed all cases for which carbapenems and anti-MRSA antibiotics were used, focusing on dose, duration of use, therapeutic impact, and adverse effect, then made recommendations to prescribing physicians when the course of therapy was completed. Recommendations included discontinuation, de-escalation, and changes in antibiotic use. Analysis of these interventions focused on clinical and microbiologic outcomes in patients treated from December 2018 through November 2019.
While previous studies have looked at the effects of similar interventions on antibiotic use, the study authors say this is the first to investigate the effect of such interventions on clinical and microbiologic outcomes.
The analysis found that favorable clinical responses were obtained in 165 of 184 cases (89.7%) in which the interventions were accepted, compared with 14 of 19 cases (73.7%) in which the intervention was not accepted. In addition, all-cause 30-day mortality was lower in the accepted group than in the not-accepted group (1.1% vs 10.5%). But there were no significant differences on the infection-related 30-day mortality between the accepted and not-accepted patients (0.5% and 0%, respectively). Microbiologic outcomes were similar between the two groups.
Duration of carbapenem and anti-MRSA antibiotic use in the accepted group was significantly lower than in the not-accepted group: 8 days versus 14 days, respectively, for carbapenems and 10 days versus 15.5 days, respectively, for anti-MRSA antibiotics.
"In our ASP, the interventions did not worsen the clinical and microbiological outcomes," they wrote.
Aug 17 Am J Infect Control abstract
New Asian clinical trial network aims to tackle resistant infections
Originally published by CIDRAP News Aug 18
The National University of Singapore (NUS) has received a $1.8 million grant from the Wellcome Trust to establish a clinical trial network focused on antibiotic-resistant infections.
The Asian Clinical Research Network will carry out clinical trials to help develop the most effective ways to treat drug-resistant infections and help improve access to clinically relevant and vulnerable populations. It's the first such network established in Asia, a region with high rates of antibiotic resistance.
The United Nations estimates that antibiotic-resistant infections could cause 10 million deaths a year by 2050, and experts predict that half of those deaths could come from Asia.
"A clinical research network based in Asia will significantly increase the quality and efficiency of clinical trials in the region, resulting in an improved understanding of drug-resistant infections, improved treatment of those infections and an increase in the supply of new drugs to fight antimicrobial resistance," Hsu Li Yang, an infectious disease expert and Vice Dean of the NUS Saw Swee Hock School of Public Health, said in a university press release. "The joint funding will also spur research collaboration and capacity building both in Singapore and the region to jointly develop solutions to the issue of antimicrobial resistance."
NUS will host the center and work with other partners in Singapore to run the clinical trials.
"We are thrilled to launch this important clinical research network with NUS and partners," said Tim Jinks, PhD, head of the Drug Resistant Infections Priority Program at the Wellcome Trust. "This multi-institutional and international collaboration will strengthen and build research capabilities in Asia and support world-class science."
Aug 17 NUS press release
Indian report notes gaps in guidance on antibiotic use in food animals
Originally published by CIDRAP News Aug 17
A new report by an Indian public interest research and advocacy organization highlights gaps in global recommendations on antibiotic use in food-producing animals and calls for more uniform guidance from the Tripartite United Nations (UN) organizations.
The report from the Centre for Science and Environment notes that while the WHO, the UN Food and Agriculture Organization (FAO), and the World Organization for Animal Health (OIE) all have their own guidance on the use of antibiotics in food-producing animals, there is significant overlap in the antibiotics considered critical for human medicine and veterinary medicine. For example, 47 of the antimicrobials listed by the OIE as being important for veterinary medicine are also on the WHO's list of critically important antibiotics for human medicine.
The report also points out a lack of coherence among the organizations on how antibiotics should be used in food-producing animals. Although there is uniform agreement that critically important antibiotics for human medicine should not be used for growth promotion in livestock, there is less agreement on whether they should be used for disease prevention and control in herds and flocks, or whether critically important antibiotics should be used to treat sick animals.
"Clearly, there is need for more clarity, coherence and, most importantly, a uniform message from the Tripartite organizations," the authors write. "In the absence of this, chances of consensus among national-level animal- and human-health stakeholders are low and the possibility for misinterpretation remains high. This can result in limited action, leading to misuse and overuse of critically important antimicrobials in the food-producing animal sector."
The authors say the organizations should develop uniform guidance that contains a clear message about which critically important antibiotics can be used across the food-animal sector, how they should be used, and which should be prohibited immediately or phased out. They also call for the Tripartite organizations to develop a better understanding of how countries are using critically important antibiotics in food-producing animals, and the levels of resistance to those antibiotics.
The report also contains recommendations for the Indian government to develop a roadmap and policy framework for conserving the use of these antibiotics in the food-animal sector.
Aug 16 Centre for Science and Environment report
Antibiotic stewardship in hospitalized seniors tied to better outcomes
Originally published by CIDRAP News Aug 16
An analysis of hospitalized geriatric patients found that rigorous de-escalation and curtailing of antibiotics was associated with reductions in hospital readmission and mortality, US researchers reported last week in JAC-Antimicrobial Resistance.
In the study, researchers compared a cohort of patients ages 65 and older at a 256-bed teaching hospital who received ASP interventions from January through June 2017 with a control group of patients in the same age-group at the same hospital who had received antibiotics before the intervention (January through June 2015).
The ASP included de-escalation of empiric or definitive antibiotic therapy, change in duration of therapy, and discontinuation of therapy. The stewardship team met daily to discuss and convey recommendations. Patients included in the study had diagnoses of pneumonia (PNA), urinary tract infection, acute bacterial skin and skin-structure infection (ABSSSI), and complicated intra-abdominal infection.
Overall, there was more than 95% adherence to stewardship recommendations, the majority of which were de-escalations (64%) and discontinuations (24%) and resulted in a significant decrease of broad-spectrum antibiotic use.
Analysis of outcomes showed that the 30-day hospital readmission rate fell from 24.9% in the control group to 9% in the ASP group, with the biggest declines observed among patients diagnosed with PNA and ABSSSI. The rate of 30-day readmission for Clostridioides difficile infection fell from 2.4% to 0.30%. Mortality fell from 9.6% in the control group to 5.4% post-intervention.
In addition, antibiotic expenditures fell from $23.30 per adjusted patient day to $4.30 following implementation of the ASP.
"Studying the association between ASP efforts and patient outcomes is of great importance as it increases our understanding of how ASPs contribute to the patient’s overall quality of care," the authors wrote. "We show that a stringent ASP can be safely implemented in an elderly hospitalized patient population without discernible adverse outcomes."
Aug 12 JAC-Antimicrob Resist study
Survey finds stewardship lagging in French nursing homes
Originally published by CIDRAP News Aug 16
A survey of French nursing homes shows there is large room for improvement in antibiotic stewardship, researchers reported yesterday in JAC-Antimicrobial Resistance.
Of the 417 nursing homes in the Grand Est region of northeastern France invited to participate in the survey, only 75 (18%) responded. The survey included 35 questions covering four topics: Nursing home characteristics, current antibiotic stewardship practices, attitudes toward antibiotic stewardship, and opinions on strategies to promote stewardship.
Core elements of antibiotic stewardship programs were overall present in fewer than half of the participating nursing homes, but only 3% did not have any stewardship activities in place. No specific nursing home characteristic was associated with the level of implementation of stewardship activities.
The three most implemented stewardship activities were antibiotic consumption monitoring (65%), antibiotic plan documentation (56%), and antibiotic prescription guide distribution (54%). Only 13% performed audit and feedback on antibiotic prescribing, and only 23% and 29% offered training on infection management and antibiotic prescribing for medical staff and nursing staff, respectively.
Participants positively perceived antibiotic stewardship and suggestions to improve stewardship in nursing homes, with the greatest interest in training for physicians, distribution of antibiotic prescribing guides, and audit and feedback.
"This survey shows that ABS [antibiotic stewardship] programmes are insufficiently implemented in French NHs [nursing homes], even though the medical and nurse coordinators who participated in this survey seemed aware this is a public health priority," the study authors wrote.
While France does not require nursing homes to have stewardship programs, there are regional initiatives promoting stewardship. The authors suggest that core elements for nursing home stewardship be defined at a national level and that regional health authorities could then take a lead role in implementing those elements.
Aug 15 JAC-Antimicrob Resist study
Program linked to better antibiotic choice in penicillin-allergic patients
Originally published by CIDRAP News Aug 16
A low-cost intervention aimed at improving perioperative antimicrobial prophylaxis for patients with penicillin allergy was associated with higher use of cephalosporins and lower antibiotic costs, researchers reported today in Infection Control & Hospital Epidemiology.
The intervention at Emory University School of Medicine was based on the results of a survey of anesthesia providers at the hospital (who are responsible for perioperative antibiotic selection). It included a decision support algorithm that recommends cephalosporins (cefazolin or cefuroxime) for all patients without a history of severe delayed hypersensitivity reactions to penicillin, along with a screening questionnaire to help identify those patients. The survey results were also used to design two educational presentations to introduce the algorithm.
Analysis of patients who received perioperative antibiotics from January 2017 through August 2019 at the hospital showed that the percentage of penicillin-allergic patients receiving a cephalosporin increased from roughly 34% to more than 80% following implementation of the algorithm and the associated educational presentations. No severe adverse events were reported. There was also a reduction in second-line agents associated with the intervention that was accompanied by a 58% reduction in the antibiotic cost for each penicillin-allergic patient.
"These findings emphasize the ongoing need for strategies to risk-stratify patients with penicillin allergy labels so that they can receive appropriate targeted antimicrobial coverage," the study authors write. "Our study results also suggest that transitioning penicillin-allergic patients to first-line therapy has significant benefits with respect to decreased use of higher-cost, less-effective second-line antibiotic agents."
Aug 16 Infect Control Hosp Epidemiol abstract