Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans
Report highlights barriers to hospital stewardship in LMICs
Interviews with clinicians at hospitals in three low- and middle-income countries highlight some of the barriers to appropriate antibiotic prescribing in these settings, according to a study published yesterday in Antimicrobial Resistance & Infection Control.
For the study, an international team led by researchers with Duke Global Health Institute conducted interviews with 45 physicians at three tertiary care centers in Sri Lanka (22), Kenya (12), and Tanzania (11). The interviews assessed knowledge of antimicrobial resistance and antimicrobial stewardship programs (ASPs), current antimicrobial prescribing practices, access to diagnostics, receptiveness to ASPs, and perceived barriers to ASPs.
The interviews revealed that limited antimicrobial availability and the prohibitive cost of antimicrobials, limited diagnostic capabilities and a lack of trust in microbiologic data, and a lack of prior knowledge of ASPs were among the most frequently cited barriers to appropriate antimicrobial prescribing.
Many physicians at all three sites had not heard of ASPs before the interviews. In addition, physicians also cited limited awareness of local antimicrobial resistance patterns and reluctance to change local clinical practice customs regarding antimicrobial prescribing as barriers to implementing ASPs.
To improve antimicrobial prescribing in these settings, interviewees recommended creating hospital-specific guidelines, providing education to physicians on appropriate prescribing, and developing multidisciplinary, physician-led ASP teams.
Mar 25 Antimicrob Resist Infect Control study
European healthcare survey: AMR knowledge, practice diverge
A survey of European healthcare workers found a high level of knowledge about antibiotic use and the connection to antibiotic resistance, but that knowledge doesn't always translate into practice, European researchers reported yesterday in Eurosurveillance.
Among the 18,365 healthcare workers from 30 European Union/European Economic Area (EU/EEA) countries who responded to the 43-item questionnaire in 2019, 96% agreed with the statement "I know what antibiotic resistance is," and 80% agreed with the statement "I have sufficient knowledge about how to use antibiotics appropriately for my current practice."
In addition, more than 80% correctly answered six of seven knowledge test statements, such as "antibiotics are effective against viruses" and "unnecessary use of antibiotics makes them become ineffective." But overall, only 58% answered all seven questions correctly.
The survey also found a wide variation in the percentage of respondents answering all seven questions correctly across the 30 EU/EEA countries (40% in Estonia to 73% in Croatia) and across healthcare professions (29% of other healthcare workers to 68% of physicians). And the percentage of respondents correctly answering questions on environmental and animal health factors and hand hygiene was lower.
In addition, fewer respondents (68%) agreed they had easy access to materials for advising patients about prudent antibiotics or had good opportunities to provide advice about antibiotic use to patients (72%), while only 63% agreed that they have a key role in helping control antibiotic use.
Of the 65% of respondents who had prescribed or dispensed antibiotics at least once in the week prior to completing the survey, only 17% had given resources (leaflets or pamphlets), and only 55% had provided advice on prudent antibiotic use.
Thirty-one percent of prescribers said they would have preferred not to prescribe an antibiotic at least once in the week before completing the survey but did so anyway.
"It is important to move from raising awareness about prudent antibiotic use and antibiotic resistance among healthcare workers to designing antimicrobial stewardship interventions aimed at changing relevant behaviours," the study authors concluded.
Mar 25 Eurosurveill study
Study finds resistance in outpatient UTIs varies by age, sex
An analysis of antibiotic susceptibility testing in outpatient settings in Washington state found that age and sex were linked to differences in resistance patterns in urinary tract infections (UTIs) involving Escherichia coli, a team based at the University of Washington School of Public health reported today in Clinical Infectious Diseases.
The scientists based their findings on outpatient urinary E coli isolates that were tested at a clinical reference lab from 2013 to 2017. The analysis included a patient's first UTI with E coli and included isolates from 24,215 patients over 5 years. For both males and females, most samples were from patients older than 50 years.
Among the variations in resistance pattern by age and sex, E coli in samples from women older than 50 were more likely than those in female patients younger than 19 to show resistance to amoxicillin-clavulanate, ciprofloxacin, ceftriaxone, and gentamicin. For males, men older than 50 were more likely than men and boys younger than 19 to have resistance to ciprofloxacin, but lower odds of resistance to amoxicillin-clavulanate.
The authors said that antibiotic resistance data from outpatient settings, given that antibiograms aren't often available, could be useful in guiding empiric prescribing for treating UTIs and for supporting antibiotic stewardship efforts.
Mar 26 Clin Infect Dis abstract
Audit and feedback tied to improved antibiotic use in long-term care
Originally published by CIDRAP News Mar 23
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
Originally published by CIDRAP News Mar 23
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
New guide helps antibiotic developers with stewardship, access plans
Originally published by CIDRAP News Mar 22
A coalition of groups funding antibiotic research and development today released new guidance for developers of antibacterial products to integrate stewardship and access into their plans.
The Stewardship & Access Plan (SAP) Development Guide provides companies working on new antibiotics and other products targeting antibiotic-resistant bacteria, including vaccines and diagnostics, with strategies to ensure their products will be used responsibly and will be widely accessible in low- and middle-income countries.
The document was produced at the request of companies that receive funding from CARB-X (the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator) to help them meet the stewardship and access obligations required of CARB-X awardees once their projects reach clinical trials. Each company that receives CARB-X funding must produce an SAP within 90 days of their product entering phase 3 trials.
Developed collaboratively by members of CARB-X, the Wellcome Trust, the Global Antibiotic Research and Development Partnership, the Access to Medicine Foundation, the Biomedical Advanced Research and Development Authority, and others, the document provides an overview of strategies and activities that product developers can adopt to create SAPs that meet the funding requirements. Beyond CARB-X awardees, it aims to encourage other antibacterial product developers, and the governments and organizations supporting them, to integrate stewardship and access principles into their efforts.
"Antibacterial innovation must go hand-in-hand with responsible use and access. Otherwise, innovative drugs that are meant to help patients risk contributing to the global burden of antibiotic-resistance," CARB-X Executive Director Kevin Outterson, JD, said in a CARB-X press release. "We all must do our part to see that antibacterials are used responsibly and that patients who need them have access to them."
"The Guide represents a new benchmark for what can be expected from companies preparing to market innovative antibiotics, as they should proactively develop robust plans enabling worldwide stewardship and equitable access alongside market entry plans," said Tim Jinks, PhD, head of the Drug-Resistant Infections Program at Wellcome Trust.
"We are delighted to see the publication of the guide and hope that these insights inform the wider pharmaceutical, scientific and global health community, as well as CARB-X awardees."
Mar 22 CARB-X press release
Mar 22 SAP development guide
New African Union plan aims to limit emergence, spread of AMR
Originally published by CIDRAP News Mar 22
The African Union (AU) late last week released its 5-year plan for antimicrobial resistance (AMR) control.
Under the plan, which was developed by an AMR task force representing agencies involved in the human, animal, and plant health sectors, the AU will work with member states and other stakeholders over the next 5 years to improve surveillance of antimicrobial use and resistant microorganisms, delay the emergence and limit the transmission of AMR, and mitigate the harm from resistant organisms.
Goals of the plan include increasing the number of member states that monitor and track antibiotic use and the number of humans, animals, and food products tested for resistant pathogens; encouraging more physicians, veterinarians, and food producers to adhere to guidelines for prudent antimicrobial use; boosting infection control and prevention programs and diagnostic testing in healthcare facilities; and strengthening water, sanitation, and hygiene in all settings.
To achieve these goals, the AU says it will advocate for policies and laws that enable long-term prevention and control of AMR, engage civil society organizations on AMR, hire and train staff to perform AMR surveillance and control measures, and collaborate with partners to develop a list of priority areas for academic research.
The AU also says it will convene a panel of experts to identify high-level AMR targets and will produce annual reports on progress in achieving those targets.
Mar 19 African Union AMR plan 2020-2025