Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans
Rapid, portable PCR test for gonorrhea shows promise
A rapid, cartridge-based polymerase chain reaction (PCR) platform developed by scientists at Johns Hopkins University for detecting gonorrhea infections and providing antibiotic susceptibility results showed promising results in a study published this week in Science Translational Medicine.
In a study conducted using penile swab samples from sexual health clinics in Baltimore and Kampala, Uganda, researchers showed that the portable, rapid, on-cartridge multifluidic purification and testing (PROMPT) PCR test returned results in less than 15 minutes and had an overall sensitivity and specificity of 97.7% (95% confidence interval [CI], 94.7% to 100%) and 97.6% (95% CI, 94.1% to 100%), respectively, for Neisseria gonorrhoeae. The platform, which performs simultaneous genotyping of samples to detect the presence of resistance genes for ciprofloxacin, also showed 100% concordance with culture results for ciprofloxacin resistance.
The PROMPT platform was designed for automated testing at the point of care (POC) in confined workspaces in limited-resource settings, with a small footprint and minimal power needs. The test uses a portable mobile phone charger, which supplies power to conduct more than 20 tests. In a survey conducted among healthcare workers in Uganda after a demonstration of the platform, 29 of 30 respondents said they would "definitely" or "probably" use the platform if it was made available.
Although the performance of the test still needs to be validated with vaginal and extragenital swabs, the study authors believe the device, because it provides faster results and is cheaper than leading POC PCR diagnostics, could enable greater access to gonorrhea testing and bolster antimicrobial stewardship in low-resource settings. Limited screening for sexually transmitted infections and poor antimicrobial stewardship in such settings, particularly in sub-Saharan Africa, have contributed to a high prevalence of gonorrhea infections and antimicrobial resistance.
"Rapid identification of the bacterial pathogen N. gonorrhoeae and associated antimicrobial susceptibility will help to promote better antimicrobial stewardship to reduce selection of antimicrobial resistant bacterial strains," the study authors wrote.
May 12 Sci Transl Med abstract
Outpatient stewardship initiative linked to reduced antibiotic prescribing for bronchitis
Implementation of a multifaceted outpatient antimicrobial stewardship initiative at ambulatory clinics in the Midwest was associated with a significant reduction in antibiotic prescribing for acute bronchitis, researchers reported today in Infection Control & Hospital Epidemiology.
The initiative, implemented at 10 clinics with the highest antibiotic prescribing rates and 5 additional clinics in the winter of 2018, included clinician- and patient-focused educational materials focused on appropriate prescribing for acute respiratory infections (ARIs). At all of the clinics, clinicians received educational videos via email. Ten received additional clinician-focused ARI management pocket cards and posters, and five were randomly selected to hand out "Be Antibiotics Aware" pledge cards to patients. Clinicians also received blinded report cards on antibiotic prescribing after the intervention was completed.
To evaluate the effectiveness of the initiative, researchers compared prescribing for acute bronchitis—which rarely requires antibiotics—during the preintervention period (January to April 2017), the intervention period (January to April 2018), and the postintervention period (January to April 2019).
The analysis evaluated 311 clinic visits for acute bronchitis during the preintervention period, 282 during the intervention period, and 256 during the postintervention period. At all clinics, overall antibiotic prescribing rates for acute bronchitis significantly decreased from 53.7% at baseline to 43.6% during the intervention period (relative reduction 18.8%). The prescribing reduction persisted during the postintervention period (relative reduction 25.9%).
Antibiotic prescribing rates in the clinics that only received education videos via email remained stable during the 3 periods: 40.8% at baseline, 41.5% during the intervention, and 42.3% postintervention. In contrast, clinics receiving more active interventions had a combined relative reduction of 20.1% during the intervention period and a significant relative reduction of 29.3% after the intervention period. A clinically relevant 12.3% absolute reduction in prescribing for acute bronchitis was observed in clinics that received more active interventions.
"In summary, a multifaceted approach including online antimicrobial stewardship education, clinician-directed and patient-directed interventions, and dissemination of blinded report cards to clinicians led to a sustained reduction in antibiotic prescribing for acute bronchitis," the study authors wrote. "Addition of communication training to address patients’ expectation for antibiotic therapy may further reduce inappropriate antibiotic prescribing."
May 14 Infect Control Hosp Epidemiol abstract
No increased Achilles tendon rupture risk with 3rd-gen fluoroquinolones
Originally published by CIDRAP News May 13
An analysis of administrative claims data in Japan found that newer, third-generation fluoroquinolones were not associated with an increased risk of Achilles tendon rupture, Japanese researchers reported this week in the Annals of Family Medicine.
Using data from patients enrolled in Japan's National Health Insurance and Elderly Health Insurance programs from April 2012 to March 2017, the study examined patients who had experienced Achilles tendon rupture after receiving an antibiotic prescription. Antibiotics were categorized into three groups: first- and second-generation fluoroquinolones, third-generation fluoroquinolones, and non-fluoroquinolones. The researchers then estimated the incidence rate ratio (IRR) of Achilles tendon rupture during the antibiotic exposure period relative to the non-exposure period.
Among the 504 patients analyzed, the risk was not significantly elevated during exposure to third-generation fluoroquinolones (IRR, 1.05; 95% CI, 0.33 to 3.37) and non-fluoroquinolones (IRR, 1.08; 95% CI, 0.80 to 1.47). In contrast, increased risk of Achilles tendon rupture tripled during exposure to first- and second-generation fluoroquinolones (IRR, 2.94; 95% CI, 1.90 to 4.54). The findings were similar when researchers analyzed subgroups stratified by sex and recent corticosteroid use.
The findings are noteworthy because several studies have found that Achilles tendon rupture is one of the adverse effects associated with fluoroquinolone use, but that association has not previously been investigated with third-generation fluoroquinolones. The authors say the findings suggest third-generation fluoroquinolones may be a safer option for patients who have an elevated risk of Achilles tendon rupture, such as athletes.
May 10 Ann Fam Med study
Decline seen in US antibiotic use since 1999, but progress has slowed
Originally published by CIDRAP News May 13
Overall short-term antibiotic use in the United States fell over the past 20 years, but progress stalled over the last decade, researchers from Johns Hopkins University School of Medicine reported today in Open Forum Infectious Diseases.
The researchers used data from National Health and Nutrition Examination Surveys (NHANES), which ask participants about medications taken over the past 30 days and have been collected and released in 2-year intervals since 1999, to identify trends in short-term non-topical antibiotic use from 1999 to 2018. They calculated the prevalence of antibiotic use overall and by subgroups of interest for the years 1999 to 2002, 2007 to 2010, and 2015 to 2018. They also calculated antibiotic use by class and examined factors associated with antibiotic use during 2015-2018.
The analysis found that the overall prevalence of past 30-day short-term non-topical antibiotic use adjusted for age, sex, race/ethnicity, poverty status, time of year of the interview, and insurance fell from 4.9% (95% CI, 3.9% to 5.0%) during 1999-2002 to 3.0% (95% CI, 2.6% to 3.0%) in 2015-2018, with the largest decline observed among children 0 to 1 years. Declines were also observed in age categories 6 to 11, 12 to 17, and 18 to 39 years. Short-term antibiotic use for all antibiotics (topical and non-topical) followed the same trend. The investigators noted significant declines in penicillins and cephalosporins.
From 2007-2010 to 2015-2018, however, there was no significant change in antibiotic use (adjusted prevalence ratio [aPR], 1.0; 95% CI, 0.8 to 1.2). Age was significantly associated with antibiotic use during this period, with children age 0 to 1 year having significantly higher antibiotic use than all other age-groups. Being non-Hispanic Black was negatively associated with antibiotic use compared with being non-Hispanic White (aPR, 0.6; 95% CI, 0.4 to 0.8).
"Overall, these data suggest that, despite the push for antimicrobial stewardship and reducing unnecessary antimicrobial prescriptions, the progress of reduction over the past decade may be slower than desired," the study authors wrote. "Further investigation should be conducted for the most recent years to verify if these finding hold across data sources, as this would imply that the US has not met the goals established in 2014 to reduce antibiotic use."
May 13 Open Forum Infect Dis abstract
Waiting room video cuts antibiotic expectations but not prescriptions
Originally published by CIDRAP News May 12
Watching a brief video about antibiotic treatment prior to a family practitioner visit reduced patients' expectations about receiving antibiotics for upper respiratory tract infections (URTIs) but had no influence on physician prescribing, according to a randomized controlled trial published this week in the Annals of Family Medicine.
In the three-armed trial, conducted by researchers at the University of Auckland in New Zealand, patients at two family practices in Auckland were randomly allocated to watch one of three video presentations on a tablet device immediately before their consultation. One video was on the futility of antibiotic treatment for URTIs, the other described the adverse effects associated with antibiotics, and the third was on the benefits of healthy diet and exercise. Before and after viewing the videos, patients filled out a questionnaire and were asked to rate, using a Likert scale, the strength of their belief that antibiotics are effective for treating URTIs and their desire to receive an antibiotic.
A total of 325 patients participated in the trial. Likert scores for patients' agreement with the statement "I wish to receive antibiotics for my/my child's cold/flu" before viewing the presentations was similar across all three groups, with a mean score of 3. After viewing the presentations, the mean reduction in Likert score for those who viewed the futility video (1.1; 95% CI, 0.8 to 1.3) or the adverse-effects video (0.7; 95% CI, 0.4 to 0.9) was significantly greater than that for those who viewed the control video (0.1; 95% 0.0 to 0.3). The effect was also observed when the analysis was restricted to the parents of 91 child participants.
Among the 306 patients who completed the post-presentation questionnaire, 30% received an antibiotic prescription. There was no significant difference in the proportion between the futility group (31%), adverse-effects group (28%), and control group (32%).
"Although we reduced patients' expectations for an antibiotic prescription, doing so did not reduce antibiotic prescribing by family practitioners," the study authors wrote, while noting that the study was not primarily designed to examine prescribing. "This finding is surprising given that patients' expectations to receive antibiotics are stated to be the main driver of antibiotic prescribing for URTIs."
The authors suggest it's possible that participants provided socially desirable responses on the questionnaires but made their real expectations clear in the consultation with family practitioners.
May 10 Ann Fam Med study
Spanish study finds high rate of inappropriate antibiotics in COVID patients
Originally published by CIDRAP News May 12
A study of COVID-19 patients in Spain during the early months of the pandemic found frequent inappropriate antibiotic use, Spanish researchers reported yesterday in PLOS One.
Of the 13,932 COVID-19 patients treated at Spanish hospitals from Mar 1 through Jun 23, 2020, 10,885 (78.1%) received systemic antibiotics other than macrolides, with 6,116 (43.9%) appropriately prescribed antibiotics and 4,769 (34.2%) inappropriately prescribed antibiotics.
Analysis of independent risk factors for inappropriate antibiotic prescribing identified admission from February through March (odds ratio [OR], 1.54; 95% CI, 1.18 to 2.00), younger age (OR, 0.98; 95% CI, 0.97 to 0.99), absence of comorbidity (OR, 1.43; 95% CI, 1.05 to 1.94), dry cough (OR, 2.51; 95% CI, 1.94 to 3.26), fever (OR, 1.33; 95% CI, 1.13 to 1.56), dyspnea (OR, 1.31; 95% CI, 1.04 to 1.69), flu-like symptoms (OR, 2.70; 95% CI, 1.75 to 4.17), and elevated C-reactive protein levels (OR, 1.01 for each mg/L increase; 95% CI, 1.00 to 1.01) as leading risk factors.
The analysis also found that patients who received antibiotics were more likely to have drug-related complications than those who didn't (4.9% vs 2.7%; OR, 1.84; 95% CI, 1.45 to 2.32).
The authors note that the percentage of COVID-19 patients who received antibiotics is similar to what's been found in other studies, and that the high prescribing rate contrasts with the low incidence of bacterial coinfection or superinfection in the cohort; only 10% of patients had confirmed pulmonary superinfection, and 2% had superinfection of another origin.
"Widespread antibiotic prescribing carries an increased risk of adverse reaction and probably other unwanted effects (such as possible increased bacterial resistances), without benefit," they wrote. "It is therefore essential to integrate antibiotic use optimization programs in patients with SARS-CoV2 infection. More research is needed to identify patients which warrant antibiotic prescription."
May 11 PLOS One study
CARB-X to fund development of rapid test for chlamydia, gonorrhea
Originally published by CIDRAP News May 11
CARB-X announced today that it is awarding Australian diagnostics company SpeeDx up to $1.8 million to develop a rapid molecular diagnostic test for chlamydia and gonorrhea infections.
The money will aid development of SpeeDx's InSignia technology, which is able to detect whether an active infection is associated with Chlamydia trachomatis or N gonorrhoeae within 60 minutes. The technology will also be able to perform antibiotic susceptibility testing to identify the most appropriate antibiotic for gonorrhea infections.
SpeeDx, of Sydney, Australia, plans to combine the test with a battery powered, easy-to-use device developed by QuantuMDx that can be used in remote or low-resource settings such as sub-Saharan Africa, where the vast majority of gonorrhea infections go undetected and untreated. If the project achieves certain milestones, it could be eligible for $1.9 million in additional funding from CARB-X (the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator).
"SpeeDx's technology is in the early stages of development and, if successful, could be used to help healthcare providers rapidly diagnose chlamydia and gonorrhea, and to identify antibiotics that could be effective, thus improving treatment decisions, and mitigating the devastating effects of these diseases," CARB-X Research and Development Chief Erin Duffy, PhD, said in a CARB-X press release. "Faster diagnostics have the potential to help inform treatment decisions, and those diagnostics that can be deployed in low-resource settings are sorely needed."
May 11 CARB-X press release
Hospital pathogens in Vietnam show increasing resistance levels
Originally published by CIDRAP News May 11
Analysis of surveillance data from hospitals in Vietnam found alarmingly high and increasing levels of antibiotic resistance in clinically important organisms, researchers reported yesterday in Antimicrobial Resistance and Infection Control.
Among the 42,553 bacterial isolates collected from 13 Vietnamese hospitals in 2016-17 by Vietnam's national antimicrobial resistance (AMR) surveillance network, 71% were gram-negative and 29% were gram-positive. Escherichia coli (21%) and Staphylococcus aureus (11%) were the most frequently detected species, followed by Klebsiella pneumoniae (9.1%) and Acinetobacter baumannii(9%).
Antibiotic susceptibility data showed that, among gram-positive bacteria, 73% of S aureus isolates were methicillin-resistant, 34% of Enterococcus faecium were resistant to vancomycin, and 58% of Streptococcus pneumoniae had reduced susceptibility to penicillin.
Among gram-negative bacteria, 59% of E coli and 40% of K pneumoniae produced extended-spectrum beta-lactamase (ESBL) enzymes, and 29% and 11% were resistant to carbapenems, respectively. In addition, 79% of Acinetobacter spp. and 45% of Pseudomonas aeruginosa were carbapenem resistant, and 88% of Haemophilus influenzae were resistant to ampicillin.
When compared with data collected from the same hospitals in 2012-13, the proportion of antibiotic-resistant isolates were higher in 2016-17 for most pathogen-antibiotic combinations of interest, including imipenem-resistant A baumannii, P aeruginosa, and Enterobacterales. The proportion of multidrug-resistant E coli, A baumannii, and P aeruginosa was also higher.
The study authors note that the findings may not reflect the true prevalence of antibiotic resistance because of sampling biases and because they did not know whether the isolates were from hospital- or community-acquired infections.
May 10 Antimicrob Resist Infect Control study
Telemedicine consults for Staph bacteremia look promising
Originally published by CIDRAP News May 10
Use of infectious diseases (ID) telemedicine for management of Staphylococcus aureus bacteremia (SAB) at 10 US hospitals resulted in similar outcomes compared with on-site consultation, researchers reported today in Open Forum Infectious Diseases.
The retrospective cohort study analyzed data on patients hospitalized with SAB belonging to North Carolina-based Atrium Health from September 2016 through December 2017. All hospitals had implemented an antimicrobial stewardship-led SAB bundle, which includes ID consult, appropriate antibiotics, repeat blood cultures until clearance, echocardiograms, and appropriate antibiotic duration. But only half the hospitals had access to on-site ID experts who could provide consultation.
Of the 870 patients admitted during the study period, 676 were admitted to one of five hospitals with on-site, standard of care (SOC) ID consultation, and 194 were admitted to one of five hospitals with telemedicine (TM) ID consultation. The study assessed SAB bundle adherence and compared clinical outcomes in SAB patients.
Among the 738 patients evaluated (576 with SOC, 162 with TM), no differences were seen in overall bundle adherence (SOC 86% vs TM 89%) or in adherence for each bundle component. Analysis of clinical outcomes showed that the SOC and TM groups had similar rates of hospital mortality, 30-day SAB-related readmission, persistent bacteremia, and time to culture clearance. Multivariable analysis showed that the groups did not differ in 30-day mortality when controlling for demographics, bacteremia source, and physiological measures.
The authors say the findings are significant for facilities that don't have access to on-site ID consultation.
"We found that the use of virtual TM ID consultation may bridge the gap, providing access to specialty care and as a result provide patient outcomes that are not significantly different from similar on-site ID consultation," they wrote. "With almost half of US hospitals without access to ID consultations, the use of TM consultation could be an alternative option, avoiding the need to transfer the patient to another hospital and likely minimize delays in care."
May 10 Open Forum Infect Dis abstract
Survey reveals no standard treatment for carbapenem-resistant infections
Originally published by CIDRAP News May 10
A survey of more than 1,000 clinicians in 95 countries found wide variability in the management of carbapenem-resistant gram-negative bacteria (CR-GNB) infections, European researchers reported last week in Clinical Microbiology and Infection.
Among the 1,012 clinicians who responded to the 36-question survey, which was disseminated from Apr 15 to Jun 28, 2019, 30% had local guidelines for treating CR-GNB at their facility and 72% had access to ID consultation, with significant discrepancies according to country economic status: 85% in high-income countries vs 59% in upper-medium-income countries and 30% in low-income countries. As for diagnostic resources, 77% of respondents had access to standard susceptibility testing at a local level, with no differences according to income status, but more complex diagnostics were significantly more available in high-income countries.
Targeted regimens varied widely, ranging from 40 regimens for CR Acinetobacter baumannii to more than 100 regimens for CR Enterobacteriaceae. Dual antibiotic combination regimens were the preferred treatment scheme (between 35% and 45% of respondents) despite the lack of evidence, and the most prescribed regimen was carbapenem-polymyxin, irrespective of pathogen and infection source. The main reasons for combination treatment were to improve clinical efficacy (81% of respondents) and to reduce resistance development (51%).
The survey also found widespread disagreement about the meaning of combination therapy.
"Our results showed that the treatment of CR-GNB infections is far from being standardized and clinicians over the world use a wide range of antibiotic strategies and combinations depending on clinical severity, local availability and clinical experience," the study authors wrote. "These results demonstrate the urgent need for public health focused strategic randomised controlled trials with the involvement of Low and Low-Middle-Income-Countries."
May 8 Clin Microbiol Infect study