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

Survey shows COVID-19 reduced AMR resources across 73 countries

A survey across 73 countries assessing the impact of COVID-19 on the prevention and control of antimicrobial resistance (AMR) highlights reduced availability of nursing, medical, and public health staff for AMR efforts. The study was published today in the Journal of Antimicrobial Chemotherapy.

The survey, conducted from October to December 2020 through the WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS), was the first to analyze how and if the pandemic was affecting AMR efforts across high-, middle-, and low-income countries. A glass point person in each of the 73 nations completed the survey.

The most significant findings were shortages in staffing: Reduced availability of nursing, medical and public health staff for AMR was reported by 71%, 69%, and 64%, of survey respondents, respectively. Additionally, 67% of countries reported limited ability to work with AMR partnerships, with low-and middle-income countries reporting the largest decreases in funding (P < 0.01).

"The effects of the COVID-19 pandemic threaten the progress made and are thought to be having wide-reaching impacts on AMR surveillance, prevention and control efforts," the authors wrote. "This underlines the importance of maintaining AMR surveillance to monitor trends during the COVID-19 pandemic."
Sep 3 J Antimicrob Chemother study

Vietnamese study finds benefits from CRE screening in newborns

Originally published by CIDRAP News Sep 1

Admission screening for carbapenem-resistant Enterobacterales (CRE) at a Vietnamese children's hospital was associated with reduced CRE acquisition, hospital-acquired infections (HAIs), duration of hospital stay, and costs, according to a study published this week in Antimicrobial Resistance and Infection Control.

In the prospective intervention cohort study, a team of Swedish and Vietnamese researchers assessed the effectiveness of CRE admission screening and cohort care in three intensive care units (ICUs) at Vietnamese National Children's Hospital. During the intervention, all newborns admitted to the ICU were screened upon admission, then treated in cohorts base on CRE colonization status. Newborns who initially tested negative were screened once a week. The primary outcomes were CRE acquisition and colonization, HAI rate, and treatment outcome and costs.

Of 941 newborns screened at admission, 337 (35.8%) were CRE-positive. Of the 694 patients that met inclusion criteria, 244 who were CRE-negative at admission and screened more than two times were stratified in eight similarly sized groups (periods), based on time of admission. In the three ICUs combined, CRE acquisition decreased significantly (odds ratio, [OR], − 3.2) over the eight periods, from 90% in period 2 to 48% in period 8.

CRE acquisition was significantly correlated with culture-confirmed HAI, weeks of hospital stay, and total treatment cost. Patients with CRE acquisition compared to no CRE acquisition had a significantly higher rate of culture confirmed HAI (14% vs 2%), longer hospital stays (3.26 vs. 2.37 weeks), and higher total treatment costs ($2,852 vs. $2,295 USD).

"The admission CRE screening and cohort care intervention showed that CRE acquisition can be reduced with limited resources and be cost-effective by reducing CRE colonization, HAI, and duration of hospital stay," the study authors wrote. "As large proportions of patients were CRE colonized at admission, indicating a significant CRE spread in non-tertiary level hospitals, CRE screening should be implemented in all healthcare levels in the endemic Vietnamese system."

The authors add that, since their study contained no control group, a randomized controlled trial is needed to better assess the impact of CRE screening and cohort care.
Aug 30 Antimicrob Resist Infect Control study

Survey: Those with minor symptoms more likely to OK delayed antibiotics

Originally published by CIDRAP News Aug 31

Severity and the type of symptoms experienced appear to be the biggest factors in accepting a delayed antibiotic prescription for a respiratory tract infection (RTI), according to a UK survey published yesterday in PLOS Medicine.

The survey, completed by 802 adults and 801 parents in the United Kingdom, presented respondents with 12 hypothetical scenarios in which they or their child might need an antibiotic for an RTI, and whether they would accept an immediate or delayed prescription from their primary care physician. While UK primary care guidelines recommend a delayed prescription for RTIs—under which patients are advised to initiate antibiotics only if their condition worsens—uptake of the practice has been modest, and researchers want to better understand the factors that affect people's decisions.

Non-parent adults were more likely to accept a delayed prescription for minor symptoms like a cough and runny nose (probability, 53%) or a sore throat with swollen glands (47%) than for a sore throat with swollen glands and a fever (37%) or a cough with a fever (30%), and they were less likely to accept a delayed prescription with increasing duration of illness (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.92 to 0.96). Parents showed an even more marked reduction when it came to delaying prescription amid lengthening illness (OR, 0.83).

Women were more likely than men to choose a delayed prescription for minor symptoms (62% probability vs 45% probability). Similar higher probability patterns for delaying prescription for minor symptoms were observed in older adults, those who were knowledgeable about antibiotics, and those who had been prescribed antibiotics in the past year.

The authors of the survey say presenting specific scenarios may have prompted responses that more closely reflect decisions that would be made in real life.

"Our findings could help to reduce consumption of antibiotics in primary care by encouraging primary care physicians to increase their use of delayed prescription in those groups who are more open to this approach and to specifically address concerns such as illness duration," they wrote. "Educational interventions to improve understanding of antibiotics could target those who are less amenable to delayed prescription and focus on the (lack of) role of antibiotics in sore throat."
Aug 30 PLOS Med study

Study links ICU stewardship to small reduction in antibiotic use

Originally published by CIDRAP News Aug 31

A randomized crossover study of antibiotic stewardship rounds (ASRs) in intensive care units (ICUs) found a small but measurable reduction in antibiotic use, Duke University researchers reported yesterday in Clinical Infectious Diseases.

The study involved five adult ICUs at Duke University Hospital from October 2017 to June 2018, and researchers compared antibiotic use during and after ICU stay in units with weekly ASRs and those assigned to routine care. The ASRs involved weekly face-to-face meetings with physicians and pharmacists from the antibiotic stewardship and ICU teams, and discussions of antibiotic optimization for reviewed patients.

The analysis included 4,683 patients, with 2,330 in the intervention group and 2,353 in the control group. Teams performed 761 reviews during ASRs, which excluded 1,569 patients from review.

The rate ratio (RR) of antibiotic use in days of therapy per 1,000 days present was 0.97 (95% CI, 0.91 to 1.04), but there was a large variation in effect size when the analysis was stratified by unit. When the unit with the highest percentage of patients excluded from ASRs (the cardiothoracic ICU) was removed, the RR was 0.93 (95% CI, 0.89 to 0.98). Antibiotic use in all five ICUs in the post-study period declined by 16% compared to antibiotic use in the baseline period, with the largest reduction observed in the neurology ICU (—28%) and the smallest in the cardiothoracic ICU (–2%).

The study authors say the results highlight the importance of customizing antibiotic stewardship strategies to match the patient population, workflow, and culture in each unit. They also note that, because ASRs are such a high-resource intervention, sustainability may be a challenge.

"Thus, future study is needed to develop selection tools that assist in identifying clinical scenarios that are most likely to result in meaningful stewardship interventions to reduce the personnel time required for reviews," they wrote.
Aug 30 Clin Infect Dis abstract

World Economic Forum warns of future risk, costs from waterborne AMR

Originally published by CIDRAP News Aug 30

A new report from the World Economic Forum predicts a future of rising risks and costs from waterborne AMR.

The report, published in collaboration with the Swiss Agency for Development and Cooperation, lays out the various drivers of AMR water pollution—hospital and community waste, food production, antibiotic manufacturing, and poor wastewater treatment—and the environmental and socio-economic factors that increase the risk associated with waterborne AMR.

With human and veterinary antimicrobial use expected to rise 28% and 50% by 2030, respectively, and antibiotic manufacturing to grow in response to this demand, the groups predict that waterborne AMR levels will climb, and the resulting human and economic costs will be highest in low- and middle-income countries where sanitation is poor and access to clean water is limited.

Among the impacts from higher levels of waterborne AMR will be increased disease burden, increased medical costs, additional costs to the wider economy due to reduced labor supply, and loss of livestock value from higher animal mortality rates.

"If these trends are left unchecked, the impacts will be severe and unaffordable in many countries," the report states. "Analysis for this study projects the effect of AMR pollution in water on the duration and quality of life up to 2050 to be equivalent to 25% of the total global burden of malaria and tropical diseases and more than the combined annual burden of conflict and terrorism, maternal disorders and natural disasters. Standard approaches to monetising these impacts value them at $340-680 billion per year."

The report estimates, for example, that an outbreak of drug-resistant cholera in Bangladesh, where only 35% of the population has access to hand washing at home and only 48% have access to sanitation, could double caseloads and significantly raise fatality rates.

The authors conclude that the scale and interconnectedness of waterborne AMR calls for a comprehensive, multisectoral response that includes expanded wastewater treatment and improved access to clean water, regulatory and incentive measures to promote prudent antibiotic use and responsible antibiotic manufacturing practices, and better data to improve understanding and monitoring of risk. 
Aug 27 World Economic Forum report

Australian antibiotic use declining, but appropriateness still a problem

Originally published by CIDRAP News Aug 30

A new report from the Australian Commission on Safety and Quality in Health Care (the Commission) shows that community antimicrobial use has declined in Australia over the last few years, but inappropriate use remains an issue.

The fourth Australian report on antimicrobial use and resistance in human health (AURA 2021) shows that, in 2019, more than 10 million Australians (40.3%) had at least one antimicrobial dispensed. While age-standardized community antimicrobial prescribing rates in Australia have declined since 2015, the country continues to prescribe antimicrobials at a higher rate than most European countries and Canada. Furthermore, in 2019, more than 80% of patients diagnosed as having acute bronchitis or acute sinusitis—two conditions for which antimicrobials are not recommended—received an antimicrobial prescription.

"It is extremely concerning that AURA 2021 shows that many patients continue to be prescribed antimicrobials for conditions for which there is no evidence of benefit," John Turnidge, MBBS, the Commission's AURA senior medical adviser, said in a Commission press release.

The report also shows a continuing gradual increase in the volume of hospital antibiotic use since 2015, along with little improvement in the overall appropriateness of prescribing in various settings, including hospitals and nursing homes. Inappropriate antimicrobial use remained high for chronic obstructive pulmonary diseases, non-surgical wounds, and surgical prophylaxis.

Analysis of national antimicrobial resistance rates shows that resistance for many priority pathogens has not changed substantially since the last AURA report in 2019, with the exception of Escherichia coli, which is showing increasing resistance to common agents. In addition, community-associated clones of methicillin-resistant Staphylococcus aureus have become more widespread nationally.

The report calls for enhanced surveillance for important resistant organisms, strategies to address the lack of improvement in appropriate prescribing, and more accessible resistance data for healthcare providers.
Aug 27 AURA 2021 report
Aug 27 Commission press release

Antimicrobial stewardship intervention in sepsis patients found effective

Originally published by CIDRAP News Aug 30

Early intervention by an antimicrobial stewardship (AMS) team in patients being treated for sepsis improved the appropriateness of antimicrobial therapy, according to the results of a clinical trial published last week in JAC-Antimicrobial Resistance.

In the randomized controlled trial, conducted at a hospital in Melbourne, Australia, from February to August 2018, 90 patients who had a medical emergency team (MET) call for suspected sepsis were assigned 1:1 to either standard care (management of antimicrobial therapy by the treating team) or early intervention (AMS review of antimicrobial therapy within 48 hours of the MET call). The primary outcome was appropriateness of antimicrobial therapy 72 hours after the MET call, as determined by a panel of blinded infectious diseases physicians.

Previous research has indicated that approximately 50% of patients with suspected sepsis received prolonged antimicrobial therapy with unnecessarily broad-spectrum agents. While other trials have found that stewardship interventions can improve the appropriateness of antimicrobial therapy in critically ill sepsis patients, this is the first randomized controlled trial assessing the impact of a stewardship intervention in non-ICU sepsis patients, the authors said.

Seventy-two hours following a MET call for suspected sepsis, a higher proportion of patients in the intervention group were assessed as having appropriate antimicrobial therapy compared with the control group (67% vs 44%). The difference was even greater in a subgroup of patients who met sepsis-3 criteria (68% vs 36%).

The median time to appropriate antimicrobial therapy was shorter in the intervention group compared with the control group (43 vs 77 hours), and the median duration of total antimicrobial therapy was shorter (8.7 vs 10.7 days). There were non-significant differences in intensive care unit admission due to sepsis (13% in the intervention group vs 18% in the control group) and sepsis-related in-hospital mortality (7% vs 9%).

"In conclusion, our study demonstrates that in patients who have a MET call for suspected sepsis, AMS team review improves appropriateness of antimicrobial therapy by 23%," the study authors wrote. "By prioritizing this important cohort, AMS teams are able to provide a balanced approach to support early antimicrobial de-escalation and optimization for patients with suspected sepsis."
Aug 27 JAC-Antimicrob Resist study

Vaccine less protective but very beneficial vs Delta SARS-CoV-2 variant

COVID-19 vaccine effectiveness (VE) against the Delta (B1617.2) variant was 65% in those fully vaccinated, according to a population-based study in Norway. The results, published in Eurosurveillance yesterday, looked at 4,204,859 infected adults without previous COVID-19 from mid-April to mid-August.

Of the cohort, 0.13% had sequences indicating the Delta variant, of which 29.6% were partly vaccinated and 10.3% were fully vaccinated. VE against Delta of the available vaccines—Pfizer/BioNTech, Moderna, AstraZeneca/Oxford, or a mix—was 22.4% after partial vaccination and 64.6% after full vaccination (95% confidence intervals, 17.0% to 27.4% and 60.6% to 68.2%, respectively).

The researchers also looked at VE against the Alpha (B117) variant, which was identified in 0.31% of individuals. They found 54.5% and 84.4% VE in those partly and fully vaccinated, respectively.

Data revealed that 84 people were hospitalized (9 fully vaccinated) and 5 died (3 fully vaccinated) after contracting the Delta variant, and that 382 were hospitalized (10 full vaccinated) and 25 died (8 fully vaccinated) after contracting the Alpha variant. VE against either condition was not calculated because of the low absolute numbers.
Sep 2 Euro Surveill study

Loss of taste or smell linked to some COVID symptoms more than others

Although loss of taste or smell has been linked to COVID-19 infection, a research letter in JAMA Otolaryngology – Head & Neck Surgery yesterday found that the condition may not be as absolute a marker as people think.

The researchers used the US Centers for Disease Control and Prevention self-checker tool to look at 59,153 uses from Feb 2 to May 3. All users were adults, with the largest age-group being 18 to 29 years (26.7%). Most were female (65.6%) or White (62.6%). Vaccination status was not recorded.

Among people with negative COVID-19 test results, loss of taste or smell was more strongly associated with congestion or runny nose compared with those who had positive test results (odds ratios [ORs], 2.26 vs 1.66). Similarly, loss of taste or smell was more strongly associated with cough and fever if the COVID-19 test was negative, not positive (ORs, 1.16 to 1.57 vs 0.95 to 1.01).

On the other hand, vomiting or diarrhea was more strongly associated with loss of taste or smell among patients with positive test results (ORs, 1.52 vs 1.23).

"The findings of this cross-sectional study suggest that differences in symptoms occurring with new loss of taste or smell were seen between groups based on SARS-CoV-2 test positivity," the researchers write. "In both groups with positive and negative test results, congestion or runny nose had strong associations with new loss of taste or smell, suggesting the latter may not be a valid marker of test positivity in this sample."
Sep 2 JAMA Otolaryngol Head Neck Surg study

Decarceration linked to 2% less daily COVID-19 cases

If jails "decarcerated," or released, 80% of their inmates—an amount the researchers say is often proportionate to people detained for nonviolent crimes—daily COVID-19 case growth rates in the community would drop 2%, according to a modeling study yesterday in JAMA Network Open. The researchers say if such a strategy had been implemented nationally at the beginning of the pandemic, millions of cases could have been prevented.

The researchers looked at 165 US counties, which encompassed 51% of all counties, 72% of the US population, and 60% of the US jail population. The average prison population was 283.4 people, and the average county density was 315.2 people per square mile.

Mathematical modeling based on data from Jan 1 to Nov 15, 2020, estimated that 80% decarceration was linked to a 2.0% drop in daily COVID-19 case growth rates (95% confidence interval [CI], 0.8% to 3.1%), which increased to 4.6% in counties with above-median population density (95% CI, 2.2% to 7.1%). Counties with below-median population density saw less of an effect (0.5%; 95% CI, 0.1% to 0.9%).

"The high rate at which people are cycled between communities and unnecessary short-term stays in jails is creating epidemiologic pumps that drive more and more infections in both jails and communities," said first author Eric Reinhart, MD, in a Northwestern University press release. Jail populations have a 55% weekly turnover rate, according to the study. "This jail churn effectively produces epidemic machines that seed outbreaks both in and beyond jails, undermining public safety for the entire country."

The study assessed 10 other COVID-19 mitigations in addition to releasing prisoners, with the most influential being bans on nursing home visitations (7.3% rate reduction), school closures (4.3%), and mask mandates (2.5%). Stay-at-home orders were associated with only a 0.8% drop in the rate of case growth.
Sep 2 JAMA Netw Open study
Sep 2 Northwestern University press release