Stewardship / Resistance Scan for Aug 16, 2021

News brief

Antibiotic stewardship in hospitalized seniors tied to better outcomes

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 antibiotic stewardship program (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

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

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

News Scan for Aug 16, 2021

News brief

US wildfires associated with excess COVID-19

US wildfires were associated with excess COVID-19 cases and deaths from mid-August to mid-October 2020, according to a study published late last week in Science Advances.

The researchers looked at 92 counties in California, Oregon, and Washington—the states most affected by 2020 US wildfires—creating a distributed lag model from synthesized county- and daily-level data on fine particulate air pollution, wildfire days, and COVID-19 cases and deaths. After accounting for weather, population size, and physical distancing data, they say that an average daily increase of 10 micrograms of particulates per cubic meters each day for 28 days was tied with an 11.7% increase in COVID-19 cases and an 8.4% increase in deaths.

In absolute numbers, the data projected that US wildfires were associated with 19,700 more cases and 750 more deaths from Aug 15 to Oct 15, 2020.

During this peak time of wildfire activity, daily levels of fine particulate air pollution were significantly higher during wildfire than non-wildfire days (median, 31.2 micrograms per cubic meter vs 6.4). Some days had much higher concentrations, they noted, such as the Creek Fire in Mono County, California, which had fine particulate air pollution reaching over 500 micrograms per cubic meter for 4 consecutive days.

Sonoma, California, and Whitman, Washington, saw the largest change in COVID-19 cases, with a 65.3% and 71.6% increase, respectively, while Calaveras, California, and San Bernardino, California, saw the largest rise in deaths, with a 52.8% and 65.9% increase, respectively.

"Climate change will likely bring warmer and drier conditions to the West, providing more fuel for fires to consume and further enhancing fire activity. This study provides policymakers with key information regarding how the effects of one global crisis—climate change—can have cascading effects on concurrent global crises—in this case, the COVID-19 pandemic," said senior author Francesca Dominici, PhD, in a Harvard T.H. Chan School of Public Health press release.
Aug 13 Sci Adv study
Aug 13 Harvard press release

Most COVID-associated ARDS patients have symptoms 8 months later

Four out of five patients with COVID-19–associated acute respiratory distress syndrome (ARDS) had lingering symptoms 8 months later, according to a study published late last week in the Journal of Infection.

The researchers looked at 113 patients with COVID-associated ARDS who were admitted to a Barcelona, Spain, hospital from Feb 28 to Apr 15, 2020 (median age, 64 years; 70% male).

At a median of 240 days (8 months) after the initial COVID-19 diagnosis, 81% still had persistent symptoms, most commonly shortness of breath (55%), joint and muscle pain (50%), weakness/lack of energy (45.5%), memory loss (42.5%), and lack of concentration (40.7%). Additionally, 57% had not returned to baseline physical health, including an inability to complete 80% or more of their theoretical 6-minute walking distance (53.5%). Almost all (93%) developed a new mental health condition, including moderate to severe post-traumatic stress disorder (49.5%), depression (36%), and anxiety at or above the 75th percentile (34%).

Overall, average SF-36 Health Assessment scores were worse than in the general population. Age was associated with a better prognosis, while being female, not White, or having a Charlson comorbidity index score greater than 2 was associated with a worse mental health component summary score. Being female or having chronic obstructive pulmonary disease was associated with a worse physical component summary score.

A subanalysis suggested that, while Latino patients in the cohort were younger (52 vs 67 years) and had lower rates of high blood pressure and dyslipidemia, they had worse outcomes at 8 months, including mental composite score on the SF-36, 6-minute walking time results, and exercise capacity.

"COVID-19 associated ARDS survivors have long-term consequences in health status, exercise capacity, and [health-related quality of life]. Strategies addressed to prevent these sequelae are needed," the researchers conclude.
Aug 13 J Infect study

COVID-19 saliva testing appears less sensitive each week post-infection

COVID-19 diagnosis via saliva samples was most sensitive during the first week of infection and was never higher than 60% in asymptomatic people, according to a research letter published late last week in JAMA.

The researchers looked at nasopharyngeal and saliva samples collected every 3 to 7 days up to 4 weeks from people exposed to household members who had COVID-19. Of the 889 paired samples from 404 participants, 58.9% of nasopharyngeal swabs were positive for COVID-19, whereas 35.7% of saliva samples were. Both types of samples in the pair were positive 29.0% of the time.

The peak of saliva sensitivity was 71.2%, during the first week of COVID-19 infection (95% confidence interval [CI], 62.6% to 78.8%). The researchers note that those who were symptomatic during their first week of infection had an 88.2% saliva sensitivity, while those who were asymptomatic had 58.2%.

Overall, the odds ratio for saliva detection was 0.94 compared with the previous day (95% CI, 0.91 to 0.96). Symptomatic people had a 2.8-fold higher likelihood of having saliva detection than those who were asymptomatic, and those with high nasopharyngeal viral loads had a 5.2-fold higher likelihood than those with low viral loads.

"Saliva was sensitive for detecting SARS-CoV-2 in symptomatic individuals during initial weeks of infection, but sensitivity in asymptomatic SARS-CoV-2 carriers was less than 60% at all time points," the researchers write. "This study suggests saliva-based RT-PCR should not be used for asymptomatic COVID-19 screening."

All participants were recruited from the Los Angeles area from Jun 17, 2020, to Feb 15, 2021.
Aug 13 JAMA study