Stewardship / Resistance Scan for Feb 21, 2022

News brief

Guideline-discordant dental antibiotics linked to increased C diff risk

A study of US veterans who developed Clostridioides difficile infection (CDI) within 30 days of a dental antibiotic prescription found that nearly 80% received guideline-discordant antibiotics, researchers reported today in Infection Control & Hospital Epidemiology.

Using data on Veterans Affairs (VA) patients with dental antibiotic prescriptions, a team of VA researchers found that 212,763 patients had an antibiotic prescribed by a VA dentist within 7 days of a dental encounter from 2015 through 2019, and 108 (0.05%) had a positive C difficile diagnostic test within 30 days.

Of the patients with CDI, 79.7% received antibiotics that were discordant with guidelines from the American Dental Association and the American Heart Association (AHA), which recommend antibiotic prophylaxis only for patients with a pre-existing cardiac condition who are undergoing gingival manipulation or being treated for acute apical abscess.

Of those with discordant prescriptions, only 19.4% had a pre-existing cardiac condition. In addition, 24.4% had prosthetic joints and 4.6% were immunocompromised. Furthermore, 59.3% had a chronic gastrointestinal issue, 34.3% had gastroesophageal reflux disease, and 50.0% had been prescribed either a proton pump inhibitor or H2 receptor antagonist for gastric conditions; all three factors have been associated with increased CDI risk.

The analysis also found that 89% with a documented penicillin allergy receive clindamycin, which the AHA recommends against because of the documented increased risk of CDI and other adverse events.

"Although our current results do not causally link the dental antibiotics to the subsequent CDI event, the antibiotics prescribed by a dentist represent an additional exposure," the authors write. "We recommend increased vigilance by dentists to antimicrobial stewardship, awareness of identified risk factors, and an increased adherence to guidelines."
Feb 21 Infect Control Hosp Epidemiol abstract

Canadian proposal aims to boost access to new antibiotics

The Canadian Antimicrobial Innovation Coalition (CAIC) and McMaster University last week released a proposal to boost access to new and innovative antibiotics in Canada.

The proposal contains 30 recommendations that aim to rectify the lack of access in Canada to several new antibiotics that have been approved and marketed in the United States and Europe in recent years. A July 2021 study published in Clinical Infectious Diseases found that, of 18 novel antibiotics approved and commercially launched in 14 high-income countries over the past decade, only 2 have been introduced in Canada.

In addition, the proposal also notes that several new antibiotics already approved in Canada are rarely used owing to costs and administrative barriers, resulting in overuse of first-line drugs in Canada.

Among the recommendations made in the proposal are guaranteed minimum revenue agreements for manufacturers of novel antibiotics that would delink sales volume from return on investment; expedited and streamlined marketing approval of select priority antibiotics that have already been approved by the US Food and Drug Administration or the European Medicines Agency; specific funding envelopes to help Canadian hospitals buy new antibiotics; national forecasts for the antibiotics that will be needed by Canadian patients; and investments in antibiotic stewardship.

"Part of the reason we're seeing drugs approved elsewhere but not here in Canada is because approval costs are high, our population is relatively small, and physicians try to use new antibiotics only as a last resort to reduce the chance of resistance to them developing," project chair Lori Burrows, PhD, of McMaster University, said in a press release. "We believe that this can be rectified through incentivization and regulatory improvements, as other G7 countries are doing."

The authors of the proposal suggest piloting it in a select region of the country using a limited number of novel antibiotics that have already been approved in Canada.
Feb 15 McMaster press release
Dec 2021 McMaster/CAIC antibiotic access and capacity proposal

News Scan for Feb 21, 2022

News brief

Fewer kids' ED visits amid COVID, but more mental healthcare in teen girls

Lower percentages of US children visited an emergency department (ED) for any indication amid the COVID-19 pandemic, while adolescent girls accounted for the largest hikes in visits for mental illness, according to two Centers for Disease Control and Prevention (CDC) studies published late last week in Morbidity and Mortality Weekly Report (MMWR).

For both studies, the researchers mined pediatric ED visit data in the National Syndromic Surveillance Program for three periods: Mar 15, 2020, to Jan 2, 2021; Jan 3, 2021, to Jan 1, 2022; and Jan 2 to 29, 2022, compared with the same periods in 2019.

The first study found that, relative to 2019, overall ED visits by children 17 years and younger in 2020, 2021, and January 2022 fell by 51%, 22%, and 23%, respectively. COVID-19 visits made up the biggest proportion of ED visits among all ages, while visits for other respiratory diseases largely declined.

At the same time, the number and percentage of visits for some injuries (eg, guns, self-harm, drugs), chronic illnesses, and mental health concerns rose but varied by age-group.

The findings point to the need for vigilance for indirect effects of the pandemic on children's and adolescents' health, including problems resulting from delayed care and increasing stress and mental health concerns—particularly among older children and adolescents, the study authors said.

"Prevention programs that improve children and adolescents' physical and mental health are critical during and after emergencies," the researchers wrote. "Reducing COVID-19 infection through vaccination and other nonpharmaceutical prevention strategies can further protect pediatric health."

The second study found that, compared with 2019, weekly ED visits among girls 12 to 17 years old rose for eating and tic disorders in 2020; depression, eating, tic, and obsessive-compulsive disorders in 2021; and anxiety, trauma- and stress-related, eating, tic, and obsessive-compulsive disorders in 2022. Over the same period, mental health–related ED visits declined for adolescent boys.

The authors called for evidence-based primary prevention, early identification, and treatment strategies that support children's physical and mental health, especially for adolescent girls.

"CDC supports efforts to promote the emotional well-being of children and adolescents and provides resources for clinicians, families, schools, and communities," they concluded.
Feb 18 MMWR pediatric study and mental health study

Family members suffer PTSD after COVID-19 ICU stay, study reveals

A new study from French researchers shows that family members of patients hospitalized in the intensive care unit (ICU) with COVID-19 acute respiratory distress syndrome (ARDS), as compared with other causes of ARDS, were at a significantly increased risk of symptoms of post-traumatic stress disorder (PTSD) at 90 days after ICU discharge.

The study was published in JAMA late last week.

The prospective study included patients seen in 23 ICUs in France from January of 2020 to June of 2020, with final follow-up ending in October of that year.

Researchers analyzed data on 517 families of ICU patients. Thirty-five percent of families with a member diagnosed as having COVID-19 ARDS reported PTSD within 3 months of hospital discharge, compared to 19% among families of patients with non-COVID ARDS.

Family members of COVID-19 patients reported more anxiety and depression, which may be attributed to the isolation family members felt as they were not allowed inside hospitals during the first part of the pandemic, the authors suggested.

"This study extends prior findings to show that the level of social support was associated with PTSD symptoms. There are many potential explanations for these findings including the need to comply with strict isolation measures to prevent viral transmission and the strain put on ICU staff due to the surge in patient numbers caused by the pandemic," the authors said.
Feb 18 JAMA study