Urgent care stewardship linked to fewer inappropriate antibiotics
Pediatric urgent care (UC) centers involved in a multisite quality improvement (QI) study saw significant reductions in inappropriate antibiotics for three target diagnoses, a team of US researchers reported yesterday in Pediatrics.
The study involved 157 participants from 20 pediatric urgent care centers who responded to an invitation from the Society of Pediatric Urgent Care Centers to participate in a QI collaborative aimed at improving antibiotic prescribing for acute otitis media (AOM, or ear infection), otitis media with effusion (OME), and pharyngitis.
From June 2019 to December 2019, participating sites completed multiple intervention cycles from a menu of publicly available antibiotic stewardship intervention tools, including provider and patient education, provider communication training, delayed prescribing, and social media. The primary outcome was the rate of inappropriate antibiotic prescriptions for all target diagnoses.
Data from 3,833 patient encounters showed that the rate of inappropriate prescribing for all encounters fell from 60.3% at the beginning of the intervention to 27.8% at the end, for a relative reduction of 53.9%. The biggest reductions in inappropriate prescription rates were observed for AOM (57% to 36.6%) and pharyngitis (66.9% to 11.7%), which were the two most common encounters, accounting for 52% and 40.9% of all diagnoses, respectively. Inappropriate prescribing for OME, which accounted for only 7.1% of patient encounters, fell from 54.6% to 48.4%.
The study authors say that while the interventions are affordable, accessible, and easy to implement, they also have low reliability, and the changes can be difficult to maintain "because new people enter the system, and humans fall back on old habits."
"Future work is needed to embed these changes into the UC system by incorporating antibiotic stewardship initiatives into local onboarding processes, annual mandatory education, audits, and national benchmarking," they concluded.
Jun 15 Pediatrics abstract
England's NHS set to begin subscription-style payments for 2 antibiotics
England's National Health Service (NHS) announced yesterday it has agreed on reimbursement contracts for the two antibiotics selected for its pioneering, subscription-style payment model, and will soon make them available to patients.
Under the first-of-its-kind payment model, the NHS will pay an annual fee of up to £10 million ($12.4 million US) a year for up to 10 years for access to cefiderocol and ceftazidime-avibactam, manufactured by Shionogi and Pfizer, respectively. The hope is that paying an annual fee to the drugmakers based on the public health value of the two drugs, rather than reimbursing them based on the quantity of antibiotics sold, will incentivize funding for research into new antibiotics.
Although the two antibiotics are critical for patients with severe, multidrug-resistant infections like sepsis, hospital- or ventilator-acquired pneumonia, and bloodstream infections, they are used sparingly to avoid development of resistance, and the people who need them are relatively few. The low sales and lack of return on investment for these and other new antibiotics have led many pharmaceutical companies and investors to abandon antibiotic development, resulting in a weak pipeline of new products.
NHS and the UK National Institute for Health and Care Excellence selected cefiderocol and ceftazidime-avibactam as the first antibiotics to be bought through the pilot program in December 2020. The NHS says around 1,700 patients a year with severe bacterial infections will be eligible for the drugs, and the agreement ensures they will be used only when necessary.
"This world-leading agreement not only provides a template for other countries to follow, incentivising antimicrobial drug innovation globally, as we collectively deal with this threat to modern medicine and public health, but also gives new hope to thousands of patients who previously had no treatment options left," NHS Chief Executive Amanda Pritchard said in a press release.
Jun 15 NHS press release
Study: Not-susceptible urinary tract infections costlier, higher-impact
A study of electronic medical record data found that female patients with uncomplicated urinary tract infections (uUTIs) caused by not-susceptible urinary bacteria had higher healthcare costs and were more likely to develop a more serious infection compared with patients with susceptible bacteria, researchers reported this week in Antimicrobial Resistance and Infection Control.
Using data from an integrated delivery network that serves patients in mid-Atlantic states, researchers analyzed all female patients ages 12 years and older who received an antibiotic for a uUTI from July 2016 through March 2020 and had at least one urine culture within 5 days of diagnosis. The primary outcome was the difference in healthcare use and costs among patients with susceptible versus not-susceptible isolates during the 6 months after the primary diagnosis. Secondary outcomes included hospital and emergency department visits and the probability of progressing to a complicated urinary tract infection (cUTI).
A total of 2,018 women were included in the final analysis, with an average age of 44 years for both groups. The most commonly prescribed antibiotics were nitrofurantoin (60.8%), trimethoprim-sulfamethoxazole (19.4%), and ciprofloxacin (14.6%).
In the 6 months post-index uUTI event, patients with not-susceptible isolates had significantly higher numbers of prescriptions (+ 1.41) and UTI-specific prescriptions (+ 0.26) versus patients with susceptible isolates. They also had a higher probability of all-cause outpatient (+ 6.1%), UTI-related outpatient (+ 3.7%), and all-cause inpatient (+ 1.4%) visits. The predicted probability of disease progression to cUTI was more than double for patients with not-susceptible versus susceptible isolates (odds ratio, 2.35; 95% confidence interval, 1.66 to 3.33). Over 6 months, patients with not-susceptible isolates had significantly higher all-cause costs (+ $426) and UTI-related costs (+ $157) than those with susceptible isolates.
The study authors say that, with antibiotic resistance increasing in community-acquired uUTIs in the United States, clinicians should transition away from purely empiric antibiotic prescribing.
"By treating these patients without specific knowledge of the pathogen or antibiotic susceptibility, there is a possibility that patients might be prescribed an antibiotic therapy to which their isolate is not-susceptible, leading to a higher probability of treatment failure and subsequent infections with antibiotic-resistant uropathogens," they wrote.
Jun 14 Antimicrob Resist Infect Control study