Stewardship / Resistance Scan for Sep 16, 2022

News brief

Unneeded broad-spectrum antibiotics may harm pneumonia patients

An analysis of data on patients hospitalized with community-acquired pneumonia (CAP) found that extended-spectrum antibiotic therapy was associated with increased mortality compared with standard antibiotic therapy, Japanese researchers reported yesterday in the International Journal of Infectious Diseases.

For the study, researchers conducted a post hoc analysis of a prospective observational study conducted at four hospitals in Japan that evaluated antibiotic treatment for CAP. Their aim was to clarify the impact of extended-spectrum antibiotic use in CAP patients at low risk of infections caused by drug-resistant pathogens (DRPs).

Physicians often suggest the administration of unnecessary extended-spectrum antibiotics, such as antipseudomonal and anti-methicillin–resistant Staphylococcus aureus (MRSA) drugs, for pneumonia patients to avoid potential delays in initiation of appropriate therapy, but many CAP patients don't need extended-spectrum antibiotics, and recent international guidelines on CAP have emphasized risk assessment for DRPs before using these broader-spectrum drugs.

Of the 750 CAP patients eligible for the study, 416 with a low risk of DRPs were analyzed; of these, 257 had been treated with standard antibiotic therapy, and 159 received extended-spectrum therapy. The 30-day mortality was 3.9% and 13.8% in the standard and extended-spectrum therapy groups, respectively.

Primary multivariable logistic regression analysis revealed that extended-spectrum therapy was associated with a nearly three-fold increase in 30-day mortality compared with standard therapy (adjusted odds ratio, 2.82; 95% confidence interval [CI], 1.20 to 6.66). The results of the sensitivity analyses were consistent with those of the primary analysis.

"These results suggest that the administration of extended-spectrum antibiotics is harmful in patients with CAP with a low risk of DRPs," the study authors wrote. "Physicians should therefore acknowledge the significance of DRPs risk assessment when determining the empirical antibiotic therapy and should refrain from administering extended-spectrum antibiotics to patients with a low risk of DRPs."

The authors say the possible explanations for the link between extended-spectrum antibiotics and increased mortality in CAP patients could include changes in the composition of gut microbiota and the risk of adverse events connected to these drugs, such as acute kidney injury and Clostridioides difficile infection.
Sep 15 Int J Infect Dis study

 

Trial: Multi-dose antibiotic preventive not needed for breast reconstruction

A randomized clinical trial conducted in Sweden found that multiple-dose intravenous antibiotic prophylaxis is not superior to a single-dose regimen for preventing postoperative infection following implant-based breast reconstruction and comes with a higher risk of adverse events, researchers reported today in JAMA Network Open.

In the multicenter randomized superiority trial, women who planned to undergo immediate or delayed implant-based breast reconstruction were randomized 1:1 to receive either multiple-dose antibiotic prophylaxis extending over 24 hours after surgery or a single dose of intravenous antibiotic.

The primary outcome was a surgical site infection (SSI) leading to removal of the implant within 6 months of surgery, and secondary outcomes included the rate of SSIs necessitating readmission and administration of intravenous antibiotics and clinically suspected SSIs not necessitating readmission but administration of oral antibiotics.

A total of 698 women were randomized, with 345 in the single-dose group and 353 in the multiple-dose group. Median ages were 46 in the single-dose group and 47 in the multiple-dose group. Within 6 months of follow-up, 30 patients (4.3%) had their implant removed because of an SSI (3.8% in the single-dose group vs 4.8% in the multiple-dose group). Readmission for intravenous antibiotics because of SSI occurred in 47 patients (7.0%; 6.1% vs 7.4%), and 190 women who received oral antibiotics because of clinically suspected SSI (27.7%; 30.4% vs 24.4%).

There was no significant difference between the randomization groups for the primary outcome of implant removal (OR, 1.26; 95% CI, 0.69 to 2.65) or for the secondary outcomes of readmission for intravenous antibiotics (OR, 1.18; 95% CI, 0.65 to 2.15) and prescription of oral antibiotics (OR, 0.72; 95% CI, 0.51 to 1.02). Adverse events associated with antibiotic treatment were more common in the multiple-dose group than in the single-dose group (16.4% [58 patients] vs 10.7% [37 patients]; OR, 1.64; 95% CI, 1.05 to 2.55).

"Multiple-dose antibiotic prophylaxis is not superior to a single-dose regimen in preventing implant removal due to SSI in implant-based breast reconstruction but is associated with more adverse events," the study authors concluded. "Thus, multiple-dose antibiotic prophylaxis is not recommended."
Sep 16 JAMA Netw Open study

News Scan for Sep 16, 2022

News brief

No antibodies in 1 in 3 unvaccinated COVID-19 survivors in Spain at 1 year

One in three unvaccinated COVID-19 survivors in a Spanish cohort had no detectable SARS-CoV-2 antibodies nearly 1 year after infection, according to a prospective study published today in BMC Medicine.

A team led by researchers from the Barcelona Institute for Global Health (ISGLOBAL) measured SARS-CoV-2 antibody levels in 1,076 adults aged 43 to 72 years from June to November 2020 and again from May to July 2021, before the emergence of the Omicron variant. Participants also completed questionnaires on lifestyle, health-related, and sociodemographic characteristics.

By the end of the study, 12.1% of participants were unvaccinated, 24.8% were partially vaccinated, and 63.1% were fully vaccinated. Median time since the last dose was 28 days. More unvaccinated participants had a previous COVID-19 diagnosis (32.3%) or positive antibody test in 2020 (49.2%) than vaccinated participants (12.5% and 28.2%, respectively). 

During the second antibody measurement more than 300 days after primary COVID-19 infection, 67.2% of infected unvaccinated participants still had antibodies, while serologic status was undetermined in 15.5%, and 20.3% had no antibodies. Those with antibodies were more likely to have had an asymptomatic infection (61.9% vs 25.6%), be older than 60 years (42.8% vs 34.8%), and smoke (19% vs 4.6%).

Nearly all vaccinated participants had antibodies (99.3% of the fully and 94.4% of partially vaccinated). Among COVID-19 survivors, vaccination improved the immune response, particularly the second dose. Vaccinated infected participants had higher antibody concentrations over time than their never-infected vaccinated counterparts.

mRNA vaccines, particularly Moderna's version, triggered greater antibody levels after two doses than the AstraZeneca/Oxford and Johnson & Johnson versions. Multivariable regression analyses showed that immune responses varied by type of vaccine, time since infection, sex, smoking status, and the presence of mental and cardiovascular illnesses.

"Our data underscore the importance of vaccinating people even if they have been previously infected, and confirm that hybrid immunity is superior and more durable," first author Marianna Karachaliou, PhD, said in an ISGLOBAL news release.
Sep 16 BMC Med study
Sep 15 ISGLOBAL
news release

 

Officials declare Marburg outbreak in Ghana over after 3 cases

Ghana's Ministry of Health today declared an end to its first-ever Marburg virus disease outbreak after officials confirmed three cases, two of them fatal, the World Health Organization (WHO) said in an update.

The outbreak is considered to be over after 42 days, or two incubation periods, have passed since the last known case. The incubation period is the time between infection and the onset of symptoms.

Officials first declared the outbreak on Jul 7 after they confirmed Marburg virus in the Ashanti, Savannah, and Western regions. They followed up with 198 contacts for 42 days of observation. In cooperation with the WHO, they rolled out outbreak control measures after the first case was identified, stepping up disease surveillance, testing, contact-tracing, clinical care, and awareness-raising.

Marburg is a highly infectious disease in the same family as Ebola and has a high case-fatality rate of 24% to 88%. Previous reports of the Ghana outbreak noted four cases and three deaths, but one of those fatal cases was later ruled out.

"Marburg is a frightening disease, as it is highly infectious and lethal. There are no vaccines or antiviral treatments. Any outbreak of Marburg is a major concern," said WHO Regional Director for Africa Matshidiso Moeti, MBBS.

The Marburg outbreak in Ghana was the second of its kind in West Africa. Guinea reported a single case in an outbreak that was declared over a year ago. Previous African outbreaks and cases have been reported in Angola, the Democratic Republic of the Congo (DRC), Kenya, South Africa, and Uganda.
Sep 16 WHO notice

 

DR Congo, Yemen report new vaccine-derived polio cases

In addition to detailing the recent New York polio case, the Global Polio Eradication Initiative (GPEI) in its weekly update yesterday noted 4 circulating vaccine-derived type 1 (cVDPV1) cases and 28 vaccine-derived type 2 (cVDPV2) cases in the DRC and 8 cVDPV2 cases in Yemen.

The 4 cVDPV1 cases in the DRC were in Haut-Lomami province and are the first to be confirmed in the country. The 28 cVDPV2 cases were in Bas-Uele and Maniema provinces (1 each), South Kivu (2), and Tanganyika (24), and they bring the number of cases in 2022 to 110. The country had 28 cVDPV2 cases in 2021.

Of Yemen's 8 cVDPV2 cases, 2 were in Al Mahwit city, 1 each in Ibb and Sa'dah governorates, and 4 in Sana'a governorate. The country has now reached 127 cVDPV2 cases for 2022 after recording 66 cVDPV2 cases and 3 cVDPV1 cases in 2021.

In officially confirming the New York polio case, which is the first US case in years, the GPEI said, "It is important to note that since initial isolation of VDPV2, local and national public health authorities have already been operating on the assumption that this strain is circulating, and as such, this official classification at this time does not affect the operational response."
Sep 15 GPEI update

ASP Scan (Weekly) for Sep 16, 2022

News brief

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

Unneeded broad-spectrum antibiotics may harm pneumonia patients

An analysis of data on patients hospitalized with community-acquired pneumonia (CAP) found that extended-spectrum antibiotic therapy was associated with increased mortality compared with standard antibiotic therapy, Japanese researchers reported yesterday in the International Journal of Infectious Diseases.

For the study, researchers conducted a post hoc analysis of a prospective observational study conducted at four hospitals in Japan that evaluated antibiotic treatment for CAP. Their aim was to clarify the impact of extended-spectrum antibiotic use in CAP patients at low risk of infections caused by drug-resistant pathogens (DRPs).

Physicians often suggest the administration of unnecessary extended-spectrum antibiotics, such as antipseudomonal and anti-methicillin–resistant Staphylococcus aureus (MRSA) drugs, for pneumonia patients to avoid potential delays in initiation of appropriate therapy, but many CAP patients don't need extended-spectrum antibiotics, and recent international guidelines on CAP have emphasized risk assessment for DRPs before using these broader-spectrum drugs.

Of the 750 CAP patients eligible for the study, 416 with a low risk of DRPs were analyzed; of these, 257 had been treated with standard antibiotic therapy, and 159 received extended-spectrum therapy. The 30-day mortality was 3.9% and 13.8% in the standard and extended-spectrum therapy groups, respectively.

Primary multivariable logistic regression analysis revealed that extended-spectrum therapy was associated with a nearly three-fold increase in 30-day mortality compared with standard therapy (adjusted odds ratio, 2.82; 95% confidence interval [CI], 1.20 to 6.66). The results of the sensitivity analyses were consistent with those of the primary analysis.

"These results suggest that the administration of extended-spectrum antibiotics is harmful in patients with CAP with a low risk of DRPs," the study authors wrote. "Physicians should therefore acknowledge the significance of DRPs risk assessment when determining the empirical antibiotic therapy and should refrain from administering extended-spectrum antibiotics to patients with a low risk of DRPs."

The authors say the possible explanations for the link between extended-spectrum antibiotics and increased mortality in CAP patients could include changes in the composition of gut microbiota and the risk of adverse events connected to these drugs, such as acute kidney injury and Clostridioides difficile infection.
Sep 15 Int J Infect Dis study

 

Trial: Multi-dose antibiotic preventive not needed for breast reconstruction

A randomized clinical trial conducted in Sweden found that multiple-dose intravenous antibiotic prophylaxis is not superior to a single-dose regimen for preventing postoperative infection following implant-based breast reconstruction and comes with a higher risk of adverse events, researchers reported today in JAMA Network Open.

In the multicenter randomized superiority trial, women who planned to undergo immediate or delayed implant-based breast reconstruction were randomized 1:1 to receive either multiple-dose antibiotic prophylaxis extending over 24 hours after surgery or a single dose of intravenous antibiotic.

The primary outcome was a surgical site infection (SSI) leading to removal of the implant within 6 months of surgery, and secondary outcomes included the rate of SSIs necessitating readmission and administration of intravenous antibiotics and clinically suspected SSIs not necessitating readmission but administration of oral antibiotics.

A total of 698 women were randomized, with 345 in the single-dose group and 353 in the multiple-dose group. Median ages were 46 in the single-dose group and 47 in the multiple-dose group. Within 6 months of follow-up, 30 patients (4.3%) had their implant removed because of an SSI (3.8% in the single-dose group vs 4.8% in the multiple-dose group). Readmission for intravenous antibiotics because of SSI occurred in 47 patients (7.0%; 6.1% vs 7.4%), and 190 women who received oral antibiotics because of clinically suspected SSI (27.7%; 30.4% vs 24.4%).

There was no significant difference between the randomization groups for the primary outcome of implant removal (OR, 1.26; 95% CI, 0.69 to 2.65) or for the secondary outcomes of readmission for intravenous antibiotics (OR, 1.18; 95% CI, 0.65 to 2.15) and prescription of oral antibiotics (OR, 0.72; 95% CI, 0.51 to 1.02). Adverse events associated with antibiotic treatment were more common in the multiple-dose group than in the single-dose group (16.4% [58 patients] vs 10.7% [37 patients]; OR, 1.64; 95% CI, 1.05 to 2.55).

"Multiple-dose antibiotic prophylaxis is not superior to a single-dose regimen in preventing implant removal due to SSI in implant-based breast reconstruction but is associated with more adverse events," the study authors concluded. "Thus, multiple-dose antibiotic prophylaxis is not recommended."
Sep 16 JAMA Netw Open study

 

Study examines inpatient antibiotic use in Japanese hospitals

Originally published by CIDRAP News Sep 15

A point-prevalence study conducted at five hospitals in Japan found that fewer than 30% of patients were prescribed an antibiotic on the survey date, but more than half of the antibiotics prescribed were broad spectrum, researchers reported yesterday in Antimicrobial Stewardship & Healthcare Epidemiology.

To better understand inpatient antibiotic use and the uptake of antimicrobial stewardship programs (ASPs) in the prefecture of Okinawa, a team of Japanese and US researchers assessed the proportion of total eligible hospitalized patients who received an antibiotic at five community hospitals on Oct 1, 2020. They also categorized antibiotics according to indication, drug class, and World Health Organization AWaRE (Access, Watch and Reserve) classification. Each hospital has one physician ASP champion, and three have an infectious diseases–trained physician as ASP champion.

Across the five hospitals, 504 of 1,728 (29%) unique patients received at least one antibiotic, with 51 (10%) receiving two antibiotics and 2 (0.4%) receiving 3 antibiotics. Of the patients who received antibiotics, 114 (23%) received them for prophylaxis (prevention) and 390 (77%) received them for treatment. Of the 390 patients who received antibiotics for treatment, 385 (98.7%) had a documented infection.

Overall, 241 (43.9%) of all 559 antibiotics prescribed were categorized as Access drugs, 304 (54.4%) were Watch drugs, and 12 (2.1%) were Reserve drugs. Cephalosporins were the most prescribed antibiotic class (56%), followed by beta-lactam/beta-lactamase inhibitors (19%), and narrow-spectrum penicillins (8.2%).

The study authors say that while the proportion of patients who received an antibiotic is lower than has been reported in many international studies, the high proportion of Watch antibiotics is a concern.

"Antibiotics in this classification may be more likely to cause resistance compared to Access antibiotics," they wrote. "Focusing on antimicrobial stewardship strategies (eg, selection of antibiotics for national or institutional guideline recommendations) that consider risk of antimicrobial resistance could be effective and beneficial."
Sep 14 Antimicrob Steward Hosp Epidemiol study

 

Study links reduced broad-spectrum antibiotics to fewer candidemia cases

Originally published by CIDRAP News Sep 13

Reduction of broad-spectrum antibiotic use at a Japanese tertiary hospital was associated with decreased incidence of hospital-acquired candidemia, researchers reported last week in Scientific Reports.

Although antibiotic pressure is considered a risk factor for hospital-acquired Candida infections, its relationship with candidemia incidence is not well established. To evaluate whether efforts by the antimicrobial susceptibility team at Japan's Itabashi Chuo Medical Center to reduce use of broad-spectrum antibiotics had an impact on hospital-acquired bloodstream infections caused by Candidaspp, researchers reviewed data on patients treated with three broad-spectrum antipseudomonal agents: carbapenems, tazobactam/piperacillin, and cefepime.

They compared monthly antibiotic consumption and candidemia incidence prior to implementation of stewardship activities (pre-intervention, April 2017 to March 2018) and after (intervention, April 2018 to September 2020).

The median monthly days of therapy (DOT) per 1,000 patient-days for the 3 antipseudomonal antibiotics combined was 69.4 in the pre-intervention period and 56.3 in intervention period, with carbapenem DOT falling from 28.4 to 10.0. Downward trends in monthly DOT continued after the intervention. The median hospital-acquired candidemia incidence was 0.17 and 0.08 per 1,000 patient-days during pre-intervention and intervention periods, respectively. Time-series analysis showed a significant change in the levels of candidemia after the intervention (−0.16 per 1,000 patient-days). The trend in the incidence of hospital-acquired candidemia did not significantly change between pre-intervention and intervention. 

"The decrease in broad-spectrum antibiotic use (especially carbapenems) achieved a sustained clinical impact by reducing the incidence of hospital-acquired candidemia," the study authors wrote. 
Sep 7 Sci Rep study

 

Study spotlights excess antibiotics in discharged hospital patients

Originally published by CIDRAP News Sep 12

A study conducted at Johns Hopkins Hospital found that three-quarters of patients evaluated were prescribed excess antibiotics at discharge, and durations were frequently longer than recommended, researchers reported last week in the American Journal of Infection Control.

For the study, researchers reviewed data on adult patients discharged from Johns Hopkins Hospital on oral antibiotics from July through August 2020, assessing antibiotic indication, appropriateness of antibiotics, and treatment duration. Excess duration was defined as days of therapy prescribed beyond institutional or national guideline-recommended treatment durations.

During the study period, 196 patients were discharged on antibiotics, with 147 (75%) prescribed excess antibiotic days. Antibiotic choice was appropriate in 70.4% of cases, but the discharge duration was appropriate in only 32.1% of cases based on antibiotic indication, and the total duration of therapy was identified as appropriate in just 24.5% of cases. Compared to all patients, those who received excess antibiotics at discharge had lower rates of appropriate therapy based on antibiotic indication. Excess antibiotic duration was particularly likely for unknown diagnosis (23%), skin and soft tissue infections (16%), and antibiotic prophylaxis (12%).

The study authors say improved adherence to recommended antibiotic prescribing practices prior to and at hospital discharge and through the completion of therapy is an "important but under-addressed"   target for antibiotic stewardship.

"Increasing antimicrobial stewardship efforts in both the outpatient setting and at hospital or emergency department discharge can improve antibiotic prescribing by clinicians and ensure that antibiotics are only prescribed when necessary," they wrote.
Sep 10 Am J Infect Control abstract

 

Study finds MRSA bacteremia rate much higher in NYC COVID-19 patients

Originally published by CIDRAP News Sep 12

The rate of  MRSA bacteremia was five times higher among COVID-19 patients than non-COVID patients at 11 New York City hospitals during the pandemic, researchers reported last week in Infection Control & Hospital Epidemiology.

From January 2019 through March 2022, there were 216 cases of healthcare facility-onset (HCFO) MRSA bacteremia across the 11 public acute care medical centers within New York City Health and Hospitals Enterprise, a healthcare system that serves primarily low-income patients in the Bronx, Brooklyn, Manhattan, and Queens. The baseline rate of MRSA bacteremia was 0.073 per 1,000 patient-days in 2019, and during four COVID-19 surges it climbed to 0.53, 0.20, 0.51, and 0.43 infections per 1,000 patient-days. From January 202o through March 2022, the overall rate of MRSA bacteremia in patients without COVID-19 was 0.065 per 1,000 patient-days, and 0.34 per 1,000 patient-days in patients with a diagnosis of COVID-19.

Compared with patients without COVID-19, MRSA bacteremia patients with COVID-19 were older (67.2 vs 55.6 years), more likely to be Asian (31% vs 4%), less likely to be Black (13% vs 36%), and more likely to be located in an intensive care area at the time of MRSA bacteremia (58% vs 34%). In addition, 77% of the patients with COVID-19 were on mechanical ventilation, 63% were on corticosteroids, and 79% met the National Healthcare Safety Network definition of pneumonia. Mortality rates were higher for patients with COVID-19 (81% vs 34%), and only 4% of patients with HCFO MRSA bacteremia and COVID-19 were discharged home, compared with 23% of patients without COVID-19.

The study authors say prolonged hospitalization and the high rates of corticosteroid use and mechanical ventilation likely contributed to superimposed MRSA infection, as did increased use of the antibiotic ceftriaxone during the initial surge of COVID-19. They also suggest the number of central-line associated MRSA bacteremia cases may be underestimated.

"The elevated rates of HCFO MRSA bacteremia during the pandemic once again emphasizes the important role of antibiotic stewardship and infection control efforts, especially during surges of patients with COVID-19," they wrote.
Sep 9 Infect Control Hosp Epidemiol abstract

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