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Source: http://www.cidrap.umn.edu/news-persp...an-feb-15-2019
Stewardship / Resistance Scan for Feb 15, 2019
Electronic stewardship intervention; Antibiotic resistance and UTI risk; C diff testing in children
Filed Under:
Antimicrobial Stewardship; Diagnostics; Clostridium difficile
Digital stewardship cuts antibiotics for respiratory infections in UK study
Electronically delivered prescribing feedback and decision support interventions reduced antibiotic prescribing for respiratory infection (RTI) in adults by 12%, according to the results of a clinical trial published this week in the British Medical Journal.
In the open label cluster randomized controlled trial, British researchers evaluated the impact of a 12-month antimicrobial stewardship intervention that included a brief training webinar, automated monthly feedback reports of antibiotic prescribing sent by email, and electronic decision support tools to inform clinicians when an antibiotic is indicated. Intervention components were supported by a local practice champion. The primary outcome was the rate of antibiotic prescriptions for respiratory tract infection (RTI) per 1,000 patient years.
The trial included 79 general practices across the United Kingdom; 41 practices were in the stewardship arm, and 38 were in the usual-care arm. The overall adjusted rate ratio for antibiotic prescribing for RTI was 0.88 (95% confidence interval [CI], 0.78 to 0.99, P = 0.04), with prescribing rates of 98.7 per 1,000 patient years in the stewardship group (31,907 prescriptions) and 107.6 per 1,000 patient years for usual care (27,923 prescriptions).
Results of the subgroup analysis showed that the intervention had the greatest impact on prescribing for adults aged 15 to 84 (adjusted rate ratio, 0.84; 95% CI, 0.75 to 0.95), with one antibiotic prescription per year avoided for every 62 patients (95% CI, 40 to 200). But there was no evidence of an effect for children under 15 (adjusted rate ratio, 0.96; 95% CI, 0.82 to 1.12) or adults over 85 (adjusted rate ratio, .97; 95% CI, 0.79 to 1.18). There was also no evidence of an increase in serious bacterial complications in the stewardship arm (rate ratio, 0.92; 95% CI, 0.74 to 1.13).
"Although the absolute impact is moderate, it is likely to be important for public health in the drive to reduce antibiotic prescribing and the risks of antimicrobial resistance," the authors of the study concluded. "Interventions using data from electronic health records might be used to promote antimicrobial stewardship in primary care and might be readily scaled up. The needs of very young or old patients need specific consideration."
Feb 13 BMJ study
Cephalosporin resistance may raise risk of recurrent UTIs
In a retrospective cohort study yesterday in BMC Infectious Diseases, researchers with the University of Pennsylvania Perelman School of Medicine reported that extended-spectrum cephalosporin (ESC) resistance in community-onset urinary tract infection (UTI) caused by Enterobacteriaceae (EB) is significantly associated with increased risk of recurrent UTI within 12 months compared with ESC-susceptible EB.
The researchers evaluated all patients presenting to emergency departments or outpatient practices within the University of Pennsylvania Health System from December 2010 through April 2013. Exposed patients were defined as those with an EB UTI demonstrating resistance to an ESC, and unexposed patients were those who had a UTI with ESC-susceptible EB. The primary outcome was time to first recurrent UTI.
A total of 302 patients with an index community-onset EB UTI were included, with 151 exposed and 151 unexposed. Overall, 163 (54%) patients experienced a recurrent UTI with a median time to recurrence of 69 days (interquartile range, 25 to 183). On multivariable analyses, ESC-resistance was associated with an increased hazard of recurrent UTI (adjusted hazard ratio [aHR], 1.39, 95% confidence interval [CI], 1.01 to 1.91, P = 0.04). Other variables that were independently associated with recurrence included a history of UTI 6 months prior to the index UTI (aHR, 1.59; 95% CI, 1.17 to 2.15, P < 0.01) and presence of a urinary catheter at the time of the index UTI (aHR 1.59; 95% CI, 1.06 to 2.38, P = 0.03).
Secondarily, the researchers found that when the treatment for the index UTI was adjusted for initial inappropriate antibiotic therapy, there was no longer a significant association between ESC-resistance and time to recurrent UTI (aHR 1.26; 95% CI, 0.91 to 1.76, P = 0.17), suggesting that the increased risk of recurrence with an ESC-resistant EB UTI could be related to the timing and selection of the treatment regimen.
The researchers say further studies are needed to determine interventions that may reduce the risk of recurrence, including different antibiotic regimens and durations.
Feb 14 BMC Infect Dis study
Survey highlights room for improvement in pediatric C diff testing
The results of an electronic survey sent to pediatric infectious disease (PID) members of the Infectious Diseases Society of America's (IDSA's) Emerging Infections Network suggest there are opportunities to improve Clostridioides difficile infection (CDI) diagnostic stewardship practices in children. The findings appear today in Infection Control and Hospital Epidemiology.
The objective of the survey was to determine the prevalence of CDI diagnostic practices in the United States as they relate to avoiding detection of asymptomatic C difficile carriage in children. Misclassification of asymptomatic carriers as having CDI can lead to unnecessary CDI antibiotic therapy and inaccurate CDI surveillance. One particular concern is the use of nucleic acid amplification tests (NAATs) without additional toxin testing. NAATs can detect C difficile strains that have the potential to produce toxins, but do not detect secreted toxins in the stool and therefore have poor diagnostic predictive value for CDI. Another is unnecessary testing in infants and young children, who have a low likelihood of CDI.
Among 345 eligible respondents, 196 (57%) responded; 162 of these (83%) were aware of their institutional policies for CDI testing and management, and 159 (98%) respondents knew their institution?s C difficile testing method. Among these respondents, 99 (62%) said they use NAAT without toxin testing and 60 (38%) use toxin testing, either as a single test or a multistep algorithm.
Of 153 respondents aware of symptom-based restrictions on C difficile testing, 10 (7%) reported that formed stools were tested for C difficile at their institution, and 76 of 151 (50%) respondents who were aware of age-based restrictions on testing reported that their institution does not restrict testing in infants and young children. The frequency of symptom- and age-based testing restrictions did not vary between institutions using NAAT alone compared with those using toxin testing for C difficile diagnosis. Of 143 respondents at institutions with neonatal intensive care units (NICUs), 26 (16%) permit testing of NICU patients and 12 of 26 (46%) treat CDI with antibiotics in this patient population.
The survey data were gathered shortly before publication of updated clinical practice guidelines for CDI from IDSA and the Society for Healthcare Epidemiology of America (SHEA), which include recommendations to limit testing in pediatric patients with low likelihood of CDI and to avoid detection of asymptomatic carriage.
The authors of the study conclude, "In summary, these data suggest that there are pervasive opportunities to improve CDI diagnostic stewardship practices in children and to develop institutional policies to align with recently updated IDSA/SHEA guidance, particularly in hospitals using NAATs alone for CDI diagnosis in children."
Feb 15 Infect Control Hosp Epidemiol abstract
Stewardship / Resistance Scan for Feb 15, 2019
Electronic stewardship intervention; Antibiotic resistance and UTI risk; C diff testing in children
Filed Under:
Antimicrobial Stewardship; Diagnostics; Clostridium difficile
Digital stewardship cuts antibiotics for respiratory infections in UK study
Electronically delivered prescribing feedback and decision support interventions reduced antibiotic prescribing for respiratory infection (RTI) in adults by 12%, according to the results of a clinical trial published this week in the British Medical Journal.
In the open label cluster randomized controlled trial, British researchers evaluated the impact of a 12-month antimicrobial stewardship intervention that included a brief training webinar, automated monthly feedback reports of antibiotic prescribing sent by email, and electronic decision support tools to inform clinicians when an antibiotic is indicated. Intervention components were supported by a local practice champion. The primary outcome was the rate of antibiotic prescriptions for respiratory tract infection (RTI) per 1,000 patient years.
The trial included 79 general practices across the United Kingdom; 41 practices were in the stewardship arm, and 38 were in the usual-care arm. The overall adjusted rate ratio for antibiotic prescribing for RTI was 0.88 (95% confidence interval [CI], 0.78 to 0.99, P = 0.04), with prescribing rates of 98.7 per 1,000 patient years in the stewardship group (31,907 prescriptions) and 107.6 per 1,000 patient years for usual care (27,923 prescriptions).
Results of the subgroup analysis showed that the intervention had the greatest impact on prescribing for adults aged 15 to 84 (adjusted rate ratio, 0.84; 95% CI, 0.75 to 0.95), with one antibiotic prescription per year avoided for every 62 patients (95% CI, 40 to 200). But there was no evidence of an effect for children under 15 (adjusted rate ratio, 0.96; 95% CI, 0.82 to 1.12) or adults over 85 (adjusted rate ratio, .97; 95% CI, 0.79 to 1.18). There was also no evidence of an increase in serious bacterial complications in the stewardship arm (rate ratio, 0.92; 95% CI, 0.74 to 1.13).
"Although the absolute impact is moderate, it is likely to be important for public health in the drive to reduce antibiotic prescribing and the risks of antimicrobial resistance," the authors of the study concluded. "Interventions using data from electronic health records might be used to promote antimicrobial stewardship in primary care and might be readily scaled up. The needs of very young or old patients need specific consideration."
Feb 13 BMJ study
Cephalosporin resistance may raise risk of recurrent UTIs
In a retrospective cohort study yesterday in BMC Infectious Diseases, researchers with the University of Pennsylvania Perelman School of Medicine reported that extended-spectrum cephalosporin (ESC) resistance in community-onset urinary tract infection (UTI) caused by Enterobacteriaceae (EB) is significantly associated with increased risk of recurrent UTI within 12 months compared with ESC-susceptible EB.
The researchers evaluated all patients presenting to emergency departments or outpatient practices within the University of Pennsylvania Health System from December 2010 through April 2013. Exposed patients were defined as those with an EB UTI demonstrating resistance to an ESC, and unexposed patients were those who had a UTI with ESC-susceptible EB. The primary outcome was time to first recurrent UTI.
A total of 302 patients with an index community-onset EB UTI were included, with 151 exposed and 151 unexposed. Overall, 163 (54%) patients experienced a recurrent UTI with a median time to recurrence of 69 days (interquartile range, 25 to 183). On multivariable analyses, ESC-resistance was associated with an increased hazard of recurrent UTI (adjusted hazard ratio [aHR], 1.39, 95% confidence interval [CI], 1.01 to 1.91, P = 0.04). Other variables that were independently associated with recurrence included a history of UTI 6 months prior to the index UTI (aHR, 1.59; 95% CI, 1.17 to 2.15, P < 0.01) and presence of a urinary catheter at the time of the index UTI (aHR 1.59; 95% CI, 1.06 to 2.38, P = 0.03).
Secondarily, the researchers found that when the treatment for the index UTI was adjusted for initial inappropriate antibiotic therapy, there was no longer a significant association between ESC-resistance and time to recurrent UTI (aHR 1.26; 95% CI, 0.91 to 1.76, P = 0.17), suggesting that the increased risk of recurrence with an ESC-resistant EB UTI could be related to the timing and selection of the treatment regimen.
The researchers say further studies are needed to determine interventions that may reduce the risk of recurrence, including different antibiotic regimens and durations.
Feb 14 BMC Infect Dis study
Survey highlights room for improvement in pediatric C diff testing
The results of an electronic survey sent to pediatric infectious disease (PID) members of the Infectious Diseases Society of America's (IDSA's) Emerging Infections Network suggest there are opportunities to improve Clostridioides difficile infection (CDI) diagnostic stewardship practices in children. The findings appear today in Infection Control and Hospital Epidemiology.
The objective of the survey was to determine the prevalence of CDI diagnostic practices in the United States as they relate to avoiding detection of asymptomatic C difficile carriage in children. Misclassification of asymptomatic carriers as having CDI can lead to unnecessary CDI antibiotic therapy and inaccurate CDI surveillance. One particular concern is the use of nucleic acid amplification tests (NAATs) without additional toxin testing. NAATs can detect C difficile strains that have the potential to produce toxins, but do not detect secreted toxins in the stool and therefore have poor diagnostic predictive value for CDI. Another is unnecessary testing in infants and young children, who have a low likelihood of CDI.
Among 345 eligible respondents, 196 (57%) responded; 162 of these (83%) were aware of their institutional policies for CDI testing and management, and 159 (98%) respondents knew their institution?s C difficile testing method. Among these respondents, 99 (62%) said they use NAAT without toxin testing and 60 (38%) use toxin testing, either as a single test or a multistep algorithm.
Of 153 respondents aware of symptom-based restrictions on C difficile testing, 10 (7%) reported that formed stools were tested for C difficile at their institution, and 76 of 151 (50%) respondents who were aware of age-based restrictions on testing reported that their institution does not restrict testing in infants and young children. The frequency of symptom- and age-based testing restrictions did not vary between institutions using NAAT alone compared with those using toxin testing for C difficile diagnosis. Of 143 respondents at institutions with neonatal intensive care units (NICUs), 26 (16%) permit testing of NICU patients and 12 of 26 (46%) treat CDI with antibiotics in this patient population.
The survey data were gathered shortly before publication of updated clinical practice guidelines for CDI from IDSA and the Society for Healthcare Epidemiology of America (SHEA), which include recommendations to limit testing in pediatric patients with low likelihood of CDI and to avoid detection of asymptomatic carriage.
The authors of the study conclude, "In summary, these data suggest that there are pervasive opportunities to improve CDI diagnostic stewardship practices in children and to develop institutional policies to align with recently updated IDSA/SHEA guidance, particularly in hospitals using NAATs alone for CDI diagnosis in children."
Feb 15 Infect Control Hosp Epidemiol abstract