Shiloh
Editor, Senior Moderator
Source: http://www.cidrap.umn.edu/news-perspective/2020/01/stewardship-resistance-scan-jan-17-2020
Stewardship / Resistance Scan for Jan 17, 2020
Suboptimal antibiotics in children's hospitals; Discordant antibiotics for kids' UTIs; Ceftazidime-avibactam resistance
Filed Under:
Antimicrobial Stewardship
[h=3]Study: Suboptimal antibiotic therapy common in US children's hospitals[/h] More than a quarter of children in US children's hospitals are receiving suboptimal antibiotic therapy, and antibiotic stewardships programs (ASPs) miss a substantial portion of it, according to a study yesterday in Clinical Infectious Diseases.
In the cross-sectional analysis of antibiotic prescribing at 32 hospitals recruited from the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative, researchers looked at pooled data from single-day surveys of antibiotic use conducted at each hospital over six quarters in 2016 and 2017. For the surveys, ASP physicians and pharmacists collected data on patients with active antibiotic orders and evaluated the appropriateness of those orders. The primary outcome of the analysis was the percentage of antibiotics prescribed for infectious use that were classified as suboptimal, defined as either inappropriate or needing modification.
Of the 34,927 children hospitalized on survey days, 12,213 (35%) had more than one active antibiotic order, with infectious use accounting for 95.9% of all orders. Analysis of suboptimal antibiotic use found that 21% of antibiotic orders were suboptimal, with 25.9% of patients receiving one or more suboptimal antibiotic on a given day. Among the suboptimal orders considered inappropriate, the most common reasons for the classification were bug-drug mismatches (27.7%), surgical prophylaxis for more than 24 hours (17.7%), overly broad empiric therapy (11.2%), and unnecessary treatment (11%).
The analysis also found that bacterial lower respiratory tract infections accounted for the largest share of suboptimal orders (18%), followed by surgical prophylaxis (17%), and that oral third-generation cephalosporins, carbapenems, fluoroquinolones, broad-spectrum gram-positive agents, and vancomycin had the highest odd of suboptimal prescribing. ASPs would not have reviewed 46.1% of suboptimal antibiotics through routine ASP activities.
"This study highlights the need for ASPs to look beyond current practices to identify and intervene upon additional suboptimal use and denotes areas in which to potentially expand efforts," the authors of the study conclude. "Such evolution is imperative to ensure optimal antibiotic use for all hospitalized children."
Jan 16 Clin Infect Dis abstract
[h=3]Pre–urine-culture antibiotics found appropriate in kids with superbug UTIs[/h] A US study found that most children who had urinary tract infections (UTIs) resistant to third-generation cephalosporins and were started on discordant antibiotics (those administered before urine tests are available) experienced initial clinical improvement, suggesting that narrow-spectrum empiric therapy is appropriate while awaiting final urine culture results, according to findings published today in Pediatrics.
The study included 316 children with third-generation cephalosporin-resistant UTIs caused by Escherichia coli (98.7% of patients) or Klebsiella spp. treated from 2012 to 2017 at one of five children's hospitals or a large managed care organization. A strong majority (78%) were girls, and the patients' median age was 2.4 years. Seven children required escalation of care.
For the 230 children (73%) with clinical response recorded, 192 (83.5%) experienced clinical improvement. In children with repeat urine testing while on discordant therapy, pyuria (the presence of pus in the urine) improved or resolved in 16 of 19 (84%), and urine cultures were pathogen-free in 11 of 17 (65%). The authors say their results are similar to smaller studies conducted outside the United States.
They conclude, "These results suggest that current empiric regimens are reasonable even with concerns of increasing antimicrobial resistance."
In an accompanying commentary Tej Mattoo, MD, DCH, and Basim Asmar, MD, two pediatricians from Wayne State University who were not involved in the study, say caution is needed when prescribing discordant antibiotics for these patients, and treatment should be fine-tuned as soon as urine tests are available. "Prospective, comparative studies are needed to help answer some of the questions raised by patient response to discordant antibiotic therapy for UTI," they add.
Jan 17 Pediatrics abstract
Jan 17 Pediatrics commentary
[h=3]Novel ceftazidime-avibactam resistance mechanism found in Greece[/h] Greek scientists yesterday reported the identification of a novel extended-spectrum beta-lactamase enzyme in two Klebsiella pneumoniae isolates that confers resistance to ceftazidime-avibactam. A description of the isolates appeared in Eurosurveillance.
The K pneumoniae isolates were obtained from two hospitalized Greek patients and were among a collection of 118 isolates analyzed after the European Centre for Disease Prevention and Control issued a rapid risk assessment on the emergence of ceftazidime-avibactam resistance in carbapenem-resistant Enterobacteriaceae in July 2019. Neither patient, one of whom was infected and the other colonized, had received ceftazidime-avibactam before the resistant strains were isolated.
Whole-genome sequencing and conjugation experiments identified the source of resistance as Vietnamese extended-spectrum beta-lactamase (VEB) variation, designated as VEB-25. The enzyme was carried on self-transferable plasmids that harbor several other resistance genes and have been acquired by high-risk K pneumoniae clones.
Although the extent of dissemination of VEB-25 producers in Greek K pneumoniae hospital isolates in unclear, the authors of the study say the use of ceftazidime-avibactam will likely increase the clinical relevance of VEB-25–mediated resistance.
Jan 16 Eurosurveill rapid communication
Stewardship / Resistance Scan for Jan 17, 2020
Suboptimal antibiotics in children's hospitals; Discordant antibiotics for kids' UTIs; Ceftazidime-avibactam resistance
Filed Under:
Antimicrobial Stewardship
[h=3]Study: Suboptimal antibiotic therapy common in US children's hospitals[/h] More than a quarter of children in US children's hospitals are receiving suboptimal antibiotic therapy, and antibiotic stewardships programs (ASPs) miss a substantial portion of it, according to a study yesterday in Clinical Infectious Diseases.
In the cross-sectional analysis of antibiotic prescribing at 32 hospitals recruited from the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative, researchers looked at pooled data from single-day surveys of antibiotic use conducted at each hospital over six quarters in 2016 and 2017. For the surveys, ASP physicians and pharmacists collected data on patients with active antibiotic orders and evaluated the appropriateness of those orders. The primary outcome of the analysis was the percentage of antibiotics prescribed for infectious use that were classified as suboptimal, defined as either inappropriate or needing modification.
Of the 34,927 children hospitalized on survey days, 12,213 (35%) had more than one active antibiotic order, with infectious use accounting for 95.9% of all orders. Analysis of suboptimal antibiotic use found that 21% of antibiotic orders were suboptimal, with 25.9% of patients receiving one or more suboptimal antibiotic on a given day. Among the suboptimal orders considered inappropriate, the most common reasons for the classification were bug-drug mismatches (27.7%), surgical prophylaxis for more than 24 hours (17.7%), overly broad empiric therapy (11.2%), and unnecessary treatment (11%).
The analysis also found that bacterial lower respiratory tract infections accounted for the largest share of suboptimal orders (18%), followed by surgical prophylaxis (17%), and that oral third-generation cephalosporins, carbapenems, fluoroquinolones, broad-spectrum gram-positive agents, and vancomycin had the highest odd of suboptimal prescribing. ASPs would not have reviewed 46.1% of suboptimal antibiotics through routine ASP activities.
"This study highlights the need for ASPs to look beyond current practices to identify and intervene upon additional suboptimal use and denotes areas in which to potentially expand efforts," the authors of the study conclude. "Such evolution is imperative to ensure optimal antibiotic use for all hospitalized children."
Jan 16 Clin Infect Dis abstract
[h=3]Pre–urine-culture antibiotics found appropriate in kids with superbug UTIs[/h] A US study found that most children who had urinary tract infections (UTIs) resistant to third-generation cephalosporins and were started on discordant antibiotics (those administered before urine tests are available) experienced initial clinical improvement, suggesting that narrow-spectrum empiric therapy is appropriate while awaiting final urine culture results, according to findings published today in Pediatrics.
The study included 316 children with third-generation cephalosporin-resistant UTIs caused by Escherichia coli (98.7% of patients) or Klebsiella spp. treated from 2012 to 2017 at one of five children's hospitals or a large managed care organization. A strong majority (78%) were girls, and the patients' median age was 2.4 years. Seven children required escalation of care.
For the 230 children (73%) with clinical response recorded, 192 (83.5%) experienced clinical improvement. In children with repeat urine testing while on discordant therapy, pyuria (the presence of pus in the urine) improved or resolved in 16 of 19 (84%), and urine cultures were pathogen-free in 11 of 17 (65%). The authors say their results are similar to smaller studies conducted outside the United States.
They conclude, "These results suggest that current empiric regimens are reasonable even with concerns of increasing antimicrobial resistance."
In an accompanying commentary Tej Mattoo, MD, DCH, and Basim Asmar, MD, two pediatricians from Wayne State University who were not involved in the study, say caution is needed when prescribing discordant antibiotics for these patients, and treatment should be fine-tuned as soon as urine tests are available. "Prospective, comparative studies are needed to help answer some of the questions raised by patient response to discordant antibiotic therapy for UTI," they add.
Jan 17 Pediatrics abstract
Jan 17 Pediatrics commentary
[h=3]Novel ceftazidime-avibactam resistance mechanism found in Greece[/h] Greek scientists yesterday reported the identification of a novel extended-spectrum beta-lactamase enzyme in two Klebsiella pneumoniae isolates that confers resistance to ceftazidime-avibactam. A description of the isolates appeared in Eurosurveillance.
The K pneumoniae isolates were obtained from two hospitalized Greek patients and were among a collection of 118 isolates analyzed after the European Centre for Disease Prevention and Control issued a rapid risk assessment on the emergence of ceftazidime-avibactam resistance in carbapenem-resistant Enterobacteriaceae in July 2019. Neither patient, one of whom was infected and the other colonized, had received ceftazidime-avibactam before the resistant strains were isolated.
Whole-genome sequencing and conjugation experiments identified the source of resistance as Vietnamese extended-spectrum beta-lactamase (VEB) variation, designated as VEB-25. The enzyme was carried on self-transferable plasmids that harbor several other resistance genes and have been acquired by high-risk K pneumoniae clones.
Although the extent of dissemination of VEB-25 producers in Greek K pneumoniae hospital isolates in unclear, the authors of the study say the use of ceftazidime-avibactam will likely increase the clinical relevance of VEB-25–mediated resistance.
Jan 16 Eurosurveill rapid communication