Examining hospital antimicrobial usage in the United States

In a recent cross-sectional study across nearly 200 U.S. hospitals, researchers found that antimicrobial usage for more than half of patients deviated from prescription recommendations. Specifically, the researchers examined patients receiving antimicrobials for community-acquired pneumonia and urinary tract infections as well as patients receiving fluoroquinolones or IV vancomycin treatment between May and September 2015. Deviations were defined in one of four ways: 1) using antimicrobials not fitting current prescription guidelines; 2) using antimicrobials for a duration longer than current recommended durations; 3) using antimicrobials without supporting data of an infection; and 4) using antimicrobials for pathogens not susceptible to the particular drug used. Out of the 1,566 patients included in the study, 876 were found to be prescribed unsupported prescriptions for antimicrobial treatment, with the most common reason for deviation being either a lack of supporting data for infection or extended treatment duration.

Multi-country study on community antibiotic use highlights key factors that drive inappropriate use

The results of a multi-country, mixed-methods study examining community antibiotic use show that various factors drove inappropriate antibiotic use in six countries across Asia and Africa. The authors determined that convenience, trust in drug suppliers, severity of illness, and the need to treat childhood illness drove patients to purchase antibiotics without prescriptions and to self-medicate without medical counsel. The study included participants in Mozambique, Ghana, South Africa, Bangladesh, Vietnam, and Thailand. Researchers mapped out both formal and informal antibiotic suppliers and conducted customer exit interviews and household surveys to determine the extent to which consumers were purchasing and using antibiotics without prescriptions or medical counsel and the factors which drove them to do so. These findings were further supported through qualitative analyses in the form of in-depth interviews and focus group discussions with drug suppliers and consumers. In general, the lower-income countries tended to have higher rates of self-medication with antibiotics filled without prescription than the higher-income countries. Where this trend did not hold, in Mozambique, access to antibiotics was mostly available only through primary healthcare facilities. While formal facilities were often preferred by patients across the six countries for more severe illness, patients in all countries except Mozambique and South Africa reported turning to drug stores as their first choice for treating mild illnesses. The convenience of the supplier was a common factor in the choice to pursue a drug store versus a public healthcare facility, including distance to the supplier, expected wait times, and the availability of antibiotics at these stores.

A lack of enforcement of regulations prohibiting the sale of antibiotics without prescriptions in countries like Thailand and Ghana rendered these regulations ineffective compared to South Africa where these regulations were strictly enforced. The prevalence of household usage of antibiotics ranged from 10.2% (South Africa) to 49.4% (Bangladesh), with at least a quarter of all households in all countries except South Africa reporting antibiotic use in the previous month. Of this use, self-treatment without prescription was as high as 65.3% in Bangladesh. When assessing the types of antibiotics used, antibiotics classified as “Access” antibiotics through the WHO AWaRe classification were most prevalent in all countries except Bangladesh, where “Watch” antibiotics made up nearly three-quarters of the total antibiotics reported by defined daily doses for the country. The researchers concluded the study by suggesting context-specific interventions such as regulations targeting both supply and demand sides, increasing quality of care and education at public health facilities, and adopting systems to allow for easy identification of antibiotics could prove fruitful in curbing the misuse of antibiotics in these settings.

The impact of travel on antimicrobial resistance

Researchers looking at the impact of travel on antimicrobial resistance have found that, based on a systematic review, international travel can serve as a significant driver of antimicrobial resistance, especially to high-income countries. Out of the more than 30,000 isolates examined, antimicrobial resistant organisms were found to originate from 139 countries, most of which were low- and middle-income countries (LMICs). Indeed, the top sources of AMR were found to be India, Kenya, and Thailand, with Asia accounting for the majority of resistant organisms. On the recipient side, the U.S. and Canada were found to “receive” the largest incidence of antimicrobial resistant bacteria, followed by the UK and Finland. Twenty-six bacterial species in total were identified in the review, with the majority being Gram-negative species, and the most common species reported being Salmonella spp., Shigella spp., and E. coli. Moreover, beta-lactams and quinolones were found to account for the greatest proportion of overall drug resistance, and those traveling for medical tourism were found to be twice as likely to carry multidrug-resistant organisms than those participating in general travel. There were some strains, such as A. baumannii and Pseudomonas aeruginosa, that were also found to be almost exclusively associated with medical travelers.

Study uses country data to predict  priority countries for AMR surveillance

While the WHO Global Antimicrobial Resistance Surveillance platform receives data from 66 countries, this means there are still substantial gaps in the global surveillance of AMR. In a new analysis aiming to fill in these gaps, Oldenkamp and colleagues examined the statistical relationships between socioeconomic characteristics of resource-limited countries and AMR prevalence for nine different resistant to different classes of antibiotics. In doing so, these researchers were able to set up models to estimate temporal trends and AMR prevalence for countries previously lacking data. They identify countries where additional surveillance could improve surveillance for carbapenem resistance in Acinetobacter baumannii and third-generation cephalosporin resistance (3GCR) prevalence in Escherichia coli. It highlights countries with active conflict in the Middle East (e.g., Syria, Yemen, and Iraq) as key areas for surveillance.

Inappropriate prescriptions common among children, study finds

A recent study published in Clinical Infectious Diseases has found that, across 32 children’s hospitals in the United States, more than a third of hospitalized children were receiving at least one antibioticover a period of a year and a half. More importantly, the study finds that nearly a quarter of these antibiotic prescriptions were inappropriate, with the most commonly prescribed antibiotic being trimethoprim-sulfamethoxazole, followed by ceftriaxone and then vancomycin. Of the inappropriate antibiotic prescriptions, the most common reasons cited included surgical prophylaxis and bug-drug mismatch, indicating these areas as potential targets for greater antibiotic stewardship programs. And of note, researchers found that nearly half of the suboptimal prescriptions found would not have been routinely reviewed by currently existing antibiotic stewardship programs, indicating that alternate interventions may be needed to prevent antimicrobial resistant bacteria among children. The findings of this recent study are consistent with previous reports of increased C. difficile cases among children in the U.S. in 2017, as well as consistently increasing cases of multidrug-resistant Enterobacteriaceae among American children.

Earlier in January, the American Academy of Pediatrics published a policy statement in Pediatrics, highlighting the rationale for antibiotic stewardship programs within pediatric hospitals, as well as identifying gaps in the knowledge and recommending approaches to evaluate the effectiveness of these programs. Among other recommendations, this policy statement highlights the need for broad diagnostic capacities, specifically for acute otitis media, acute sinusitis, and group A streptococcal pharyngitis. Similarly, the statement recommends against the prescription of antibiotics for urinary tract infections among children, absent a urinalysis and urine culture. In an effort to both evaluate the effectiveness of antibiotic stewardship programs and provide technical support, stewardship specialists, specifically with pediatric expertise, are recommended for healthcare settings.

Optimal hospital designs to control the spread of multidrug-resistant bacteria unveiled

In an effort to control the spread of multidrug-resistant bacteria, researchers from the U.S. and South Africa have developed an “Infection De-Escalation Model” for hospitals, as well as cost saving estimates and infection control rates from this model. Pairing existing hospital models with various interventions, the study found that an optimal combination of handwashing stations and negative pressure treatment rooms, as well as the control of relative humidity, could reduce by nearly 70% the incidence of multidrug-resistant infections in large hospitals. Specifically, the pathogens examined were methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), and carbapenem-resistant Enterobacteriaceae (CRE). Assuming an average cost of $3,289 per MRSA infection, $1,535 per CRE infection, and $1,067 per VRE infection, it was estimated that this optimal intervention combination could save large hospitals more than $1.5 million in direct costs. While implementation of such an infection de-escalation model would require significant investment, researchers hope the findings provide insights into optimal interventions and the potential costs saved by taking such measures.

Inappropriate recommendations of antibiotic use common in veterinary supply stores in Ecuador

Researchers out of California and Ecuador recently published the results of a simulated client (also known as ‘mystery shopper’) method to examine the factors which influence antibiotic use in small-scale food animal production. Through this method, trained simulated clients posed as small-scale poultry farmers and visited veterinary supply stores in Quito, Ecuador. There, they presented scenarios where they either asked for recommendations for increasing their chickens’ growth or for treating diseased chickens with colistin. Following these inquiries, sales agents were asked for an initial recommendation. In both the growth promotion (n=38) and disease treatment (n=40) scenarios, the simulated client asked specifically whether antibiotics or colistin, respectively, would be effective or appropriate following their initial questions. Sales agents then provided a final recommendation in both scenarios. While 37% of sales agents initially recommended antibiotics, this proportion rose to 61% when prompted by the simulated client. Where an antibiotic was recommended, a ‘low caution’ antibiotic (considered a first-line treatment for sick animals but not growth promotion) was recommended 73% of the time. In the disease treatment scenario, antibiotics were recommended as an initial or final recommendation 83% of the time, with nearly half (48%) of the recommendations being for antibiotics which were second-line treatments or recommended for restricted use by the European Medicines Agency. Only one of the visited stores offered to sell colistin to the simulated client. This was particularly noteworthy because the study was conducted following announcement of a country-wide ban on colistin's use in food animal production, but during a grace period when the sale of colistin was legal, albeit discouraged.

The researchers indicated that pressure from shoppers could encourage sales agents to recommend antibiotics as their final recommendation. Notably, the presence of a veterinarian in the shop was associated with sales agents making a final recommendation of antibiotics in the growth promotion scenario. The authors suggested that the support and knowledge provided by these on-site veterinarians could influence sales agents’ recommendations, though this led to an increase in antibiotic recommendations. Training and encouraging sales agents to offer substitutes for antibiotics could help to decrease this inappropriate use. The compliance with an announced ban on colistin’s use in raising livestock in this simulated client study suggests that national legislation may play an effective role in restricting the use of such last-line antibiotics.