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Behavioral interventions cut inappropriate antibiotic prescribing
Two behavioral interventions for primary care clinicians cut the rate of inappropriate antibiotic prescribing for acute respiratory tract infections significantly, according to a report published online Feb. 9 in JAMA.
Compared with a control condition that included clinician education, the two interventions reduced inappropriate prescribing by 5.2% and 7.0%, respectively.
“We believe these effect sizes are clinically significant, especially when measured against control clinicians who were motivated to join a trial, knew they were being monitored, and who had relatively low antibiotic prescribing rates at baseline,” said Daniella Meeker, Ph.D., of the Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, and her associates.
In a cluster-randomized trial involving 248 clinicians at 47 primary care practices in Boston and Los Angeles, the investigators designed three interventions and tested various combinations of them against a control condition during an 18-month period. The number of inappropriate antibiotic prescriptions given during this intervention period was then compared with that during a baseline period, the 18 months preceding the intervention.
The analysis included 14,753 patient visits for acute respiratory tract infections during the baseline period and 16,959 visits during the intervention period.
The first behavioral intervention, termed “accountable justification,” used an alert each time a clinician prescribed an antibiotic in a patient’s electronic health record – a prompt asking for an explicit justification for doing so. That approach was based on the hope that to preserve their reputations, clinicians would tailor their behavior to fall in line with norms followed by their peers and recommended in clinical guidelines.
The second intervention, “peer comparison,” used monthly e-mails to inform clinicians whether or not they were “top performers” (within the lowest decile) for inappropriate prescribing in their geographical region. The emails included the number and proportion of antibiotic prescriptions they wrote inappropriately for acute upper respiratory tract infections, compared with the proportion written by top performers.
The mean rate of antibiotic prescribing decreased during the intervention in all the study groups, including the control group, which showed an absolute decrease of 11% (from 24.1% to 13.1%). The absolute decrease was significantly greater, at 18.1%, in the accountable justification group (from 23.2% to 5.2%) and at 16.3% in the peer comparison group (from 19.9% to 3.7%), Dr. Meeker and her associates said (JAMA. 2016 Feb 9;315[6]:562-70). The rate of return visits for possible bacterial infections within 30 days of the index visit was used as a measure of safety for withholding antibiotic prescriptions. This rate was 0.4% in the control group. The only intervention group that showed a “modestly higher” rate of return visits was the one that used both the accountable justification and the peer comparison interventions together, for which the rate of return visits was 1.4%.
The study was supported by the American Recovery and Reinvestment Act of 2009, the National Institutes of Health, the National Institute on Aging, the Agency for Healthcare Research and Quality, the University of Southern California’s Medical Information Network for Experimental Research, and the Patient-Centered Outcomes Research Institute. Dr. Meeker and her associates reported having no relevant financial disclosures.
Even though the reductions in inappropriate prescribing in this study might be considered modest, they were real, important, and potentially sustainable.
Baseline levels of inappropriate prescribing were already low to start with among the study participants, which suggests that they already were judicious prescribers in relation to national averages. In addition, the control group participants knew their antibiotic prescribing was being monitored and may have decreased it, consciously or unconsciously. Both of these factors may have blunted the potential effectiveness of the interventions.
Dr. Jeffrey S. Gerber is in the division of infectious diseases at the Children’s Hospital of Philadelphia and in the department of pediatrics at the University of Pennsylvania, Philadelphia. He reported having no conflicts of interest. Dr. Gerber made these remarks in an editorial accompanying Dr. Meeker’s report (JAMA. 2016 Feb 9;315[6]:558-9).
Even though the reductions in inappropriate prescribing in this study might be considered modest, they were real, important, and potentially sustainable.
Baseline levels of inappropriate prescribing were already low to start with among the study participants, which suggests that they already were judicious prescribers in relation to national averages. In addition, the control group participants knew their antibiotic prescribing was being monitored and may have decreased it, consciously or unconsciously. Both of these factors may have blunted the potential effectiveness of the interventions.
Dr. Jeffrey S. Gerber is in the division of infectious diseases at the Children’s Hospital of Philadelphia and in the department of pediatrics at the University of Pennsylvania, Philadelphia. He reported having no conflicts of interest. Dr. Gerber made these remarks in an editorial accompanying Dr. Meeker’s report (JAMA. 2016 Feb 9;315[6]:558-9).
Even though the reductions in inappropriate prescribing in this study might be considered modest, they were real, important, and potentially sustainable.
Baseline levels of inappropriate prescribing were already low to start with among the study participants, which suggests that they already were judicious prescribers in relation to national averages. In addition, the control group participants knew their antibiotic prescribing was being monitored and may have decreased it, consciously or unconsciously. Both of these factors may have blunted the potential effectiveness of the interventions.
Dr. Jeffrey S. Gerber is in the division of infectious diseases at the Children’s Hospital of Philadelphia and in the department of pediatrics at the University of Pennsylvania, Philadelphia. He reported having no conflicts of interest. Dr. Gerber made these remarks in an editorial accompanying Dr. Meeker’s report (JAMA. 2016 Feb 9;315[6]:558-9).
Two behavioral interventions for primary care clinicians cut the rate of inappropriate antibiotic prescribing for acute respiratory tract infections significantly, according to a report published online Feb. 9 in JAMA.
Compared with a control condition that included clinician education, the two interventions reduced inappropriate prescribing by 5.2% and 7.0%, respectively.
“We believe these effect sizes are clinically significant, especially when measured against control clinicians who were motivated to join a trial, knew they were being monitored, and who had relatively low antibiotic prescribing rates at baseline,” said Daniella Meeker, Ph.D., of the Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, and her associates.
In a cluster-randomized trial involving 248 clinicians at 47 primary care practices in Boston and Los Angeles, the investigators designed three interventions and tested various combinations of them against a control condition during an 18-month period. The number of inappropriate antibiotic prescriptions given during this intervention period was then compared with that during a baseline period, the 18 months preceding the intervention.
The analysis included 14,753 patient visits for acute respiratory tract infections during the baseline period and 16,959 visits during the intervention period.
The first behavioral intervention, termed “accountable justification,” used an alert each time a clinician prescribed an antibiotic in a patient’s electronic health record – a prompt asking for an explicit justification for doing so. That approach was based on the hope that to preserve their reputations, clinicians would tailor their behavior to fall in line with norms followed by their peers and recommended in clinical guidelines.
The second intervention, “peer comparison,” used monthly e-mails to inform clinicians whether or not they were “top performers” (within the lowest decile) for inappropriate prescribing in their geographical region. The emails included the number and proportion of antibiotic prescriptions they wrote inappropriately for acute upper respiratory tract infections, compared with the proportion written by top performers.
The mean rate of antibiotic prescribing decreased during the intervention in all the study groups, including the control group, which showed an absolute decrease of 11% (from 24.1% to 13.1%). The absolute decrease was significantly greater, at 18.1%, in the accountable justification group (from 23.2% to 5.2%) and at 16.3% in the peer comparison group (from 19.9% to 3.7%), Dr. Meeker and her associates said (JAMA. 2016 Feb 9;315[6]:562-70). The rate of return visits for possible bacterial infections within 30 days of the index visit was used as a measure of safety for withholding antibiotic prescriptions. This rate was 0.4% in the control group. The only intervention group that showed a “modestly higher” rate of return visits was the one that used both the accountable justification and the peer comparison interventions together, for which the rate of return visits was 1.4%.
The study was supported by the American Recovery and Reinvestment Act of 2009, the National Institutes of Health, the National Institute on Aging, the Agency for Healthcare Research and Quality, the University of Southern California’s Medical Information Network for Experimental Research, and the Patient-Centered Outcomes Research Institute. Dr. Meeker and her associates reported having no relevant financial disclosures.
Two behavioral interventions for primary care clinicians cut the rate of inappropriate antibiotic prescribing for acute respiratory tract infections significantly, according to a report published online Feb. 9 in JAMA.
Compared with a control condition that included clinician education, the two interventions reduced inappropriate prescribing by 5.2% and 7.0%, respectively.
“We believe these effect sizes are clinically significant, especially when measured against control clinicians who were motivated to join a trial, knew they were being monitored, and who had relatively low antibiotic prescribing rates at baseline,” said Daniella Meeker, Ph.D., of the Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, and her associates.
In a cluster-randomized trial involving 248 clinicians at 47 primary care practices in Boston and Los Angeles, the investigators designed three interventions and tested various combinations of them against a control condition during an 18-month period. The number of inappropriate antibiotic prescriptions given during this intervention period was then compared with that during a baseline period, the 18 months preceding the intervention.
The analysis included 14,753 patient visits for acute respiratory tract infections during the baseline period and 16,959 visits during the intervention period.
The first behavioral intervention, termed “accountable justification,” used an alert each time a clinician prescribed an antibiotic in a patient’s electronic health record – a prompt asking for an explicit justification for doing so. That approach was based on the hope that to preserve their reputations, clinicians would tailor their behavior to fall in line with norms followed by their peers and recommended in clinical guidelines.
The second intervention, “peer comparison,” used monthly e-mails to inform clinicians whether or not they were “top performers” (within the lowest decile) for inappropriate prescribing in their geographical region. The emails included the number and proportion of antibiotic prescriptions they wrote inappropriately for acute upper respiratory tract infections, compared with the proportion written by top performers.
The mean rate of antibiotic prescribing decreased during the intervention in all the study groups, including the control group, which showed an absolute decrease of 11% (from 24.1% to 13.1%). The absolute decrease was significantly greater, at 18.1%, in the accountable justification group (from 23.2% to 5.2%) and at 16.3% in the peer comparison group (from 19.9% to 3.7%), Dr. Meeker and her associates said (JAMA. 2016 Feb 9;315[6]:562-70). The rate of return visits for possible bacterial infections within 30 days of the index visit was used as a measure of safety for withholding antibiotic prescriptions. This rate was 0.4% in the control group. The only intervention group that showed a “modestly higher” rate of return visits was the one that used both the accountable justification and the peer comparison interventions together, for which the rate of return visits was 1.4%.
The study was supported by the American Recovery and Reinvestment Act of 2009, the National Institutes of Health, the National Institute on Aging, the Agency for Healthcare Research and Quality, the University of Southern California’s Medical Information Network for Experimental Research, and the Patient-Centered Outcomes Research Institute. Dr. Meeker and her associates reported having no relevant financial disclosures.
FROM JAMA
Key clinical point: Two behavioral interventions for primary care clinicians cut the rate of inappropriate antibiotic prescribing for acute respiratory tract infections.
Major finding: The absolute decrease in inappropriate antibiotics prescribing was significantly greater – at 18.1% in the “accountable justification” group and at 16.3% in the “peer comparison” group – than the control group (11%).
Data source: A cluster-randomized clinical trial involving 248 clinicians at 47 primary care practices in Boston and Los Angeles.
Disclosures: The study was supported by the American Recovery and Reinvestment Act of 2009, the National Institutes of Health, the National Institute on Aging, the Agency for Healthcare Research and Quality, the University of Southern California’s Medical Information Network for Experimental Research, and the Patient-Centered Outcomes Research Institute. Dr. Meeker and her associates reported having no relevant financial disclosures.
Chlorhexidine baths help hospitals control extensively drug-resistant pathogen
With an outbreak of the extensively drug-resistant pathogen Acinetobacter baumannii (XDR-Ab), patient screening and daily chlorhexidine baths were part of a comprehensive outbreak control strategy, a new study suggested.
XDR-Ab transmission within hospitals has been documented via direct and indirect patient contact, inadequate sterilization of medical devices, contamination of rooms, and colonized health care workers, said Dr. Yves Longtin, chair of the infection prevention and control unit at Jewish General Hospital in Montreal. Dr. Longtin and his coauthors described the epidemiology and control of an XDR-Ab outbreak that involved multiple units of a large Canadian hospital in a recent article published in the Journal of Hospital Infection.
The outbreak was the result of a single clonal strain of XDR-Ab that colonized or infected 29 patients, 5 of whom died of XDR-Ab bacteremia. Transmission occurred primarily on two wards, either directly between patients or indirectly through staff, shared equipment, or the environment, investigators found. There is currently no consensus on optimal screening procedures, nor on the best combination of interventions to prevent transmission among patients, Dr. Longtin and his colleagues said.
The outbreak described in the study ended following the application of intensive screening, environmental disinfection, source control, reinforcement of routine hygiene, and isolation procedures including cohorting and unit closure. Intensive screening – screening of rectum, groin, throat, urine (in catheterized patients), wounds, and other catheter sites – revealed that 57% of infected patients were rectal carriers of the bacterium. Thus, a single rectal screening, considered standard for detection of carbapenem-resistant Enterobacteriaceae, would not have been sufficient to detect all infected patients.
Colonized patients received daily chlorhexidine baths, a strategy that is a useful tool in the control of other antibiotic-resistant nosocomial pathogens, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, but is not mentioned in the recent acinetobacter-specific guidelines or reviews, Dr. Longtin and coauthors said. They hypothesized that the prompt resolution of the outbreak may have been due in part to the use of the chlorhexidine baths.
Read the full study in the Journal of Hospital Infection (doi: 10.1016/j.jhin.2015.12.013).
On Twitter @richpizzi
With an outbreak of the extensively drug-resistant pathogen Acinetobacter baumannii (XDR-Ab), patient screening and daily chlorhexidine baths were part of a comprehensive outbreak control strategy, a new study suggested.
XDR-Ab transmission within hospitals has been documented via direct and indirect patient contact, inadequate sterilization of medical devices, contamination of rooms, and colonized health care workers, said Dr. Yves Longtin, chair of the infection prevention and control unit at Jewish General Hospital in Montreal. Dr. Longtin and his coauthors described the epidemiology and control of an XDR-Ab outbreak that involved multiple units of a large Canadian hospital in a recent article published in the Journal of Hospital Infection.
The outbreak was the result of a single clonal strain of XDR-Ab that colonized or infected 29 patients, 5 of whom died of XDR-Ab bacteremia. Transmission occurred primarily on two wards, either directly between patients or indirectly through staff, shared equipment, or the environment, investigators found. There is currently no consensus on optimal screening procedures, nor on the best combination of interventions to prevent transmission among patients, Dr. Longtin and his colleagues said.
The outbreak described in the study ended following the application of intensive screening, environmental disinfection, source control, reinforcement of routine hygiene, and isolation procedures including cohorting and unit closure. Intensive screening – screening of rectum, groin, throat, urine (in catheterized patients), wounds, and other catheter sites – revealed that 57% of infected patients were rectal carriers of the bacterium. Thus, a single rectal screening, considered standard for detection of carbapenem-resistant Enterobacteriaceae, would not have been sufficient to detect all infected patients.
Colonized patients received daily chlorhexidine baths, a strategy that is a useful tool in the control of other antibiotic-resistant nosocomial pathogens, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, but is not mentioned in the recent acinetobacter-specific guidelines or reviews, Dr. Longtin and coauthors said. They hypothesized that the prompt resolution of the outbreak may have been due in part to the use of the chlorhexidine baths.
Read the full study in the Journal of Hospital Infection (doi: 10.1016/j.jhin.2015.12.013).
On Twitter @richpizzi
With an outbreak of the extensively drug-resistant pathogen Acinetobacter baumannii (XDR-Ab), patient screening and daily chlorhexidine baths were part of a comprehensive outbreak control strategy, a new study suggested.
XDR-Ab transmission within hospitals has been documented via direct and indirect patient contact, inadequate sterilization of medical devices, contamination of rooms, and colonized health care workers, said Dr. Yves Longtin, chair of the infection prevention and control unit at Jewish General Hospital in Montreal. Dr. Longtin and his coauthors described the epidemiology and control of an XDR-Ab outbreak that involved multiple units of a large Canadian hospital in a recent article published in the Journal of Hospital Infection.
The outbreak was the result of a single clonal strain of XDR-Ab that colonized or infected 29 patients, 5 of whom died of XDR-Ab bacteremia. Transmission occurred primarily on two wards, either directly between patients or indirectly through staff, shared equipment, or the environment, investigators found. There is currently no consensus on optimal screening procedures, nor on the best combination of interventions to prevent transmission among patients, Dr. Longtin and his colleagues said.
The outbreak described in the study ended following the application of intensive screening, environmental disinfection, source control, reinforcement of routine hygiene, and isolation procedures including cohorting and unit closure. Intensive screening – screening of rectum, groin, throat, urine (in catheterized patients), wounds, and other catheter sites – revealed that 57% of infected patients were rectal carriers of the bacterium. Thus, a single rectal screening, considered standard for detection of carbapenem-resistant Enterobacteriaceae, would not have been sufficient to detect all infected patients.
Colonized patients received daily chlorhexidine baths, a strategy that is a useful tool in the control of other antibiotic-resistant nosocomial pathogens, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, but is not mentioned in the recent acinetobacter-specific guidelines or reviews, Dr. Longtin and coauthors said. They hypothesized that the prompt resolution of the outbreak may have been due in part to the use of the chlorhexidine baths.
Read the full study in the Journal of Hospital Infection (doi: 10.1016/j.jhin.2015.12.013).
On Twitter @richpizzi
FROM THE JOURNAL OF HOSPITAL INFECTION
Hospitalist Cynthia Cheung, MD, Joins Hospital Committee, Promotes Antibiotic Stewardship
Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die as a result of these infections. To promote improved antibiotic-prescribing behaviors among the nation’s hospitalists, SHM launched its “Fight the Resistance” campaign in November 2015. Cynthia Cheung, MD, a hospitalist in the Triton Hospitalists group at Houston Methodist Willowbrook Hospital and assistant professor of clinical medicine at Houston Methodist, recently shared efforts by a team at her hospital that are closely aligned with SHM’s campaign.
Question: What led you to a career in hospital medicine?
Answer: I was very fortunate to train in a program that had excellent hospitalists at the University of California at Los Angeles. Our general wards were staffed by very talented attending physicians, many of whom were hospitalists, and I quickly fell in love with the fast pace of hospital medicine. My UCLA experience confirmed that hospital medicine was the path for me. I finished my residency in 2010 and began my current role at Houston Methodist early in 2014. Almost two years later, I still love what I do.
Q: How did you get involved in antibiotic stewardship at your hospital?
A: One of my colleagues, an infectious disease specialist and chair of our antimicrobial stewardship committee, invited me to join her team. In retrospect, I had never really thought very much about antibiotic stewardship aside from trying to prescribe the proper antibiotics and the appropriate dosages to my patients. I had not fully considered the quality perspective under such a focused lens; being a part of this committee really opened my eyes, especially since the committee’s goals are completely focused on optimizing clinical outcomes and minimizing unintended consequences of antibiotic use.
Q: What most excites you about SHM’s “Fight the Resistance” campaign?
A: I joined SHM a year ago, and I think it’s really exciting that SHM is drawing attention to hospitalists’ roles in promoting antibiotic stewardship in addition to its other quality improvement initiatives. Previously, antibiotic stewardship appeared to be mostly the province of infectious disease physicians, but that isn’t the case anymore. As frontline providers, we are poised to make a difference in appropriate antibiotic use if armed with the proper knowledge and tools.
Q: As part of “Fight the Resistance,” SHM developed recommendations for promoting antibiotic stewardship in hospitals. How do your team efforts align with SHM’s campaign?
A: One of SHM’s recommendations is to engage with a team of hospital-based clinicians to improve stewardship, and our committee oversees a pharmacist-driven real-time audit and feedback intervention to optimize antibiotic use. Often, after a provider places an antibiotic order, additional culture results and clinical information become available. Our pharmacists evaluate this information and contact the provider if they feel the antibiotic dose prescribed is not the most effective or if there is a culture-antibiotic mismatch.
Or the pharmacist might notice that a patient has been taking an antibiotic for an extended duration and may discuss with the provider whether an appropriate duration can be defined. They will call and consult with providers to help them consider discontinuation or de-escalation if necessary. This is in line with SHM’s recommendation to rethink antibiotic treatment time course. Our clinician acceptance rate has been 90 percent in favor of interventions proposed by the pharmacists.
Any time a provider declines pharmacist intervention, our committee reviews these cases to determine whether or not the decision was in the best interest of the patient given the information available. The reviewers include an interdisciplinary team of hospitalists, infectious disease physicians, critical care physicians, and emergency physicians. If one particular clinician has a record of prescribing suboptimally, the team would review that particular provider’s prescribing habits with more detail.
Our committee is also aligned with SHM’s recommendation to identify mechanisms to educate providers on appropriate prescribing by creating guidelines for different classes of bacterial infections and communicating them to our clinical staff. For gram-negative infections, we recommend avoiding the use of carbapenems and antipseudomonal agents in known pathogens that are not pseudonomous. For gram-positive infections, we advise against use of MRSA/VRE-active antibiotics in known pathogens that are not resistant and the use of double coverage in non-synergistic settings. In the case of anaerobic infections, our guidelines suggest clinicians not use double coverage when susceptibilities are known. These guidelines form the backbone of our reviews and assist the pharmacists in their feedback and audit.
Moving forward, one of our committee’s primary action items is to develop a method of communicating our resistance patterns effectively to our clinical staff to make them more widely known. The information is currently sitting in a silo and is not as easily accessible to assist clinicians in their decision-making process when prescribing antibiotics. We also hope to address appropriate usage of daptomycin and ceftaroline, reduce rates of inappropriate treatment of asymptomatic bacteriuria, and seek additional ways to reduce rates of Clostridium difficile infection.
Q: What do you think is most important for hospitalists to know about their roles in antibiotic stewardship?
A: It is extremely important to remember that antibiotics are one of the few classes of drugs that can harm a patient through promotion of resistance—even if the medication was not given to the patient directly. A lot of clinicians may have been taught a certain way to prescribe antibiotics in training or have become rooted in habit. Hospitalists need to proactively stay abreast of antibiotic stewardship developments, share with fellow providers, and not be afraid to alter the way they prescribe.
While this personal education process might seem daunting at first, medicine is a lifelong learning experience. As physicians, we see new things and learn new things every day. I encourage all hospitalists—and all hospital-based staff—to try to take a greater role in stewardship. You do not have to be a specialist to make a difference, and it doesn’t matter at which point in your career you are. Antibiotic resistance affects everyone. Now is the time to step up and fight it. TH
Brett Radler is SHM’s communications coordinator.
Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die as a result of these infections. To promote improved antibiotic-prescribing behaviors among the nation’s hospitalists, SHM launched its “Fight the Resistance” campaign in November 2015. Cynthia Cheung, MD, a hospitalist in the Triton Hospitalists group at Houston Methodist Willowbrook Hospital and assistant professor of clinical medicine at Houston Methodist, recently shared efforts by a team at her hospital that are closely aligned with SHM’s campaign.
Question: What led you to a career in hospital medicine?
Answer: I was very fortunate to train in a program that had excellent hospitalists at the University of California at Los Angeles. Our general wards were staffed by very talented attending physicians, many of whom were hospitalists, and I quickly fell in love with the fast pace of hospital medicine. My UCLA experience confirmed that hospital medicine was the path for me. I finished my residency in 2010 and began my current role at Houston Methodist early in 2014. Almost two years later, I still love what I do.
Q: How did you get involved in antibiotic stewardship at your hospital?
A: One of my colleagues, an infectious disease specialist and chair of our antimicrobial stewardship committee, invited me to join her team. In retrospect, I had never really thought very much about antibiotic stewardship aside from trying to prescribe the proper antibiotics and the appropriate dosages to my patients. I had not fully considered the quality perspective under such a focused lens; being a part of this committee really opened my eyes, especially since the committee’s goals are completely focused on optimizing clinical outcomes and minimizing unintended consequences of antibiotic use.
Q: What most excites you about SHM’s “Fight the Resistance” campaign?
A: I joined SHM a year ago, and I think it’s really exciting that SHM is drawing attention to hospitalists’ roles in promoting antibiotic stewardship in addition to its other quality improvement initiatives. Previously, antibiotic stewardship appeared to be mostly the province of infectious disease physicians, but that isn’t the case anymore. As frontline providers, we are poised to make a difference in appropriate antibiotic use if armed with the proper knowledge and tools.
Q: As part of “Fight the Resistance,” SHM developed recommendations for promoting antibiotic stewardship in hospitals. How do your team efforts align with SHM’s campaign?
A: One of SHM’s recommendations is to engage with a team of hospital-based clinicians to improve stewardship, and our committee oversees a pharmacist-driven real-time audit and feedback intervention to optimize antibiotic use. Often, after a provider places an antibiotic order, additional culture results and clinical information become available. Our pharmacists evaluate this information and contact the provider if they feel the antibiotic dose prescribed is not the most effective or if there is a culture-antibiotic mismatch.
Or the pharmacist might notice that a patient has been taking an antibiotic for an extended duration and may discuss with the provider whether an appropriate duration can be defined. They will call and consult with providers to help them consider discontinuation or de-escalation if necessary. This is in line with SHM’s recommendation to rethink antibiotic treatment time course. Our clinician acceptance rate has been 90 percent in favor of interventions proposed by the pharmacists.
Any time a provider declines pharmacist intervention, our committee reviews these cases to determine whether or not the decision was in the best interest of the patient given the information available. The reviewers include an interdisciplinary team of hospitalists, infectious disease physicians, critical care physicians, and emergency physicians. If one particular clinician has a record of prescribing suboptimally, the team would review that particular provider’s prescribing habits with more detail.
Our committee is also aligned with SHM’s recommendation to identify mechanisms to educate providers on appropriate prescribing by creating guidelines for different classes of bacterial infections and communicating them to our clinical staff. For gram-negative infections, we recommend avoiding the use of carbapenems and antipseudomonal agents in known pathogens that are not pseudonomous. For gram-positive infections, we advise against use of MRSA/VRE-active antibiotics in known pathogens that are not resistant and the use of double coverage in non-synergistic settings. In the case of anaerobic infections, our guidelines suggest clinicians not use double coverage when susceptibilities are known. These guidelines form the backbone of our reviews and assist the pharmacists in their feedback and audit.
Moving forward, one of our committee’s primary action items is to develop a method of communicating our resistance patterns effectively to our clinical staff to make them more widely known. The information is currently sitting in a silo and is not as easily accessible to assist clinicians in their decision-making process when prescribing antibiotics. We also hope to address appropriate usage of daptomycin and ceftaroline, reduce rates of inappropriate treatment of asymptomatic bacteriuria, and seek additional ways to reduce rates of Clostridium difficile infection.
Q: What do you think is most important for hospitalists to know about their roles in antibiotic stewardship?
A: It is extremely important to remember that antibiotics are one of the few classes of drugs that can harm a patient through promotion of resistance—even if the medication was not given to the patient directly. A lot of clinicians may have been taught a certain way to prescribe antibiotics in training or have become rooted in habit. Hospitalists need to proactively stay abreast of antibiotic stewardship developments, share with fellow providers, and not be afraid to alter the way they prescribe.
While this personal education process might seem daunting at first, medicine is a lifelong learning experience. As physicians, we see new things and learn new things every day. I encourage all hospitalists—and all hospital-based staff—to try to take a greater role in stewardship. You do not have to be a specialist to make a difference, and it doesn’t matter at which point in your career you are. Antibiotic resistance affects everyone. Now is the time to step up and fight it. TH
Brett Radler is SHM’s communications coordinator.
Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die as a result of these infections. To promote improved antibiotic-prescribing behaviors among the nation’s hospitalists, SHM launched its “Fight the Resistance” campaign in November 2015. Cynthia Cheung, MD, a hospitalist in the Triton Hospitalists group at Houston Methodist Willowbrook Hospital and assistant professor of clinical medicine at Houston Methodist, recently shared efforts by a team at her hospital that are closely aligned with SHM’s campaign.
Question: What led you to a career in hospital medicine?
Answer: I was very fortunate to train in a program that had excellent hospitalists at the University of California at Los Angeles. Our general wards were staffed by very talented attending physicians, many of whom were hospitalists, and I quickly fell in love with the fast pace of hospital medicine. My UCLA experience confirmed that hospital medicine was the path for me. I finished my residency in 2010 and began my current role at Houston Methodist early in 2014. Almost two years later, I still love what I do.
Q: How did you get involved in antibiotic stewardship at your hospital?
A: One of my colleagues, an infectious disease specialist and chair of our antimicrobial stewardship committee, invited me to join her team. In retrospect, I had never really thought very much about antibiotic stewardship aside from trying to prescribe the proper antibiotics and the appropriate dosages to my patients. I had not fully considered the quality perspective under such a focused lens; being a part of this committee really opened my eyes, especially since the committee’s goals are completely focused on optimizing clinical outcomes and minimizing unintended consequences of antibiotic use.
Q: What most excites you about SHM’s “Fight the Resistance” campaign?
A: I joined SHM a year ago, and I think it’s really exciting that SHM is drawing attention to hospitalists’ roles in promoting antibiotic stewardship in addition to its other quality improvement initiatives. Previously, antibiotic stewardship appeared to be mostly the province of infectious disease physicians, but that isn’t the case anymore. As frontline providers, we are poised to make a difference in appropriate antibiotic use if armed with the proper knowledge and tools.
Q: As part of “Fight the Resistance,” SHM developed recommendations for promoting antibiotic stewardship in hospitals. How do your team efforts align with SHM’s campaign?
A: One of SHM’s recommendations is to engage with a team of hospital-based clinicians to improve stewardship, and our committee oversees a pharmacist-driven real-time audit and feedback intervention to optimize antibiotic use. Often, after a provider places an antibiotic order, additional culture results and clinical information become available. Our pharmacists evaluate this information and contact the provider if they feel the antibiotic dose prescribed is not the most effective or if there is a culture-antibiotic mismatch.
Or the pharmacist might notice that a patient has been taking an antibiotic for an extended duration and may discuss with the provider whether an appropriate duration can be defined. They will call and consult with providers to help them consider discontinuation or de-escalation if necessary. This is in line with SHM’s recommendation to rethink antibiotic treatment time course. Our clinician acceptance rate has been 90 percent in favor of interventions proposed by the pharmacists.
Any time a provider declines pharmacist intervention, our committee reviews these cases to determine whether or not the decision was in the best interest of the patient given the information available. The reviewers include an interdisciplinary team of hospitalists, infectious disease physicians, critical care physicians, and emergency physicians. If one particular clinician has a record of prescribing suboptimally, the team would review that particular provider’s prescribing habits with more detail.
Our committee is also aligned with SHM’s recommendation to identify mechanisms to educate providers on appropriate prescribing by creating guidelines for different classes of bacterial infections and communicating them to our clinical staff. For gram-negative infections, we recommend avoiding the use of carbapenems and antipseudomonal agents in known pathogens that are not pseudonomous. For gram-positive infections, we advise against use of MRSA/VRE-active antibiotics in known pathogens that are not resistant and the use of double coverage in non-synergistic settings. In the case of anaerobic infections, our guidelines suggest clinicians not use double coverage when susceptibilities are known. These guidelines form the backbone of our reviews and assist the pharmacists in their feedback and audit.
Moving forward, one of our committee’s primary action items is to develop a method of communicating our resistance patterns effectively to our clinical staff to make them more widely known. The information is currently sitting in a silo and is not as easily accessible to assist clinicians in their decision-making process when prescribing antibiotics. We also hope to address appropriate usage of daptomycin and ceftaroline, reduce rates of inappropriate treatment of asymptomatic bacteriuria, and seek additional ways to reduce rates of Clostridium difficile infection.
Q: What do you think is most important for hospitalists to know about their roles in antibiotic stewardship?
A: It is extremely important to remember that antibiotics are one of the few classes of drugs that can harm a patient through promotion of resistance—even if the medication was not given to the patient directly. A lot of clinicians may have been taught a certain way to prescribe antibiotics in training or have become rooted in habit. Hospitalists need to proactively stay abreast of antibiotic stewardship developments, share with fellow providers, and not be afraid to alter the way they prescribe.
While this personal education process might seem daunting at first, medicine is a lifelong learning experience. As physicians, we see new things and learn new things every day. I encourage all hospitalists—and all hospital-based staff—to try to take a greater role in stewardship. You do not have to be a specialist to make a difference, and it doesn’t matter at which point in your career you are. Antibiotic resistance affects everyone. Now is the time to step up and fight it. TH
Brett Radler is SHM’s communications coordinator.
NSAIDs for UTI
Urinary tract infections (UTIs) unfortunately present an abundant opportunity for us to reflexively and mindlessly contribute to filling up the globe with multidrug resistant bacteria. Many of us have patients with recurrent UTIs, who, despite our best efforts at trying to reduce recurrence through non–medication approaches, frequently call for treatment. We stand by helplessly as we watch the resistance of these organisms increase.
Is there another way?
Investigators in Germany evaluated the benefit and harms of prescribing ibuprofen in place of an antibiotic in women with symptoms of a UTI and no risk factors (BMC Med. 2010 May 26;8:30). Women aged 18-65 years were randomized to a single dose of the broad-spectrum antibiotic fosfomycin 3 g (n = 246) or ibuprofen three 400-mg doses (n = 248) for 3 days. Patients were excluded if they had any signs of upper urinary tract infection, pregnancy, urinary catheterization, gastrointestinal ulcers, or chronic conditions. Antibiotics were prescribed for persistent, worsening, or recurrent symptoms.
Women in the ibuprofen group received significantly fewer antibiotic prescriptions (283 in the fosfomycin group and 94 in the ibuprofen group; incidence rate reduction of 66.5%; 95% confidence interval, 58.8%-74.4%; P less than .001). The ibuprofen group had more symptoms that lasted a day longer. On day 4, 56% of women in the fosfomycin vs. 39% of participants in the ibuprofen group were symptom free, which increased to 82% and 70% by day 7. The ibuprofen group were more likely to develop pyelonephritis (five cases in the ibuprofen group and one in the fosfomycin group; P = .12), but all women were treated and recovered fully. Four events led to “hospital referrals,” only one of which was related to trial drug (gastrointestinal hemorrhage).
In summary, two-thirds of women in the ibuprofen group recovered without antibiotic treatment and one-third received antibiotics for persistent or worsening symptoms. The authors concluded that ibuprofen was inferior to fosfomycin for initial symptomatic treatment. The nonstatistically higher rate of upper urinary tract infection with ibuprofen may make some clinicians nervous.
However, perhaps this is worth exploring for select patients with mild symptoms. The investigators mention data suggesting women may be aware of disadvantages of antibiotics and may be open to the idea of delaying or avoiding treatment, which opens the door to informed discussions. I am planning to discuss it with my patient who has frequent UTIs to see if we can delay intravenous antibiotics for UTI. Intravenous antibiotics for UTI make me uncomfortable for a variety of reasons.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.
Urinary tract infections (UTIs) unfortunately present an abundant opportunity for us to reflexively and mindlessly contribute to filling up the globe with multidrug resistant bacteria. Many of us have patients with recurrent UTIs, who, despite our best efforts at trying to reduce recurrence through non–medication approaches, frequently call for treatment. We stand by helplessly as we watch the resistance of these organisms increase.
Is there another way?
Investigators in Germany evaluated the benefit and harms of prescribing ibuprofen in place of an antibiotic in women with symptoms of a UTI and no risk factors (BMC Med. 2010 May 26;8:30). Women aged 18-65 years were randomized to a single dose of the broad-spectrum antibiotic fosfomycin 3 g (n = 246) or ibuprofen three 400-mg doses (n = 248) for 3 days. Patients were excluded if they had any signs of upper urinary tract infection, pregnancy, urinary catheterization, gastrointestinal ulcers, or chronic conditions. Antibiotics were prescribed for persistent, worsening, or recurrent symptoms.
Women in the ibuprofen group received significantly fewer antibiotic prescriptions (283 in the fosfomycin group and 94 in the ibuprofen group; incidence rate reduction of 66.5%; 95% confidence interval, 58.8%-74.4%; P less than .001). The ibuprofen group had more symptoms that lasted a day longer. On day 4, 56% of women in the fosfomycin vs. 39% of participants in the ibuprofen group were symptom free, which increased to 82% and 70% by day 7. The ibuprofen group were more likely to develop pyelonephritis (five cases in the ibuprofen group and one in the fosfomycin group; P = .12), but all women were treated and recovered fully. Four events led to “hospital referrals,” only one of which was related to trial drug (gastrointestinal hemorrhage).
In summary, two-thirds of women in the ibuprofen group recovered without antibiotic treatment and one-third received antibiotics for persistent or worsening symptoms. The authors concluded that ibuprofen was inferior to fosfomycin for initial symptomatic treatment. The nonstatistically higher rate of upper urinary tract infection with ibuprofen may make some clinicians nervous.
However, perhaps this is worth exploring for select patients with mild symptoms. The investigators mention data suggesting women may be aware of disadvantages of antibiotics and may be open to the idea of delaying or avoiding treatment, which opens the door to informed discussions. I am planning to discuss it with my patient who has frequent UTIs to see if we can delay intravenous antibiotics for UTI. Intravenous antibiotics for UTI make me uncomfortable for a variety of reasons.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.
Urinary tract infections (UTIs) unfortunately present an abundant opportunity for us to reflexively and mindlessly contribute to filling up the globe with multidrug resistant bacteria. Many of us have patients with recurrent UTIs, who, despite our best efforts at trying to reduce recurrence through non–medication approaches, frequently call for treatment. We stand by helplessly as we watch the resistance of these organisms increase.
Is there another way?
Investigators in Germany evaluated the benefit and harms of prescribing ibuprofen in place of an antibiotic in women with symptoms of a UTI and no risk factors (BMC Med. 2010 May 26;8:30). Women aged 18-65 years were randomized to a single dose of the broad-spectrum antibiotic fosfomycin 3 g (n = 246) or ibuprofen three 400-mg doses (n = 248) for 3 days. Patients were excluded if they had any signs of upper urinary tract infection, pregnancy, urinary catheterization, gastrointestinal ulcers, or chronic conditions. Antibiotics were prescribed for persistent, worsening, or recurrent symptoms.
Women in the ibuprofen group received significantly fewer antibiotic prescriptions (283 in the fosfomycin group and 94 in the ibuprofen group; incidence rate reduction of 66.5%; 95% confidence interval, 58.8%-74.4%; P less than .001). The ibuprofen group had more symptoms that lasted a day longer. On day 4, 56% of women in the fosfomycin vs. 39% of participants in the ibuprofen group were symptom free, which increased to 82% and 70% by day 7. The ibuprofen group were more likely to develop pyelonephritis (five cases in the ibuprofen group and one in the fosfomycin group; P = .12), but all women were treated and recovered fully. Four events led to “hospital referrals,” only one of which was related to trial drug (gastrointestinal hemorrhage).
In summary, two-thirds of women in the ibuprofen group recovered without antibiotic treatment and one-third received antibiotics for persistent or worsening symptoms. The authors concluded that ibuprofen was inferior to fosfomycin for initial symptomatic treatment. The nonstatistically higher rate of upper urinary tract infection with ibuprofen may make some clinicians nervous.
However, perhaps this is worth exploring for select patients with mild symptoms. The investigators mention data suggesting women may be aware of disadvantages of antibiotics and may be open to the idea of delaying or avoiding treatment, which opens the door to informed discussions. I am planning to discuss it with my patient who has frequent UTIs to see if we can delay intravenous antibiotics for UTI. Intravenous antibiotics for UTI make me uncomfortable for a variety of reasons.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.
SecA inhibitors show in vitro efficacy against MRSA
A promising approach to treating methicillin-resistant Staphylococcus aureus (MRSA) infections may lie in small molecules that target SecA, an indispensable ATPase of the general protein translocation machinery present in bacteria, according to Jinshan Jin, Ph.D.
Dr. Jin and his coinvestigators at Georgia State University developed small molecule analogs of Rose Bengal that target SecA. In in vitro studies, the analogs had potent antimicrobial activities, reduced the secretion of toxins, and overcame the effect of efflux pumps, which are responsible for multi-drug resistance. The ability to inhibit virulence factor secretion is something most currently available and commonly prescribed antibiotics are unable to do, making small molecule treatments an attractive option if such treatments are proven effective in vivo. The small molecule inhibitors reduced the secretion of three toxins from S. aureus and exerted potent bacteriostatic effects against three MRSA strains, the researchers reported (Bioorganic & Medicinal Chemistry Vol. 23; 2015, 7061–68). “Our best inhibitor SCA-50 showed potent concentration-dependent bactericidal activity against MRSA Mu50 strain and very importantly, 2–60 fold more potent inhibitory effect on MRSA Mu50 than all the commonly used antibiotics including vancomycin, which is considered the last resort option in treating MRSA-related infections.”
“The results obtained demonstrated an important proof of concept [that] targeting SecA could achieve antimicrobial effect through three mechanisms, which are not seen with any single class of antimicrobial agents,” Dr. Jin and his coauthors wrote.
This study was funded by the National Institutes of Health and by Georgia State University. Dr. Jin is now with the National Center of Toxicological Research, in Jefferson, Ariz.
A promising approach to treating methicillin-resistant Staphylococcus aureus (MRSA) infections may lie in small molecules that target SecA, an indispensable ATPase of the general protein translocation machinery present in bacteria, according to Jinshan Jin, Ph.D.
Dr. Jin and his coinvestigators at Georgia State University developed small molecule analogs of Rose Bengal that target SecA. In in vitro studies, the analogs had potent antimicrobial activities, reduced the secretion of toxins, and overcame the effect of efflux pumps, which are responsible for multi-drug resistance. The ability to inhibit virulence factor secretion is something most currently available and commonly prescribed antibiotics are unable to do, making small molecule treatments an attractive option if such treatments are proven effective in vivo. The small molecule inhibitors reduced the secretion of three toxins from S. aureus and exerted potent bacteriostatic effects against three MRSA strains, the researchers reported (Bioorganic & Medicinal Chemistry Vol. 23; 2015, 7061–68). “Our best inhibitor SCA-50 showed potent concentration-dependent bactericidal activity against MRSA Mu50 strain and very importantly, 2–60 fold more potent inhibitory effect on MRSA Mu50 than all the commonly used antibiotics including vancomycin, which is considered the last resort option in treating MRSA-related infections.”
“The results obtained demonstrated an important proof of concept [that] targeting SecA could achieve antimicrobial effect through three mechanisms, which are not seen with any single class of antimicrobial agents,” Dr. Jin and his coauthors wrote.
This study was funded by the National Institutes of Health and by Georgia State University. Dr. Jin is now with the National Center of Toxicological Research, in Jefferson, Ariz.
A promising approach to treating methicillin-resistant Staphylococcus aureus (MRSA) infections may lie in small molecules that target SecA, an indispensable ATPase of the general protein translocation machinery present in bacteria, according to Jinshan Jin, Ph.D.
Dr. Jin and his coinvestigators at Georgia State University developed small molecule analogs of Rose Bengal that target SecA. In in vitro studies, the analogs had potent antimicrobial activities, reduced the secretion of toxins, and overcame the effect of efflux pumps, which are responsible for multi-drug resistance. The ability to inhibit virulence factor secretion is something most currently available and commonly prescribed antibiotics are unable to do, making small molecule treatments an attractive option if such treatments are proven effective in vivo. The small molecule inhibitors reduced the secretion of three toxins from S. aureus and exerted potent bacteriostatic effects against three MRSA strains, the researchers reported (Bioorganic & Medicinal Chemistry Vol. 23; 2015, 7061–68). “Our best inhibitor SCA-50 showed potent concentration-dependent bactericidal activity against MRSA Mu50 strain and very importantly, 2–60 fold more potent inhibitory effect on MRSA Mu50 than all the commonly used antibiotics including vancomycin, which is considered the last resort option in treating MRSA-related infections.”
“The results obtained demonstrated an important proof of concept [that] targeting SecA could achieve antimicrobial effect through three mechanisms, which are not seen with any single class of antimicrobial agents,” Dr. Jin and his coauthors wrote.
This study was funded by the National Institutes of Health and by Georgia State University. Dr. Jin is now with the National Center of Toxicological Research, in Jefferson, Ariz.
FROM BIOORGANIC & MEDICINAL CHEMISTRY
Patients may safely self-administer long-term IV antibiotics
Uninsured patients can be trained to safely and efficiently self-administer long-term intravenous antibiotics, according to a 4-year outcomes study published in PLOS Medicine.
Between 2010 and 2013, 994 uninsured patients at Parkland Hospital in Dallas were enrolled in a self-administered outpatient parenteral antimicrobial therapy (S-OPAT) program, and 224 insured patients were discharged to a health care–administered OPAT program. Patients in the S-OPAT group were trained to self-administer intravenous antimicrobials, tested for their ability to treat themselves before discharge, and then monitored by weekly visits to the S-OPAT outpatient clinic. The 224 insured patients in the H-OPAT program had antibiotics administered by a health care worker.
A research team led by Dr. Kavita Bhavan of University of Texas Southwestern Medical Center, Dallas, estimated the effect of S-OPAT versus H-OPAT on 30-day all-cause readmission and 1-year all-cause mortality after controlling for selection bias with a propensity score developed using baseline clinical and sociodemographic information collected from the patients.
The 30-day readmission rate was 47% lower in the S-OPAT group than in the H-OPAT group, and the 1-year mortality rate did not differ significantly between the two groups. Because the S-OPAT program resulted in patients spending fewer days having inpatient infusions, 27,666 inpatient days were avoided over the study period.
Thus, S-OPAT was associated with similar or better outcomes than H-OPAT, meaning S-OPAT may be an acceptable model of treatment for uninsured, medically stable patients to complete extended courses of intravenous antimicrobials at home.
Read the full study online at PLOS Medicine (PLoS Med. 2015 Dec 15;12[12]. doi: 10.1371/journal.pmed.1001922).
On Twitter @richpizzi
Uninsured patients can be trained to safely and efficiently self-administer long-term intravenous antibiotics, according to a 4-year outcomes study published in PLOS Medicine.
Between 2010 and 2013, 994 uninsured patients at Parkland Hospital in Dallas were enrolled in a self-administered outpatient parenteral antimicrobial therapy (S-OPAT) program, and 224 insured patients were discharged to a health care–administered OPAT program. Patients in the S-OPAT group were trained to self-administer intravenous antimicrobials, tested for their ability to treat themselves before discharge, and then monitored by weekly visits to the S-OPAT outpatient clinic. The 224 insured patients in the H-OPAT program had antibiotics administered by a health care worker.
A research team led by Dr. Kavita Bhavan of University of Texas Southwestern Medical Center, Dallas, estimated the effect of S-OPAT versus H-OPAT on 30-day all-cause readmission and 1-year all-cause mortality after controlling for selection bias with a propensity score developed using baseline clinical and sociodemographic information collected from the patients.
The 30-day readmission rate was 47% lower in the S-OPAT group than in the H-OPAT group, and the 1-year mortality rate did not differ significantly between the two groups. Because the S-OPAT program resulted in patients spending fewer days having inpatient infusions, 27,666 inpatient days were avoided over the study period.
Thus, S-OPAT was associated with similar or better outcomes than H-OPAT, meaning S-OPAT may be an acceptable model of treatment for uninsured, medically stable patients to complete extended courses of intravenous antimicrobials at home.
Read the full study online at PLOS Medicine (PLoS Med. 2015 Dec 15;12[12]. doi: 10.1371/journal.pmed.1001922).
On Twitter @richpizzi
Uninsured patients can be trained to safely and efficiently self-administer long-term intravenous antibiotics, according to a 4-year outcomes study published in PLOS Medicine.
Between 2010 and 2013, 994 uninsured patients at Parkland Hospital in Dallas were enrolled in a self-administered outpatient parenteral antimicrobial therapy (S-OPAT) program, and 224 insured patients were discharged to a health care–administered OPAT program. Patients in the S-OPAT group were trained to self-administer intravenous antimicrobials, tested for their ability to treat themselves before discharge, and then monitored by weekly visits to the S-OPAT outpatient clinic. The 224 insured patients in the H-OPAT program had antibiotics administered by a health care worker.
A research team led by Dr. Kavita Bhavan of University of Texas Southwestern Medical Center, Dallas, estimated the effect of S-OPAT versus H-OPAT on 30-day all-cause readmission and 1-year all-cause mortality after controlling for selection bias with a propensity score developed using baseline clinical and sociodemographic information collected from the patients.
The 30-day readmission rate was 47% lower in the S-OPAT group than in the H-OPAT group, and the 1-year mortality rate did not differ significantly between the two groups. Because the S-OPAT program resulted in patients spending fewer days having inpatient infusions, 27,666 inpatient days were avoided over the study period.
Thus, S-OPAT was associated with similar or better outcomes than H-OPAT, meaning S-OPAT may be an acceptable model of treatment for uninsured, medically stable patients to complete extended courses of intravenous antimicrobials at home.
Read the full study online at PLOS Medicine (PLoS Med. 2015 Dec 15;12[12]. doi: 10.1371/journal.pmed.1001922).
On Twitter @richpizzi
FROM PLOS MEDICINE
Delayed response predicts need for extended antibiotics for inpatients with low-risk, gram-negative bacteremias
Antibiotic therapy for 7 days or less may be just as effective as longer courses of antibiotics for select inpatients with uncomplicated gram-negative bacteremia from urinary infections, based on a retrospective, single-center analysis by researchers at Maimonides Medical Center in New York.
Hospitalized patients whose temperatures returned to levels below 100.4º F within 72 hours of starting therapy appeared to do well on short-course (7 days or less) antibiotic therapy, Siddharth Swamy, Pharm.D., and his colleagues reported in a study in Infectious Diseases in Clinical Practice posted online Dec. 30, 2015. However, increased clinical failures were noted in patients with a delayed response to therapy, indicating that duration of therapy needs to be individualized for each patient.
The researchers reviewed 178 eligible cases of gram-negative bacteremia. The most common source of bacteremia was the urinary tract (53%), followed by catheters (14%), and unknown sources (14%).
Patients were treated with antibiotics for either 7 days or less (42 patients), 8-14 days (100 patients), or more than 14 days (36 patients). The patients in the study were comparable, with the exception of a higher percentage of patients in the short-course antibiotic group who no longer had temperatures above 100.4º F within 72 hours of initiating therapy. The respective percentage of patients who had defervesced in 72 hours or less was 79% for 7 days or less of therapy, 69% for 8-14 days of therapy, and 36% for more than 14 days of therapy (P = .0002). Overall clinical response rates were 79% for 7 days or less of antibiotics, 89% for 8-14 days of therapy, and 81% for more than 14 days of therapy. Microbiologic cure rates were 83%, 89, and 92%, respectively; the differences were nonsignificant.
However, persisting fever predicted clinical response: Among patients who defervesced after 72 hours, the short-course treatment group had a significantly decreased clinical response rate, compared with intermediate- and long-course treatment groups (11%, 65%, 70%, respectively; P = .03).
The most common infectious pathogens were Escherichia coli (46%) and Klebsiella pneumoniae (22%); most cases were low-inocula bacteremias and were related to urinary tract infections in 53% of the cases. Thus, the findings “are not necessarily applicable to high-inocula bacteremias, nonlactose-fermenting gram-negative organisms, or multidrug-resistant gram-negative organisms,” the researchers wrote.
On Twitter @whitneymcknight
Antibiotic therapy for 7 days or less may be just as effective as longer courses of antibiotics for select inpatients with uncomplicated gram-negative bacteremia from urinary infections, based on a retrospective, single-center analysis by researchers at Maimonides Medical Center in New York.
Hospitalized patients whose temperatures returned to levels below 100.4º F within 72 hours of starting therapy appeared to do well on short-course (7 days or less) antibiotic therapy, Siddharth Swamy, Pharm.D., and his colleagues reported in a study in Infectious Diseases in Clinical Practice posted online Dec. 30, 2015. However, increased clinical failures were noted in patients with a delayed response to therapy, indicating that duration of therapy needs to be individualized for each patient.
The researchers reviewed 178 eligible cases of gram-negative bacteremia. The most common source of bacteremia was the urinary tract (53%), followed by catheters (14%), and unknown sources (14%).
Patients were treated with antibiotics for either 7 days or less (42 patients), 8-14 days (100 patients), or more than 14 days (36 patients). The patients in the study were comparable, with the exception of a higher percentage of patients in the short-course antibiotic group who no longer had temperatures above 100.4º F within 72 hours of initiating therapy. The respective percentage of patients who had defervesced in 72 hours or less was 79% for 7 days or less of therapy, 69% for 8-14 days of therapy, and 36% for more than 14 days of therapy (P = .0002). Overall clinical response rates were 79% for 7 days or less of antibiotics, 89% for 8-14 days of therapy, and 81% for more than 14 days of therapy. Microbiologic cure rates were 83%, 89, and 92%, respectively; the differences were nonsignificant.
However, persisting fever predicted clinical response: Among patients who defervesced after 72 hours, the short-course treatment group had a significantly decreased clinical response rate, compared with intermediate- and long-course treatment groups (11%, 65%, 70%, respectively; P = .03).
The most common infectious pathogens were Escherichia coli (46%) and Klebsiella pneumoniae (22%); most cases were low-inocula bacteremias and were related to urinary tract infections in 53% of the cases. Thus, the findings “are not necessarily applicable to high-inocula bacteremias, nonlactose-fermenting gram-negative organisms, or multidrug-resistant gram-negative organisms,” the researchers wrote.
On Twitter @whitneymcknight
Antibiotic therapy for 7 days or less may be just as effective as longer courses of antibiotics for select inpatients with uncomplicated gram-negative bacteremia from urinary infections, based on a retrospective, single-center analysis by researchers at Maimonides Medical Center in New York.
Hospitalized patients whose temperatures returned to levels below 100.4º F within 72 hours of starting therapy appeared to do well on short-course (7 days or less) antibiotic therapy, Siddharth Swamy, Pharm.D., and his colleagues reported in a study in Infectious Diseases in Clinical Practice posted online Dec. 30, 2015. However, increased clinical failures were noted in patients with a delayed response to therapy, indicating that duration of therapy needs to be individualized for each patient.
The researchers reviewed 178 eligible cases of gram-negative bacteremia. The most common source of bacteremia was the urinary tract (53%), followed by catheters (14%), and unknown sources (14%).
Patients were treated with antibiotics for either 7 days or less (42 patients), 8-14 days (100 patients), or more than 14 days (36 patients). The patients in the study were comparable, with the exception of a higher percentage of patients in the short-course antibiotic group who no longer had temperatures above 100.4º F within 72 hours of initiating therapy. The respective percentage of patients who had defervesced in 72 hours or less was 79% for 7 days or less of therapy, 69% for 8-14 days of therapy, and 36% for more than 14 days of therapy (P = .0002). Overall clinical response rates were 79% for 7 days or less of antibiotics, 89% for 8-14 days of therapy, and 81% for more than 14 days of therapy. Microbiologic cure rates were 83%, 89, and 92%, respectively; the differences were nonsignificant.
However, persisting fever predicted clinical response: Among patients who defervesced after 72 hours, the short-course treatment group had a significantly decreased clinical response rate, compared with intermediate- and long-course treatment groups (11%, 65%, 70%, respectively; P = .03).
The most common infectious pathogens were Escherichia coli (46%) and Klebsiella pneumoniae (22%); most cases were low-inocula bacteremias and were related to urinary tract infections in 53% of the cases. Thus, the findings “are not necessarily applicable to high-inocula bacteremias, nonlactose-fermenting gram-negative organisms, or multidrug-resistant gram-negative organisms,” the researchers wrote.
On Twitter @whitneymcknight
FROM INFECTIOUS DISEASES IN CLINICAL PRACTICE
Key clinical point: Antibiotic therapy for 7 days or less may be just as effective as longer courses of antibiotics for select inpatients with uncomplicated gram-negative bacteremia due to urinary infections.
Major finding: Among inpatients who defervesced after 72 hours, the short-course treatment group had a significantly decreased clinical response rate compared with intermediate- and long-course treatment groups (11%, 65%, 70%, respectively, P = 0.03).
Data source: Single-center, retrospective, case-cohort review of 178 cases.
Disclosures: The researchers had no relevant disclosures.
White House launches new plan to combat multidrug-resistant TB
The Obama administration has announced a new action plan to combat the rise of multidrug-resistant tuberculosis (MDR-TB).
The plan, published Dec. 22, outlines three primary goals to accomplish between 2016 and 2020: strengthening domestic capacity to treat the disease, improving international ability and collaboration, and accelerating research and treatment of MDR-TB.
To strengthen state and local capacity to prevent transmission of TB, the action plan proposes improving surge capacity for rapid response to individual patients, patient clusters, and larger outbreaks of drug-resistant TB, as well as advancing the treatment of latent TB infection and disease among vulnerable populations.
Disease surveillance will be upgraded to “gather, store, analyze, and report electronic data on drug-resistant TB.” As part of the effort, the Centers for Disease Control and Prevention will increase its capacity to use “whole-genome sequencing to elucidate paths of transmission, identify recent transmission, and identify emerging patterns of resistance,” according to the action plan.
Taken with other preventive activities, the measures are estimated to result in a 15% reduction in newly diagnosed MDR-TB cases by 2020, as specified in the National Action Plan for Combating Antibiotic-Resistant Bacteria.
Additionally, the U.S. government will work with partners including the World Health Organization and the Stop TB Partnership to support countries in developing new approaches to MDR-TB. The focus is expected to initiate treatment for an additional 200,000 people with MDR-TB during 2015-2019; an estimated 360,000 people are currently treated under the U.S. government’s Global TB Strategy. The action plan also aims to improve access to patient-centered diagnostic and treatment services in countries with limited health care resources.
Developing a TB vaccine is a key initiative. The plan details that the National Institutes of Health and the CDC will focus on expanding the dialogue among basic scientists, funders, and vaccine developers to identify strategies for vaccine development and preventive drugs.
The plan also urges focused research into the discovery of biological markers that indicate early response to therapy or protection against TB.
Pulmonologist Daniel R. Ouellette of Henry Ford Hospital in Detroit, said “the three goals are certainly worthy,” but the plan does not address the budgetary measures to be taken to increase domestic capacity to combat TB nor does it explain where resources will be found to encourage the development of new medications.
“How much money are we willing to spend in addition to what we spend now in treating general TB? he asked in an interview. “How are we going to incentivize industry to develop new drugs? It all sounds really good, but all of this is going to cost money. Where are the dollars that go with that?” said Dr. Ouellette, who is chair of the Guideline Oversight Committee for CHEST (the American College of Chest Physicians).
The national action plan states that all activities noted will be subject to budgetary constraints and other approvals, including the “weighing of priorities and available resources by the administration in formulating its annual budget and by Congress in legislating appropriations.”
TB causes the deaths of more than 1.5 million people worldwide annually, according to White House data. Nearly one-third of the world’s population is thought to be infected with Mycobacterium tuberculosis; each year, more than 9.5 million develop active TB and about 480,000 people develop MDR-TB. Fewer than 20% with MDR-TB receive appropriate therapy, and less than half are effectively treated.
On Twitter @legal_med
The Obama administration has announced a new action plan to combat the rise of multidrug-resistant tuberculosis (MDR-TB).
The plan, published Dec. 22, outlines three primary goals to accomplish between 2016 and 2020: strengthening domestic capacity to treat the disease, improving international ability and collaboration, and accelerating research and treatment of MDR-TB.
To strengthen state and local capacity to prevent transmission of TB, the action plan proposes improving surge capacity for rapid response to individual patients, patient clusters, and larger outbreaks of drug-resistant TB, as well as advancing the treatment of latent TB infection and disease among vulnerable populations.
Disease surveillance will be upgraded to “gather, store, analyze, and report electronic data on drug-resistant TB.” As part of the effort, the Centers for Disease Control and Prevention will increase its capacity to use “whole-genome sequencing to elucidate paths of transmission, identify recent transmission, and identify emerging patterns of resistance,” according to the action plan.
Taken with other preventive activities, the measures are estimated to result in a 15% reduction in newly diagnosed MDR-TB cases by 2020, as specified in the National Action Plan for Combating Antibiotic-Resistant Bacteria.
Additionally, the U.S. government will work with partners including the World Health Organization and the Stop TB Partnership to support countries in developing new approaches to MDR-TB. The focus is expected to initiate treatment for an additional 200,000 people with MDR-TB during 2015-2019; an estimated 360,000 people are currently treated under the U.S. government’s Global TB Strategy. The action plan also aims to improve access to patient-centered diagnostic and treatment services in countries with limited health care resources.
Developing a TB vaccine is a key initiative. The plan details that the National Institutes of Health and the CDC will focus on expanding the dialogue among basic scientists, funders, and vaccine developers to identify strategies for vaccine development and preventive drugs.
The plan also urges focused research into the discovery of biological markers that indicate early response to therapy or protection against TB.
Pulmonologist Daniel R. Ouellette of Henry Ford Hospital in Detroit, said “the three goals are certainly worthy,” but the plan does not address the budgetary measures to be taken to increase domestic capacity to combat TB nor does it explain where resources will be found to encourage the development of new medications.
“How much money are we willing to spend in addition to what we spend now in treating general TB? he asked in an interview. “How are we going to incentivize industry to develop new drugs? It all sounds really good, but all of this is going to cost money. Where are the dollars that go with that?” said Dr. Ouellette, who is chair of the Guideline Oversight Committee for CHEST (the American College of Chest Physicians).
The national action plan states that all activities noted will be subject to budgetary constraints and other approvals, including the “weighing of priorities and available resources by the administration in formulating its annual budget and by Congress in legislating appropriations.”
TB causes the deaths of more than 1.5 million people worldwide annually, according to White House data. Nearly one-third of the world’s population is thought to be infected with Mycobacterium tuberculosis; each year, more than 9.5 million develop active TB and about 480,000 people develop MDR-TB. Fewer than 20% with MDR-TB receive appropriate therapy, and less than half are effectively treated.
On Twitter @legal_med
The Obama administration has announced a new action plan to combat the rise of multidrug-resistant tuberculosis (MDR-TB).
The plan, published Dec. 22, outlines three primary goals to accomplish between 2016 and 2020: strengthening domestic capacity to treat the disease, improving international ability and collaboration, and accelerating research and treatment of MDR-TB.
To strengthen state and local capacity to prevent transmission of TB, the action plan proposes improving surge capacity for rapid response to individual patients, patient clusters, and larger outbreaks of drug-resistant TB, as well as advancing the treatment of latent TB infection and disease among vulnerable populations.
Disease surveillance will be upgraded to “gather, store, analyze, and report electronic data on drug-resistant TB.” As part of the effort, the Centers for Disease Control and Prevention will increase its capacity to use “whole-genome sequencing to elucidate paths of transmission, identify recent transmission, and identify emerging patterns of resistance,” according to the action plan.
Taken with other preventive activities, the measures are estimated to result in a 15% reduction in newly diagnosed MDR-TB cases by 2020, as specified in the National Action Plan for Combating Antibiotic-Resistant Bacteria.
Additionally, the U.S. government will work with partners including the World Health Organization and the Stop TB Partnership to support countries in developing new approaches to MDR-TB. The focus is expected to initiate treatment for an additional 200,000 people with MDR-TB during 2015-2019; an estimated 360,000 people are currently treated under the U.S. government’s Global TB Strategy. The action plan also aims to improve access to patient-centered diagnostic and treatment services in countries with limited health care resources.
Developing a TB vaccine is a key initiative. The plan details that the National Institutes of Health and the CDC will focus on expanding the dialogue among basic scientists, funders, and vaccine developers to identify strategies for vaccine development and preventive drugs.
The plan also urges focused research into the discovery of biological markers that indicate early response to therapy or protection against TB.
Pulmonologist Daniel R. Ouellette of Henry Ford Hospital in Detroit, said “the three goals are certainly worthy,” but the plan does not address the budgetary measures to be taken to increase domestic capacity to combat TB nor does it explain where resources will be found to encourage the development of new medications.
“How much money are we willing to spend in addition to what we spend now in treating general TB? he asked in an interview. “How are we going to incentivize industry to develop new drugs? It all sounds really good, but all of this is going to cost money. Where are the dollars that go with that?” said Dr. Ouellette, who is chair of the Guideline Oversight Committee for CHEST (the American College of Chest Physicians).
The national action plan states that all activities noted will be subject to budgetary constraints and other approvals, including the “weighing of priorities and available resources by the administration in formulating its annual budget and by Congress in legislating appropriations.”
TB causes the deaths of more than 1.5 million people worldwide annually, according to White House data. Nearly one-third of the world’s population is thought to be infected with Mycobacterium tuberculosis; each year, more than 9.5 million develop active TB and about 480,000 people develop MDR-TB. Fewer than 20% with MDR-TB receive appropriate therapy, and less than half are effectively treated.
On Twitter @legal_med
Key clinical point: A new action plan to combat the rise of multidrug-resistant tuberculosis focuses on strengthening the domestic capacity to treat the MDR-TB, improving international capacity and collaboration to combat the disease, and accelerating research and treatment developments.
Multidrug-resistant TB response boosted by six-drug therapy
Using more than five agents to treat multidrug-resistant tuberculosis markedly increases the cure rate by as much as 65%, according to a report published online Dec. 29 in PLOS Medicine.
At present, the World Health Organization recommends a regimen of pyrazinamide plus at least four second-line drugs that are likely to be effective, based on the patient’s previous exposure, background resistance levels in the community, and any drug susceptibility testing results from known cases in contact with the patient. But recent evidence suggested that including even more drugs in the regimen might improve clinical outcomes, said Courtney M. Yuen, Ph.D., of the Centers for Disease Control and Prevention, and her associates.
The researchers performed a secondary analysis of data for 1,137 participants in the Preserving Effective Tuberculosis Treatment Study (PETTS), an international prospective cohort study of patients with multidrug-resistant pulmonary TB. These patients were followed for a median of 20 months, undergoing sputum cultures for TB every month. The researchers used time to sputum culture conversion as the indicator of treatment effectiveness.
Receiving at least six potentially effective drugs per day raised the likelihood of sputum culture conversion by 36%, compared with using the recommended five drugs. In addition, for patients receiving at least one untested drug – any antituberculosis agent given empirically, without susceptibility testing – in their five-drug regimen, adding an extra potentially effective drug raised the likelihood of sputum culture conversion by 65%. Even adding an extra untested drug to a five-drug regimen improved the likelihood of sputum culture conversion by 33%, Dr. Yuen and her associates said (PLOS Med. 2015 Dec 29. doi:10.1371/pmed.1001932).
“We observed a benefit to receiving a greater number of potentially effective drugs ... as well as an interaction in which the presence of more effective drugs enhanced the benefit of untested drugs. Both of these results add to existing evidence that increasing the number of drugs in multidrug-resistant TB regimens is advantageous,” they noted.
The WHO initially recommended a regimen of four drugs for these patients in 2006, then raised that number to five in 2011. “Our results suggest that treatment might be further fortified by adding additional potentially effective drugs,” the investigators said.
Using more than five agents to treat multidrug-resistant tuberculosis markedly increases the cure rate by as much as 65%, according to a report published online Dec. 29 in PLOS Medicine.
At present, the World Health Organization recommends a regimen of pyrazinamide plus at least four second-line drugs that are likely to be effective, based on the patient’s previous exposure, background resistance levels in the community, and any drug susceptibility testing results from known cases in contact with the patient. But recent evidence suggested that including even more drugs in the regimen might improve clinical outcomes, said Courtney M. Yuen, Ph.D., of the Centers for Disease Control and Prevention, and her associates.
The researchers performed a secondary analysis of data for 1,137 participants in the Preserving Effective Tuberculosis Treatment Study (PETTS), an international prospective cohort study of patients with multidrug-resistant pulmonary TB. These patients were followed for a median of 20 months, undergoing sputum cultures for TB every month. The researchers used time to sputum culture conversion as the indicator of treatment effectiveness.
Receiving at least six potentially effective drugs per day raised the likelihood of sputum culture conversion by 36%, compared with using the recommended five drugs. In addition, for patients receiving at least one untested drug – any antituberculosis agent given empirically, without susceptibility testing – in their five-drug regimen, adding an extra potentially effective drug raised the likelihood of sputum culture conversion by 65%. Even adding an extra untested drug to a five-drug regimen improved the likelihood of sputum culture conversion by 33%, Dr. Yuen and her associates said (PLOS Med. 2015 Dec 29. doi:10.1371/pmed.1001932).
“We observed a benefit to receiving a greater number of potentially effective drugs ... as well as an interaction in which the presence of more effective drugs enhanced the benefit of untested drugs. Both of these results add to existing evidence that increasing the number of drugs in multidrug-resistant TB regimens is advantageous,” they noted.
The WHO initially recommended a regimen of four drugs for these patients in 2006, then raised that number to five in 2011. “Our results suggest that treatment might be further fortified by adding additional potentially effective drugs,” the investigators said.
Using more than five agents to treat multidrug-resistant tuberculosis markedly increases the cure rate by as much as 65%, according to a report published online Dec. 29 in PLOS Medicine.
At present, the World Health Organization recommends a regimen of pyrazinamide plus at least four second-line drugs that are likely to be effective, based on the patient’s previous exposure, background resistance levels in the community, and any drug susceptibility testing results from known cases in contact with the patient. But recent evidence suggested that including even more drugs in the regimen might improve clinical outcomes, said Courtney M. Yuen, Ph.D., of the Centers for Disease Control and Prevention, and her associates.
The researchers performed a secondary analysis of data for 1,137 participants in the Preserving Effective Tuberculosis Treatment Study (PETTS), an international prospective cohort study of patients with multidrug-resistant pulmonary TB. These patients were followed for a median of 20 months, undergoing sputum cultures for TB every month. The researchers used time to sputum culture conversion as the indicator of treatment effectiveness.
Receiving at least six potentially effective drugs per day raised the likelihood of sputum culture conversion by 36%, compared with using the recommended five drugs. In addition, for patients receiving at least one untested drug – any antituberculosis agent given empirically, without susceptibility testing – in their five-drug regimen, adding an extra potentially effective drug raised the likelihood of sputum culture conversion by 65%. Even adding an extra untested drug to a five-drug regimen improved the likelihood of sputum culture conversion by 33%, Dr. Yuen and her associates said (PLOS Med. 2015 Dec 29. doi:10.1371/pmed.1001932).
“We observed a benefit to receiving a greater number of potentially effective drugs ... as well as an interaction in which the presence of more effective drugs enhanced the benefit of untested drugs. Both of these results add to existing evidence that increasing the number of drugs in multidrug-resistant TB regimens is advantageous,” they noted.
The WHO initially recommended a regimen of four drugs for these patients in 2006, then raised that number to five in 2011. “Our results suggest that treatment might be further fortified by adding additional potentially effective drugs,” the investigators said.
FROM PLOS MEDICINE
Key clinical point: Using more than the recommended five drugs to treat multidrug-resistant TB increased the cure rate by as much as 65%.
Major finding: Receiving at least six potentially effective drugs per day raised the likelihood of sputum culture conversion by 36%, compared with using the recommended five drugs.
Data source: A secondary analysis of data regarding 1,137 participants in an international prospective cohort study.
Disclosures: This study was supported by the U.S. Agency for International Development, the CDC, the National Institute for Allergy and Infectious Diseases, and the Korean Ministry of Health and Welfare. Dr. Yuen and her associates reported having no relevant financial disclosures.
Tricks for treating C. diff in IBD
ORLANDO – You can confidently treat mild to severe Clostridium difficile infection in persons with inflammatory bowel disease, without disrupting their immunosuppression or other treatments, according to an expert.
“If your patient with IBD needs a fecal transplant for C. diff., you should not be concerned about withholding it,” Dr. Alan C. Moss said during a basic science presentation at a conference on inflammatory bowel diseases (IBD), sponsored by the Crohn’s and Colitis Foundation of America. Dr. Moss is an associate professor of medicine and the director of translational research at Harvard Medical School, Boston.
The first step, after you’ve determined that your patient has a true C. diff. infection, as opposed to having only been colonized by the bacteria, is choosing the best antibiotic. “Unfortunately, almost all IBD patients are excluded from controlled trials of antibiotics in C. diff. infection, so all we really have to go on are retrospective cohort data,” said Dr. Moss.
One such study, uncontrolled for disease severity, showed that a third of 114 inpatients with IBD who had a co-occurring C. diff. infection had higher 30-day readmission rates when treated first with metronidazole, per current standards of care, compared with the remaining two-thirds of patients who were treated first with vancomycin. The metronidazole group also averaged double the length of stays of the vancomycin group (Antimicrob Agents Chemother. 2014 Sep;58:5054-9 [doi: 10.1128/AAC.02606-13]).
“This suggests that in IBD patients, especially for those who meet criteria for a severe C. diff. infection, vancomycin is the way to go,” Dr. Moss said, noting a trend of metronidazole for mild infections in this cohort having ever less efficacy.
Beyond mild infection, Dr. Moss said the first line of treatment should be vancomycin 125 mg four times daily, or 500 mg four times daily if it is complicated disease.
If your patient has recurrent C. diff. infection, Dr. Moss recommended a prolonged taper of vancomycin, but to be vigilant about it being truly an infection and not a flare-up of colonized bacteria.
“My bar for doing fecal transplant in these patients has dropped considerably in the last few years, because if you really want to squeeze out the niche that C. diff. occupies in the microbiome, fecal transplant is really the most effective way we have of doing that,” Dr. Moss said.
While there is a division in the field over whether to continue immunosuppression during antibiotic treatment, Dr. Moss cited a small study indicating that if a patient were on two or more immunosuppressants, they had a higher risk of death, megacolon, or shock during C. diff. treatment. “I think it’s hard to draw many conclusions from that,” Dr. Moss said. “It may just be a surrogate marker of severity of disease rather than infection, per se.”
The standard of care for recurrent and refractory C. diff. infection is now fecal transplant, according to Dr. Moss. A recent study of fecal transplantation showed an 89% cure rate of C. diff. infection after a single fecal transplant in IBD patients. Of the 36 IBD patients in the study, half of whom were on biologic and immunosuppressive therapies, four experienced disease flare-ups (Am J Gastroenterol. 2014 Jul;109:1065-71 [doi: 10.1038/ajg.2014.133]. N Engl J Med. 2013 Jan 31;368:474-5 [doi: 10.1056/NEJMe1214816]).
As for determining if there is an actual infection rather than colonization of C. diff., Dr. Moss said switching from using ELISA (enzyme-linked immunoassay) testing to PCR (polymerase chain reaction) testing instead was helpful in first-time infections because the latter is more sensitive for determining actual infection; however, if a patient has recurrent infection, the higher clinical specificity of PCR makes it harder to tell if a positive result is infection or simply colonization.
Some institutions have dropped ELISA testing altogether, Dr. Moss said, although he thinks the use of single molecule array testing is, with its exponential sensitivity, a “good half-way step” between ELISA and PCR, and is useful for determining who is colonized vs. who is actually producing the toxin, even at a very low level.
Dr. Moss disclosed he has consulted for Janssen, Theravance, and Seres, and has received research support from the National Institute for Diabetes, Digestive, and Kidney Disease, and Helmsley.
On Twitter @whitneymcknight
ORLANDO – You can confidently treat mild to severe Clostridium difficile infection in persons with inflammatory bowel disease, without disrupting their immunosuppression or other treatments, according to an expert.
“If your patient with IBD needs a fecal transplant for C. diff., you should not be concerned about withholding it,” Dr. Alan C. Moss said during a basic science presentation at a conference on inflammatory bowel diseases (IBD), sponsored by the Crohn’s and Colitis Foundation of America. Dr. Moss is an associate professor of medicine and the director of translational research at Harvard Medical School, Boston.
The first step, after you’ve determined that your patient has a true C. diff. infection, as opposed to having only been colonized by the bacteria, is choosing the best antibiotic. “Unfortunately, almost all IBD patients are excluded from controlled trials of antibiotics in C. diff. infection, so all we really have to go on are retrospective cohort data,” said Dr. Moss.
One such study, uncontrolled for disease severity, showed that a third of 114 inpatients with IBD who had a co-occurring C. diff. infection had higher 30-day readmission rates when treated first with metronidazole, per current standards of care, compared with the remaining two-thirds of patients who were treated first with vancomycin. The metronidazole group also averaged double the length of stays of the vancomycin group (Antimicrob Agents Chemother. 2014 Sep;58:5054-9 [doi: 10.1128/AAC.02606-13]).
“This suggests that in IBD patients, especially for those who meet criteria for a severe C. diff. infection, vancomycin is the way to go,” Dr. Moss said, noting a trend of metronidazole for mild infections in this cohort having ever less efficacy.
Beyond mild infection, Dr. Moss said the first line of treatment should be vancomycin 125 mg four times daily, or 500 mg four times daily if it is complicated disease.
If your patient has recurrent C. diff. infection, Dr. Moss recommended a prolonged taper of vancomycin, but to be vigilant about it being truly an infection and not a flare-up of colonized bacteria.
“My bar for doing fecal transplant in these patients has dropped considerably in the last few years, because if you really want to squeeze out the niche that C. diff. occupies in the microbiome, fecal transplant is really the most effective way we have of doing that,” Dr. Moss said.
While there is a division in the field over whether to continue immunosuppression during antibiotic treatment, Dr. Moss cited a small study indicating that if a patient were on two or more immunosuppressants, they had a higher risk of death, megacolon, or shock during C. diff. treatment. “I think it’s hard to draw many conclusions from that,” Dr. Moss said. “It may just be a surrogate marker of severity of disease rather than infection, per se.”
The standard of care for recurrent and refractory C. diff. infection is now fecal transplant, according to Dr. Moss. A recent study of fecal transplantation showed an 89% cure rate of C. diff. infection after a single fecal transplant in IBD patients. Of the 36 IBD patients in the study, half of whom were on biologic and immunosuppressive therapies, four experienced disease flare-ups (Am J Gastroenterol. 2014 Jul;109:1065-71 [doi: 10.1038/ajg.2014.133]. N Engl J Med. 2013 Jan 31;368:474-5 [doi: 10.1056/NEJMe1214816]).
As for determining if there is an actual infection rather than colonization of C. diff., Dr. Moss said switching from using ELISA (enzyme-linked immunoassay) testing to PCR (polymerase chain reaction) testing instead was helpful in first-time infections because the latter is more sensitive for determining actual infection; however, if a patient has recurrent infection, the higher clinical specificity of PCR makes it harder to tell if a positive result is infection or simply colonization.
Some institutions have dropped ELISA testing altogether, Dr. Moss said, although he thinks the use of single molecule array testing is, with its exponential sensitivity, a “good half-way step” between ELISA and PCR, and is useful for determining who is colonized vs. who is actually producing the toxin, even at a very low level.
Dr. Moss disclosed he has consulted for Janssen, Theravance, and Seres, and has received research support from the National Institute for Diabetes, Digestive, and Kidney Disease, and Helmsley.
On Twitter @whitneymcknight
ORLANDO – You can confidently treat mild to severe Clostridium difficile infection in persons with inflammatory bowel disease, without disrupting their immunosuppression or other treatments, according to an expert.
“If your patient with IBD needs a fecal transplant for C. diff., you should not be concerned about withholding it,” Dr. Alan C. Moss said during a basic science presentation at a conference on inflammatory bowel diseases (IBD), sponsored by the Crohn’s and Colitis Foundation of America. Dr. Moss is an associate professor of medicine and the director of translational research at Harvard Medical School, Boston.
The first step, after you’ve determined that your patient has a true C. diff. infection, as opposed to having only been colonized by the bacteria, is choosing the best antibiotic. “Unfortunately, almost all IBD patients are excluded from controlled trials of antibiotics in C. diff. infection, so all we really have to go on are retrospective cohort data,” said Dr. Moss.
One such study, uncontrolled for disease severity, showed that a third of 114 inpatients with IBD who had a co-occurring C. diff. infection had higher 30-day readmission rates when treated first with metronidazole, per current standards of care, compared with the remaining two-thirds of patients who were treated first with vancomycin. The metronidazole group also averaged double the length of stays of the vancomycin group (Antimicrob Agents Chemother. 2014 Sep;58:5054-9 [doi: 10.1128/AAC.02606-13]).
“This suggests that in IBD patients, especially for those who meet criteria for a severe C. diff. infection, vancomycin is the way to go,” Dr. Moss said, noting a trend of metronidazole for mild infections in this cohort having ever less efficacy.
Beyond mild infection, Dr. Moss said the first line of treatment should be vancomycin 125 mg four times daily, or 500 mg four times daily if it is complicated disease.
If your patient has recurrent C. diff. infection, Dr. Moss recommended a prolonged taper of vancomycin, but to be vigilant about it being truly an infection and not a flare-up of colonized bacteria.
“My bar for doing fecal transplant in these patients has dropped considerably in the last few years, because if you really want to squeeze out the niche that C. diff. occupies in the microbiome, fecal transplant is really the most effective way we have of doing that,” Dr. Moss said.
While there is a division in the field over whether to continue immunosuppression during antibiotic treatment, Dr. Moss cited a small study indicating that if a patient were on two or more immunosuppressants, they had a higher risk of death, megacolon, or shock during C. diff. treatment. “I think it’s hard to draw many conclusions from that,” Dr. Moss said. “It may just be a surrogate marker of severity of disease rather than infection, per se.”
The standard of care for recurrent and refractory C. diff. infection is now fecal transplant, according to Dr. Moss. A recent study of fecal transplantation showed an 89% cure rate of C. diff. infection after a single fecal transplant in IBD patients. Of the 36 IBD patients in the study, half of whom were on biologic and immunosuppressive therapies, four experienced disease flare-ups (Am J Gastroenterol. 2014 Jul;109:1065-71 [doi: 10.1038/ajg.2014.133]. N Engl J Med. 2013 Jan 31;368:474-5 [doi: 10.1056/NEJMe1214816]).
As for determining if there is an actual infection rather than colonization of C. diff., Dr. Moss said switching from using ELISA (enzyme-linked immunoassay) testing to PCR (polymerase chain reaction) testing instead was helpful in first-time infections because the latter is more sensitive for determining actual infection; however, if a patient has recurrent infection, the higher clinical specificity of PCR makes it harder to tell if a positive result is infection or simply colonization.
Some institutions have dropped ELISA testing altogether, Dr. Moss said, although he thinks the use of single molecule array testing is, with its exponential sensitivity, a “good half-way step” between ELISA and PCR, and is useful for determining who is colonized vs. who is actually producing the toxin, even at a very low level.
Dr. Moss disclosed he has consulted for Janssen, Theravance, and Seres, and has received research support from the National Institute for Diabetes, Digestive, and Kidney Disease, and Helmsley.
On Twitter @whitneymcknight
EXPERT ANALYSIS FROM 2015 ADVANCES IN IBD
