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Some 4% of healthy U.S. children carry antibiotic-resistant E. coli isolates
SAN DIEGO – Third-generation cephalosporin-resistant Escherichia coli infection carriage was present in 4.2% of healthy children who underwent stool testing, especially in young children and in those with a household member who traveled internationally within the last year.
Those are key findings from a multicenter study which set out to examine the epidemiology of antibiotic-resistant E. coli colonization in healthy children.
“Overall, the results suggest that there is circulation and spread of third-generation cephalosporin-resistant Escherichia coli infection at the community and global level,” Dr. Shamim M. Islam said at an annual scientific meeting on infectious diseases.
Dr. Islam of the department of pediatrics at the State University of New York at Buffalo characterized the management of extended-spectrum beta-lactamase infections as “particularly complicated in children given limited antibiotic options. ESBL [Extended spectrum beta-lactamase]–producing Enterobacteriaceae infections are steadily rising, including in the community setting.”
As part of the Centers for Disease Control and Prevention’s New Vaccine Surveillance Network acute gastroenteritis project, the researchers enrolled 520 healthy children ranging in age from 14 days to 11 years during well-child visits in Oakland, Calif.; Kansas City, Mo.; and Nashville, Tenn., between December of 2013 and March of 2015. Dr. Islam and his associates administered a four-question survey to parents of the children, including questions about recent antibiotic use in the child and travel and hospitalization history of all members of their household. They collected stool samples from the children and used chromogenic commercial media technology to screen for ESBL-producing bacteria, and also performed confirmatory testing.
Dr. Islam reported that third-generation cephalosporin-resistant E. coli was present in 4.2% of overall stools, with a range from 3.4% to 5.1% among the three study sites. It was found to be more prevalent in children younger than age 5, compared with those aged 5 and older (4.9% vs. 1.7%, respectively; P = .21).
At the Oakland site, 50% of children carrying third-generation cephalosporin-resistant E. coli isolates had a household member who traveled internationally in the past year, compared with 11% of noncarriers (P = .05), while international travel at the other two sites was low. Combined results from those two sites indicated that 18.2% of children carrying third-generation cephalosporin-resistant E. coli isolates had a household member who traveled internationally in the past year, compared with 6.1% of noncarriers (P = .07).
Going forward, the researchers are planning to conduct further genetic and molecular characterization of the isolates they found with mutliplex pCR and whole-genome sequencing. “We’re going to continue surveillance of bacterial carriage at our current three sites for another year to try and expand our risk factor analysis to include more dietary risk factors and more antibiotic exposure,” Dr. Islam said.
IDWeek marks the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. The researchers reported having no financial disclosures.
SAN DIEGO – Third-generation cephalosporin-resistant Escherichia coli infection carriage was present in 4.2% of healthy children who underwent stool testing, especially in young children and in those with a household member who traveled internationally within the last year.
Those are key findings from a multicenter study which set out to examine the epidemiology of antibiotic-resistant E. coli colonization in healthy children.
“Overall, the results suggest that there is circulation and spread of third-generation cephalosporin-resistant Escherichia coli infection at the community and global level,” Dr. Shamim M. Islam said at an annual scientific meeting on infectious diseases.
Dr. Islam of the department of pediatrics at the State University of New York at Buffalo characterized the management of extended-spectrum beta-lactamase infections as “particularly complicated in children given limited antibiotic options. ESBL [Extended spectrum beta-lactamase]–producing Enterobacteriaceae infections are steadily rising, including in the community setting.”
As part of the Centers for Disease Control and Prevention’s New Vaccine Surveillance Network acute gastroenteritis project, the researchers enrolled 520 healthy children ranging in age from 14 days to 11 years during well-child visits in Oakland, Calif.; Kansas City, Mo.; and Nashville, Tenn., between December of 2013 and March of 2015. Dr. Islam and his associates administered a four-question survey to parents of the children, including questions about recent antibiotic use in the child and travel and hospitalization history of all members of their household. They collected stool samples from the children and used chromogenic commercial media technology to screen for ESBL-producing bacteria, and also performed confirmatory testing.
Dr. Islam reported that third-generation cephalosporin-resistant E. coli was present in 4.2% of overall stools, with a range from 3.4% to 5.1% among the three study sites. It was found to be more prevalent in children younger than age 5, compared with those aged 5 and older (4.9% vs. 1.7%, respectively; P = .21).
At the Oakland site, 50% of children carrying third-generation cephalosporin-resistant E. coli isolates had a household member who traveled internationally in the past year, compared with 11% of noncarriers (P = .05), while international travel at the other two sites was low. Combined results from those two sites indicated that 18.2% of children carrying third-generation cephalosporin-resistant E. coli isolates had a household member who traveled internationally in the past year, compared with 6.1% of noncarriers (P = .07).
Going forward, the researchers are planning to conduct further genetic and molecular characterization of the isolates they found with mutliplex pCR and whole-genome sequencing. “We’re going to continue surveillance of bacterial carriage at our current three sites for another year to try and expand our risk factor analysis to include more dietary risk factors and more antibiotic exposure,” Dr. Islam said.
IDWeek marks the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. The researchers reported having no financial disclosures.
SAN DIEGO – Third-generation cephalosporin-resistant Escherichia coli infection carriage was present in 4.2% of healthy children who underwent stool testing, especially in young children and in those with a household member who traveled internationally within the last year.
Those are key findings from a multicenter study which set out to examine the epidemiology of antibiotic-resistant E. coli colonization in healthy children.
“Overall, the results suggest that there is circulation and spread of third-generation cephalosporin-resistant Escherichia coli infection at the community and global level,” Dr. Shamim M. Islam said at an annual scientific meeting on infectious diseases.
Dr. Islam of the department of pediatrics at the State University of New York at Buffalo characterized the management of extended-spectrum beta-lactamase infections as “particularly complicated in children given limited antibiotic options. ESBL [Extended spectrum beta-lactamase]–producing Enterobacteriaceae infections are steadily rising, including in the community setting.”
As part of the Centers for Disease Control and Prevention’s New Vaccine Surveillance Network acute gastroenteritis project, the researchers enrolled 520 healthy children ranging in age from 14 days to 11 years during well-child visits in Oakland, Calif.; Kansas City, Mo.; and Nashville, Tenn., between December of 2013 and March of 2015. Dr. Islam and his associates administered a four-question survey to parents of the children, including questions about recent antibiotic use in the child and travel and hospitalization history of all members of their household. They collected stool samples from the children and used chromogenic commercial media technology to screen for ESBL-producing bacteria, and also performed confirmatory testing.
Dr. Islam reported that third-generation cephalosporin-resistant E. coli was present in 4.2% of overall stools, with a range from 3.4% to 5.1% among the three study sites. It was found to be more prevalent in children younger than age 5, compared with those aged 5 and older (4.9% vs. 1.7%, respectively; P = .21).
At the Oakland site, 50% of children carrying third-generation cephalosporin-resistant E. coli isolates had a household member who traveled internationally in the past year, compared with 11% of noncarriers (P = .05), while international travel at the other two sites was low. Combined results from those two sites indicated that 18.2% of children carrying third-generation cephalosporin-resistant E. coli isolates had a household member who traveled internationally in the past year, compared with 6.1% of noncarriers (P = .07).
Going forward, the researchers are planning to conduct further genetic and molecular characterization of the isolates they found with mutliplex pCR and whole-genome sequencing. “We’re going to continue surveillance of bacterial carriage at our current three sites for another year to try and expand our risk factor analysis to include more dietary risk factors and more antibiotic exposure,” Dr. Islam said.
IDWeek marks the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. The researchers reported having no financial disclosures.
AT IDWEEK 2015
Key clinical point: About 4% of healthy children in the United States harbor antibitotic-resistant E. coli.
Major finding: Third-generation cephalosporin-resistant E. coli was present in 4.2% of overall stools, with a range from 3.4% to 5.1%.
Data source: An analysis of stool samples obtained from 520 healthy children during well-child visits in three different centers in the United States.
Disclosures: The researchers reported having no financial disclosures.
VIDEO: Take steps now to keep gram-negative resistance at bay
CHICAGO – Gram-negative bacteria are the new frontier of antimicrobial resistance.
Resistant Escherichia coli, Klebsiella, and other organisms are increasingly common in Asia, South America, and southern Europe, but haven’t quite established themselves yet in the United States.
In an interview at the annual clinical congress of the American College of Surgeons, Dr. John Mazuski, a professor of surgery at Washington University in St. Louis, explained what’s known so far, and the steps to take now to keep the organisms in check.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
CHICAGO – Gram-negative bacteria are the new frontier of antimicrobial resistance.
Resistant Escherichia coli, Klebsiella, and other organisms are increasingly common in Asia, South America, and southern Europe, but haven’t quite established themselves yet in the United States.
In an interview at the annual clinical congress of the American College of Surgeons, Dr. John Mazuski, a professor of surgery at Washington University in St. Louis, explained what’s known so far, and the steps to take now to keep the organisms in check.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
CHICAGO – Gram-negative bacteria are the new frontier of antimicrobial resistance.
Resistant Escherichia coli, Klebsiella, and other organisms are increasingly common in Asia, South America, and southern Europe, but haven’t quite established themselves yet in the United States.
In an interview at the annual clinical congress of the American College of Surgeons, Dr. John Mazuski, a professor of surgery at Washington University in St. Louis, explained what’s known so far, and the steps to take now to keep the organisms in check.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
EXPERT ANALYSIS FROM THE ACS CLINICAL CONGRESS
Results mixed in hospital efforts to tackle antimicrobial resistance
SAN DIEGO – Canadian hospitals are making progress in reducing the rates of methicillin-resistant Staphylococcus aureus, but the rates of antimicrobial resistance in Canadian hospitals increased significantly for extended-spectrum beta-lactamase–producing Escherichia coli and Klebsiella pneumoniae, as well as vancomycin-resistant enterococci.
Those are among the key findings from a large national analysis known as CANWARD that were presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “What it’s telling us is that some of the things that we’re doing on the antimicrobial resistance side are working,” lead study author George G. Zhanel, Pharm.D., professor of microbiology and infectious diseases at the University of Manitoba, Winnipeg, said in an interview. “But it also tells us that some of these pathogens like [vancomycin-resistant enterococci] and [extended-spectrum beta-lactamase]–producing E. coli continue to go up. So there is some good news and some bad news, but it tells us that it’s not all just doom and gloom. Some progress has been made, but there’s still a long way to go.”
Conducted annually, CANWARD is a national health surveillance study that assesses pathogens causing infections in Canadian hospitals and their patterns of antimicrobial resistance. For the current analysis, Dr. Zhanel and his associates collected 36,607 isolates from patients in tertiary care hospitals in Canada from January 2007 to December 2014. They used Clinical and Laboratory Standards Institute broth microdilution methods to perform antimicrobial susceptibility testing on more than 45 marketed and investigational agents.
Slightly more than half of the patients (55%) were male, and 87% were over age 18. The most common pathogens were E. coli (19.7%), methicillin-susceptible Staphylococcus aureus (MSSA; 16.4%), Pseudomonas aeruginosa (8.7%), S. pneumoniae (6.5%), K. pneumoniae (6.1%), methicillin-resistant S. aureus (MRSA; 4.7%), Enterococcus species (4.0%), and Hemophilus influenzae (4.0%). Susceptibility rates for E. coli were 99.9% for meropenem and tigecycline, 99.7% for ertapenem, 97.7% for piperacillin/tazobactam, 92.5% for ceftriaxone, 90.4% for gentamicin, 77.2% for ciprofloxacin, and 73.0% for trimethoprim and sulfamethoxazole. Susceptibility rates for P. aeruginosa were 94.2% for colistin, 84.3% for piperacillin/tazobactam, 83.3% for ceftazidime, 81.2% for meropenem, 77.6% for gentamicin, and 74.1% for ciprofloxacin. Susceptibility rates for MRSA were 100% for linezolid and telavancin, 99.9% for daptomycin, 99.4% for tigecycline, 99.1% for vancomycin, and 93.3% for trimethoprim and sulfamethoxazole. The rates of resistant organisms between 2007 and 2014 increased significantly for extended-spectrum beta-lactamase–producing E. coli (from 3.4% to 11.6%) and K. pneumoniae (from 1.5% to 6.5%), as well as vancomycin-resistant enterococci (from 1.8% to 7.0%), while rates of MRSA significantly declined (from 26.1% to 20.2%).
“The biggest surprise to me is that the hospital-acquired genotype of MRSA is going down,” Dr. Zhanel commented. “The community-acquired genotype is still going up, but the hospital-acquired [genotype] has plummeted in hospitals.”
He noted that CANWARD data suggest that antimicrobial resistance “is not confined to one part of the hospital. We have resistance happening in medical wards, ICUs, and hospital emergency rooms. We consistently find that resistance is highest in the ICU and by far the lowest in the ER. With clinics we find that it’s a variable scenario.”
The study was supported in part by Abbott, Achaogen, Affinium, Astellas, Astra Zeneca, Bayer, Cerexa/Forest, Cubist, Galderma Laboratories, Merck, Paladin Labs, Pfizer/Wyeth, Sunovion, and the Medicines Co. The researchers reported having no relevant financial disclosures.
SAN DIEGO – Canadian hospitals are making progress in reducing the rates of methicillin-resistant Staphylococcus aureus, but the rates of antimicrobial resistance in Canadian hospitals increased significantly for extended-spectrum beta-lactamase–producing Escherichia coli and Klebsiella pneumoniae, as well as vancomycin-resistant enterococci.
Those are among the key findings from a large national analysis known as CANWARD that were presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “What it’s telling us is that some of the things that we’re doing on the antimicrobial resistance side are working,” lead study author George G. Zhanel, Pharm.D., professor of microbiology and infectious diseases at the University of Manitoba, Winnipeg, said in an interview. “But it also tells us that some of these pathogens like [vancomycin-resistant enterococci] and [extended-spectrum beta-lactamase]–producing E. coli continue to go up. So there is some good news and some bad news, but it tells us that it’s not all just doom and gloom. Some progress has been made, but there’s still a long way to go.”
Conducted annually, CANWARD is a national health surveillance study that assesses pathogens causing infections in Canadian hospitals and their patterns of antimicrobial resistance. For the current analysis, Dr. Zhanel and his associates collected 36,607 isolates from patients in tertiary care hospitals in Canada from January 2007 to December 2014. They used Clinical and Laboratory Standards Institute broth microdilution methods to perform antimicrobial susceptibility testing on more than 45 marketed and investigational agents.
Slightly more than half of the patients (55%) were male, and 87% were over age 18. The most common pathogens were E. coli (19.7%), methicillin-susceptible Staphylococcus aureus (MSSA; 16.4%), Pseudomonas aeruginosa (8.7%), S. pneumoniae (6.5%), K. pneumoniae (6.1%), methicillin-resistant S. aureus (MRSA; 4.7%), Enterococcus species (4.0%), and Hemophilus influenzae (4.0%). Susceptibility rates for E. coli were 99.9% for meropenem and tigecycline, 99.7% for ertapenem, 97.7% for piperacillin/tazobactam, 92.5% for ceftriaxone, 90.4% for gentamicin, 77.2% for ciprofloxacin, and 73.0% for trimethoprim and sulfamethoxazole. Susceptibility rates for P. aeruginosa were 94.2% for colistin, 84.3% for piperacillin/tazobactam, 83.3% for ceftazidime, 81.2% for meropenem, 77.6% for gentamicin, and 74.1% for ciprofloxacin. Susceptibility rates for MRSA were 100% for linezolid and telavancin, 99.9% for daptomycin, 99.4% for tigecycline, 99.1% for vancomycin, and 93.3% for trimethoprim and sulfamethoxazole. The rates of resistant organisms between 2007 and 2014 increased significantly for extended-spectrum beta-lactamase–producing E. coli (from 3.4% to 11.6%) and K. pneumoniae (from 1.5% to 6.5%), as well as vancomycin-resistant enterococci (from 1.8% to 7.0%), while rates of MRSA significantly declined (from 26.1% to 20.2%).
“The biggest surprise to me is that the hospital-acquired genotype of MRSA is going down,” Dr. Zhanel commented. “The community-acquired genotype is still going up, but the hospital-acquired [genotype] has plummeted in hospitals.”
He noted that CANWARD data suggest that antimicrobial resistance “is not confined to one part of the hospital. We have resistance happening in medical wards, ICUs, and hospital emergency rooms. We consistently find that resistance is highest in the ICU and by far the lowest in the ER. With clinics we find that it’s a variable scenario.”
The study was supported in part by Abbott, Achaogen, Affinium, Astellas, Astra Zeneca, Bayer, Cerexa/Forest, Cubist, Galderma Laboratories, Merck, Paladin Labs, Pfizer/Wyeth, Sunovion, and the Medicines Co. The researchers reported having no relevant financial disclosures.
SAN DIEGO – Canadian hospitals are making progress in reducing the rates of methicillin-resistant Staphylococcus aureus, but the rates of antimicrobial resistance in Canadian hospitals increased significantly for extended-spectrum beta-lactamase–producing Escherichia coli and Klebsiella pneumoniae, as well as vancomycin-resistant enterococci.
Those are among the key findings from a large national analysis known as CANWARD that were presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “What it’s telling us is that some of the things that we’re doing on the antimicrobial resistance side are working,” lead study author George G. Zhanel, Pharm.D., professor of microbiology and infectious diseases at the University of Manitoba, Winnipeg, said in an interview. “But it also tells us that some of these pathogens like [vancomycin-resistant enterococci] and [extended-spectrum beta-lactamase]–producing E. coli continue to go up. So there is some good news and some bad news, but it tells us that it’s not all just doom and gloom. Some progress has been made, but there’s still a long way to go.”
Conducted annually, CANWARD is a national health surveillance study that assesses pathogens causing infections in Canadian hospitals and their patterns of antimicrobial resistance. For the current analysis, Dr. Zhanel and his associates collected 36,607 isolates from patients in tertiary care hospitals in Canada from January 2007 to December 2014. They used Clinical and Laboratory Standards Institute broth microdilution methods to perform antimicrobial susceptibility testing on more than 45 marketed and investigational agents.
Slightly more than half of the patients (55%) were male, and 87% were over age 18. The most common pathogens were E. coli (19.7%), methicillin-susceptible Staphylococcus aureus (MSSA; 16.4%), Pseudomonas aeruginosa (8.7%), S. pneumoniae (6.5%), K. pneumoniae (6.1%), methicillin-resistant S. aureus (MRSA; 4.7%), Enterococcus species (4.0%), and Hemophilus influenzae (4.0%). Susceptibility rates for E. coli were 99.9% for meropenem and tigecycline, 99.7% for ertapenem, 97.7% for piperacillin/tazobactam, 92.5% for ceftriaxone, 90.4% for gentamicin, 77.2% for ciprofloxacin, and 73.0% for trimethoprim and sulfamethoxazole. Susceptibility rates for P. aeruginosa were 94.2% for colistin, 84.3% for piperacillin/tazobactam, 83.3% for ceftazidime, 81.2% for meropenem, 77.6% for gentamicin, and 74.1% for ciprofloxacin. Susceptibility rates for MRSA were 100% for linezolid and telavancin, 99.9% for daptomycin, 99.4% for tigecycline, 99.1% for vancomycin, and 93.3% for trimethoprim and sulfamethoxazole. The rates of resistant organisms between 2007 and 2014 increased significantly for extended-spectrum beta-lactamase–producing E. coli (from 3.4% to 11.6%) and K. pneumoniae (from 1.5% to 6.5%), as well as vancomycin-resistant enterococci (from 1.8% to 7.0%), while rates of MRSA significantly declined (from 26.1% to 20.2%).
“The biggest surprise to me is that the hospital-acquired genotype of MRSA is going down,” Dr. Zhanel commented. “The community-acquired genotype is still going up, but the hospital-acquired [genotype] has plummeted in hospitals.”
He noted that CANWARD data suggest that antimicrobial resistance “is not confined to one part of the hospital. We have resistance happening in medical wards, ICUs, and hospital emergency rooms. We consistently find that resistance is highest in the ICU and by far the lowest in the ER. With clinics we find that it’s a variable scenario.”
The study was supported in part by Abbott, Achaogen, Affinium, Astellas, Astra Zeneca, Bayer, Cerexa/Forest, Cubist, Galderma Laboratories, Merck, Paladin Labs, Pfizer/Wyeth, Sunovion, and the Medicines Co. The researchers reported having no relevant financial disclosures.
AT ICAAC 2015
Key clinical point: In Canadian hospitals, the rate of resistant organisms have increased significantly for E. coli and other pathogens but have decreased for MRSA.
Major finding: Rates of resistant organisms between 2007 and 2014 increased significantly for extended-spectrum beta-lactamase–producing E. coli (from 3.4% to 11.6%) and K. pneumoniae (from 1.5% to 6.5%), as well as vancomycin-resistant enterococci (from 1.8% to 7.0%), while rates of MRSA significantly declined (from 26.1% to 20.2%).
Data source: A lab analysis of 36,607 isolates from patients in tertiary care hospitals in Canada from January 2007 to December 2014.
Disclosures: The study was supported in part by Abbott, Achaogen, Affinium, Astellas, Astra Zeneca, Bayer, Cerexa/Forest, Cubist, Galderma Laboratories, Merck, Paladin Labs, Pfizer/Wyeth, Sunovion, and the Medicines Co. The researchers reported having no relevant financial disclosures.
Joint Commission Resource Educates Patients, Hospitalists about Antibiotics
The Joint Commission has launched a new online resource for patients and hospitalists to help change mindsets and start conversations about proper antibiotic usage.
The SpeakUp: Antibiotics campaign is a package of free materials, including an infographic illustrating which illnesses may require an antibiotic, a list of questions for patients to ask when prescribed an antibiotic, a podcast, and a video reminding patients that antibiotics are not needed for colds or the flu.
“The new SpeakUp campaign provides a variety of resources to help patients and caregivers understand that how they use antibiotics today can affect how well the drugs work for them tomorrow,” says Lisa Waldowski, MS, APRN, CIC, infection control specialist at The Joint Commission.
The primary audience for these materials is the consumer, but hospitalists and healthcare workers are the crucial secondary audience. “This is a partnership; the knowledge needs to go both ways,” Waldowski says. “Sometimes there’s an expectation that when you see a physician, you are somehow shortchanged if you don’t leave with a prescription for an antibiotic.
There’s an education that needs to go on in the mindset of the physician, [in terms of] looking at whether this situation warrants an antibiotic and educating the patient if it does not. It takes time to have that conversation.”
The campaign can also provide a starting point for hospitalists to make changes in the workplace. “The information needs to be digested by everyone individually, but collectively in the organization where you work, this can lead to an antibiotic stewardship program, a coordinated intervention,” she says. She recommends a multidisciplinary approach. “Sometimes successful programs are led by a physician, and they have a strong pharmacy component, working together and supporting one another to use antibiotics appropriately.”
Visit our website for more information on antibiotic overuse.
The Joint Commission has launched a new online resource for patients and hospitalists to help change mindsets and start conversations about proper antibiotic usage.
The SpeakUp: Antibiotics campaign is a package of free materials, including an infographic illustrating which illnesses may require an antibiotic, a list of questions for patients to ask when prescribed an antibiotic, a podcast, and a video reminding patients that antibiotics are not needed for colds or the flu.
“The new SpeakUp campaign provides a variety of resources to help patients and caregivers understand that how they use antibiotics today can affect how well the drugs work for them tomorrow,” says Lisa Waldowski, MS, APRN, CIC, infection control specialist at The Joint Commission.
The primary audience for these materials is the consumer, but hospitalists and healthcare workers are the crucial secondary audience. “This is a partnership; the knowledge needs to go both ways,” Waldowski says. “Sometimes there’s an expectation that when you see a physician, you are somehow shortchanged if you don’t leave with a prescription for an antibiotic.
There’s an education that needs to go on in the mindset of the physician, [in terms of] looking at whether this situation warrants an antibiotic and educating the patient if it does not. It takes time to have that conversation.”
The campaign can also provide a starting point for hospitalists to make changes in the workplace. “The information needs to be digested by everyone individually, but collectively in the organization where you work, this can lead to an antibiotic stewardship program, a coordinated intervention,” she says. She recommends a multidisciplinary approach. “Sometimes successful programs are led by a physician, and they have a strong pharmacy component, working together and supporting one another to use antibiotics appropriately.”
Visit our website for more information on antibiotic overuse.
The Joint Commission has launched a new online resource for patients and hospitalists to help change mindsets and start conversations about proper antibiotic usage.
The SpeakUp: Antibiotics campaign is a package of free materials, including an infographic illustrating which illnesses may require an antibiotic, a list of questions for patients to ask when prescribed an antibiotic, a podcast, and a video reminding patients that antibiotics are not needed for colds or the flu.
“The new SpeakUp campaign provides a variety of resources to help patients and caregivers understand that how they use antibiotics today can affect how well the drugs work for them tomorrow,” says Lisa Waldowski, MS, APRN, CIC, infection control specialist at The Joint Commission.
The primary audience for these materials is the consumer, but hospitalists and healthcare workers are the crucial secondary audience. “This is a partnership; the knowledge needs to go both ways,” Waldowski says. “Sometimes there’s an expectation that when you see a physician, you are somehow shortchanged if you don’t leave with a prescription for an antibiotic.
There’s an education that needs to go on in the mindset of the physician, [in terms of] looking at whether this situation warrants an antibiotic and educating the patient if it does not. It takes time to have that conversation.”
The campaign can also provide a starting point for hospitalists to make changes in the workplace. “The information needs to be digested by everyone individually, but collectively in the organization where you work, this can lead to an antibiotic stewardship program, a coordinated intervention,” she says. She recommends a multidisciplinary approach. “Sometimes successful programs are led by a physician, and they have a strong pharmacy component, working together and supporting one another to use antibiotics appropriately.”
Visit our website for more information on antibiotic overuse.
Antibiotic Therapy, Appendectomy for Uncomplicated Acute Appendicitis
Clinical question: Is antibiotic therapy noninferior to appendectomy for treatment of uncomplicated acute appendicitis?
Background: Previous randomized clinical trials have compared antibiotic therapy versus appendectomy for the treatment of uncomplicated, acute appendicitis. Each of these studies had significant limitations, and appendectomy has remained the standard of care.
Study design: Noninferiority, randomized clinical trial.
Setting: Six hospitals in Finland.
Synopsis: Investigators randomized 530 patients with uncomplicated appendicitis confirmed on CT to appendectomy or antibiotic therapy, with a noninferiority margin of 24%. Of the 256 patients randomized to antibiotics who were available for follow-up, 70 received surgical intervention within one year. This resulted in a difference between treatment groups of -27%. Further analysis revealed that five of those patients had normal appendices and did not actually require appendectomy. Secondary outcome analysis demonstrated a significantly lower complication rate among patients in the antibiotic group (2.8%) compared with the surgical group (20.5%); however, the open operative approach used on most patients may have resulted in increased wound complications.
Although noninferiority of antibiotic treatment was not demonstrated, the majority of patients in the antibiotic group (73%) were found to have successful treatment with antibiotics alone. None of these patients, including those eventually undergoing appendectomy, suffered major complications. Although the overall approach to uncomplicated appendicitis may not change, physicians and patients should utilize this data to make an informed decision between antibiotic treatment and appendectomy.
Bottom line: In patients with CT-proven, uncomplicated acute appendicitis, antibiotic treatment did not meet the pre-specified threshold for noninferiority compared with appendectomy, yet a significant majority of patients in the antibiotic arm had successful recovery.
Citation: Salminen P, Paajanen H, Rautio T, et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: The APPAC randomized clinical trial. JAMA. 2015;313(23):2340-2348
Clinical question: Is antibiotic therapy noninferior to appendectomy for treatment of uncomplicated acute appendicitis?
Background: Previous randomized clinical trials have compared antibiotic therapy versus appendectomy for the treatment of uncomplicated, acute appendicitis. Each of these studies had significant limitations, and appendectomy has remained the standard of care.
Study design: Noninferiority, randomized clinical trial.
Setting: Six hospitals in Finland.
Synopsis: Investigators randomized 530 patients with uncomplicated appendicitis confirmed on CT to appendectomy or antibiotic therapy, with a noninferiority margin of 24%. Of the 256 patients randomized to antibiotics who were available for follow-up, 70 received surgical intervention within one year. This resulted in a difference between treatment groups of -27%. Further analysis revealed that five of those patients had normal appendices and did not actually require appendectomy. Secondary outcome analysis demonstrated a significantly lower complication rate among patients in the antibiotic group (2.8%) compared with the surgical group (20.5%); however, the open operative approach used on most patients may have resulted in increased wound complications.
Although noninferiority of antibiotic treatment was not demonstrated, the majority of patients in the antibiotic group (73%) were found to have successful treatment with antibiotics alone. None of these patients, including those eventually undergoing appendectomy, suffered major complications. Although the overall approach to uncomplicated appendicitis may not change, physicians and patients should utilize this data to make an informed decision between antibiotic treatment and appendectomy.
Bottom line: In patients with CT-proven, uncomplicated acute appendicitis, antibiotic treatment did not meet the pre-specified threshold for noninferiority compared with appendectomy, yet a significant majority of patients in the antibiotic arm had successful recovery.
Citation: Salminen P, Paajanen H, Rautio T, et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: The APPAC randomized clinical trial. JAMA. 2015;313(23):2340-2348
Clinical question: Is antibiotic therapy noninferior to appendectomy for treatment of uncomplicated acute appendicitis?
Background: Previous randomized clinical trials have compared antibiotic therapy versus appendectomy for the treatment of uncomplicated, acute appendicitis. Each of these studies had significant limitations, and appendectomy has remained the standard of care.
Study design: Noninferiority, randomized clinical trial.
Setting: Six hospitals in Finland.
Synopsis: Investigators randomized 530 patients with uncomplicated appendicitis confirmed on CT to appendectomy or antibiotic therapy, with a noninferiority margin of 24%. Of the 256 patients randomized to antibiotics who were available for follow-up, 70 received surgical intervention within one year. This resulted in a difference between treatment groups of -27%. Further analysis revealed that five of those patients had normal appendices and did not actually require appendectomy. Secondary outcome analysis demonstrated a significantly lower complication rate among patients in the antibiotic group (2.8%) compared with the surgical group (20.5%); however, the open operative approach used on most patients may have resulted in increased wound complications.
Although noninferiority of antibiotic treatment was not demonstrated, the majority of patients in the antibiotic group (73%) were found to have successful treatment with antibiotics alone. None of these patients, including those eventually undergoing appendectomy, suffered major complications. Although the overall approach to uncomplicated appendicitis may not change, physicians and patients should utilize this data to make an informed decision between antibiotic treatment and appendectomy.
Bottom line: In patients with CT-proven, uncomplicated acute appendicitis, antibiotic treatment did not meet the pre-specified threshold for noninferiority compared with appendectomy, yet a significant majority of patients in the antibiotic arm had successful recovery.
Citation: Salminen P, Paajanen H, Rautio T, et al. Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: The APPAC randomized clinical trial. JAMA. 2015;313(23):2340-2348
Study tracks long-term mortality risk in MRSA bacteremia patients
SAN DIEGO – Among patients with MRSA bacteremia, age, markers of severity of acute treatment, and duration of treatment are predictive of mortality risk at 90 days and 1 year, a long-term single-center study showed.
At the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, Renee-Claude Mercier, Pharm.D., presented results from an analysis which set out to describe the trajectory and long-term outcomes of patients with MRSA bacteremia, including the influence of bacterial, treatment, and host factors on outcomes.
Dr. Mercier and her associates identified 273 patients who were diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia during admission to the University of New Mexico Hospital between 2003 and 2013. The main outcomes were mortality at 90 days and 1 year, while secondary outcomes were hospital readmission, nursing home placement, and continued need for hemodialysis. Dr. Mercier, professor of pharmacy and medicine at the University of New Mexico, Albuquerque, and her associates used multivariable logistic regression and survival analysis to evaluate predictors of outcomes.
The mean age of the 273 patients was 52 years, 71% were male, and USA300 accounted for more than half of the strains (57%). A total of 66 patients (24%) died. “Importantly, we do not know the [mortality] status of 30% of our [study] population,” said Dr. Mercier. “We’re working right now with the [Centers for Disease Control and Prevention] to determine the cause or whether or not some of our patients that were included died in the 365 days following their infection with MRSA.”
At 30 days, the mortality rate was 17.7%, most commonly because of MRSA infection (75% of cases), followed by cancer (6.8% of cases) and secondary infection (2.3% of cases). The researchers followed the patients for a median of 237 days. Nearly half (44.8%) were discharged to home, 40.6% were discharged to a skilled nursing facility, and 2.9% returned to prison. “If patients were to die, they died in the first 30 days after infection with MRSA,” Dr. Mercier said. Independent predictors of mortality at 30 days included older age, the presence of liver disease, an ICU stay, a higher Pitt bacteremia score, and unresolved fever.
When the researchers excluded mortality that occurred in the first 30 days, the mortality rate at 90 days was 5.8%, mainly because of MRSA infection (in 46% of the cases), followed by other infection and unspecified sepsis (9%). On multivariable analysis, independent predictors of mortality at 90 days were use of mechanical ventilation (hazard ratio, 4.8; P = .02) and duration of treatment in days (HR .97; P = .078). “Treatment duration was an important determinant of survival in our study,” Dr. Mercier said. “Whether used as a continuous variable or as a dichotomous variable, using 4 weeks as our cutoff showed that the longer the treatment, the [greater the] decrease in mortality.”
After excluding mortality that occurred in the first 30 days, the researchers found that the mortality rate at 1 year was 17.8%, mainly because of MRSA infection (in 28% of the cases), followed by cancer (in 16% of cases) and secondary infections and unspecified sepsis (in 4% of cases). On multivariable analysis, independent predictors of mortality at 90 days were use of mechanical ventilation (HR 1.04; P = .005) and duration of treatment in days (HR .98; P = .05).
The majority of patients (64%) were not readmitted to the hospital within 1 year, while 16% were readmitted for other types of infections not related to S. aureus. In addition, 4% were readmitted because of cardiovascular causes, and 3% were readmitted because of a S. aureus infection.
Finally, Dr. Mercier and her colleagues performed a competing risk regression analysis examining different factors and their impact on mortality. Having an ICU stay as well as the presence of liver disease and receiving antibiotics for less than 4 weeks were significant predictors of mortality.
The researchers reported having no financial disclosures.
SAN DIEGO – Among patients with MRSA bacteremia, age, markers of severity of acute treatment, and duration of treatment are predictive of mortality risk at 90 days and 1 year, a long-term single-center study showed.
At the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, Renee-Claude Mercier, Pharm.D., presented results from an analysis which set out to describe the trajectory and long-term outcomes of patients with MRSA bacteremia, including the influence of bacterial, treatment, and host factors on outcomes.
Dr. Mercier and her associates identified 273 patients who were diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia during admission to the University of New Mexico Hospital between 2003 and 2013. The main outcomes were mortality at 90 days and 1 year, while secondary outcomes were hospital readmission, nursing home placement, and continued need for hemodialysis. Dr. Mercier, professor of pharmacy and medicine at the University of New Mexico, Albuquerque, and her associates used multivariable logistic regression and survival analysis to evaluate predictors of outcomes.
The mean age of the 273 patients was 52 years, 71% were male, and USA300 accounted for more than half of the strains (57%). A total of 66 patients (24%) died. “Importantly, we do not know the [mortality] status of 30% of our [study] population,” said Dr. Mercier. “We’re working right now with the [Centers for Disease Control and Prevention] to determine the cause or whether or not some of our patients that were included died in the 365 days following their infection with MRSA.”
At 30 days, the mortality rate was 17.7%, most commonly because of MRSA infection (75% of cases), followed by cancer (6.8% of cases) and secondary infection (2.3% of cases). The researchers followed the patients for a median of 237 days. Nearly half (44.8%) were discharged to home, 40.6% were discharged to a skilled nursing facility, and 2.9% returned to prison. “If patients were to die, they died in the first 30 days after infection with MRSA,” Dr. Mercier said. Independent predictors of mortality at 30 days included older age, the presence of liver disease, an ICU stay, a higher Pitt bacteremia score, and unresolved fever.
When the researchers excluded mortality that occurred in the first 30 days, the mortality rate at 90 days was 5.8%, mainly because of MRSA infection (in 46% of the cases), followed by other infection and unspecified sepsis (9%). On multivariable analysis, independent predictors of mortality at 90 days were use of mechanical ventilation (hazard ratio, 4.8; P = .02) and duration of treatment in days (HR .97; P = .078). “Treatment duration was an important determinant of survival in our study,” Dr. Mercier said. “Whether used as a continuous variable or as a dichotomous variable, using 4 weeks as our cutoff showed that the longer the treatment, the [greater the] decrease in mortality.”
After excluding mortality that occurred in the first 30 days, the researchers found that the mortality rate at 1 year was 17.8%, mainly because of MRSA infection (in 28% of the cases), followed by cancer (in 16% of cases) and secondary infections and unspecified sepsis (in 4% of cases). On multivariable analysis, independent predictors of mortality at 90 days were use of mechanical ventilation (HR 1.04; P = .005) and duration of treatment in days (HR .98; P = .05).
The majority of patients (64%) were not readmitted to the hospital within 1 year, while 16% were readmitted for other types of infections not related to S. aureus. In addition, 4% were readmitted because of cardiovascular causes, and 3% were readmitted because of a S. aureus infection.
Finally, Dr. Mercier and her colleagues performed a competing risk regression analysis examining different factors and their impact on mortality. Having an ICU stay as well as the presence of liver disease and receiving antibiotics for less than 4 weeks were significant predictors of mortality.
The researchers reported having no financial disclosures.
SAN DIEGO – Among patients with MRSA bacteremia, age, markers of severity of acute treatment, and duration of treatment are predictive of mortality risk at 90 days and 1 year, a long-term single-center study showed.
At the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, Renee-Claude Mercier, Pharm.D., presented results from an analysis which set out to describe the trajectory and long-term outcomes of patients with MRSA bacteremia, including the influence of bacterial, treatment, and host factors on outcomes.
Dr. Mercier and her associates identified 273 patients who were diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia during admission to the University of New Mexico Hospital between 2003 and 2013. The main outcomes were mortality at 90 days and 1 year, while secondary outcomes were hospital readmission, nursing home placement, and continued need for hemodialysis. Dr. Mercier, professor of pharmacy and medicine at the University of New Mexico, Albuquerque, and her associates used multivariable logistic regression and survival analysis to evaluate predictors of outcomes.
The mean age of the 273 patients was 52 years, 71% were male, and USA300 accounted for more than half of the strains (57%). A total of 66 patients (24%) died. “Importantly, we do not know the [mortality] status of 30% of our [study] population,” said Dr. Mercier. “We’re working right now with the [Centers for Disease Control and Prevention] to determine the cause or whether or not some of our patients that were included died in the 365 days following their infection with MRSA.”
At 30 days, the mortality rate was 17.7%, most commonly because of MRSA infection (75% of cases), followed by cancer (6.8% of cases) and secondary infection (2.3% of cases). The researchers followed the patients for a median of 237 days. Nearly half (44.8%) were discharged to home, 40.6% were discharged to a skilled nursing facility, and 2.9% returned to prison. “If patients were to die, they died in the first 30 days after infection with MRSA,” Dr. Mercier said. Independent predictors of mortality at 30 days included older age, the presence of liver disease, an ICU stay, a higher Pitt bacteremia score, and unresolved fever.
When the researchers excluded mortality that occurred in the first 30 days, the mortality rate at 90 days was 5.8%, mainly because of MRSA infection (in 46% of the cases), followed by other infection and unspecified sepsis (9%). On multivariable analysis, independent predictors of mortality at 90 days were use of mechanical ventilation (hazard ratio, 4.8; P = .02) and duration of treatment in days (HR .97; P = .078). “Treatment duration was an important determinant of survival in our study,” Dr. Mercier said. “Whether used as a continuous variable or as a dichotomous variable, using 4 weeks as our cutoff showed that the longer the treatment, the [greater the] decrease in mortality.”
After excluding mortality that occurred in the first 30 days, the researchers found that the mortality rate at 1 year was 17.8%, mainly because of MRSA infection (in 28% of the cases), followed by cancer (in 16% of cases) and secondary infections and unspecified sepsis (in 4% of cases). On multivariable analysis, independent predictors of mortality at 90 days were use of mechanical ventilation (HR 1.04; P = .005) and duration of treatment in days (HR .98; P = .05).
The majority of patients (64%) were not readmitted to the hospital within 1 year, while 16% were readmitted for other types of infections not related to S. aureus. In addition, 4% were readmitted because of cardiovascular causes, and 3% were readmitted because of a S. aureus infection.
Finally, Dr. Mercier and her colleagues performed a competing risk regression analysis examining different factors and their impact on mortality. Having an ICU stay as well as the presence of liver disease and receiving antibiotics for less than 4 weeks were significant predictors of mortality.
The researchers reported having no financial disclosures.
AT ICAAC 2015
Key clinical point: Longer treatment for MRSA infection was linked to lower mortality risk.
Major finding: The mortality rate at 1 year was 17.8%, mainly because of MRSA (in 28% of the cases) and cancer (16% of cases).
Data source: A study of 273 patients who were diagnosed with MRSA bacteremia during admission to the University of New Mexico Hospital between 2003 and 2013.
Disclosures: The researchers reported having no financial disclosures.
Long-term ceftaroline use associated with neutropenia
SAN DIEGO – The long-term use of ceftaroline is associated with neutropenia, results from a single-center retrospective study showed.
A fifth-generation cephalosporin antibiotic with activity against methicillin-resistant Staphylococcus aureus, ceftaroline is approved for the treatment of community-acquired pneumonia and skin and skin structure infections. It’s also an option for treating orthopedic and endovascular infections when primary therapy fails or is contraindicated, according to one of the study authors, Dr. Hollis R. O’Neal Jr. “There are small case reports of associations between ceftaroline use and neutropenia, and we were noticing that many patients in our clinical practice were developing neutropenia,” Dr. O’Neal, a pulmonologist at Louisiana State University Health Baton Rouge, said in an interview at the Interscience Conference on Antimicrobial Agents and Chemotherapy.
In an effort to determine the incidence, severity, and outcome of neutropenia in patients receiving long-term ceftaroline therapy, Dr. O’Neal and his associates retrospectively evaluated 38 patients who received at least 7 days of ceftaroline initiated at LSU Health Baton Rouge between June 2012 and December 2014. They defined clinically significant neutropenia as having an absolute neutrophil count (ANC) below 2500 cells/mm3 and gathered pertinent data from medical records including comorbidities, chronic medications, and diagnoses.
The median age of the 38 patients was 47 years and their median body mass index was 28 kg/m2. Of the 38 patients, 10 (26%) developed neutropenia. “That was surprising to me,” Dr. O’Neal said. “I thought we would find three or four cases.” Compared with those who were nonneutropenic, those who developed neutropenia tended to be younger (a median of 44 years vs. 51 years), have a lower body mass index (a median of 25 kg/m2 vs. 32 kg/m2), and be more likely to have a longer duration of ceftaroline therapy (a median of 36 days vs. 26 days).
Of the 10 neutropenic patients, 7 had an ANC below 1,500 cells/mm3, and 4 had an ANC below 500 cells/mm3. The median time to first neutropenic day was day 21, with a median nadir of 1,156 cells/mm3. One hospitalization occurred that was believed to be due to neutropenia, but all 30 patients were alive at least 30 days after completing ceftaroline therapy.
“Once the ANC falls below 2,500 cells/mm3, the risk of developing true neutropenia is high,” Dr. O’Neal said. “So what we’re doing is monitoring ANC levels weekly. When they fall below 2,500 we monitor [ANC levels] twice weekly. When they reach 1,500 we stop the drug. So it’s really changed how we monitor the drug’s use.”
The study’s lead author is Dr. Katherine W. Lavie, an infectious diseases fellow at LSU Health Baton Rouge. The researchers reported having no financial disclosures.
SAN DIEGO – The long-term use of ceftaroline is associated with neutropenia, results from a single-center retrospective study showed.
A fifth-generation cephalosporin antibiotic with activity against methicillin-resistant Staphylococcus aureus, ceftaroline is approved for the treatment of community-acquired pneumonia and skin and skin structure infections. It’s also an option for treating orthopedic and endovascular infections when primary therapy fails or is contraindicated, according to one of the study authors, Dr. Hollis R. O’Neal Jr. “There are small case reports of associations between ceftaroline use and neutropenia, and we were noticing that many patients in our clinical practice were developing neutropenia,” Dr. O’Neal, a pulmonologist at Louisiana State University Health Baton Rouge, said in an interview at the Interscience Conference on Antimicrobial Agents and Chemotherapy.
In an effort to determine the incidence, severity, and outcome of neutropenia in patients receiving long-term ceftaroline therapy, Dr. O’Neal and his associates retrospectively evaluated 38 patients who received at least 7 days of ceftaroline initiated at LSU Health Baton Rouge between June 2012 and December 2014. They defined clinically significant neutropenia as having an absolute neutrophil count (ANC) below 2500 cells/mm3 and gathered pertinent data from medical records including comorbidities, chronic medications, and diagnoses.
The median age of the 38 patients was 47 years and their median body mass index was 28 kg/m2. Of the 38 patients, 10 (26%) developed neutropenia. “That was surprising to me,” Dr. O’Neal said. “I thought we would find three or four cases.” Compared with those who were nonneutropenic, those who developed neutropenia tended to be younger (a median of 44 years vs. 51 years), have a lower body mass index (a median of 25 kg/m2 vs. 32 kg/m2), and be more likely to have a longer duration of ceftaroline therapy (a median of 36 days vs. 26 days).
Of the 10 neutropenic patients, 7 had an ANC below 1,500 cells/mm3, and 4 had an ANC below 500 cells/mm3. The median time to first neutropenic day was day 21, with a median nadir of 1,156 cells/mm3. One hospitalization occurred that was believed to be due to neutropenia, but all 30 patients were alive at least 30 days after completing ceftaroline therapy.
“Once the ANC falls below 2,500 cells/mm3, the risk of developing true neutropenia is high,” Dr. O’Neal said. “So what we’re doing is monitoring ANC levels weekly. When they fall below 2,500 we monitor [ANC levels] twice weekly. When they reach 1,500 we stop the drug. So it’s really changed how we monitor the drug’s use.”
The study’s lead author is Dr. Katherine W. Lavie, an infectious diseases fellow at LSU Health Baton Rouge. The researchers reported having no financial disclosures.
SAN DIEGO – The long-term use of ceftaroline is associated with neutropenia, results from a single-center retrospective study showed.
A fifth-generation cephalosporin antibiotic with activity against methicillin-resistant Staphylococcus aureus, ceftaroline is approved for the treatment of community-acquired pneumonia and skin and skin structure infections. It’s also an option for treating orthopedic and endovascular infections when primary therapy fails or is contraindicated, according to one of the study authors, Dr. Hollis R. O’Neal Jr. “There are small case reports of associations between ceftaroline use and neutropenia, and we were noticing that many patients in our clinical practice were developing neutropenia,” Dr. O’Neal, a pulmonologist at Louisiana State University Health Baton Rouge, said in an interview at the Interscience Conference on Antimicrobial Agents and Chemotherapy.
In an effort to determine the incidence, severity, and outcome of neutropenia in patients receiving long-term ceftaroline therapy, Dr. O’Neal and his associates retrospectively evaluated 38 patients who received at least 7 days of ceftaroline initiated at LSU Health Baton Rouge between June 2012 and December 2014. They defined clinically significant neutropenia as having an absolute neutrophil count (ANC) below 2500 cells/mm3 and gathered pertinent data from medical records including comorbidities, chronic medications, and diagnoses.
The median age of the 38 patients was 47 years and their median body mass index was 28 kg/m2. Of the 38 patients, 10 (26%) developed neutropenia. “That was surprising to me,” Dr. O’Neal said. “I thought we would find three or four cases.” Compared with those who were nonneutropenic, those who developed neutropenia tended to be younger (a median of 44 years vs. 51 years), have a lower body mass index (a median of 25 kg/m2 vs. 32 kg/m2), and be more likely to have a longer duration of ceftaroline therapy (a median of 36 days vs. 26 days).
Of the 10 neutropenic patients, 7 had an ANC below 1,500 cells/mm3, and 4 had an ANC below 500 cells/mm3. The median time to first neutropenic day was day 21, with a median nadir of 1,156 cells/mm3. One hospitalization occurred that was believed to be due to neutropenia, but all 30 patients were alive at least 30 days after completing ceftaroline therapy.
“Once the ANC falls below 2,500 cells/mm3, the risk of developing true neutropenia is high,” Dr. O’Neal said. “So what we’re doing is monitoring ANC levels weekly. When they fall below 2,500 we monitor [ANC levels] twice weekly. When they reach 1,500 we stop the drug. So it’s really changed how we monitor the drug’s use.”
The study’s lead author is Dr. Katherine W. Lavie, an infectious diseases fellow at LSU Health Baton Rouge. The researchers reported having no financial disclosures.
AT ICAAC 2015
Key clinical point: Long-term ceftaroline use is associated with neutropenia.
Major finding: Of 38 patients who received at least 7 days of ceftaroline, 10 (26%) developed neutropenia.
Data source: A retrospective cohort study of 38 patients who received long-term ceftaroline therapy between June 2012 and December 2014.
Disclosures: The researchers reported having no financial disclosures.
ICAAC: Prescribing guide successful in a children’s hospital
SAN DIEGO – The introduction and dissemination of an antibiotic prescribing guide in a children’s hospital resulted in a statistically significant increase in appropriate prescribing, a prospective study showed.
“Antimicrobial drugs are one of the largest groups of medications prescribed to hospitalized children worldwide,” Dr. Jacqueline Wong wrote in an abstract presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “Inappropriate antibiotic use is a major factor driving increasing bacterial antibiotic resistance. There are few published data on the effectiveness of stewardship strategies in a pediatric setting.”
In a prospective observational study conducted during Dr. Wong’s pediatrics residency at British Columbia Children’s Hospital, Vancouver, she and her associates set out to compare the proportion of patients who received appropriate antimicrobials before and after the introduction of a new empiric antibiotic guide that was gradually rolled out at the hospital beginning in April of 2012 via lectures, paper copies, and pocket-sized and electronic versions. The time period studied was January 2012 to June 2013. All children admitted and treated with antibiotics were included in the analysis. Exclusion criteria included patients who were admitted to the neonatal unit or hematology/oncology ward, patients with cystic fibrosis, patients who were immunocompromised, and those receiving antibiotics solely for prophylaxis.
The researchers obtained prescribing information from hospital pharmacy data and electronic medical records, and two members of the study team used the updated empiric antibiotic guidelines to determine if the empiric prescribing was appropriate or not.
A total of 1,815 admissions were initially studied. Of these, 63% of the patients were younger than 3 months old, 16% were 4-6 months old, and 21% were 7-11 months old. These percentages did not vary significantly during the study time frame (P greater than .05). The five most common clinical syndromes were septicemia/meningitis (n = 556), respiratory tract infections (n = 532), intra-abdominal infections (n = 195), skin and soft tissue infections (n = 193), and urinary tract infections (n = 184).
Next, the researchers reviewed 752 admissions: 430 prior to introduction of the guidelines and 322 afterward. When they combined the five most common clinical syndromes, they observed a statistically significant increase in appropriate empiric antibiotic therapy between the preintervention period and postintervention period, from 65% to 74%, respectively (P = .035).
“What was interesting to learn from this study was the distribution of the various syndromes and distribution of the age groups of the children that were admitted,” Dr. Wong, now an infectious diseases fellow at The Hospital for Sick Children, Toronto, said in an interview. “The vast majority were 1 year and under.”
While the findings represent success in terms of patient care and cost savings, “the overall limited impact of such a passive antimicrobial stewardship program intervention suggests additional active strategies may be required to further enhance implementation, such as prospective audit with intervention, and feedback may be required to further enhance implementation of antimicrobial guidelines,” the researchers wrote in their abstract. For example, in response to the study findings, British Columbia Children’s Hospital implemented a formal multidisciplinary antimicrobial stewardship program including daily audit and feedback of all admitted patients on antimicrobials within 24 hours. “Data from this program are currently awaiting analysis,” they wrote.
The researchers reported having no financial disclosures.
SAN DIEGO – The introduction and dissemination of an antibiotic prescribing guide in a children’s hospital resulted in a statistically significant increase in appropriate prescribing, a prospective study showed.
“Antimicrobial drugs are one of the largest groups of medications prescribed to hospitalized children worldwide,” Dr. Jacqueline Wong wrote in an abstract presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “Inappropriate antibiotic use is a major factor driving increasing bacterial antibiotic resistance. There are few published data on the effectiveness of stewardship strategies in a pediatric setting.”
In a prospective observational study conducted during Dr. Wong’s pediatrics residency at British Columbia Children’s Hospital, Vancouver, she and her associates set out to compare the proportion of patients who received appropriate antimicrobials before and after the introduction of a new empiric antibiotic guide that was gradually rolled out at the hospital beginning in April of 2012 via lectures, paper copies, and pocket-sized and electronic versions. The time period studied was January 2012 to June 2013. All children admitted and treated with antibiotics were included in the analysis. Exclusion criteria included patients who were admitted to the neonatal unit or hematology/oncology ward, patients with cystic fibrosis, patients who were immunocompromised, and those receiving antibiotics solely for prophylaxis.
The researchers obtained prescribing information from hospital pharmacy data and electronic medical records, and two members of the study team used the updated empiric antibiotic guidelines to determine if the empiric prescribing was appropriate or not.
A total of 1,815 admissions were initially studied. Of these, 63% of the patients were younger than 3 months old, 16% were 4-6 months old, and 21% were 7-11 months old. These percentages did not vary significantly during the study time frame (P greater than .05). The five most common clinical syndromes were septicemia/meningitis (n = 556), respiratory tract infections (n = 532), intra-abdominal infections (n = 195), skin and soft tissue infections (n = 193), and urinary tract infections (n = 184).
Next, the researchers reviewed 752 admissions: 430 prior to introduction of the guidelines and 322 afterward. When they combined the five most common clinical syndromes, they observed a statistically significant increase in appropriate empiric antibiotic therapy between the preintervention period and postintervention period, from 65% to 74%, respectively (P = .035).
“What was interesting to learn from this study was the distribution of the various syndromes and distribution of the age groups of the children that were admitted,” Dr. Wong, now an infectious diseases fellow at The Hospital for Sick Children, Toronto, said in an interview. “The vast majority were 1 year and under.”
While the findings represent success in terms of patient care and cost savings, “the overall limited impact of such a passive antimicrobial stewardship program intervention suggests additional active strategies may be required to further enhance implementation, such as prospective audit with intervention, and feedback may be required to further enhance implementation of antimicrobial guidelines,” the researchers wrote in their abstract. For example, in response to the study findings, British Columbia Children’s Hospital implemented a formal multidisciplinary antimicrobial stewardship program including daily audit and feedback of all admitted patients on antimicrobials within 24 hours. “Data from this program are currently awaiting analysis,” they wrote.
The researchers reported having no financial disclosures.
SAN DIEGO – The introduction and dissemination of an antibiotic prescribing guide in a children’s hospital resulted in a statistically significant increase in appropriate prescribing, a prospective study showed.
“Antimicrobial drugs are one of the largest groups of medications prescribed to hospitalized children worldwide,” Dr. Jacqueline Wong wrote in an abstract presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “Inappropriate antibiotic use is a major factor driving increasing bacterial antibiotic resistance. There are few published data on the effectiveness of stewardship strategies in a pediatric setting.”
In a prospective observational study conducted during Dr. Wong’s pediatrics residency at British Columbia Children’s Hospital, Vancouver, she and her associates set out to compare the proportion of patients who received appropriate antimicrobials before and after the introduction of a new empiric antibiotic guide that was gradually rolled out at the hospital beginning in April of 2012 via lectures, paper copies, and pocket-sized and electronic versions. The time period studied was January 2012 to June 2013. All children admitted and treated with antibiotics were included in the analysis. Exclusion criteria included patients who were admitted to the neonatal unit or hematology/oncology ward, patients with cystic fibrosis, patients who were immunocompromised, and those receiving antibiotics solely for prophylaxis.
The researchers obtained prescribing information from hospital pharmacy data and electronic medical records, and two members of the study team used the updated empiric antibiotic guidelines to determine if the empiric prescribing was appropriate or not.
A total of 1,815 admissions were initially studied. Of these, 63% of the patients were younger than 3 months old, 16% were 4-6 months old, and 21% were 7-11 months old. These percentages did not vary significantly during the study time frame (P greater than .05). The five most common clinical syndromes were septicemia/meningitis (n = 556), respiratory tract infections (n = 532), intra-abdominal infections (n = 195), skin and soft tissue infections (n = 193), and urinary tract infections (n = 184).
Next, the researchers reviewed 752 admissions: 430 prior to introduction of the guidelines and 322 afterward. When they combined the five most common clinical syndromes, they observed a statistically significant increase in appropriate empiric antibiotic therapy between the preintervention period and postintervention period, from 65% to 74%, respectively (P = .035).
“What was interesting to learn from this study was the distribution of the various syndromes and distribution of the age groups of the children that were admitted,” Dr. Wong, now an infectious diseases fellow at The Hospital for Sick Children, Toronto, said in an interview. “The vast majority were 1 year and under.”
While the findings represent success in terms of patient care and cost savings, “the overall limited impact of such a passive antimicrobial stewardship program intervention suggests additional active strategies may be required to further enhance implementation, such as prospective audit with intervention, and feedback may be required to further enhance implementation of antimicrobial guidelines,” the researchers wrote in their abstract. For example, in response to the study findings, British Columbia Children’s Hospital implemented a formal multidisciplinary antimicrobial stewardship program including daily audit and feedback of all admitted patients on antimicrobials within 24 hours. “Data from this program are currently awaiting analysis,” they wrote.
The researchers reported having no financial disclosures.
AT ICAAC 2015
Key clinical point: A new antibiotic prescribing guide introduced at a children’s hospital resulted in a statistically significant increase in appropriate prescribing.
Major finding: Following introduction of a new antibiotic prescribing guide, the rate of appropriate empiric antibiotic therapy between rose significantly from 65% to 74% (P = .035).
Data source: A prospective observational study of 752 pediatric hospital admissions.
Disclosures: The researchers reported having no financial disclosures.
Antibiotic Stewardship and Hospitalists: How to Educate Patients on Antibiotics
Editor’s note: This article originally appeared on SHM’s official blog, “The Hospital Leader,” in June 2015.
“Tell me what you know about antibiotics.”
That’s the discussion I start with hospitalized patients all the time, right after they ask me to prescribe antibiotics for their simple cough or other viral-like illness.
And, from their perspective, asking for antibiotics makes sense. After all, antibiotics have been the physician’s knee-jerk reaction to a number of patient symptoms for decades, especially for a cough or upper respiratory infection. We have inadvertently trained our patients that there is an easy solution to almost any common medical problem.
But patients often answer my question with something like “not much,” coupled with a little surprise that I haven’t already started ordering the prescription.
That’s when I talk about the potential harms of antibiotics. And that’s also when their eyebrows go up. I start with the easy harms, like the fact that many antibiotics can cause diarrhea, a symptom nobody wants to deal with along with their runny nose. Then I move on to the big ones: Use of antibiotics today could make the patient resistant to antibiotics later in life, when they might really need them, and using antibiotics can lead to other painful and even fatal conditions, like Clostridium difficile.
After that, every patient agrees with my recommendations that we hold off on antibiotics for certain, particularly viral-like, ailments.
Change the Conversation. Change the Approach.
It’s a longer conversation, but it’s worth it. Overuse of antibiotics affects not only the patient in front of me, but also entire communities. By creating antibiotic-resistant bacteria, we make everyone more vulnerable to the very diseases the antibiotics were originally intended to treat, like tuberculosis, staph infections, and numerous others.
That’s why the hospitalists in my hospital at Johns Hopkins Bayview teamed up with the infectious diseases division to improve our approach to cellulitis and antibiotic use.
In short, cellulitis is a bacterial skin infection. The most feared bacterial skin infection is MRSA (methicillin-resistant Staphylococcus aureus), a “super bug” that requires highly selective antibiotics like vancomycin; however, other more common and less virulent bacteria also cause cellulitis, and they don’t need super bug fighter medications. Some types of skin ailments, like those caused by poor circulation in the legs, are not infectious at all but can look like cellulitis, even to experienced doctors.
Thanks to the collaboration between infectious disease doctors and hospitalists, the hospitalists are much less likely to prescribe inappropriate antibiotics. That’s a triple-win: It reduces the length of stay for the patient, the incidence of C. diff, and costs.
The Front Line
This concern isn’t limited to a single hospital. There are now more than 44,000 hospitalists nationwide, and every one of us plays an important role in antibiotic stewardship. The bedside is the front line of the fight against antibiotic resistance.
tuberculosis, staph infections, and numerous others.
—Eric Howell, MD, SFHM
There are more than 5,000 hospitals across the country, and hospitalists in every one of them must take responsibility for the appropriate use of antibiotics for their patients.
Announcing SHM’s National Commitment to Antibiotic Stewardship
SHM was proud to join more than 150 major organizations at the White House Forum on Antibiotic Stewardship to announce commitments to implement changes over the next five years that will slow the emergence of antibiotic-resistant bacteria, detect resistant strains, preserve the efficacy of our existing antibiotics, and prevent the spread of resistant infections.
Specifically, SHM has committed to three national initiatives that are aligned with our organizational goal of providing the best possible care for the hospitalized patient and the federal government’s dedication to this important issue:
- Enhance hospitalists’ awareness of key antimicrobial stewardship best practices and ask them to formally commit to at least two behavior changes to reduce inappropriate antimicrobial use and antimicrobial resistance;
- Support national initiatives that advocate for the appropriate use of antimicrobials and promote strategies to reduce antimicrobial resistance; and
- Identify partnerships and other opportunities to support the development of a comprehensive program to implement antimicrobial stewardship best practices in America’s hospitals.
These commitments, which I shared with White House Forum participants, play to the strengths of hospitalists in healthcare: advocacy on behalf of patients and quality improvement and collaboration with others.
What Hospitalists Can Do Now
I also know, however, that you aren’t the kind of people to wait for official pronouncements and campaigns to start a program that will improve the care of hospitalized patients. That’s why SHM and I are recommending that all hospitalists begin to take steps immediately to address this national healthcare crisis:
- Start the conversation with your patients. It’s easy to prescribe antibiotics, but it can also be harmful. Talk with your patients about when antibiotics are medically appropriate and the potential harms they may cause.
- Prescribe antibiotics for specific diagnoses. Prescribing “just in case” is a prescription for antibiotic resistance. Make sure you understand the signs and symptoms of the conditions for which you’re prescribing antibiotics. As we learned at our hospital, cellulitis and venous insufficiency can look similar, but only one responds to antibiotic treatment.
- Work with your infectious disease colleagues. They can help you create systems and diagnose patients to help improve your hospital’s antibiotic stewardship.
After all, we are on the front lines, protecting our current and future patients. And we can’t afford to wait.
Dr. Howell is a veteran hospitalist at Johns Hopkins Bayview Hospital in Baltimore and a past president of SHM.
Editor’s note: This article originally appeared on SHM’s official blog, “The Hospital Leader,” in June 2015.
“Tell me what you know about antibiotics.”
That’s the discussion I start with hospitalized patients all the time, right after they ask me to prescribe antibiotics for their simple cough or other viral-like illness.
And, from their perspective, asking for antibiotics makes sense. After all, antibiotics have been the physician’s knee-jerk reaction to a number of patient symptoms for decades, especially for a cough or upper respiratory infection. We have inadvertently trained our patients that there is an easy solution to almost any common medical problem.
But patients often answer my question with something like “not much,” coupled with a little surprise that I haven’t already started ordering the prescription.
That’s when I talk about the potential harms of antibiotics. And that’s also when their eyebrows go up. I start with the easy harms, like the fact that many antibiotics can cause diarrhea, a symptom nobody wants to deal with along with their runny nose. Then I move on to the big ones: Use of antibiotics today could make the patient resistant to antibiotics later in life, when they might really need them, and using antibiotics can lead to other painful and even fatal conditions, like Clostridium difficile.
After that, every patient agrees with my recommendations that we hold off on antibiotics for certain, particularly viral-like, ailments.
Change the Conversation. Change the Approach.
It’s a longer conversation, but it’s worth it. Overuse of antibiotics affects not only the patient in front of me, but also entire communities. By creating antibiotic-resistant bacteria, we make everyone more vulnerable to the very diseases the antibiotics were originally intended to treat, like tuberculosis, staph infections, and numerous others.
That’s why the hospitalists in my hospital at Johns Hopkins Bayview teamed up with the infectious diseases division to improve our approach to cellulitis and antibiotic use.
In short, cellulitis is a bacterial skin infection. The most feared bacterial skin infection is MRSA (methicillin-resistant Staphylococcus aureus), a “super bug” that requires highly selective antibiotics like vancomycin; however, other more common and less virulent bacteria also cause cellulitis, and they don’t need super bug fighter medications. Some types of skin ailments, like those caused by poor circulation in the legs, are not infectious at all but can look like cellulitis, even to experienced doctors.
Thanks to the collaboration between infectious disease doctors and hospitalists, the hospitalists are much less likely to prescribe inappropriate antibiotics. That’s a triple-win: It reduces the length of stay for the patient, the incidence of C. diff, and costs.
The Front Line
This concern isn’t limited to a single hospital. There are now more than 44,000 hospitalists nationwide, and every one of us plays an important role in antibiotic stewardship. The bedside is the front line of the fight against antibiotic resistance.
tuberculosis, staph infections, and numerous others.
—Eric Howell, MD, SFHM
There are more than 5,000 hospitals across the country, and hospitalists in every one of them must take responsibility for the appropriate use of antibiotics for their patients.
Announcing SHM’s National Commitment to Antibiotic Stewardship
SHM was proud to join more than 150 major organizations at the White House Forum on Antibiotic Stewardship to announce commitments to implement changes over the next five years that will slow the emergence of antibiotic-resistant bacteria, detect resistant strains, preserve the efficacy of our existing antibiotics, and prevent the spread of resistant infections.
Specifically, SHM has committed to three national initiatives that are aligned with our organizational goal of providing the best possible care for the hospitalized patient and the federal government’s dedication to this important issue:
- Enhance hospitalists’ awareness of key antimicrobial stewardship best practices and ask them to formally commit to at least two behavior changes to reduce inappropriate antimicrobial use and antimicrobial resistance;
- Support national initiatives that advocate for the appropriate use of antimicrobials and promote strategies to reduce antimicrobial resistance; and
- Identify partnerships and other opportunities to support the development of a comprehensive program to implement antimicrobial stewardship best practices in America’s hospitals.
These commitments, which I shared with White House Forum participants, play to the strengths of hospitalists in healthcare: advocacy on behalf of patients and quality improvement and collaboration with others.
What Hospitalists Can Do Now
I also know, however, that you aren’t the kind of people to wait for official pronouncements and campaigns to start a program that will improve the care of hospitalized patients. That’s why SHM and I are recommending that all hospitalists begin to take steps immediately to address this national healthcare crisis:
- Start the conversation with your patients. It’s easy to prescribe antibiotics, but it can also be harmful. Talk with your patients about when antibiotics are medically appropriate and the potential harms they may cause.
- Prescribe antibiotics for specific diagnoses. Prescribing “just in case” is a prescription for antibiotic resistance. Make sure you understand the signs and symptoms of the conditions for which you’re prescribing antibiotics. As we learned at our hospital, cellulitis and venous insufficiency can look similar, but only one responds to antibiotic treatment.
- Work with your infectious disease colleagues. They can help you create systems and diagnose patients to help improve your hospital’s antibiotic stewardship.
After all, we are on the front lines, protecting our current and future patients. And we can’t afford to wait.
Dr. Howell is a veteran hospitalist at Johns Hopkins Bayview Hospital in Baltimore and a past president of SHM.
Editor’s note: This article originally appeared on SHM’s official blog, “The Hospital Leader,” in June 2015.
“Tell me what you know about antibiotics.”
That’s the discussion I start with hospitalized patients all the time, right after they ask me to prescribe antibiotics for their simple cough or other viral-like illness.
And, from their perspective, asking for antibiotics makes sense. After all, antibiotics have been the physician’s knee-jerk reaction to a number of patient symptoms for decades, especially for a cough or upper respiratory infection. We have inadvertently trained our patients that there is an easy solution to almost any common medical problem.
But patients often answer my question with something like “not much,” coupled with a little surprise that I haven’t already started ordering the prescription.
That’s when I talk about the potential harms of antibiotics. And that’s also when their eyebrows go up. I start with the easy harms, like the fact that many antibiotics can cause diarrhea, a symptom nobody wants to deal with along with their runny nose. Then I move on to the big ones: Use of antibiotics today could make the patient resistant to antibiotics later in life, when they might really need them, and using antibiotics can lead to other painful and even fatal conditions, like Clostridium difficile.
After that, every patient agrees with my recommendations that we hold off on antibiotics for certain, particularly viral-like, ailments.
Change the Conversation. Change the Approach.
It’s a longer conversation, but it’s worth it. Overuse of antibiotics affects not only the patient in front of me, but also entire communities. By creating antibiotic-resistant bacteria, we make everyone more vulnerable to the very diseases the antibiotics were originally intended to treat, like tuberculosis, staph infections, and numerous others.
That’s why the hospitalists in my hospital at Johns Hopkins Bayview teamed up with the infectious diseases division to improve our approach to cellulitis and antibiotic use.
In short, cellulitis is a bacterial skin infection. The most feared bacterial skin infection is MRSA (methicillin-resistant Staphylococcus aureus), a “super bug” that requires highly selective antibiotics like vancomycin; however, other more common and less virulent bacteria also cause cellulitis, and they don’t need super bug fighter medications. Some types of skin ailments, like those caused by poor circulation in the legs, are not infectious at all but can look like cellulitis, even to experienced doctors.
Thanks to the collaboration between infectious disease doctors and hospitalists, the hospitalists are much less likely to prescribe inappropriate antibiotics. That’s a triple-win: It reduces the length of stay for the patient, the incidence of C. diff, and costs.
The Front Line
This concern isn’t limited to a single hospital. There are now more than 44,000 hospitalists nationwide, and every one of us plays an important role in antibiotic stewardship. The bedside is the front line of the fight against antibiotic resistance.
tuberculosis, staph infections, and numerous others.
—Eric Howell, MD, SFHM
There are more than 5,000 hospitals across the country, and hospitalists in every one of them must take responsibility for the appropriate use of antibiotics for their patients.
Announcing SHM’s National Commitment to Antibiotic Stewardship
SHM was proud to join more than 150 major organizations at the White House Forum on Antibiotic Stewardship to announce commitments to implement changes over the next five years that will slow the emergence of antibiotic-resistant bacteria, detect resistant strains, preserve the efficacy of our existing antibiotics, and prevent the spread of resistant infections.
Specifically, SHM has committed to three national initiatives that are aligned with our organizational goal of providing the best possible care for the hospitalized patient and the federal government’s dedication to this important issue:
- Enhance hospitalists’ awareness of key antimicrobial stewardship best practices and ask them to formally commit to at least two behavior changes to reduce inappropriate antimicrobial use and antimicrobial resistance;
- Support national initiatives that advocate for the appropriate use of antimicrobials and promote strategies to reduce antimicrobial resistance; and
- Identify partnerships and other opportunities to support the development of a comprehensive program to implement antimicrobial stewardship best practices in America’s hospitals.
These commitments, which I shared with White House Forum participants, play to the strengths of hospitalists in healthcare: advocacy on behalf of patients and quality improvement and collaboration with others.
What Hospitalists Can Do Now
I also know, however, that you aren’t the kind of people to wait for official pronouncements and campaigns to start a program that will improve the care of hospitalized patients. That’s why SHM and I are recommending that all hospitalists begin to take steps immediately to address this national healthcare crisis:
- Start the conversation with your patients. It’s easy to prescribe antibiotics, but it can also be harmful. Talk with your patients about when antibiotics are medically appropriate and the potential harms they may cause.
- Prescribe antibiotics for specific diagnoses. Prescribing “just in case” is a prescription for antibiotic resistance. Make sure you understand the signs and symptoms of the conditions for which you’re prescribing antibiotics. As we learned at our hospital, cellulitis and venous insufficiency can look similar, but only one responds to antibiotic treatment.
- Work with your infectious disease colleagues. They can help you create systems and diagnose patients to help improve your hospital’s antibiotic stewardship.
After all, we are on the front lines, protecting our current and future patients. And we can’t afford to wait.
Dr. Howell is a veteran hospitalist at Johns Hopkins Bayview Hospital in Baltimore and a past president of SHM.
Avoid Trimethoprim-Sulfamethoxazole for Severe MRSA Infections
Clinical question: Is trimethoprim-sulfamethoxazole equivalent to vancomycin for the treatment of severe infections caused by methicillin-resistant Staphyloccus aureus?
Bottom line: Trimethoprim-sulfamethoxazole (TMP-SMX) did not achieve noninferiority as compared with vancomycin for the treatment of severe methicillin-resistant Staphyloccus aureus (MRSA) infections in hospitalized patients, and it may lead to increased mortality in the subset of patients with bacteremia. (LOE = 1b)
Reference: Paul M, Bishara J, Yahav D, et al. Trimethoprim-sulfamethoxazole versus vancomycin for severe infections caused by meticillin-resistant Staphylococcus aureus. BMJ 2015;350:h2219.
Study design: Randomized controlled trial (nonblinded)
Funding source: Foundation
Allocation: Concealed
Setting: Inpatient (any location)
Synopsis
Although TMP-SMX can be used to treat uncomplicated skin and soft-tissue infections caused by MRSA, it is not currently recommended for more serious MRSA infections such as bacteremia or pneumonia. In this study, investigators tested whether TMP-SMX is noninferior to vancomycin for the treatment of hospitalized patients with severe MRSA infections. Patients included in the study (N = 252) had microbiologically documented MRSA infections, including complicated skin and soft-tissue infections, bone or joint infections, pneumonia, or primary bacteremia. Patients with MRSA isolates resistant to TMP-SMX or vancomycin were excluded.
Using concealed allocation, the investigators randomized the patients to receive either high-dose TMP-SMX (320 mg trimethoprim/1600 mg sulfamethoxazole intravenously twice daily) or vancomycin (1 mg intravenously twice daily) for at least 7 days. In the TMP-SMX group, treatment could be transitioned to an oral regimen of an equivalent dose at the clinician's discretion. The 2 groups had similar baseline characteristics with a mean age of 66 years and similar comorbidities, though the vancomycin group had a higher percentage of patients with bacteremia than the TMP-SMX group (30% vs 43%; P = .042). The primary outcome was treatment failure at 7 days, defined as a composite of death, persistent fever or hypotension, stable or worsening Sequential Organ Failure Assessment score, or persistent bacteremia. There was no statistically significant difference detected between the 2 groups for this outcome (38% treatment failure with TMP-SMX vs 27% with vancomycin; absolute difference 10.4%, 95% CI -1.2% to 21.5%).
However, since the 95% confidence interval for the absolute difference fell outside the predefined lower limit of noninferiority of 15%, the authors concluded that TMP-SMX failed to achieve noninferiority as compared with vancomycin. Additionally, in the subgroup of patients with bacteremia, patients were more likely to die in the TMP-SMX group as compared with the vancomycin group, although this difference again was not statistically significant (34% with TMP-SMX vs 18% with vancomycin; relative risk 1.90, 0.92-3.93).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question: Is trimethoprim-sulfamethoxazole equivalent to vancomycin for the treatment of severe infections caused by methicillin-resistant Staphyloccus aureus?
Bottom line: Trimethoprim-sulfamethoxazole (TMP-SMX) did not achieve noninferiority as compared with vancomycin for the treatment of severe methicillin-resistant Staphyloccus aureus (MRSA) infections in hospitalized patients, and it may lead to increased mortality in the subset of patients with bacteremia. (LOE = 1b)
Reference: Paul M, Bishara J, Yahav D, et al. Trimethoprim-sulfamethoxazole versus vancomycin for severe infections caused by meticillin-resistant Staphylococcus aureus. BMJ 2015;350:h2219.
Study design: Randomized controlled trial (nonblinded)
Funding source: Foundation
Allocation: Concealed
Setting: Inpatient (any location)
Synopsis
Although TMP-SMX can be used to treat uncomplicated skin and soft-tissue infections caused by MRSA, it is not currently recommended for more serious MRSA infections such as bacteremia or pneumonia. In this study, investigators tested whether TMP-SMX is noninferior to vancomycin for the treatment of hospitalized patients with severe MRSA infections. Patients included in the study (N = 252) had microbiologically documented MRSA infections, including complicated skin and soft-tissue infections, bone or joint infections, pneumonia, or primary bacteremia. Patients with MRSA isolates resistant to TMP-SMX or vancomycin were excluded.
Using concealed allocation, the investigators randomized the patients to receive either high-dose TMP-SMX (320 mg trimethoprim/1600 mg sulfamethoxazole intravenously twice daily) or vancomycin (1 mg intravenously twice daily) for at least 7 days. In the TMP-SMX group, treatment could be transitioned to an oral regimen of an equivalent dose at the clinician's discretion. The 2 groups had similar baseline characteristics with a mean age of 66 years and similar comorbidities, though the vancomycin group had a higher percentage of patients with bacteremia than the TMP-SMX group (30% vs 43%; P = .042). The primary outcome was treatment failure at 7 days, defined as a composite of death, persistent fever or hypotension, stable or worsening Sequential Organ Failure Assessment score, or persistent bacteremia. There was no statistically significant difference detected between the 2 groups for this outcome (38% treatment failure with TMP-SMX vs 27% with vancomycin; absolute difference 10.4%, 95% CI -1.2% to 21.5%).
However, since the 95% confidence interval for the absolute difference fell outside the predefined lower limit of noninferiority of 15%, the authors concluded that TMP-SMX failed to achieve noninferiority as compared with vancomycin. Additionally, in the subgroup of patients with bacteremia, patients were more likely to die in the TMP-SMX group as compared with the vancomycin group, although this difference again was not statistically significant (34% with TMP-SMX vs 18% with vancomycin; relative risk 1.90, 0.92-3.93).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.
Clinical question: Is trimethoprim-sulfamethoxazole equivalent to vancomycin for the treatment of severe infections caused by methicillin-resistant Staphyloccus aureus?
Bottom line: Trimethoprim-sulfamethoxazole (TMP-SMX) did not achieve noninferiority as compared with vancomycin for the treatment of severe methicillin-resistant Staphyloccus aureus (MRSA) infections in hospitalized patients, and it may lead to increased mortality in the subset of patients with bacteremia. (LOE = 1b)
Reference: Paul M, Bishara J, Yahav D, et al. Trimethoprim-sulfamethoxazole versus vancomycin for severe infections caused by meticillin-resistant Staphylococcus aureus. BMJ 2015;350:h2219.
Study design: Randomized controlled trial (nonblinded)
Funding source: Foundation
Allocation: Concealed
Setting: Inpatient (any location)
Synopsis
Although TMP-SMX can be used to treat uncomplicated skin and soft-tissue infections caused by MRSA, it is not currently recommended for more serious MRSA infections such as bacteremia or pneumonia. In this study, investigators tested whether TMP-SMX is noninferior to vancomycin for the treatment of hospitalized patients with severe MRSA infections. Patients included in the study (N = 252) had microbiologically documented MRSA infections, including complicated skin and soft-tissue infections, bone or joint infections, pneumonia, or primary bacteremia. Patients with MRSA isolates resistant to TMP-SMX or vancomycin were excluded.
Using concealed allocation, the investigators randomized the patients to receive either high-dose TMP-SMX (320 mg trimethoprim/1600 mg sulfamethoxazole intravenously twice daily) or vancomycin (1 mg intravenously twice daily) for at least 7 days. In the TMP-SMX group, treatment could be transitioned to an oral regimen of an equivalent dose at the clinician's discretion. The 2 groups had similar baseline characteristics with a mean age of 66 years and similar comorbidities, though the vancomycin group had a higher percentage of patients with bacteremia than the TMP-SMX group (30% vs 43%; P = .042). The primary outcome was treatment failure at 7 days, defined as a composite of death, persistent fever or hypotension, stable or worsening Sequential Organ Failure Assessment score, or persistent bacteremia. There was no statistically significant difference detected between the 2 groups for this outcome (38% treatment failure with TMP-SMX vs 27% with vancomycin; absolute difference 10.4%, 95% CI -1.2% to 21.5%).
However, since the 95% confidence interval for the absolute difference fell outside the predefined lower limit of noninferiority of 15%, the authors concluded that TMP-SMX failed to achieve noninferiority as compared with vancomycin. Additionally, in the subgroup of patients with bacteremia, patients were more likely to die in the TMP-SMX group as compared with the vancomycin group, although this difference again was not statistically significant (34% with TMP-SMX vs 18% with vancomycin; relative risk 1.90, 0.92-3.93).
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.