Stewardship / Resistance Scan for Sep 28, 2022 - CIDRAP

Trial supports protocol for reducing antibiotics in suspected sepsis cases

An opt-out protocol for antibiotic de-escalation in patients with suspected sepsis resulted in more antibiotic discontinuations and less exposure to broad-spectrum antibiotics, with no evidence of harm, according to the results of a randomized controlled trial published today in Clinical Infectious Diseases.

The trial, conducted in 10 US acute care hospitals from September 2018 through May 2020, aimed to quantify the effect of an antibiotic opt-out program targeting low-risk patients in whom systemic infection was not confirmed or who recovered quickly and were therefore candidates for antibiotic de-escalation.

Eligible patients were randomly assigned to the opt-out protocol versus usual care. In the intervention arm, the clinician responsible for antibiotic treatment was encouraged to stop antibiotics based on an initial safety screen that determined the patient was not likely to have sepsis. If the clinician decided to continue antibiotics, a study team member initiated a guided antibiotic de-escalation discussion. The primary outcome of the trial was 30-day post-enrollment antibacterial days of therapy (DOT).

Among 9,606 patients screened, 767 were enrolled. Patients in the intervention arm had 32% lower odds of antibiotic continuation (79% vs 84; odds ratio [OR], 0.68; 95% confidence interval [CI], 0.47 to 0.98). Among those who had antibiotics continued, DOT (mean, 10.4 vs 9.9; ratio of means, 1.06; 95% CI, 0.88 to 1.26) were not different. Fewer intervention patients were exposed to extended-spectrum antibiotics (36% vs 44%). Thirty-day safety events were similar in both arms.

The most common rationales for continuing antibiotics were treatment of localized infection (76%) and belief that stopping antibiotics was unsafe (31%).

The study authors suggest the screening tools and standardized opt-out language and questions were critical factors in the success of the intervention.

"The opt-out language set expectations for antibiotic discontinuation based on patient-specific review and screening criteria," they wrote. "Thus, it sped up decisions to stop antibiotics among patients who ultimately may have had antibiotics stopped at a later timepoint in the absence of an intervention."
Sep 28 Clin Infect Dis abstract

 

Report: Resistant Campylobacter common in UK chicken

A new report from the United Kingdom's Food Safety Agency (FSA) finds that antimicrobial resistance (AMR) in Campylobacter bacteria isolated from retail chicken meat and chicken at slaughter is common but appears to have plateaued since 2014.

The analysis of AMR trends in Campylobacter, which causes an estimated 500,000 cases of foodborne illness annually in the United Kingdom, found that resistance to quinolones (ciprofloxacin), nalidixic acid, and tetracycline is common in Campylobacter jejuni and Campylobacter coli in UK broiler chickens.

The prevalence of ciprofloxacin resistance in C jejuni rose from 13% in 2001 to 2005 to 47% in 2011 to 2018, while ciprofloxacin resistance in C coli rose from 18% in the years 2001 to 2005 to 48% in 2016 to 2018. But for both species, there has been no significant change in resistance to ciprofloxacin since 2014.

Similar trends were observed for resistance to tetracycline, with resistance climbing from 27% in 2001 to 66% in 2018 among C jejuni isolates and from 23% in 2001 to 55% post-2013 in C coli, but no significant changes were observed since 2014. Rates of resistance to nalidixic acid rose from 16% in 2001 to 52% in 2018 in C jejuni, and from 16% in 2001 to 50% in 2017 in C coli, but resistance has declined post-2014.

Rates of resistance to erythromycin, gentamicin, and streptomycin were low, as were multidrug-resistant phenotypes.

"It is possible that this is related to the significant reductions in usage of antimicrobials (AMU) undertaken by the poultry industry in the past decade," the report states. "However, more data is required to provide convincing evidence that historical increases in the prevalence of quinolone and tetracycline resistance have ceased."

The authors say monitoring of AMR in C jejuni and C coli from chicken should continue and that further research should investigate the impact of other variables, including the effect of production system and seasonality on the incidence of resistance in Campylobacter.
Sep 28 FSA report