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Stewardship / Resistance Scan for Sep 24, 2021

Stewardship / Resistance Scan for Sep 24, 2021

Nursing home trial ties CRP testing to safe antibiotic reduction

Point-of-care testing for C-reactive protein (CRP) in nursing home residents with suspected lower respiratory tract infections resulted in a large reduction in antibiotic prescribing at initial consultation, according to the results of a cluster-randomized trial published this week in BMJ.

The trial, conducted in the Netherlands, involved 11 nursing homes and 241 participants with suspected lower respiratory tract infections. The nursing homes were allocated to either an intervention group that had access to CRP point-of-care testing (CRP POCT), which measures the level of a protein produced by the liver in response to inflammation, or to a control group that provided usual care without CRP POCT.

The primary outcome was antibiotic prescribing at initial consultation. Secondary outcomes included full recovery at 3 weeks, changes in antibiotic management during follow-up, hospital admission, and all-cause mortality at any point.

Antibiotics were prescribed at initial consultation at for 84 patients (53.5%) in the intervention group and 65 patients (82.3%) in the control group. The between-group difference in initial antibiotic prescribing at any point from initial consultation to follow-up was 23.6%. Patients in the intervention group had 4.93 higher odds (95% confidence interval [CI], 1.91 to 12.73) of not being prescribed antibiotics at initial consultation, compared with patients in the control group, irrespective of patient characteristics or treating physician.

Differences in secondary outcomes between the intervention and control groups were 4.4% for full recovery at 3 weeks (86.4% vs 90.8%), 2.2% for all-cause mortality (3.5% vs 1.3%), and 0.7% for hospital admission (7.2% vs 6.5%), though mortality and hospital admission were low in both groups. The odds of full recovery at 3 weeks, and the odds of hospital admission and mortality at any point, did not significantly differ between the two groups.

“The high full recovery rate in both groups, the low occurrence of hospital admissions and mortality, and the non-significant difference in odds of these secondary outcomes between groups suggest that CRP POCT can be safely used in nursing homes,” the study authors wrote. “Because of the pragmatic trial design, we believe that the results can be generalised to other nursing homes and other countries with similar long term care facilities.” 
Sep 21 BMJ study

Acid suppressants, MDR bacteria carriage not linked, study finds

Analysis of data from a subcohort of a nationwide Dutch seroprevalence study found that use of acid suppressants was not associated with intestinal carriage of multidrug-resistant (MDR) Enterobacterales, Dutch researchers reported this week in The Journal of Antimicrobial Chemotherapy.

The subcohort included healthy individuals 18 years and older who had provided fecal specimens from February 2016 through June 2017. The primary outcome was carriage of extended-spectrum beta-lactamase- and carbapenemase-producing Enterobacterales (ESBL-E). To determine whether acid-suppressing medications are a risk factor for ESBL-E, the researchers assessed data from self-administered questionnaires and conducted multivariable analysis that controlled for confounding factors.

Among the 2,746 participants, the prevalence of ESBL-E carriage was 7.4%, and 11.5% used acid suppressants. In the primary analysis, current use of acid suppressants was not associated with ESBL-E carriage (adjusted odds ratio [aOR], 1.05; 95% CI, 0.64 to 1.74), and lifestyle and comorbidity did not modify the association. But in a secondary analysis, a higher BMI (aOR, 1.42; 95% CI, 1.02 to 1.98), non-Western ethnic origin (aOR, 1.96; 95% CI 1.34 to 2.87), travel to Eastern-Mediterranean, Western-Pacific, or South East Asia regions (aOR, 3.16; 95% CI, 1.71 to 5.83) were associated with ESBL-E carriage.

The study authors note that the findings are inconsistent with a previous meta-analysis of Dutch hospital patients that had found the use of proton pump inhibitors nearly doubled the risk of ESBL-E carriage. They suggest that finding could be explained by the fact that hospital patients are more likely to be exposed to a resistant organism and may have other risk factors that predispose them to enteric bacterial colonization when using acid suppressants.

While several of the observed risk factors associated with ESBL-E carriage have been previously documented, the association with higher BMI is a novel finding, according to the authors.

“The latter may play a role via alterations in gut microbiota composition and merits further study,” they wrote.
Sep 22 J Antimicrob Chemother study

Black fungus cases exemplify a need for in-house pharma, letter says

India’s black fungus (mucormycosis) surge and subsequent treatment shortages highlight a need for the country to on-shore pharmaceutical supply chains, according to a letter by six authors from St. Joseph’s College and other higher education institutes in India. The World Health Organization has noted that mucormycosis, which has an overall 50% case fatality rate, has an 80-fold higher prevalence in India than in developed countries (up to 140 infections per million people vs 1.7). It is commonly treated with the antifungal amphotericin B.

The letter, published yesterday in Infection Control & Hospital Epidemiology, says that despite the Indian government’s efforts to increase amphotericin B by exempting custom duties on imports, reallocating the drug, and creating new facilities for treatment, there was very little improvement to treatment access. The in-country manufacturers, Bharat Serums & Vaccines, BDR Pharmaceuticals, Sun Pharma, Cipla, and Life Care Innovations, didn’t have sufficient supplies on their own.

The authors add that on top of the black fungus cases, some cases of white fungus have been identified, which is of particular concern because of its association with multidrug-resistant nosocomial infections as well as its own frequent fluconazole and amphotericin B resistance.

“With the pandemic still looming over the country’s heads, it is imperative that efforts are made to invest in local pharma as a means of meeting the demand of the nation, and simultaneously reduce dependency and expenses on import,” they write. “Apart from all this, the ancient field of herbal and indigenous medicine in India, through the likes of Ayurveda and Unani should be re-examined and probed in the hopes of finding replacement options or cheaper, safe treatment options.”

International headlines have largely moved on from the black fungus surge in India, and a Hindustan Times article from Sep 3 says that the head of the ENT department at Delhi’s Sir Ganga Hospital was not seeing any active cases from patients coming in. Still, as of Jul 21, the BBC reported 45,374 cases and more than 4,300 deaths in India.
Sep 23 Infect Control Hosp Epidemiol letter

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