ICHE Special Issue: Antimicrobial Stewardship

Infection Control and Hospital Epidemiology has just announced that it will publish a special issue devoted to antimicrobial stewardship in conjunction with the SHEA spring meeting in Jacksonville, Florida, April 13-16, 2012. 

Topics of interest include:

• Antimicrobial stewardship for special populations, including pediatrics, oncology, hemodialysis, and critical care
• Health outcome and cost effectiveness impact of antimicrobial stewardship
• Use of diagnostic tools and role of microbiology in antimicrobial stewardship
• Effective implementation of programs in community hospitals, long-term care acute care facilities, outpatient settings and non-acute healthcare settings (e.g., dialysis, ambulatory care and ambulatory surgery centers)

Due date: October 1, 2011.

Get writing and submit your paper here.

Call for manuscripts PDF available here.

Good luck!

The case for antimicrobial stewardship: Fluoroquinolone edition

Gobo and Wembly Fraggle deliver fluoroquinolones to the wise Trash Heap

Dan posted yesterday about the scary emergence of ceftriaxone-resistant Neisseria gonorrhoeae. I remember back in my Cleveland medical school days that we were the first in the continental US to lose the ability to treat gonoccocal infections with fluoroquinolones.  I distinctly remember the Sanford Guide recommending against quinolones if the patient had traveled to Asia or Cleveland!  I always thought that was funny.  Here is a quote from an EID article: "In the CDC-sponsored Gonococcal Isolate Surveillance Project in the United States, the frequency of strains with intermediate resistance has increased significantly from 1991 to 1994...the increase in strains with intermediate resistance is associated largely, but not exclusively, with the persistence of such strains in Cleveland, Ohio."

Now we have some more news about fluoroquinolones and again it comes from Cleveland.  Nicole Werner and colleagues reviewed six weeks of fluoroquinolones prescriptions at a city-hospital in Cleveland. The study covered 227 courses in 226 patients (why not exclude the single patient treated twice?) and 1,773 total days of therapy. 70 (31%) or the regimens were deemed unnecessary and fully 690 days (39%) were determined to be unnecessary.

Twenty-seven percent of the regimens were associated with adverse effects -  GI adverse effects (14% of regimens), colonization by resistant pathogens (8%), and Clostridium difficile infection (4%).

I know, it is probably too late to save fluoroquinolones from the trash heap of used-up antibiotics, but when will we ever learn?  Do you think it's time that antimicrobial stewardship programs are finally mandated for all hospitals?  I suspect we will probably have to limit antibiotic prescriptions to ID specialists to have much of an effect.  Many of us have wondered why only oncologists can prescribe chemotherapy while every clinician can go about prescribing antibiotics willy-nilly.  Why do we continue to squander a limited public health resource like antibiotics?  It is not like the findings of this new study are all that surprising - I actually thought it might be worse. Yet 40% of fluoroquinolone-days are wasted and 27% of patients get a side-effect with 4% getting C. diff?? Really? That means for every 25 patients treated, one gets C. diff. How bad does it have to get before we change our system of antibiotic prescriptions? EOR

Werner NL et al BMC Infectious Diseases 2011

Low hanging fruit: making antibiotic treatment of skin infections less awful

I recently posted about withholding antibiotics after drainage of uncomplicated purulent skin infections. The group at Denver Health now points to another opportunity for antimicrobial stewardship when treating skin or soft tissue infections (SSTI). Believe it or not, patients admitted with SSTI do not all require treatment with vancopime (or its close relative vancopiptaz (piptamycin?)). These investigators implemented a clinical practice guideline to standardize and simplify the management of patients hospitalized with cellulitis and/or skin abscess. The guideline encouraged more judicious use of testing and imaging, avoidance of broad spectrum gram negative and anaerobic coverage, and shorter courses of therapy with earlier IV to oral transition. You can read the details here, but the guideline resulted in improvement in all areas, significant reductions in use of broad spectrum antibiotics, and no difference in clinical failure rates. The study was single center and quasi-experimental, but clearly points out an area ripe for drastic improvement in most hospitals.

The accompanying editorial by Brad Spellberg is also well worth reading, and locates the cloud in this silver lining: even after the intervention, over one-third of the patients were receiving broad spectrum gram negative active agents and almost half were still receiving broad spectrum anaerobic coverage. And yes, the investigators did exclude those patients who had complicating features (e.g. diabetes, recurrence, fasciitis, etc.) that may have justified such broad spectrum therapy. So even though the intervention was a partial success, challenges to optimizing therapy for SSTI remain.

Just drain it

Check out this article from Hopkins on treatment of uncomplicated skin and soft tissue infections (SSTI) due to MRSA…..more evidence that antibiotic therapy makes very little difference in outcome. A previous large observational study of antibiotic treatment for MRSA SSTI demonstrated a benefit to receiving an “active” antimicrobial agent, but the response rate for the group who didn’t receive active therapy was still 87% (versus 95% in the active antibiotic group).

This new randomized controlled trial was smaller, confined to children, and showed no difference in outcome between those children treated with cephalexin versus clindamycin for MRSA SSTI. Although when the investigators looked at subgroups, they did find some slight evidence for a short-term benefit:

For the subset of subjects for whom an organism was isolated from the initial wound culture and susceptibility data were known (183), 2% (2 of 111) of those who received an antibiotic with in vitro activity against the isolate versus 10% (7 of 72) of those who received an inactive antibiotic had worsened by the 48-to-72– hour visit (P=0.02).

Treatment of uncomplicated MRSA SSTI now involves a balance between the benefits of avoiding antimicrobial therapy (individual and societal) and what appears to be a very small risk for slower response to therapy. There is also the issue of whether receipt of an “inactive” antibiotic (e.g. cephalexin for MRSA) is the same thing as receiving no antibiotic (or placebo). Another recent study of managing pediatric SSTI suggests that it is.

The bottom line? Avoid antibiotic therapy in the management of purulent (i.e. drainable) uncomplicated SSTI. Incision and drainage, and good wound care, should suffice.

And as long as we’re talking about good antimicrobial stewardship, go read this JAMA piece by Jim Hughes on preserving the power of antimicrobials….

Post #610: Happy "Get Smart About Antibiotics Week" (November 15-21, 2010)

Man, have we done a lot of posting in the past 1.5 years.  I think Dan and Mike will agree with me here when I say that none of our posts have been as important as this one.  None.  The reason for this is that I'm announcing a whole 7 days of celebrating and not just one day. The world has witnessed Global Handwashing Day,  World Hand Hygiene Day, and World MRSA Day this past year.

But notice, these were just on single days.  Thus, we can officially announce that the smart use of antibiotics is 7 times more important than MRSA and 7/2 or 3.5 times more important than the domain of handwashing/hand hygiene. These are two questions that as an epidemiologist I've been struggling to answer for 10+ years and now I finally know.  While it is true that this is the 3rd annual "Get Smart About Antibiotics Week" and I should have officially known this two years ago, I do like to wait for "replication of results" or reproducibility before drawing a firm conclusion on such important questions. Alright everybody, get ready and Get Smart about antibiotics!

Vancopime

A humorous video that makes a few serious points about antibiotic overuse (hat tip to Neil Fishman, antimicrobial steward par excellence, who forwarded it along)....

Happy Weekend: How 'bout getting off these antibiotics

Yes.  I know most will mock me for posting an Alanis video; but hey, how many people can get a whole crowd to shout about getting off antibiotics, in Japan no less.  Some of my old co-fellows will get the humor behind this too...come on eileen...thank u