New Clinical Usage Guidelines Issued for Superbug Antibiotic

An international panel of infectious disease and antimicrobial researchers have published new practice guidelines for the clinical use of polymyxin antibiotics.

Polymyxins are a class of antibiotics that have "… assumed an important role as salvage therapy for otherwise untreatable gram‐negative infections, most notably multidrug‐resistant (MDR) and extensively drug‐resistant (XDR) strains of Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterobacteriaceae," according to the guidelines, which were published in Pharmacotherapy.

The guidelines specifically concern the polymyxin antibiotics colistin (polymyxin E) and polymyxin B. They became available in the 1950s, but their use fell out of favor because of toxicity concerns, according to a news release. However, in the effort to combat superbugs, their clinical use has resurged. 

Unfortunately, as the researchers note in the guidelines, "Since their reintroduction into the clinic, significant confusion remains due to the existence of several different conventions used to describe doses of the polymyxins, differences in their formulations, outdated product information and uncertainties about susceptibility testing that has led to lack of clarity on how to optimally utilize and dose colistin and polymyxin B."

The guidelines establish new standards for polymyxins in areas including maximum dosage, treatment strategies and best practice for use in combination with other antibiotics.

"These guidelines represent consensus recommendations from expert clinicians and scientists around the globe to guide polymyxin therapy in gram-negative infections where no treatments appear to exist," said Brian Tsuji, who co-led the panel and is professor of pharmacy practice in the University of Buffalo School of Pharmacy and Pharmaceutical Sciences, in the release.

The guidelines have received endorsements from the American College of Clinical Pharmacy, European Society of Clinical Microbiology and Infectious Diseases, Infectious Diseases Society of America, International Society for Anti-infective Pharmacology, Society of Critical Care Medicine and Society of Infectious Diseases Pharmacists.

Study: Outpatient Surgical Infection Guidelines Adherence Improves With Ancillary Services Support

Timely discontinuation of antimicrobial prophylaxis following outpatient surgery is better achieved in higher complexity organizations with stronger infection prevention and antimicrobial stewardship services and support, according to a new study.

Published in Antimicrobial Resistance & Infection Control, the study examined more than 150,000 outpatient procedures in general surgery, urology, ophthalmology, otolaryngology (ENT) and orthopedics performed in Veterans Health Administration (VA) facilities. The procedures were performed at 70 higher complexity hospital outpatient departments (HOPDs), 41 lower complexity HOPDs and 22 ambulatory surgery centers (ASCs), also considered lower complexity, with complexity defined by the VA. Researchers identified which patients continued to receive antimicrobial prophylaxis lasting more than 24 hours after surgery.

Evidence-based guidelines, as the study notes, recommend discontinuation of antimicrobial prophylaxis within 24 hours after incision closure in uninfected patients. Unnecessary antimicrobial exposure, the researchers note, can lead to increases in postoperative adverse events.

Findings included the following:

  • About 7,700 patients (5.0%) received antimicrobial prophylaxis lasting more than 24 hours after surgery.

  • Highest rates were associated with cystoscopies and cystoureteroscopy with lithotripsy (16% and 20%, respectively).

  • Hernia repair, cataract surgeries and laparoscopic cholecystectomies had the lowest rates (0.2%-0.3%).

Furthermore, the researchers found that organizations with applicable ancillary services (e.g., infectious diseases, infection prevention, antimicrobial stewardship) typically found in higher complexity facilities leads to lower rates of postoperative prophylactic antimicrobial use and more guideline-consistent care compared to lower complexity facilities where such services are not often available or readily accessible.

The researchers conclude, "Lower complexity facilities with limited infection prevention and antimicrobial stewardship resources may be important targets for quality improvement. … Increasing pharmacy, antimicrobial stewardship and/or infection prevention resources to promote more evidence-based care may support surgical providers in lower complexity ASCs and HOPDs in their efforts to improve this facet of patient safety."

ECRI: Infection Risks, Antimicrobial Stewardship Top Patient Safety Concerns

Challenges concerning antimicrobial stewardship, sepsis and peripheral intravenous (PIV) catheter infections appear on the ECRI Institute's "2019 Top 10 Patient Safety Concerns for Healthcare Organizations" report.

Coming in second on the list is "Antimicrobial Stewardship in Physician Practices and Aging Services." In an executive brief, Sharon Bradley, senior infection prevention and patient safety analyst/consultant with ECRI Institute, notes, "Antibiotic stewardship does not mean withholding necessary treatment. But we have casually and cavalierly handed around the candy dish of antibiotics without a second thought as to how we may be harming our patients."

Coming in eighth is "Early Recognition of Sepsis across the Continuum." In the brief, ECRI notes, "Healthcare workers throughout the continuum of care must be able to recognize sepsis. Certified nursing assistants can be trained to use screening tools, and physician practices can screen for sepsis both in the exam room and on the phone. Simulation and skills practice can help workers recognize sepsis and communicate their concerns."

Ninth on the top 10 list is "Infections from Peripherally Inserted IV Lines." The brief notes, "Often, PIVs are inserted upon admission as a matter of course, in case the patient needs IV therapy at a later point. However, PIVs can expose patients to a significant risk of infection — one that is underreported, underrecognized and often ignored…"

ECRI states that it creates the annual list of patient safety concerns to support healthcare organizations to proactively identify and respond to safety threats. The list is compiled using data on adverse events and concerns gathered by ECRI and "expert judgment."

The top patient safety concern for 2019 is "Diagnostic Stewardship and Test Result Management Using EHRs." Rounding out the top three is "Burnout and Its Impact on Patient Safety."

CDC: Nearly 20,000 People Died From Staph Infections in 2017

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Staphylococcus aureus (staph) infections remain a significant threat, and efforts to reduce them appear to be stalling, according to a Centers for Disease Control and Prevention (CDC) report.

More than 119,000 people suffered from staph infections in the United States in 2017, with nearly 20,000 people dying from them.

Furthermore, while hospital infection control efforts successfully reduced rates of serious staph infections in the United States by about 17% each year from 2005-2012, recent data show that this success is trailing off. The recent rise in staph infections may be linked, in part, to the nationwide opioid epidemic. Nearly 1 in 10 serious staph infections in 2016 occurred in people who inject drugs, such as opioids.

As the report notes, "Despite significant reductions in healthcare–associated methicillin-resistant S. aureus (MRSA) infections, progress is slowing. Methicillin-susceptible S. aureus (MSSA) infections have not decreased as much in hospitals and might be increasing in the community." 

According to CDC, the risk for serious staph infection is greatest when people:

  • stay in healthcare facilities or have surgery;

  • have medical devices placed in their body;

  • inject drugs; and

  • come into close contact with someone who has already staph.

To better protect patients from staph, CDC advises healthcare organizations to:

  • make staph prevention a priority;

  • follow CDC recommendations, including contact precautions (gloves and gowns), to prevent the spread of staph;

  • consider additional interventions (e.g., screening, decolonizing high-risk patients);

  • treat infections appropriately and rapidly; and

  • educate patients about how to avoid infection and spread, and about early signs of sepsis.

Study: Electric System Change Drastically Cuts Unnecessary UTI Tests

A simple change to how physicians order urine tests can reduce unnecessary urinary tract infection (UTI) tests by nearly half without compromising the identification of patients requiring treatment, according to research by a team at Washington University School of Medicine in St. Louis.

The study, published in Infection Control and Hospital Epidemiology, measured the effectiveness of changing the electronic ordering system used by physicians. The first option presented in the system for ordering urine tests was culture test alone. Researchers changed the default to urine dipstick test followed by a bacterial culture test. Clinicians could still order a culture test alone but were required to open an additional screen.

The rationale behind this change is that it encourages physicians to check for signs of a UTI before testing urine for bacteria, thus reducing over-testing, unnecessary prescribing and use of antibiotics and cost.

Researchers compared all urine culture tests ordered at Barnes-Jewish Hospital in the 15 months prior to the intervention to the 15 months after. Before the intervention, physicians ordered nearly 16,000 urine cultures. After the intervention, they ordered about 8,800 cultures — about 45% fewer. There were 125 diagnosed catheter-associated UTIs in each time period.

"Ordering tests when the patient needs them is a good thing," said senior author and infectious diseases specialist David Warren, MD, a professor of medicine, in a news release. "But ordering tests when it's not indicated wastes resources and can subject patients to unnecessary treatment. We were able to reduce the number of tests ordered substantially without diminishing the quality of care at all."