Antibiotic Resistance in Infants 2 months old

Researchers conducted a study about antibiotic resistance in infants under three months year old, specifically those experiencing uropathogens.  Within the study, previously healthy infants with urinary tract infections were observed.  Because there are limited data on antibiotic resistance of uropathogens in young infants, this study was of interest to the researchers.  The infants’ susceptibility to antibiotics was recorded, and this was conducted utilizing a urine sample or supra-pubic aspiration.

There has been a problem in which sepsis in neonates and UTIs in children are occurring due to antimicrobial resistance in Gram-negative bacteria (GNBs).  Many of the infants observed in this study who had UTIs were caused by GNBs that were resistant to several antibiotic classes.  The resistance rates observed were 73.7% to ampicillin, 22.1% cefazoline, 21.8% ampicillin/clavulanate, 7.8% cefuroxime, and 7% gentamicin.

The current standard treatment for infants with UTIs who are less than two months old is by IV.  It is an inpatient therapy, but there is evidence that there is equal efficacy in oral therapy.  Regardless of route of administration, gram-negative uropathogens express resistance even at two months of age.  This challenges the empirical therapy and compromises oral treatment options.  For this, antibiotic resistance and therapy choices should be monitored in infants to determine the correct antibiotic for them.

It was surprising to me how infants can experience antibiotic resistance prior to any exposure in the past.  Resistance is troublesome in any patient, but the idea of resistance in infants creates a different struggle.  What, as pharmacists can we do to assist in treating infants with antibiotic resistance?  When should the baby be screened for resistance?  Should it wait until the diagnosis and when the infant starts treatment?

Segal Z, Cohen MJ, Engelhard D, et al. Infants under two months of age with urinary tract infection are showing increasing resistance to empirical and oral antibiotics.  Acta Paediatricia. 2015:1-5.

Back to the Future: Penicillin-Susceptible Staphylococcus Aureus

All health professionals know and fear antibiotic resistance. A penicillin resistance has been present in Staphylococcus aureus for years due to its widespread usage for bacterial infections. However, penicillin may be making its come back! New data suggests that penicillin may becoming out of a period of antibiotic resistance. A study published by the American Journal of Medicine examined penicillin resistance in methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia.

At the McGill University Health Centre in Montreal, Canada, all adult MSSA bacteremia from April 2010 to April 2015 were reviewed for susceptibility to penicillin, erythromycin, clindamycin, and trimethoprim-sulfamethoxazole.  Out of 324 samples of MSSA bacteremia, 90 were susceptible to penicillin. This means that more than one quarter of patients with MSSA bacterium could use parenteral penicillin for treatment. This returning treatment may possibly have pharmacokinetic advantages over other beta-lactam, such as amoxicillin. Such pharmacokinetic advantages could potentially lead to better outcomes in the treatment of bacterial infections.

While working at a community pharmacy, I often fill prescriptions for amoxicillin, but I have never seen a prescription for penicillin. This new discovery regarding penicillin resistance could lead to a change in prescribing patterns from physicians in the future. I think that this discovery is also valuable at this time because other antibiotic resistances are emerging in our population. Bringing back an old antibiotic would be very useful to combat bacterial infections that are not responding to current top antibiotics. Although it is great to see the renaissance of an old antibiotic, antibiotic resistance is a serious problem and will continue to be a serious problem unless pharmacists step in to provide effective patient counseling and form beneficial interprofessional relationships with prescribers.

Am J Med. Published online February 25, 2016.

Link to article

Implementation of Penicillin Allergy Screening Tool to Optimize Aztreonam Use

In this article from the American Journal of Health System Pharmacy, researchers looked to determine whether pre-screening for a penicillin allergy could help to reduce the use of aztreonam.  Aztreonam is an antibiotic used to treat gram-negative infections.

The study looked at patients prior to and after intervention to account for inappropriate aztreonam use.  After intervention, the number of inappropriate doses decreased significantly.  And overall, the screening allowed for a cost avoidance of up to $100,000.  Use of B-lactam alternatives became more popular over the use of aztreonam.

This article is interesting because it shows that educating providers and doing pre-screening can help patients receive the appropriate medication and avoid adverse reactions.

Stacie ML, Brundige ML, Brown J, et al.  Implementation of a penicillin allergy screening tool to optimize aztreonam use.  Am. J. Health Syst. Pharm.  2016;73:298-306.

Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices

In this article, the scientists involved looked at the effects of behavioral interventions and rates of inappropriate antibiotic prescribing during ambulatory visits for acute respiratory tract infections.  The experiment had clinicians held responsible for their antibiotic prescriptions in 3 ways: they were either given electronic alternative suggestions, had to enter a rationale for prescribing into the patient chart, or had to report their prescribing numbers to a group of other clinicians.  The study found that two of the interventions had a statistically significant impact on the rates of antibiotic prescriptions. Having the clinicians enter rationale for their prescriptions and reporting their prescribing numbers to peers both reduced the number of inappropriate antibiotic prescribing for respiratory tract infection.

I think that this article is really interesting because we all know that there is a widespread problem with antibiotics.  We know that antibiotic resistance is becoming more and more of a serious threat. If there is a way that we may reduce the number of  antibiotic prescriptions that could have a significant impact on fighting/reducing resistance.

Reference:

Meeker D, Linder JA, Fox CR, et al. Affect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices. JAMA 2016; 315(6):562-570.

Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices

Improving Outpatient Antibiotic Prescribing

Over 250 millions antibiotic medications are prescribed each year and a large percentage of these prescriptions are unnecessary. Unneeded and extended antibiotic use can lead to adverse drug effects and antibacterial-resistant infections. There are regulatory agencies that require acute care hospitals to have stewardship programs to improve antibiotic use. Unfortunately, the majority of antibiotic use occurs in the outpatient setting where there are no steward programs.

A study over 18 months was completed to compare the effect of behavioral interventions that occurred after an antibiotic was prescribed for a respiratory tract infection. The interventions were suggested alternatives to antibiotic use, accountable justification for antibiotic treatment, and peer comparison by other providers. Inappropriate prescribing decreased from 22% to 6% with suggested alternatives, from 23% to 5% with accountable justification, and from 20% to 4% with peer comparison. The control group also had a decrease from 24% to 13%.

This study justifies further investigation to create interventions to decrease inappropriate antibiotic use. This includes specifying tactics toward each outpatient clinics and certain common antibiotics. A suggestion is to require clinicians to justify every prescription for antibiotics with indication documentation and comparison with peers.

This is very interesting. If all prescribers were required to justify their prescriptions, I believe that there would be less antibiotic use. Additionally, the prescribers could provide the pharmacists with test results if applicable, proving that an antibiotic is needed. This would greatly reduce antibiotic resistance and the related complications. Can you think of any cons to this solution?

JAMA. doi: 10.1001/jama.2016.0430. (accessed 11 Feb 2016). 

Host gene expression classifiers diagnose acute respiratory illness etiology

Antibiotic resistance is becoming an increasingly hot topic in the news.  The drugs we have been using in the last few decades are starting to face some serious problems with the development of various antibiotic-resistant super bugs.  A great deal of research has been conducted lately regarding ways we can curb this trend to ensure the medications we have will be able to work long into the future.

One cause of growing antibiotic resistant is the mis-diagnosis and subsequent mis-treatment of common respiratory infections.  Often when a patient visits the doctor with this kind of illness, the doctor will prescribe antibiotics without determining if the infection is actually bacterial based or viral based.  A recent article looked at a possible test that could distinguish between the two types of infections, therefore leading to more accurate treatment and curbing inappropriate use of antibiotics.

The researchers analyzed host RNA looking for identifiers that would indicate whether the host, or patient, was responding to a bacterial or viral infection.  It analyzed data on what genes are expressed or over-expressed during each kind of infection to set classifications by which they would be able to analyze the subject’s genetics.

Using these new classifications the prediction of infection type overall in subjects was 87% accurate.

I feel like this could be an extremely impactful test if it becomes implemented in the community setting.  I know so many friends who simply expect antibiotics from their physician when they have a cough.  This puts pressure on the physician to prescribe even if they are not sure of the diagnosis.  With this test it would aid physicians in making a firm diagnosis that they could explain to the patients, curbing inappropriate antibiotic use for viral respiratory infections.

Overall, it seems like this would be a worthwhile test to implement. What problems could arise with the implementation of such a test in a physician’s office?

Tsalik EL, Henao R, Nichols M, et al. Host gene expression classifiers diagnose acute respiratory illness etiology. Sci Transl Med. 2016;8:1-11.

http://stm.sciencemag.org/content/8/322/322ra11

Battling increasing cases of multi-drug resistant tuberculosis by modifying current treatments

With the upcoming renewal of our TB tests, I thought this article was appropriate. Mycobacterium tuberculosis (Mtb) infects one-third of the world’s population and accounted for 1.5 million deaths in 2013. Recently, first line treatments of TB are decreasing as multidrug-resistant strains are increasing worldwide. Therefore it is imperative to begin researching how to alter and modify our current treatments to combat drug-resistant strains. Fluoroquinolone antibacterials, such as our top drug ciprofloxacin, target DNA gyrase and are used to treat tuberculosis. DNA gyrase alters the coiling of DNA by breaking its strands and then resealing them. Quinolones work by targeting tuberculosis gyrase and preventing the resealing of the DNA, therefore causing the bacteria to die.

In this study, researchers used x-ray crystallography to generate 3-D models of how TB’s gyrase interacts with various drugs. Through this modeling, researchers have discovered two different sites where drugs could potentially interact. However, they found that current drugs only interact with one of the sites, revealing the untapped potential of the other site, or even the possibility of altering current drugs to interact with both sites at once, therefore decreasing the risk of the bacteria developing resistance. Because of this study, researchers have more information on how quinolones work and have a direction to focus their attention on in an attempt to fight tuberculosis antibiotic resistance.

Blower TR, Williamson BH, Kerns RJ et al. Crystal structure and stability of gyrase-fluoroquinolone cleaved complexes from mycobacterium tuberculosis. PNAS. 2016; published ahead of print January 20, 2016.

Link to article

Pharmacists Help Encourage Short Term Antibiotic Regimines

This study aimed to reduce the duration of antibiotics prescribed to children with uncomplicated skin and skin structure infections. Uncomplicated skin and skin structure infections, or uSSTIs, usually are treated with antibiotic therapy and include simple abscesses, cellulitis, impetiginous lesions, and furuncles. Complicated skin structure and skin structure infections (cSSTIs) affect deeper skin or are considered complicated in an immune-deficient patient. These include major abscesses, infected burns and ulcers, other infected wounds, and diabetic foot infections. The guidelines from Infectious Diseases Society of America for the management of SSTIS suggest a 5 day course of antibiotic treatment for uSSTIs, and can be extended if improvement is not made. The short antibiotic courses can help prevent antibiotic resistant bacteria from forming, lower costs, and reduce adverse effects. This study took place at the Cincinnati Children’s Hospital Medical Center, and aimed to increase short course antibiotic treatment (less than 7 days) in patients who came in with uSSTIs, compared to the previously used long-course therapy which lasts 7 to 14 days. At the beginning of this study 23% of patients with uSSTIs were prescribed short course antibiotic treatment.

To accomplish the study’s goal, they used a few methods. First, they had two 15-minute information sessions with residents and attendants. They also attached information cards about optimal antibiotic regimens for SSTIs to medical personnel’s identification badges. Pharmacists identified the third intervention as part of a multidisciplinary team, who noted that the order set default for uSSTIs was a 14-day course of therapy. The last intervention method was having a team member from the study contacting the physicians attending to SSTI patients and reiterating that short term antibiotic therapies can be used for uSSTIs, and to contact them with any questions. 5 months after the project began, 74% of patients with uSSTIs were discharged with the short term antibiotic therapies, and there was no significant difference in the amount of readmissions or recurrence for those who received the short term antibiotic treatment.

I really thought that this article showed the importance of pharmacists as part of a healthcare team, and how pharmacists can contribute innovative practices to medication changes. While changing the automatic duration of therapy in the prescribing system may seem simple, it can remind and alert the physician about the benefits of short term antibiotics and lead to less human error and increased savings. Also, this was the first time I had heard about short-term antibiotic regimens. While at first it seemed a little strange to me since I’ve been taught a lot about the importance of finishing antibiotic treatments to avoid resistance, it makes sense that shorter term antibiotic regimens would lead to increased patient adherence. Do you think that any of these methods could be implemented into a community pharmacy setting? Could pharmacists have played a more important role in this study, perhaps by educating pharmacists as well so that they can perform interventions when filling out prescriptions?

 

Citation: Schuler CL, Courter JD, Conneely SE, et al. Decreasing Duration of Antibiotic Prescribing for Uncomplicated Skin and Soft Tissue Infections. Pediatrics. doi: 10.1542/peds.2015-1223 (published 18 January 2016).

 

Link: http://pediatrics.aappublications.org/content/early/2016/01/15/peds.2015-1223