CDC Antibiotic Use Data Shows Progress, But Significant Challenges Remain

The Centers for Disease Control and Prevention (CDC) has issued a report on antibiotic use in the United States.

The report ­­­— Antibiotic Use in the United States: Progress and Opportunities, 2018 Update —is an update to the antibiotic stewardship report CDC issued in 2017.

Below are some of the key takeaways from this year's report.

1. Outpatient antibiotic prescribing remains a problem, although some improvement has been made. According to 2016 outpatient antibiotic prescribing data, about 47 million antibiotic courses are prescribed in doctors' offices and emergency departments annually for infections that do not require antibiotics. That's about 30% of all antibiotics prescribed. Some good news: Outpatient antibiotic prescribing has improved a bit, with a 5% national decrease from 2011 to 2016.

2. Hospitals are more committed to antibiotic stewardship. According to 2017 hospital antibiotic stewardship program data, the number of hospitals reporting an antibiotic stewardship program meeting all of CDC's "Core Elements of Hospital Antibiotic Stewardship Programs" almost doubled from 2014 to 2017. Slightly more than three out of every four acute-care hospitals reported uptake of all seven core elements. While that's encouraging, significant work remains: The national goal is 100% by 2020.

3. Urgent care centers are a significant source of unnecessary antibiotics for respiratory illnesses. A study of antibiotic prescribing for respiratory illnesses by four outpatient settings — urgent care centers, emergency departments (EDs), retail health clinics and traditional medical offices — found that urgent care centers prescribed antibiotics unnecessarily 46% of the time. This compared to 25% in EDs, 17% in medical offices and 14% in retail health clinics.

4. Fluoroquinolones prescribing remains problematic. A study found that fluoroquinolones are routinely and unnecessarily prescribed for urinary tract infections (UTIs) and respiratory conditions. About 5% of all fluoroquinolone antibiotics prescribed for adults in medical offices and EDs in 2014 were unnecessary; furthermore, about 20% of all fluoroquinolone prescriptions in these settings were not the recommended first-line treatment.

Fluoroquinolones are not the recommended first-line treatment for UTIs or sinusitis. Yet, these conditions accounted for an estimated 6.3 million prescriptions in 2014. Fluoroquinolones were the most commonly prescribed antibiotic for UTIs. Colds and bronchitis, which should never be treated with antibiotics, led to an estimated 1.6 million unnecessary fluoroquinolone prescriptions in medical offices and EDs.

5. A majority of antibiotic courses for sinus infections are longer than expected. A study found that nearly 70% of antibiotic courses for sinus infections were longer than recommended. Guidelines advise 5-7 days of antibiotic treatment for most sinus infections in adults. However, almost 70% of antibiotic prescriptions for sinus infections are for 10 days.

6. There is significant opportunity for improvement in antibiotic selection for children. A study found that azithromycin, a commonly prescribed antibiotic in children, is often prescribed when not recommended or when not the recommended first-line drug by clinical guidelines.

GI Societies Push Back Against NY Times Article on Duodenoscopes

Several national gastroenterology (GI) societies have issued a joint statement that challenges points raised in a recent article in The New York Times.

This article, as we previously wrote, primarily focused on the difficulty healthcare providers face in sterilizing duodenoscopes.

A letter to the editor, as well as a longer statement, written by the GI societies acknowledged the importance of pursuing solutions to eliminate infection risks associated with duodenoscopes, but pushed back on the article, saying that it "largely understates the value of duodenoscopes and the procedure they are used for: endoscopic retrograde cholangiopancreatography (ERCP)."

The societies argue for the importance and value of ERCP, stating that patients who undergo the procedure are often very ill and that the infection risks associated with sterilizing duodenoscopes do not outweigh the benefits of ERCP. Nearly 700,000 patients undergo ERCP annually, the statement notes.

Furthermore, the GI societies acknowledge that while they are working with the Food and Drug Administration (FDA) and industry to "identify and properly vet potential solutions," withdrawal of duodenoscopes in the meantime is "simply not feasible."

The letter is signed by the presidents of the American Society for Gastrointestinal Endoscopy (ASGE), American College of Gastroenterology (ACG), American Gastroenterological Association (AGA) and Society of Gastroenterology Nurses and Associates (SGNA).

Adult Immunization Schedules Receive Update

The Advisory Committee on Immunization Practices (ACIP), a committee within the Centers for Disease Control and Prevention (CDC), recently issued recommended updates to adult immunization schedules.

As an American College of Physicians (ACP) news release notes, noteworthy ACIP recommendations included the following:

• Raise the upper age for catch-up vaccination against HPV in men to age 26 years, which would mirror the recommendation for women.

• Patients 27-45 years of age should discuss receiving the HPV vaccine with their doctors.

• Administer the 13-valent pneumococcal conjugate vaccine (PCV13) "based on shared clinical decision making" in adults 65 years or older who do not have an immunocompromising condition and who have not previously received PCV13.

• Maintain that adults 65 years or older receive a dose of the 23-valent pneumococcal polysaccharide vaccine (PPSV23).

Recommendations also touched on the influenza, hepatitis B and hepatitis A vaccines, among others. View all of the recommendations approved at ACIP's June 2019 meeting here. View the 2019 recommended adult immunization schedule in the Annals of Internal Medicine here.

The recommendations must be reviewed and approved by the CDC director, with the final recommendation published in an upcoming Morbidity and Mortality Weekly Report.

August is National Immunization Awareness Month. In its news release, ACP reminds people that vaccinations are not just for children. ACP President Dr. Robert McLean is quoted as saying, "Many adults are not aware that they need vaccines throughout their lives and so have not received recommended vaccinations. Adults should get a seasonal flu shot and internists should use that opportunity to make sure their patients are up to date on the latest recommended immunizations."

Growing Reports of Hepatitis A: Guidance for Healthcare Facilities

Infection Control Consulting Services (ICCS) has been inundated with concerns from healthcare facilities regarding the increasing reports of hepatitis A in the nation. Florida, where ICCS is based, has seen its department of health recently take action in response.

On August 1, Florida's Surgeon General Dr. Scott Rivkees declared a Public Health Emergency to address the increase in hepatitis A cases in the state, which had reached nearly 2,600 reported cases as of July 27. This declaration builds upon a Public Health Advisory issued by the Florida Department of Health in November 2018 and reemphasizes the importance of the vaccination as the best way to prevent hepatitis A infection. Please note that a "public health emergency" is different from a "state of emergency."

At this time, the Centers for Disease Control and Prevention (CDC) has stated that healthcare workers (HCWs) are not perceived to be at high risk for hepatitis A and, therefore, there is no recommendation for HCWs to be vaccinated. However, it is reported that there is no harm in HCWs choosing to receive the vaccine and the decision should be made on an individual basis.

In terms of screening patients, this is an oral/fecal virus and potentially communicable prior to diagnosis. Some patients may present asymptomatic despite carrying the virus whilst others may show signs of mild to severe illness. Organizations should ask themselves whether it is best for their setting to ask patients if they have hepatitis A or are at risk for it.

While ICCS is not downplaying this viral illness, we need to keep in mind that hepatitis A is not a new infection threat and is still not prevalent in the general population. In fact, CDC is not advocating for food service workers to be vaccinated, which goes to show that CDC does not believe hepatitis A to be a significant general public health threat at this time. It is still of the utmost importance that you share information about hepatitis A with your HCWs. As noted, the cause for concern in the healthcare setting surrounds the handling of stool as well as the need to wash hands with soap and water versus using alcohol sanitizer.

To summarize, ICCS stresses the importance of reviewing current information, providing updates for staff and determining what's best for your setting (and, if necessary, developing policies). ICCS advises that HCWs should make their own decisions about obtaining the vaccine. Finally, ICCS continues to stress the importance of hand hygiene when dealing with all patients, regardless of their diagnoses or health status. 

If you have any questions about infection prevention practices, policies and processes for your organization, contact ICCS.

Study: No Infection Prevention Benefits of Antibiotic Cement for TKA

A study has shown that routine use of antibiotic-loaded bone cement in primary total knee arthroplasty (TKA) has no measurable impact on periprosthetic joint infection rates.

Published in The Journal of Arthroplasty, the study involved review of a consecutive series of patients undergoing cemented primary TKA at two hospitals from 2015 to 2017. More than 2,500 patients were analyzed.

Of the 2,500 patients, about 1,100 received antibiotic-loaded bone cement during their procedure. Researchers found there was no difference in periprosthetic joint infection rates between patients receiving and not receiving antibiotic cement. Furthermore, patients receiving the antibiotic cement had overall high procedure costs — by about $300.

As Healio reports, one of the study's authors — Dr. Michael Yayac — recently presented on the findings at the 29th annual Musculoskeletal Infection Society Annual Open Scientific Meeting. During the presentation, Healio quotes Dr. Yayac as saying, "Routine use of antibiotic cement is not cost effective in preventing infection in primary TKA and should be avoided with value-based alterative payment models that incentivize to reduce unnecessary costs. However, given that this was performed in a relatively healthy population at orthopedic specialty hospitals, further studies would be needed to determine [whether] certain high-risk patients would benefit from its use and would be considered a cost-effective measure."