Will Antimicrobial Stewardship be the Next Target for De-implementation?

First, an honest confession, Mike's tweet had nothing to do with antimicrobial stewardship, but rather contact precautions. But his point is just as valid when discussing antimicrobial stewardship and there will come a time when forces will align to question the benefits and costs of stewardship programs since now and in the future they will lack the "necessary" cluster-randomized trial evidence supporting their existence.

There is a longer discussion to be had here sometime in the future, when I'm not writing a Center grant renewal, but the key question is what we consider "high-level" evidence. For most de-implementation supporters and indeed most infection control and stewardship guideline authors, high-level evidence is synonymous with individual or cluster-randomized trials. They simply cannot accept non-randomized, quasi-experimental designs as evidence. It is gotten to the point that the recent CDI Guidelines completely excluded quasi-expermintal designs from their level of evidence figure, despite the fact that one of the original Grade Criteria papers lists QE studies in its table and allows them to be ranked higher than RCTs, if certain criteria are met.

OK.  So why am I rambling on about level of evidence and misapplying a tweet from 2 weeks ago? There was a new systematic review just published in AJIC by Leandro Bertollo and colleagues that asked the question: "Are antimicrobial stewardship programs effective strategies for preventing antibiotic resistance?" To answer this question they reviewed all studies published between from January 2012 to January 2017 and followed the standard PRISMA statement recommendations for reporting their findings.

Results: They identified and extracted data from 26 studies, of which 22 were single-center and four were multicenter studies. Study designs are listed in Table 2, below, with the special note that none of the before/after studies included a contemporaneous, unexposed control group. A major concern that the authors identified was that in 7 of the 26 studies (30%), there was evidence that infection control interventions were implemented at the same time as the stewardship intervention and that the majority (57%) of the stewardship studies that reported positive results were confounded by simultaneous implementation of new infection control practices. High fives for hand hygiene.

Their conclusion: "There is no solid evidence that ASPs are effective in reducing antibiotic resistance in hospital settings. There are still few studies analyzing this matter, most of them with inappropriate study designs. We uphold the need for more studies with appropriate study designs and standardized ASP interventions targeting common microorganism-antibiotic pairs."

The need for more studies. Sounds like the siren call for de-implementation to me. Sure, we can wait around a decade or four for some magical $20 million cluster-randomized study that swabs all patients on admission/discharge, completes a full microbiome analysis and tracks patients for a year post discharge for resistant infections. Or, we can expand our ideas around what "high-level" evidence means and fund well-designed and controlled quasi-experimental studies and also consider strong epidemiological evidence, such as exposure to antibiotics leads to colonization with resistant pathogens. We can be logical. Yeah, not gonna happen. But at least you were warned.

We need to implement shoe decontamination interventions!

You pass through places and places pass through you 

But you carry them with you on the soles of your travelers shoes

"The Littlest Birds" - The Be Good Tanyas

I know we really shouldn't be looking for other interventions to reduce pathogen transmission in hospitals since we're too busy eliminating contact precautions at the moment. But I can't resist highlighting this recent systematic review on contamination of shoe soles from Tasnuva Rashid and colleagues published in Journal of Applied Microbiology. 

The authors reviewed the published literature from 1946 through 2015 to identify studies evaluating (1) shoes as vectors for infectious pathogens and (2) evidence on possible decontamination strategies.  Their extensive review identified 13 studies (10 cross-sectional and 3 longitudinal) for inclusion. Three studies were completed in hospitals. One study found MRSA and VRE on 56% of physician shoes before rounds and 65% after rounds. Two additional studies found significant contamination of operating theater shoes with pathogens including staphylococcus, streptococcus and bacillus species. It doesn't get any better when looking at shoes worn in the community with significant contamination by C. difficile (40%), Listeria spp., Salmonella spp., and E. coli. I won't even mention the contamination found on the shoes of folks that work with animals. 

Possible interventions evaluated include placing chemical filled mats in OR and ward entry points and shoe covers. While the reviewed studies suggest possible benefits for these interventions, more studies are needed. Of course, you know where I'm heading based on my intro paragraph - we need to implement shoe covers and chemical mats immediately in all hospitals. The data is clearly just as compelling as eliminating contact precautions based on single center studies. Oh, and we can fund these new shoe-targeted interventions using the savings generated through the elimination of contact precautions. Awesome!

Guest Post: AHRQ Report Calls for Environmental Cleaning Research

This guest post was written by Alexandra McGhie, Megan Campbell and Nick Graves to highlight a new AHRQ Report as it relates to an NHMRC (Australia) Partnership Grant led by Queensland University of Technology (QUT) & The Wesley-St. Andrew’s Research Institute (WSARI) called REACH.

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New report calls for further research examining the impact of environmental cleaning interventions on Healthcare Associated Infection (HAI) rates

A new report by the US Agency for Healthcare Research and Quality (AHRQ) calls for further studies on emerging strategies for environmental cleaning and their impact on healthcare associated infection rates.

The report, Environmental Cleaning for the Prevention of Healthcare-Associated Infections (Technical Brief Number 22) details a systematic review of 80 studies that aimed to  determine the evidence base and comparative effectiveness of environmental cleaning methods and monitoring strategies of frequent touch surfaces in hospital rooms. The report concluded there was a lack of studies directly comparing cleaning methods and monitoring strategies, and calls upon the research community to undertake further research that:

·       Examines and compares emerging strategies (including ATP and UV light technologies).

·       Includes patient colonisation and infection rates as outcome measures.

·       Identifies surfaces in hospital rooms posing the greatest risk of pathogen transmission.

·       Examines factors that affect the real-world implementation of cleaning interventions (organizational culture, training, feedback).

An obvious omission to the report is that the value for money of any change to practice is not considered. Current health spending growth will not continue as it has. And infection prevention communities must think about the returns per dollar spent on new programmes.

Both effectiveness and cost-effectiveness evidence for a new ‘bundle’ approach to hospital cleaning will be generated by the REACH project. The effect on the transmission of healthcare associated infections (HAIs) in eleven Australian hospitals will be estimated and the value for money assessed.

The randomised controlled trial funded by the an NHMRC Partnership grant (GNT1076006) is led by QUT and The Wesley-St. Andrew’s Research Institute (WSARI) in conjunction with industry, policy and professional partners.

For more information about the REACH Project, please visit:  http://reach.cre-rhai.org.au/

The post originally appeared on the AusHSI Blog.

Stewardship Effective in C. difficile Prevention: A Meta-Analysis

As Dan mentioned last week, when 15% of asymptomatic hospitalized adults carry toxigenic strains of Clostridium difficile, it should alert us to focus on antimicrobial stewardship as a way to prevent CDI. But how effective are stewardship programs and does it matter what type of program you implement in your hospital? If only there was some sort of systematic review or meta-analysis to guide or decision making.

As if on queue, Leah Feazel and Marin Schweizer at University of Iowa published such a review and meta-analysis titled "Effect of antibiotic stewardship programmes on Clostridium difficile incidence" in JAC earlier this spring. Typical of projects completed by Marin and her group, they thoroughly combed the literature for papers. Here they identified 891 articles, reviewed 78 full articles and included 16 studies in their final analysis. Over all, stewardship programs were associated with a 52% reduction in CDI incidence. Importantly, programs appeared effective when implemented in whole hospital or geriatric settings and when utilizing a persuasive approach or a restrictive approach. I've provided the forest plot of studies below. An additional note is that the studies utilized various quasi-experimental study designs and based on the funnel plot, there appeared to be little publication bias.

Key points: (1) Stewardship works for CDI prevention, but it would have been nice if there was at least one funded RCT or cluster-RCT. (2) The meta-analytic approach, that Marin has pushed through her reviews of SSI bundles and hand hygiene interventions, is a fantastic way to guide medical decision making and should be considered for inclusion in future HAI guidelines. The reality is that infection prevention studies overwhelmingly utilize quasi-experimental designs. Why not identify the highest-quality QE studies and rigorously meta-analyze them as done here?