ASP Scan (Weekly) for Apr 28, 2017

Antimicrobial resistance plan in India
;
High MDR prevalence in asylum seekers
;
Colistin rapid test
;
Urologist overprescribing
;
Staph aureus antibiotic
;
Drug-resistance sepsis risks
;
Preventive antimicrobial use

Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans

India launches national plan to fight antimicrobial resistance

Originally published by CIDRAP News Apr 26

India's health ministry has announced the launch of a nationwide, multi-sectoral effort to curb antimicrobial resistance.

According to the British Medical Journal (BMJ), the National Action Plan on Antimicrobial Resistance aims to tackle antibiotic misuse in the country's human and animal health sectors and boost infection control and antimicrobial surveillance. The effort will involve multiple government agencies, including those that are responsible for health, the environment, agriculture, and education.

BMJ reports that the plan calls for the enforcement of regulations that prohibit the sale of antibiotics without prescriptions and promote guidelines for appropriate use, the establishment of national surveillance systems, and the introduction of lessons on antimicrobial resistance and appropriate use in schools and colleges.

The plan also proposes the phase-out of non-therapeutic antibiotic use in food animals and regulations to reduce the spread of resistance elements into the environment from farms, healthcare facilities, and pharmaceutical manufacturing plants, according to the Times of India.

Although there is scant national data on antimicrobial resistance, it's widely seen as an emerging public health crisis in India, which has one of the highest infectious disease burdens in the world, poor sanitation, and is one of the largest consumers of antibiotics for human health. In addition, antimicrobial misuse is common in the country; doctors frequently prescribe antibiotics for diarrheal diseases and upper respiratory infections for which they have limited value, and many antibiotics can be purchased over-the-counter.

A 2016 essay in PLoS Medicine by Ramanan Laxminarayan, PhD, MPH, of the Center for Disease Dynamics, Economics and Policy noted a steep increase in methicillin-resistant Staphylococcus aureus (MRSA) isolates (from 29% in 2009 to 47% in 2014) and  high rates of resistance in Escherichia coli to ampicillin, naladixic acid, co-trimoxazole, and third-generation cephalosporins, along with rising resistance to carbapenems. Laxminarayan said the burden of resistance was likely focused on neonates and the elderly.

"Although accurate estimates of the overall burden of resistance are not available, it is estimated that 58,000 neonatal deaths are attributable to sepsis caused by drug-resistance to first-line antibiotics each year," Laxminarayan wrote.

Under a global action plan on antimicrobial resistance put forward by the World Health Organization (WHO) in 2015, WHO member states are being asked to have national plans in place by 2017.
Apr 26 BMJ article
Apr 24 Times of India article
March 2016 PLoS Med essay

 

High prevalence of multidrug-resistant organisms found in asylum seekers

Originally published by CIDRAP News Apr 26

Researchers in the Netherlands have found a high prevalence of multidrug-resistant organisms (MDROs) among asylum seekers, according to a study yesterday in PLoS One.

In a study that aimed to assess carriage rate of MRSA and multidrug-resistant Enterobacteriaceae (MDRE) among asylum seekers (mainly from the Middle East and North Africa), investigators analyzed all cultures performed in asylum seekers from January 2014 through December 2015 and compared them with cultures from Dutch patients at risk for carriage of MDROs. The cultures were obtained from screening samples and clinical samples that were collected to diagnose possible infection.

Among the isolates collected from 898 asylum seekers actively screened for MRSA and 118 who provided clinical samples, 10.3% were found to carry MRSA (9.7% in screened patients and 18.6% in clinical cultures). The general patient population (nearly 13,000 patients) was found to have a MRSA carriage rate of 2.1% (2.8% in screened patients and 1.3% in clinical cultures). Asylum seekers also had a much higher rate of MRSA strains harboring Pantone-Valentine leucocidin, a toxin associated with higher virulence.

Among the isolates from 751 asylum seekers who were screened for MDRE and 150 who provided clinical samples, 21.4% were positive for MDRE (21% in screened patients and 21.3% in clinical samples), compared to an MDRE carriage of 5.1% in more than 32,000 patients from the general population (24.4% in screened patients and 4.1% in clinical samples). Most the MDREs were extended-spectrum beta-lactamase producers.

The authors of the study suggest high MRSA and MDRE rates in asylum seekers may be due to high prevalence in their homelands, or could be the result of transmission among refugees, and say the findings support screening policies for MDROs in asylum seekers at Dutch hospitals.

"These differences justify screening of the asylum seekers’ population at admission in the hospital as these organisms may be a threat to the patient and transmission in the hospital should be prevented," the authors write.
Apr 25 PLoS One study

 

Test can detect colistin rapidly, cheaply

Originally published by CIDRAP News Apr 25

Data presented at the 27th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), which wrapped up today, suggest that equipment already owned by most hospitals can quickly and accurately detect resistance to last-resort antibiotics like colistin.

Researchers from Imperial College London tested two Enterobacteriacae strains, E coli and Klebsiella pneumoniae, for resistance to the class of antibiotics called polymixins, which includes colistin. In recent years MCR-1 and other genes that confer resistance to colistin have been increasingly reported.

The team analyzed 134 different colonies of bacteria using a mass spectrometer. Using test results, they were able to distinguish not only between bacteria that are colistin-resistant and those that are not, but also which bacteria have plasmid-encoded resistance. This type of resistance is especially worrisome because it can be passed from one type of bacteria to another type.

The investigators say the test can be carried out in about 15 minutes and would cost less than $1 per sample, according to an ECCMID press release yesterday. Author Gerald Larrouy-Maumus, PhD, said, "The exciting thing about this technique is that it relies on technology that is already available in most hospitals. This means that it could be rolled out quickly and cheaply, and potentially have a rapid impact on tackling drug resistance."
Apr 24 ECCMID abstract
Apr 24 ECCMID news release

 

German survey finds higher antibiotic prescribing by urologists

Originally published by CIDRAP News Apr 25

A survey of 18 German hospitals found that urologists prescribe antibiotics more frequently than other specialists, but almost a third of them would incorrectly prescribe broad-spectrum antibiotics to a woman who has an uncomplicated urinary tract infection.

Of 1,061 questionnaires targeted to general surgeons, internists, gynecologists, and urologists, 456 physicians responded, for a 43% response rate, according to the study in International Urology and Nephrology.

The share of urologists who prescribed antibiotics to more than five patients in the previous 7 workdays was 50.7%, compared with 24.3% for the other specialists. Urologists were more confident than the other physicians regarding dosage, frequency, and duration of antibiotic treatment, in interpreting antibiograms, and regarding local resistance patterns. Both urologists and non-urologists, though, had poor knowledge about antibiotic stewardship.

Despite this confidence, local rates of ciprofloxacin-resistant E coli strains were correctly categorized by only 36.3% and 31.2% of urologists and non-urologists, respectively. And 31.5% and 30.7% of urologists and non-urologists, respectively, would prescribe broad-spectrum antibiotics to a female patient who has an uncomplicated urinary tract infection. On the upside, urologists more often acknowledged the use of broad-spectrum antibiotic agents as a problem.

The authors conclude, "There is substantial need for advanced training regarding [multidrug-resistant organisms] and antibiotic stewardship, regardless of medical specialty."
Apr 21 Int Urol Nephrol study

 

Antibiotic shows promise for treating Staph aureus

Originally published by CIDRAP News Apr 25

Drug maker Theravance Biopharma, Inc., of Dublin, reported positive preliminary data  yesterday from an observational study designed to evaluate how telavancin, a US Food and Drug Administration–approved antibiotic for the treatment of skin infections and pneumonia caused by Staphylococcus aureus, is being used to treat patients in real-world settings.

The findings, presented at ECCMID, were based on a review of data from 593 patients diagnosed as having complicated skin and skin structure infections (cSSSIs), bone and joint infections, and lower respiratory tract infections (LRTIs). The company also announced additional findings from studies that evaluated the in vitro and in vivo potency of televancin—which is sold under the brand name Vibativ—against S aureus.

According a company press release yesterday, researchers reported positive clinical response in 75.3% of 279 patients with confirmed cSSSIs mainly caused by methicillin-resistant S aureus (MRSA) and methicillin-susceptible S aureus (MSSA), with telavancin generally being well-tolerated by patients. In 174 patients with confirmed bone and joint infections predominantly caused by MRSA and MSSA, the positive response rate was 68.4%, with 33 patients experiencing at least one adverse event and 7 patients having one serious adverse event. There were 3 deaths within 28 days of the first dose of the drug, and 20 patients discontinued treatment because of adverse events.

In 36 patients with LRTIs caused by hospital-acquired bacterial pneumonia, ventilator-associated bacterial pneumonia, and MRSA, researchers reported a positive clinical response for in 58.3% of patients treated with telavancin, with eight patients having at least one adverse event and four having at least one serious adverse event. Six patients died within 28 days of the first dose, and two patients discontinued treatment.

In findings presented today at ECCMID, researchers reported that telavancin demonstrated the greatest in vitro activity of all antibiotics evaluated against a global collection of difficult-to-treat S aureus clinical isolates, including MRSA and MSSA. They also reported that telavancin showed more potency than vancomycin against S aureus strains in neutropenic murine thigh and lung infection models.
Apr 24 Theravance Biopharma press release 
Apr 25 Theravance Biopharma press release

 

Long-term sepsis risks shown in patients colonized with resistant bacteria

Originally published by CIDRAP News Apr 24

People who've had drug-resistant bacteria detected in their urine or feces have a higher risk of developing a drug-resistant bloodstream infection for several years afterward, according to a study presented yesterday at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID).

In the study, researchers from the Karolinska Institute in Sweden examined all patients found to have extended-spectrum beta-lactamase producing Enterobacteriaceae (EPE) in their feces or urine from 2007 through 2012, and compared them to a cohort of individuals with no known EPE exposure. EPE are multidrug-resistant pathogens that frequently cause urinary tract and gastrointestinal infections and are a risk factor for subsequent bloodstream infections, but little is known about the long-term risks. All cases of EPE must be reported to the Swedish Public Health Agency.

Overall, the researchers found 22,000 patients with EPE in their feces or urine and followed them for 6 years. Compared with the 44,000 people who had no EPE exposure, patients with EPE in their feces or urine were 57 times and 113 times more likely to develop a bloodstream infection, respectively, with the risk being elevated for at least 3 years. Over the 6-year study period, 2% of patients with EPE in their stool and 4% with an EPE urinary tract infection went on to develop a bloodstream infection, compared with 0.02% in the general population.

"We found that the riskiest time was in the days and weeks after the bacteria were found in the urine or stool sample, but there is still an increased risk up to three years later," lead author Joakim Isendahl, a graduate student at Karolinska Institute, said in an ECCMID press release.

Isendahl suggested the drug-resistant bacteria could be spreading from urine and feces into the bloodstream, or sharing the enzymes that confer resistance to beta-lactams and other antibiotics with other bacteria in the body, which then cause the bloodstream infections.

Sepsis affects up to 30 million people each year and can be deadly if not treated quickly. Isendahl explained that knowing whether a bloodstream infection has been caused by drug-resistant bacteria can help guide proper antibiotic treatment and prevent overuse of last-resort antibiotics.
Apr 23 ECCMID abstract
Apr 22 ECCMID press release

 

German study notes high use of nonsurgical preventive antimicrobials

Originally published by CIDRAP News Apr 24

Antimicrobial prophylaxis—or using antibiotics and other drugs for preventing infections—outside the operating room accounts for a considerable share of total hospital antimicrobial use, according to a new study in BMC Infectious Diseases.

German investigators analyzed data on 1,020 antimicrobial prescriptions in a university hospital, of which 317 (31%) were given as prophylaxis. Of the 827 antibiotic prescriptions, 17.0% were prescribed for medical prophylaxis, 2.7% for other prevention related to nonsurgical interventions, and 6.9% for surgical prophylaxis. Of the 96 antiviral and 97 antifungal prescriptions, 42.7% and 57.8%, respectively, were for medical prophylaxis.

The study also found a high rate of adherence to protocols. For medical antibiotic prophylaxis, a protocol was followed in 118 of 125 cases (94.4%). For prophylaxis for other nonsurgical interventions and surgical prophylaxis on the wards, protocol adherence rates were 92.3% and 97.6%, respectively. Protocol adherence rates were 95.1% and 96.3%, respectively, for antiviral and antifungal prescriptions.

The authors conclude, "Antimicrobial prophylaxis outside the operating theatre is responsible for a considerable part of total in-hospital antimicrobial use."
Apr 21 BMC Infect Dis study

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