ASP Scan (Weekly) for Jan 26, 2018

No antibiotics for sore throat
;
Old antibiotic shows promise
;
Antibiotic-free fast food
;
Drug-resistant typhoid
;
Fecal transplant for recurrent C diff
;
Carbapenem reduction in France
;
CARB-X seeks partners
;
C diff in children
;
Resistant Acinetobacter
;
C diff reduction in long-term care
;
Costs of C diff

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

UK health officials advise against antibiotics for acute sore throat

New guidance today from the United Kingdom's National Institute for Health and Care Excellence (NICE) and Public Health England says general practitioners should not offer, and patients should not expect, antibiotics in most cases of acute sore throat.

The recommendations, aimed at limiting antibiotic use and reducing antimicrobial resistance, explain that acute sore throat (including pharyngitis and tonsillitis) is often self-limiting, most frequently triggered by a viral infection of the upper respiratory tract, and that most people will get better within a week without antibiotics. They advise physicians to explain to patients the usual course of acute sore throat and to recommend tips for management of symptoms. They also advise patients to seek medical help if symptoms worsen rapidly or don't improve after a week.

The guidance also lays out criteria for physicians to use when evaluating patients with acute sore throat. It recommends that patients who score low on clinical criteria scoring systems (0 or 1 points on FeverPAIN or 0,1, or 2 on Centor) should not receive an antibiotic and should be advised to drink adequate fluids and consider pain relievers and medicated lozenges. Patients with FeverPAIN scores of 2 or 3 should be given a back-up antibiotic prescription if their symptoms don't improve in 3 to 5 days. For patients most likely to benefit from an antibiotic (those with a FeverPAIN score or 4 or 5 or a Centor score of 3 or 4), the guidance calls for an immediate antibiotic, taking into account possible adverse effects and the unlikely event of complications if antibiotics are withheld.

"We are living in a world where bacteria are becoming more resistant to antibiotics," Gillian Leng, deputy chief executive at NICE, told the BBC. "It is vital these medicines are protected, and only used when they are effective."
Jan 26 NICE guidance on acute sore throat
Jan 26 BBC 
story

 

Australian scientists find potential in a neglected class of antibiotics

Australian scientists report that a synthetic version of a neglected class of antibiotics showed efficacy against multidrug-resistant (MDR) bacteria in preclinical tests, according to a study today in Cell Chemical Biology.

In the study, scientists from the University of Queensland identified the biosynthetic pathway of octapeptins, a family of lipopeptide antibiotics that were discovered nearly four decades ago and are structurally related to the last-resort antibiotic colistin. Octapeptins displayed activity against gram-negative bacteria in several studies but were ultimately neglected due to a proliferation of other antibiotics.

In vitro testing against a panel of MDR bacteria revealed that one of the octapeptins identified, octapeptin C4, was more effective than colisitin against polymixin-resistant isolates of Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae, but was not as effective against polymixin-resistant P aeruginosa in a mouse blood infection model, most likely due to high plasma protein binding. The scientists then designed a synthetic octapeptin with a similar structure to octapeptin C4 but reduced plasma protein binding that showed dramatically improved in vivo activity.

"Our in vitro and in vivo efficacy data indicate the significant potential of novel octapeptin-like lipopeptides as new antibiotics against polymyxin-resistant Gram-negative superbugs," the authors of the study write. They also note that octapeptins are potentially less toxic to the kidneys than colistin and polymixin B
Jan 26 Cell Chem Biol abstract

 

Consumer group urges McDonald's to detail an antibiotic-free-meat plan

As part of the launch of a national campaign, the consumer and public health advocacy group US PIRG Education Fund is calling on McDonald's Corp to commit to a specific timeline to phase out routine use of medically important antibiotics in its beef and pork supply chain, US PIRG (Public Interest Research Group) said in a news release yesterday.

The organization is spotlighting McDonald's because of its "outsized influence" as the largest US buyer of beef and has only a vague long-term antibiotics plan. Public health experts across the globe have warned that routine use of antibiotics in food animals helps spur antimicrobial resistance in a wide range of pathogens and poses a distinct threat to people.

"Protecting antibiotics requires action, not reaction. If we don't act now to preserve the effectiveness of these medicines, we'll face a world in which common infections once again kill," said Matthew Wellington, antibiotics program director for US PIRG Education Fund. "The Big Mac can make a big dent in stopping the misuse of antibiotics in our food system," he added, referring to McDonald's flagship hamburger.

As part of its "Hold the Antibiotics" campaign launch, US PIRG has had nearly 10,000 people sign a petition to support its efforts. The group's state affiliates also held events in front of McDonald's franchises across the country to educate people about the perils of antibiotic-resistant bacteria and the important role that McDonald's can play.

In August 2017, McDonald's announced that it will phase out use of highest-value human antibiotics in its global chicken supply, after having reached its US goal of serving broiler chickens raised without antibiotics in 2016. It has also signaled that it would take similar actions for its supply of beef, dairy cows, pork, and laying hens.
Jan 25 US PIRG news release
Aug 24, 2017, CIDRAP News story "McDonald's expands antibiotic-cutting steps globally"

 

Officials in India announce world's first drug-resistant typhoid outbreak

Originally published by CIDRAP News Jan 25

In what is being called the world's first outbreak of drug-resistant typhoid, more than 100 children are sick and dozens have died in Hyderabad, India, The News International, which is based in Pakistan, reported yesterday.

"Typhoid cases resistant to third-generation antibiotic Ceftriaxone have been reported from different areas of Hyderabad, but so far we’re unable to find its source," Health Services Sindh Director General Dr Muhammad Akhlaq Khan said.

"Children in the age group of 2-10 years are being affected by this type of disease, but so far we don't have any exact data on the deaths caused by this lethal disease." Scientists at Aga Khan University (AKU) in Karachi, Pakistan, blamed the outbreak on contaminated water, but the Sindh Health Department has ruled that cause out, the story said.

No official case count has been cited, but the city's health department and local gastroenterologists have said more than 100 drug-resistant cases have been reported since November 2016, compared with only 6 cases from 2009 to 2014. The health department, in collaboration with AKU, has launched a mass vaccination campaign aimed at immunizing 250,000 children in the district.

Typhoid is mainly caused by Salmonella enterica serotype Typhi bacteria. About 8 million people live in the Hyderabad metropolitan area.
Jan 24 News International story

 

Bowel disease, antibiotics tied to fecal transplant for recurrent C difficile

Originally published by CIDRAP News Jan 25

A single-center study in Rhode Island found several risk factors, including inflammatory bowel disease and the use of metronidazole, for fecal microbiota transplantation (FMT) to address recurrent Clostridium difficile infection (CDI), according to a study yesterday in Infection Control and Hospital Epidemiology.

The retrospective study compared 200 adults who underwent FMT for recurrent CDI to 75 patients who did not. The strongest risk factors for FMT for recurrent CDI were concomitant inflammatory bowel disease (P = .002), use of immunosuppressive therapy (P = .04), and use of metronidazole within 2 months before the first CDI (P = .02). The use of vancomycin for the first CDI was also a potential risk factor.

The authors concluded, "This study provides important insights into the factors predictive for FMT in patients with recurrent CDI and highlights the potential racial and medical characteristics that affect the access of the patients to FMT."
Jan 24 Infect Control Hosp Epidemiol study

 

Study finds reduced carbapenem consumption in French hospitals
Originally published by CIDRAP News Jan 23

Researchers in France report that a reduction in carbapenem consumption in French hospitals occurred after the release of national guidelines on carbapenem use in 2010, according to a study yesterday in Antimicrobial Resistance and Infection Control. They suggest that further carbapenem reduction could be linked to reduced use of fluoroquinolones and third-generation cephalosporins (3GCs).

The ward-level multicenter retrospective study, which sought to determine factors associated with reduced carbapenem use in intensive care units (ICUs), medical wards, and surgical wards from 2009 through 2013, was based on data from French surveillance networks of antibiotics and multidrug-resistant bacteria in healthcare facilities. France released guidelines to limit the use of carbapenems in 2010, in response to a rise in carbapenemase-producing Enterobacteriaceae that's been driven in part by a 145% increase in carbapenem use since 2000. The increase in carbapenem use was in response to the spread of extended-spectrum beta-lactamase–producing Enterobacteriaceae (ESBL-PE).

A total of 493 wards from 259 healthcare facilities were included in the study (85 ICUs, 227 medical wards, and 181 surgical wards). Overall carbapenem consumption over the study period was equal to 73.4 defined daily doses per 1,000 patient days for ICUs, compared with 6.2 in medical wards and 5.4 in surgical wards. While the overall trend showed an increase in carbapenem use from 2009 through 2013 in all wards, the period following release of the guidelines (2011-2013) showed a 2.9% decrease in carbapenem use in ICUs and 1.6% decrease in medical wards. Carbapenem use continued to rise in surgical wards, but the annual growth rate declined from 17.8% to 2.7%.

In multivariable analysis, factors associated with a higher probability of reducing carbapenem consumption included a geographic location in eastern France, a higher initial carbapenem-prescribing profile, and reductions in consumption of fluoroquinolones, glycopeptides, and piperacillin/tazobactam. A higher initial prescribing profile for 3GCs and location in high-risk regions for ESBL-PEs were associated with a lower probability of reducing carbapenem use. The authors note that this finding is explained by ESBL-PE risk, which is promoted by 3GC use and thus leads to more frequent carbapenem prescribing.

The authors conclude, "Our study, carried out on a national scale, in a large number of hospital wards, suggests that a decrease in 3GC proportion in the overall antibiotic use, as well as the continuation of the reduction in fluoroquinolone use, could allow reducing ward-level carbapenem use." 
Jan 22 Antimicrob Resist Infect Control study

 

CARB-X seeks partners to support antibiotic development

Originally published by CIDRAP News Jan 23

CARB-X, the public-private initiative that provides financial and technical support to companies in the early stages of antibiotic discovery and development, is looking to partner with additional accelerator organizations to support its pipeline of research projects.

According to a press release today from CARB-X (the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator), the new accelerators are expected to provide a broad range of support to the 22 active research projects in the Powered by CARB-X portfolio. CARB-X says more projects will be added in the coming months.

"Our accelerator partners are essential to CARB-X's mission, providing guidance and expertise to help partner companies accelerate their research and deliver new life-saving antibiotics, vaccines, diagnostics, and other products to patients," CARB-X Executive Director Kevin Outterson, JD, said in the press release.

To date, CARB-X has awarded more than $60 million to help fund early research in new antibiotics, vaccines, and rapid diagnostics to treat drug-resistant infections. The organization is looking to partner with up to six additional accelerator partners in Europe, North America, and the rest of the world. 
Jan 23 CARB-X press release

 

Single-center study finds low levels of C difficile transmission in kids

Originally published by CIDRAP News Jan 23

A single-center Clostridium difficile infection (CDI) study from Northwestern University in Chicago found transmission among symptomatic children uncommon, and they noted that investigation of shared healthcare exposures often did not identify a potential transmission source, according to a study today in Clinical Infectious Diseases.

The investigators performed whole-genome sequencing on C difficile isolates collected from children diagnosed as having CDI from December 2012 to December 2013. Among 131 CDIs in 107 children, the authors identified 104 genetically distinct isolates. Of 84 CDIs occurring 8 weeks or longer after the start of the study, only 10 (11.9%) were caused by a strain similar to another isolate, which would indicate likely in-hospital transmission. The researchers identified shared healthcare facility exposures in only 7 of those 10 cases.

The authors conclude, "C. difficile transmission among symptomatic children was very uncommon, and among putatively transmitted cases, investigation of shared healthcare exposures often did not identify a potential transmission source."
Jan 23 Clin Infect Dis abstract

 

Deadly outbreak of resistant Acinetobacter frequently involved pneumonia

Originally published by CIDRAP News Jan 23

A separate study yesterday in Antimicrobial Resistance and Infection Control determined that multidrug-resistant A baumannii (MDR-Ab) infections in a Beirut hospital from 2007 through 2014 mostly consisted of ventilator-associated pneumonia and killed up to two thirds of patients.

The researchers conducted a case-control study after MDR-Ab cases more than doubled at the American University of Beirut Medical Center ICU in 2007. That study involved patients diagnosed as having MDR-Ab in 2007 and 2008. The team also conducted a prospective study of MDR-Ab spread in the ICU in 2007 through 2014. The studies included 128 cases collectively and 99 patients who had MDR-Ab colonization but no evidence of active infection.

The vast majority—84%—of cases were deemed hospital acquired, and 53% were ventilator-associated pneumonia. Mortality rates ranged from 52% to 66%. The investigators listed a range because "it was difficult to calculate the attributable mortality due to the fact that many patients were critically ill with multiple comorbid conditions."

The authors concluded, "Infection control measures should be reinforced to control the transmission of these organisms in the ICU."
Jan 22 Antimicrob Resist Infect Control study

 

C diff prevention initiative helps reduce rates in VA facilities

Originally published by CIDRAP News Jan 22

A significant decrease in rates of clinically confirmed long-term care facility onset CDI at 132 Veteran's Affairs facilities coincided with implementation of a nationwide prevention initiative, researchers report in a new study in Infection Control and Hospital Epidemiology.

The initiative for prevention of CDI in VA long-term care facilities (LTCFs) was implemented in February 2014 following implementation in VA acute care facilities in July 2012. The initiative, which emphasizes environmental management, hand hygiene, contact precautions, and institutional culture change, was extended and tailored to VA LTCFs because they are often linked to VA acute care facilities, where CDI has become the most common healthcare-associated infection. To evaluate the impact of the initiative, the researchers analyzed quarterly CDI trends from the first 33 months of the program and compared them with the 2 years prior to implementation.

The analysis found that there were 137,289 admissions, 9,288,098 resident days, and 1,373 clinically confirmed LTCF-onset CDI cases from April 2014 through December 2016. The nationwide number of clinically confirmed LTCF-onset CDI cases did not change in the 2 years prior to implementation of the prevention initiative but decreased by 36.1% over the 33-month analysis period.

The results mirror the experience in VA acute care facilities, which saw a 15% drop in hospital-acquired CDI cases over the first 33 months of the prevention initiative, and the authors note that this may have had an impact on their findings, along with strong leadership from the VA Central Office and individual facility accountability. 

"The exact reason for the decrease in cases within the VA LTCFs is not known," they write. "Given the large number of facilities involved and the long observation period, we were not able to collect data on individual facility activities or sustainability of activities; hence, we cannot report a 'magic bullet' responsible for the declining trend."
Jan 21 Infect Control Hosp Epidemiol abstract

 

Study shows substantial burden of primary, recurrent C diff

Originally published by CIDRAP News Jan 22

In another study on CDI, researchers with Merck's Center for Observational and Real World Evidence estimated the healthcare resource utilization (HCRU) and costs attributable to primary CDI and recurrent CDI (rCDI).

In the retrospective observational study, published in Clinical Infectious Diseases, the researchers analyzed administrative claims data from two commercial databases representing nearly 50 million individuals with private health insurance. To obtain hospitalized days and costs attributable to primary CDI, patients without CDI were matched 1:1 by propensity score to those with primary CDI but no recurrences. To obtain hospitalized days and costs associated with rCDI, patients with primary CDI but no recurrences were matched 1:1 to those with primary CDI plus one recurrence.

A total of 55,504 CDI patients were identified from July 2010 through June 2014, and among those patients 24.8% had a recurrence. Compared to those patients without CDI, the cumulative hospitalized days and healthcare costs attributable to primary CDI were 5.20 days and $24,205. Compared to those patients with primary CDI only, the cumulative hospitalized days and healthcare costs attributable to rCDI were 1.95 days and $10,580.

"In conclusion, the HCRU and economic burden associated with primary and rCDI are quite substantial," the authors write. "Better prevention and treatment of CDI, especially rCDI, are needed."
Jan 19 Clin Infect Dis study

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