ASP Scan (Weekly) for Mar 09, 2018

Animal antibiotic use in Cambodia
MDR bacteria in Italy
Guidance in C diff prevention
MCR-1, CPE in Portugal
New CARB-X funding
US antibiotic-resistance funds

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

Study finds widespread, arbitrary antimicrobial use in Cambodian pigs

Originally published by CIDRAP News Mar 8

A study yesterday in Antimicrobial Resistance and Infection Control reports widespread and arbitrary use of antibiotics on small-scale pig farms in Cambodia.

In the study, a team of Swedish and Cambodian researchers conducted a survey of small-scale pig farms in and around Phnom Penh to assess the farmers' knowledge, attitudes, and practices related to antibiotic use in pig production. In addition to asking the farmers to fill out a questionnaire, the researchers collected fecal samples from three healthy pigs at each farm, isolated Escherichia coliisolates from those samples, and tested the susceptibility of the isolates to 14 antibiotics.

The results showed that at least 70 different brands of antimicrobial drugs were used on the farms, with amoxicillin, tylosin, gentamicin, and colistin being the most commonly mentioned or kept by the farmers. While nearly all the respondents (99%) said antimicrobial use was necessary to keep pigs healthy, knowledge of antimicrobials and how they work was low, and antimicrobial use was mainly based on farmers' experiences. Around 66% of the farmers reported frequently self-adjusting treatment duration and dosage. Fewer than half (45%) had heard the term antimicrobial resistance.

The E coli isolates exhibited high prevalence of resistance to several antimicrobials considered critical for human medicine, including ampicillin (75%), ciprofloxacin (59%), and colistin (20%), and multidrug-resistance was found in 79% of the samples. Isolates on farms where antimicrobials were administered preventatively showed a higher prevalence of resistance, as did those from farms where entire groups of pigs were treated, rather than just sick individuals.

"These results confirm the hypothesis that non-rational use of antimicrobials results in higher prevalence of AMR and highlight the need for professional animal health systems that involve medically rational use of antimicrobials in emerging economies such as Cambodia," the authors conclude.
Mar 7 Antimicrob Resist Infect Control study


Italian study finds large reservoir of MDR bacteria in nursing homes

Originally published by CIDRAP News Mar 7

Researchers in Italy report widespread diffusion of multidrug-resistant (MDR) bacteria in residents from long-term care facilities (LTCFs) in three different northern Italian regions, according to a study yesterday in Antimicrobial Resistance and Infection Control.

The study, conducted in October and November of 2016, involved multicenter point prevalence screening in four LTCFs in the provinces of Milan, Piacenza, and Bolzano. The aim was to compare colonization frequencies with MDR bacteria in the facilities. The screening included Enterobacteriaceae expressing extended-spectrum beta-lactamases (ESBLs), high-level AmpC cephlasporinases, and carbapenemases, Pseudomonas aeruginosa or Acinetobacter baumannii with carbapenemases, methicillin-resistant Staphylococcus aureus (MRSA), or vancomycin-resistant enterococci (VRE).

Among the LTCF residents, 75.0% (78/104), 69.4% (84/121) and 66.1% (76/115) were colonized with at least one of the target organisms in LTCFs located in Milan, Piacenza, and Bolzano, respectively, and many residents had more than one organism. ESBL producers (60.5%, 66.1%, and 53.0%) were highly predominant, mainly belonging to E coli expressing CTX-M group-1 enzymes. Carbapenemase-producing enterobacteriaceae were found in 7.6%, 0.0%, and 1.6% of residents; carbapemenase-producing P aeruginosa and A baumannii were also detected. Colonization by MRSA (24.0%, 5.7%, and 14.8%) and VRE (20.2%, 0.8%, and 0.8%) was highly variable.

Variability between the facilities was partly attributed to different risk factors for MDR colonization, resident populations and staff/resident ratios, applied hygiene measures, and differences in the local antibiotic resistance epidemiology.

"This widespread diffusion of MDR bacteria in LTCFs of three Italian Provinces confirms that these healthcare facilities are an important reservoir for MDR organisms," the authors conclude. "Future efforts should focus on screening activities, infection control strategies tailored on the complex aspects of LTCFs and implementation of antibiotic stewardship programs."
Mar 6 Antimicrob Resist Infect Control abstract


European C diff guidance stresses stewardship, diagnostics, other steps

Originally published by CIDRAP News Mar 7

The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) has published new guidelines on preventing Clostridium difficile infection (CDI) in acute-care settings that include strong recommendations for a two-stage diagnostic test, surveillance with timely feedback, the use of personal protective equipment (PPE) in outbreak settings, and other steps.

Writing in Clinical Microbiology and Infection, the ESCMID panel of experts detailed their current literature review on interventions to control CDI in adults. In contrast to the previous ESCMID guideline on the topic, they used the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach to rate the quality of evidence.

The guidance includes 36 statements on preventing CDI, including 18 strong recommendations. Strong recommendations include a two-stage test to diagnose CDI, performance of surveillance with timely feedback, no screening of healthcare workers, the use of PPE in outbreak settings, implementation of contact precautions, introduction of daily environmental sporicidal disinfection and terminal disinfection of rooms in outbreak settings, antibiotic stewardship interventions, and education of healthcare workers, patients, and visitors on prevention measures. The experts said the highest quality of evidence grading was for antibiotic stewardship interventions.

"Overall the document aims to provide guidance to those responsible for institutional infection control programs, serving as a reference for best medical practice," lead author Sarah Tschudin-Sutter, MD, MSc, told CIDRAP News.
Mar 2 Clin Microbiol Infect guidance document


Klebsiella with MCR-1, carbapenemase genes found in Portuguese patients

Originally published by CIDRAP News Mar 6

Researchers in Portugal have identified 16 patients from a previously unnoticed hospital outbreak with carbapenemase-producing and MCR-1-producing Klebsiella pneumoniae, according to a case report yesterday in Emerging Infectious Diseases.

Using rectal swabs specimens from more than 5,000 patients admitted to Centro Hospitalar do Porto from October 2015 through July 2017, the researchers identified 359 carpenemase-producing Enterobacteriaceae (CPE) isolates from 283 patients. They then screened the isolates for other resistance genes, including MCR-1, which confers resistance to the last-resort antibiotic colistin.

Overall, the researchers found 26 carbapenemase-producing and MCR-1 producing K pneumoniaeisolates from samples collected from 16 patients; 17 isolates were colonizers (found in the patients' gastrointestinal tract) and 7 were from other parts of the body (3 in urine, 2 in blood, and 2 in other biologic fluids). The patients were 50-87 years of age, and their clinical history included prolonged hospitalization, complicated conditions, surgical intervention, and previous antibiotic use, but none had used colistin or traveled abroad before MCR-1 detection. Five patients developed infections.

In addition to colistin, the K pneumoniae isolates were resistant to third- and fourth-generation cephalosporins (100%), nalidixic acid (100%), ciprofloxacin (96%), tigecycline (96%), tetracycline (92%), tobramycin (88%), gentamicin (88%), fosfomycin (83%), trimethoprim/sulfamethoxazole (79%), and chloramphenicol (67%). All but one of the isolates belonged to K pneumoniae sequence type (ST) 45. In all of the isolates, the MCR-1 gene was located on an IncX4-type plasmid, which has been circulating among humans, pigs, and poultry in many different countries.

"High rates of CPE and colistin use together with an ongoing community-based dissemination of mcr forebodes of future similar events," the authors write. "Our data stresses the need for a concerted action involving different professionals and healthcare institutions to monitor and contain the spread of mcr across human and veterinary niches, the food chain, and the environment."
Mar 5 Emerg Infect Dis dispatch


CARB-X announces funding for new antibiotic and diagnostic tests

Originally published by CIDRAP News Mar 6

CARB-X, a public-private collaboration that supports companies in early-stage discovery and development of antibiotics, diagnostics, and novel antibacterial treatments, has announced funding for two more partners.

Yesterday CARB-X announced an initial award of up to $2.5 million to MicuRx Pharmaceuticals to support early development of its polymixin antibiotic MRX-8 to treat the most serious multidrug-resistant infections. Polymixin antibiotics, which include colistin and polymixin B, are a last-resort drug for treatment of multidrug-resistant infections, but are associated with high incidence of kidney toxicity. Preclinical data for MRX-8 has shown high efficacy with reduced nephrotoxicity when compared with current polymixins, according to a CARB-X press release.

Today, CARB-X announced an initial award of up to $1.1 million to T2 Biosystems to support the development of new tests that would enable doctors to quickly diagnose and treat life-threatening, drug-resistant bacterial infections in whole blood. The tests, which use the company's T2 Magnetic Resonance technology, aim to identify 20 infectious bacterial species, including carbapenem-resistant Enterobacteriaceae and MRSA, and resistance genes directly from whole blood. The current method of diagnosing invasive bacterial infections using blood cultures can take several days.

"The ability to rapidly diagnose and treat drug-resistant bacteria will save lives by enabling doctors to treat patients more quickly and effectively than is possible with today's diagnostic tools," Kevin Outterson, JD, executive director of CARB-X, said in a press release.

Both projects will receive additional CARB-X funding based on achievement of certain project milestones. Since it was established in 2016, CARB-X has awarded more than $68 million to accelerate the development of antibiotics and other products. 
Mar 5 CARB-X press release
Mar 5 CARB-X press release


PACCARB votes to promote, fund One Health antibiotic-resistance efforts

Originally published by CIDRAP News Mar 5

Late last week a subcommittee of the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria (PACCARB) unanimously passed two resolutions to promote federal antibiotic-resistance programs and to maintain or bolster funding to those programs, Medscape reported.

PACCARB was established via executive order in 2014 by President Barack Obama and includes experts in a range of scientific fields. It uses a One Health approach to combat antimicrobial resistance. The public meeting addressing the two resolutions was held via teleconference on Mar 2.

The first resolution, addressed to Alex Azar, secretary of the Department of Health and Human Services, says, "Federal efforts to address antibiotic-resistant bacterial infections must be included as part of the Department's all-hazards approach to protecting our nation and in legislation to be maintained as a priority."

In the resolution, PACCARB chair Martin J. Blaser, MD, and vice chair Lonnie J. King, DVM, go on to write, "Although initiated through Executive Order, we unanimously recommend that the PACCARB be codified into law to sustain the One Health partnerships formed and continue its mission to produce reports and recommendations that influence federal CARB-related activities, both domestic and abroad."

The second resolution proposes that 2017 funding levels for the Centers for Disease Control and Prevention's Antibiotic Resistance Solutions Initiative (ARSI) and for the Agency for Healthcare Research and Quality's healthcare-associated infection and antibiotic-resistance programs must be maintained or increased. It also said related research by the US Department of Agriculture must be fully funded.

Blaser and King write in the second resolution, "The current federal efforts that are using One Health approaches to fight antibiotic-resistance are at risk of being undermined by significant loss or redirection of funding."
Mar 2 Medscape story (free registration required)
meeting page

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