Stewardship / Resistance Scan for Mar 20, 2018

Resistant TB in Europe
Appropriate C diff testing
Fast sepsis detection

TB incidence falling in Europe, but drug-resistant cases rising

A new surveillance report from the European Centre for Disease Prevention and Control (ECDC) shows that the tuberculosis (TB) incidence rate in Europe is declining by an average of 4.3% a year, the fastest decline in the world compared with other regions. But officials warn that it's not falling fast enough to achieve the World Health Organization (WHO) goal of TB elimination in Europe by 2050.

The report, based on data from 2016, shows that 58,994 cases of TB were reported in 30 European Union/European Economic Area countries in 2016, with decreasing notification rates observed in most countries. Of all notified TB cases in 2016, 70.4% were newly diagnosed and 71% were confirmed by culture, smear, or nucleic amplification test; 33% of all TB cases were of foreign origin, mostly in low-incidence countries.

Multidrug-resistant (MDR) TB was reported for 3.7% of 36,071 cases, and extensively drug-resistant TB was reported for 20.1% of 984 MDR-TB cases tested for second-line drug susceptibility. Diagnosis of MDR-TB patients increased from 33% in 2011 to 73% in 2016, and treatment success for cases with drug resistance rose from 46% in 2013 to 55% in 2016.

From 2007 through 2016, TB incidence in the WHO European region, which includes 52 countries, fell from 47 to 32 cases per 100,000 population, and the TB mortality rate dropped from 6.5 deaths to 2.8 deaths per 100,00 population. Overall 26,000 TB deaths occurred in the region in 2016.

"It is not enough to 'walk' towards ending TB, as this way we would arrive too late for too many people," Zsuzsanna Jakab, PhD, WHO Regional Director for Europe, said in an ECDC press release. "We need to revamp political commitment at all levels to achieve tangible and immediate results that change and save the lives of all those people suffering from TB today and ensure a TB-free world for our children tomorrow."

Europe accounted for 3% of the 10.4 million global TB cases estimated by the WHO in 2016.  
Mar 19 ECDC 2018 TB surveillance and monitoring report
Mar 19 ECDC press release


Electronic tool helps reduce inappropriate C difficile testing

New research from the University of California Irvine School Medicine indicates an electronic tool for enforcing clinically appropriate Clostridium difficile infection (CDI) testing significantly reduced inappropriate testing and rates of hospital-onset CDI.

In a research brief published yesterday in Infection Control and Hospital Epidemiology, the researchers describe a pre- and post-intervention cohort study to evaluate the impact of an automated, real-time computer physician order entry (CPOE) alert on CDI testing in adults hospitalized at a 417-bed academic hospital from April 2015 through June 2017. The CPOE alert was developed to enforce appropriate use of polymerase chain reaction–based testing, which cannot distinguish between C difficile colonization and active colitis and can result in unnecessary antibiotic treatment.

CPOE verification involves five criteria for ordering CDI testing: (1) diarrhea, (2) no alternate cause for diarrhea, (3) no laxative use within 24 hours, (4) no previous CDI test result within 7 days, and (5) age 1 year or older. Any contraindication to testing results in a "hard stop" that prompts prescribers to either exit the order or submit the name of an approving infectious diseases or gastrointestinal physician to override hospital protocol.

The results of the study showed that CDI testing in the hospital-onset period decreased 46%, from 155 tests per 10,000 patient-days pre-intervention (April 2015 through March 2016) to 84 tests per 10,000 patient-days post-intervention (June 2016 through June 2017). Testing while on laxatives decreased 69%, from 77 per 10,000 patient days to 24, and the number of CDI tests reordered within 7 days also decreased 71%, from 28 per 10,000 patient days to 8. Hospital-onset CDI rates decreased 59%, from 17 cases per 10,000 patient days to 7 cases.

"As data showing the harms of overtesting and overtreatment for CDI emerge, CPOE strategies can be an effective training tool to improve use and stewardship of diagnostic tests," the authors write.
Mar 19 Infect Control Hosp Epidemiol research brief


New assay diagnoses sepsis from a drop of blood

Scientists with Massachusetts General Hospital report that a test that can quickly detect sepsis from a single drop of blood showed high sensitivity and specificity in a small observational study.

In a study published yesterday in Nature Biomedical Engineering, the researchers describe the microfluidic assay, which uses a droplet of diluted blood to measure the spontaneous motility of neutrophils in the presence of plasma. Neutrophils are a type of white blood cell that lead the immune system's response to infection, and neutrophil dysfunction has long been thought to play a role in septic responses.

Previous research has shown that a sepsis-specific spontaneous motility signature displayed by neutrophils isolated from blood enabled the prediction of sepsis in patients with major burns. The researchers hypothesized that measuring neutrophil movement using whole-blood samples could amplify these behavioral changes and enable much quicker differentiation of patients with sepsis from those without.

The scientists measured the performance of the assay in two independent cohorts of critically ill patients suspected of having sepsis. Using data from a first cohort, they developed a sepsis score that segregated patients with sepsis from those without sepsis. They then validated the sepsis score in a double-blind, prospective case-control study. For the 42 patients across the two cohorts, the assay identified sepsis patients with 97% sensitivity and 98% specificity.

The authors of the study say the assay, which requires minimal handling and can be performed in less than 7 hours, will need to be validated in larger and more diverse cohorts of patients. But they suggest it could be a dramatic improvement over current diagnostic tests.
Mar 19 Nat Biomed Eng study

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