Stewardship / Resistance Scan for Sep 13, 2018

Candida auris in New York
;
Resistance and rising temps
;
European One Health AMR plan
;
India bans combo drugs

Investigation provides details on Candida auris outbreak in New York

A study published yesterday in Emerging Infectious Diseases describes the outbreak of the multidrug-resistant fungal infection Candida auris in New York healthcare facilities.

Since C auris was first detected in the United States in 2016, New York has consistently reported the highest number of cases. Of the 391 confirmed and probable cases reported to the Centers for Disease Control and Prevention (CDC) in 11 states as of Aug 17, 213 are in New York. To better understand the spread of C auris in New York healthcare facilities, researchers from the New York State Department of Health, New York City Department of Health and Mental Hygiene, and the CDC conducted an epidemiologic investigation that included review of clinical cases reported by Apr 30, 2017, contract tracing and screening, and collection of environmental samples from facilities where case-patients resided.

The investigators detected 51 cases in 19 healthcare facilities, all but one of which were in New York City. Of these case-patients, 31 (61%) had lived in long-term care facilities before being admitted to the hospital where the infection was diagnosed. The 90-day mortality rate among these cases was 45% (23/51), although the number of deaths attributable to C auris is unknown. Exploration of epidemiologic links revealed a large, interconnected web of affected healthcare facilities throughout New York City.

Screening cultures performed for 572 patients in the 19 facilities where cases were identified revealed an additional 61 patients who were colonized with C auris. Environmental samples were positive for C auris at 15 of 20 facilities, with contamination of surfaces and objects in case-patient rooms and mobile equipment outside those rooms common. Assessment of infection control found that adherence to recommended practices—including hand hygiene, implementation of contact precautions, use of personal protective equipment, and environmental cleaning with proper disinfectants—varied.

The investigators say the reasons for the preponderance of C auris cases in New York City are unknown. The possibilities include a true higher prevalence from multiple introductions into the city, more detection from aggressive case finding, the presence of a large, interconnected network of healthcare facilities, or a combination of all three factors. The infection prevention and control lapses observed by investigators have since prompted intensive improvement efforts.

"The goals are delaying endemicity, preventing outbreaks within facilities, reducing transmission and geographic spread, and blunting the effect of C auris in New York and the rest of the United States," the investigators write.
Sep 12 Emerg Infect Dis article

 

Analysis of European data finds link between warmer temps, resistance

A team of researchers that earlier this year identified a link between antibiotic resistance and warmer temperatures across the United States is reporting similar findings in an analysis of European data.

In a study yesterday on the preprint server bioRxiv, the researchers from Harvard, Boston Children's Hospital, and Statens Serum Institut in Denmark performed an ecological analysis of country-level antibiotic resistance prevalence in three common bacterial pathogens—Escherichia coli, Klebsiella pneumoniae, and Staphylococcus aureus—across 28 European countries. They used multivariable models to evaluate associations with minimum temperature and other predictors, including antibiotic consumption and population density, over a 17-year period (2000-2016), then quantified those effects on the rate of change of antibiotic resistance across geographies.

The results of the analysis showed that countries with warmer ambient minimum temperatures were experienced faster increases in antibiotic resistance over time for most pathogens and antibiotic classes, even after accounting for rates of antibiotic consumption and population density. Specifically, a 10°C (18°F) increase in the average minimum temperature was associated with an increased rate of change in resistance to aminoglycosides, third-generation cephalosporins, and fluoroquinolones in E coli and K pneumoniae—ranging from 0.33% per year to 1.2% per year.

The researchers also found, however, that the rate of S aureus resistance to methicillin decreased by 0.4% a year as minimum temperatures increased, a finding they argue reflects widespread declines in methicillin-resistant S aureus across Europe over the study period.

As in their previous study, the researchers note that their findings do not show that increasing temperatures are causing antibiotic resistance rates to rise, but that temperature may be playing a role in modulating the rate of change of antibiotic resistance in a region and deserves further exploration. They conclude, "We hope this work will drive further avenues of research to investigate the role of climate as well as other sociodemographic factors on the distribution and transmission of antibiotic resistance."
Sep 12 bioRxiv abstract
May 23 CIDRAP News story "Study finds antibiotic resistance rise tied to hotter temps"

 

European Parliament representatives adopt One Health AMR action plan

Stressing the need to take into account that human, animal, and environmental health are interlinked, members of the European Parliament (MEPs) today voted to adopt a One Health action plan against antimicrobial resistance.

In the non-binding resolution, adopted with 589 votes for and 12 against, MEPs urged the European Union (EU) Commission and EU member states to restrict the sale of antibiotics by human and animal health professionals and to remove any incentives for prescribing them. The resolution also called for penalties for illegal sales, and sales without prescriptions, of antibiotics.

"We have to start looking at the whole cycle, because people's and animal health are interconnected," rapporteur Karin Kadenbach, an MEP from Austria, said in a European Parliament press release. "Diseases are transmitted to people from animals and vice versa, and that is why we support the holistic approach of the 'One Health' initiative."

MEPs also recommended that the EU Commission draft a list of priority pathogens for humans and animals that could be used to guide future antibiotic research and development efforts, and they emphasized the need for cheaper rapid diagnostic tests to determine whether infections or bacterial or viral. 
Sep 13 European Parliament press release

 

India bans 328 combination drugs, including antibiotics

In a blow to pharmaceutical firms but with antimicrobial stewardship ramifications, the government of India has banned 328 combination drugs, Reuters reported today.

The Indian government in 2016 had banned 350 such drugs, called fixed-dose combinations (FDCs), but a scientific advisory board was reviewing the ban after industry groups mounted a legal challenge. The country's Supreme Court ordered the review.

India's health ministry said yesterday that the board of experts had found "no therapeutic justification for the ingredients contained in 328 FDCs and that these FDCs may involve risk to human beings." The ministry is immediately prohibiting the manufacture, sale, and use of the drugs in people. The Times of India reports that two of the drugs are the antibiotic Lupidiclox and the antibacterial Taxim AZ.

Health advocates have cheered the ban over concern about antibiotic resistance because of the misuse of FDCs, Reuters said.

The president of the Indian Drug Manufacturers' Association, Deepnath Roychowdhury, said the order would affect drugs worth about 16 billion rupees ($222 million) a year, but he said the industry would respect the verdict.
Sep 13 Reuters news story
Sep 13 Times of India report

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