ASP Scan (Weekly) for Oct 12, 2018

Antibiotic duration for group B strep
C diff risk and antibiotics
Veterinary pharma controversy
Carbapenem-resistant Pseudomonas
Antibiotic use in animals
Vaccines for AMR
Stewardship guide for low-resource settings
Resistant bacteria transmission in nursing homes

Study examines shorter IV antibiotics for group B strep bacteremia

A study yesterday in Pediatrics has found that, contrary to national guidelines, a portion of infants with uncomplicated, late-onset group B Streptococcus (GBS) bacteremia are being treated with shortened intravenous (IV) antibiotic courses, with low rates of recurrence and treatment failure.

Although guidelines recommend prolonged IV antibiotic therapy (10 days) to treat uncomplicated, late-onset cases of GBS bacteremia, questions about the optimal duration of IV antibiotic therapy for this condition remain. Complications from peripherally inserted central catheters are common, and a 2007 study found that conversion to oral therapy after 48 hours was a successful strategy in 29 infants with GBS bacteremia. In addition, shortened IV antibiotic courses could decrease healthcare costs and allow patients to leave the hospital sooner.

The multicenter retrospective cohort study looked at infants aged 7 days to 4 months who were admitted to 49 children's hospitals with GBS bacteremia from 2000 to 2015. The purpose was to see how often infants with late-onset, uncomplicated GBS bacteremia are being treated with IV antibiotic durations that are shorter than the guideline recommendation (less than 8 days), and to compare rates of disease recurrence and treatment failure among infants treated with prolonged versus shortened IV antibiotic treatment.

Among 775 infants diagnosed as having late-onset, uncomplicated GBS bacteremia, 612 (79%) received a prolonged course of IV antibiotics and 162 (21%) received a shortened course. Patients who received a shortened course were older, more often admitted in later years, and more likely to have a concomitant urinary tract infection. The proportion of children who received a shortened IV course varied considerably by hospital (range, 0% to 67%; standard deviation, 20%), with 14 hospitals administering shortened courses to no patients and 5 hospitals treating more than 50% of their patients with shortened courses.

Overall, 17 patients (2.2%) suffered a recurrence—three (1.8%) in the shortened-IV-duration group and 14 (2.3%) in the prolonged-duration group (adjusted absolute risk difference, −0.2%; 95% confidence interval [CI], −0.3% to 2.5%).

The authors of the study conclude that, in lieu of a randomized controlled trial (which would be difficult to conduct because of the modest prevalence of GBS disease), their findings suggest early transition to oral antibiotic therapy may be appropriate for carefully selected infants with GBS bacteremia.
Oct 11 Pediatrics study


Longer antibiotic therapy tied to C diff risk in bloodstream infections

Patients hospitalized with Enterobacteriaceae bloodstream infections (BSI) who received anti-pseudomonal beta-lactam (APBL) antibiotics for more than 48 hours had triple the risk of developing Clostridioides difficile infection (CDI), researchers report today in Clinical Infectious Diseases.

The study, conducted by researchers with the University of South Carolina School of Medicine and College of Pharmacy, looked at adult patients hospitalized for more than 48 hours for Enterobacteriaceae BSI at two South Carolina hospitals from January 2011 through June 2015. They were looking to determine the effect of early de-escalation of antibiotic therapy on CDI rates. Previous research on APBLs, which are among the most frequently used antibiotics in US hospitals despite the relatively low prevalence of Pseudomonas aeruginosa BSIs, has found an increased risk of CDI compared with other antibiotics. The researchers wanted to know if early de-escalation might reduce that risk.

Among 808 patients with Enterobacteriaceae BSI, 414 received more than 48 hours of ABPL and 394 received less than 48 hours. Overall incidence of CDI was 4.4%. Incidence of CDI among patients receiving more than 48 hours of APBL was 7.0%, compared with 1.8% among patients treated for less than 48 hours. After adjustment for propensity to receive more than 48 hours of APBL and other variables in the multivariable model, receipt of more than 48 hours of APBL was found to be independently associate with higher risk of CDI (hazard ratio [HR], 3.38; 95% CI, 1.40 to 9.47; P = 0.006), along with end-stage renal disease (HR, 4.04; 95% CI, 1.75 to 8.78; P = 0.002).

"The current study highlights the importance of initial selection of antimicrobial regimen in hospitalized patients with suspected BSI," the authors of the study write. "It enhances antimicrobial stewardship message as it provides objective evidence demonstrating clinical benefit of minimizing unnecessary broad spectrum therapy."          
Oct 12 Clin Infect Dis abstract


Veterinary pharmaceutical company accused of 'double standard'

The Bureau of Investigative Journalism reports today that Zoetis, the world's largest animal health company, is selling antibiotics for growth promotion to Indian farmers.

Although there are no Indian laws against the use of antibiotics for growth promotion in livestock and poultry, the practice is banned in the United States and Europe, and the World Health Organization has called for a worldwide ban. Public health and infectious disease experts argue that using medically important antibiotics to help food-producing animals gain weight more quickly contributes to antibiotic resistance and endangers the future use of those drugs.

Zoetis started removing growth promotion from the labels of medically important antibiotics sold to US farmers in 2016, and has publicly supported the US Food and Drug Administration's efforts to promote antibiotic stewardship in food-producing animals. The bureau reports that on the company's Indian website, however, antibiotics are being sold with the claim that they will make animals grow bigger and faster.

The company told the bureau that it works with national regulatory authorities in various countries, including India, to "understand, respect, and comply with local regulatory interpretation and oversight.”
Oct 12 Bureau of Investigative Journalism report


Investigation finds cluster of carbapenem-resistant Pseudomonas carriers

Originally published by CIDRAP News Oct 11

An investigation by the Chicago Department of Health has identified a large cluster of residents colonized with Verona integron-encoded beta-lactamase-producing carbapenem-resistant P aeruginosa (VIM-CRPA) at several healthcare facilities in the city. The findings appear today in the CDC's Morbidity and Mortality Weekly Report (MMWR).

The outbreak centers around a single skilled nursing facility with ventilated residents (called "vSNF A" by the authors), where a November 2016 point prevalence survey identified 20 residents with VIM-CRPA colonization. VIM-CRPA are rare in the United States; a surveillance study conducted by the CDC at five US sites found only 2 carbapenemase-producing CRPA among 129 isolates.

To determine whether transmission was ongoing at that facility, the investigators conducted 10 additional point prevalence surveys from November 2016 to March 2018. Screening of 903 swabs from 209 residents identified an additional 18 residents colonized with VIM-CRPA, with one other resident identified by screening upon admission to an acute care hospital. Point prevalence surveys conducted at six other vSNFs and six long-term acute care facilities in Chicago identified 12 more VIM-CRPA–positive patients (at five vSNFs and one long-term acute care hospital).

Whole-genome sequencing of 26 isolates from five different facilities revealed that 25 belonged to multilocus sequence type (ST) 233, and clusters of highly related isolates indicated transmission at the index facility (vSNF A). The authors of the study say it's the largest healthcare-associated cluster of VIM-CRPA colonizing residents reported in the United States.

"Although centered in one vSNF, this investigation highlights the interconnectedness of health care facilities through patient sharing and how prolonged, undetected transmission can result in spread through a region," the authors write. 
Oct 12 CDC MMWR Notes from the field


UK Parliament group urges lower antibiotic use in animals

Originally published by CIDRAP News Oct 9

The UK Parliamentary Office of Science and Technology (POST) released a report yesterday on the country's current use of antibiotics in animals and options for reducing use, including better animal husbandry and improved housing for livestock.

The POST report notes that UK antibiotic use in animals declined 22% from 2011 to 2014, but the authors note that more work is needed to meet targets set for 2020. They note that antibiotic use varies widely across sectors, with the pig industry being the highest user but also showing the greatest gains. Overall antibiotic use in this sector has dropped 50% since 2015.

The report also notes that antibiotics considered critical for human medicine make up 39% of antibiotic prescriptions for cats and 5.4% of antibiotic prescriptions for dogs in Britain.

"Approaches to reducing antibiotic use in animals include better animal husbandry, improved housing, better herd/flock management, vaccination and disease eradication," the authors wrote. "Enacting change involves managing the expectations that people who use vets (clients such as farmers or pet owners) have of being prescribed antibiotics when their animals are ill."
Oct 8 UK POST news release
Oct 8 UK POST full report


Report identifies bacterial pathogens that could be addressed by vaccines

Originally published by CIDRAP News Oct 8

A new report from the Wellcome Trust and Boston Consulting Group identifies antibiotic-resistant pathogens that could be addressed by increased vaccine uptake and vaccine development.

The report evaluates the potential health impact of vaccines against all strains of bacterial pathogens identified by the World Health Organization (WHO) as "priority pathogens." It also considers the feasibility of developing vaccines for these pathogens and the likelihood of implementing a successful vaccination program. Through this assessment, the report identifies pathogen clusters that would most benefit from a vaccine.

In the "increase uptake" cluster are the pathogens Haemophilus influenza, Streptococcus pneumoniae, and Salmonella typhi. While vaccines have been developed for these pathogens, the report recommends expanding coverage for these vaccines to increase their health impact. In the "bring to market" category are Escherichia coli, non-typhoidal Salmonella, and Shigella—pathogens with significant health impact and sufficiently advanced research and development (R&D) to recommend accelerated clinical development of a vaccine. In the "advance early R&D" cluster are pathogens with significant health impact that require more early-stage investment in R&D. These include Mycobacterium tuberculosis, Neisseria gonorrhoeae, P aeruginosa, Staphylococcus aureus, and urinary E coli.

The report concludes that other pathogens on the WHO priority list—Acinetobacter baumannii, Enterobacteriaceae, Campylobacter, Klebsiella pneumoniae, Enterococcus faecium, Helicobacter pylori, and Salmonella paratyphi—are less well-suited to vaccine development because of significant outstanding epidemiological questions and low incidence and associated morbidity and mortality. It recommends exploring alternative strategies for addressing these pathogens.

"By employing a carefully considered prioritisation framework to evaluate these pathogens, this report enables comprehensive comparisons across pathogens," the report states. "This assessment and prioritisation provides a guide for research priorities, policy focus and investment decisions, while recognising that individuals and institutions have varied areas of focus and seek to interact at different parts of the value chain."
Oct 5 Vaccines for AMR report


New CDC document highlights ASP strategies for low-resource settings

Originally published by CIDRAP News Oct 8

The CDC has released the latest in a series of guidelines for developing and implementing antibiotic stewardship programs (ASPs).

The Core Elements of Human Antibiotic Stewardship Programs in Resource-Limited Settings guide contains ASP strategies that can be implemented in low- and middle-income countries with weak health systems, based on the resources available. "Such strategies must be feasible, sustainable, and tailored to the resources that are currently available in such countries while capacity is built in areas of need to ensure access and reduce the inappropriate use of antibiotic agents," the report states.

The document includes both national and facility-level activities. National-level activities are grouped into basic, intermediate, and advanced categories, with basic activities requiring only limited resources and intermediate and advanced categories requiring additional resources and staff. Basic activities include setting up a national ASP committee and developing a national antibiotic stewardship plan, while intermediate and advanced activities include developing and ensuring access to recommended formularies, measuring antibiotic use, and setting national targets for improvement.

At the facility level, the guide recommends that hospitals in resource-limited settings begin by identifying a single point of contact for an ASP. That individual should preferably be an infectious disease (ID) trained physician, but could be a physician without formal ID training if necessary. In addition, the ASP focal point should have support from the hospital administration. Beyond this foundation, the guide recommends that hospitals form antibiotic stewardship committees, identify a single priority area for reducing antibiotic use, educate staff, and implement stewardship activities targeted at the priority area.

The CDC says the document, which is based on expert opinion and experiences in implementing ASPs in the United States and elsewhere, is intended to serve as a starting point for stakeholders in resource-limited settings. 
Sep 24 CDC core elements guide


Nursing home study illustrates risk of resistant bacteria transmission

Originally published by CIDRAP News Oct 8

A multicenter study of nursing home residents has found that 11% of interactions with healthcare workers resulted in the transmission of antibiotic-resistant gram-negative bacteria (RGNB) to gloves and gowns worn by those workers when providing care.

In the study, which was published today in Infection Control and Hospital Epidemiology, investigators collected perianal swabs from 399 residents of 13 community-based nursing facilities in Maryland and Michigan to detect RGNB. Healthcare personnel (HCP) at the facilities were asked to wear gowns and gloves during usual care activities, and those items were swabbed when HCP were finished with those activities. The objective was to estimate the risk of transmission of RGNB to gloves and gowns worn by HCP when providing care and to identify the types of care and resident characteristics associated with transmission.

Overall, 19% of the residents were colonized with at least one RGNB at enrollment. Either gloves or gowns were contaminated with RGNB during 11% of 584 interactions with colonized residents. RGNB transmission to HCP varied by activity, but showering and bathing residents, changing wound dressings, and assisting with hygiene and toilet needs were associated with a high risk of transmission, while glucose monitoring and assisting with feeding or medication were associated with low risk of transmission. Residents with a pressure ulcer were three times more likely to transmit RGNB than residents without one.

The findings are noteworthy because though previous studies have found that more half (57%) of nursing home residents are colonized with multidrug-resistant organisms, there are few evidence-based guidelines describing best practices for preventing transmission of these organisms in nursing homes. The authors of the study suggest that glove and gown use in community nursing facilities should be prioritized for certain residents and care interactions that are deemed a high risk for transmission.
Oct 8 Infect Control Hosp Epidemiol abstract

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