Stewardship / Resistance Scan for Oct 05, 2018

MRSA de-colonization of therapy dogs
;
Multiple Candida auris introductions
;
Early stewardship intervention

De-colonization of therapy dogs lessens risk of MRSA spread, study finds

A pilot study conducted by researchers at Johns Hopkins has found that using a special antiseptic shampoo and wipes to decolonize therapy dogs before and between visits with young cancer patients can reduce the transmission of methicillin-resistant Staphylococcus aureus (MRSA). The findings were presented today at IDWeek 2018.

In the study, the investigators sampled 45 cancer patients and four therapy dogs at Johns Hopkins Bloomberg Children's Hospital for the presence of MRSA before and after 13 therapy dog visits. Seven of those visits were control visits, in which the dogs were not decolonized; in the six intervention visits, the dogs were bathed with a chlorhexidine-based shampoo prior to visiting patients and were cleaned with chlorhexidine wipes between patient visits.

The hypothesis was that the dogs could be a vector for transmitting MRSA between patients. MRSA carriage in cancer patients is a concern because their weakened immune systems put them at greater risk of infection.

The investigators found that 4 of the 45 patients became MRSA carriers after the control visits, as did three of the dogs. Patients who interacted more closely with the dogs were six times more likely to be colonized with MRSA than those who didn't interact closely.

But during the six interventions visits, only one of the patients and two of the dogs became colonized, and the risk for MRSA transmission among patients who interacted closely with the dogs was significantly reduced. Overall, regardless of the level of interaction, the intervention reduced the risk of MRSA colonization in patients by 90%.

"While there was still a risk of children for children being involved in these therapy visits, because of their direct contact with other patients or other environments, it essentially removed the dog from the equation, which overall increased the safety of the visit," lead study author Kathryn Dalton, VDM, MPH, of Johns Hopkins Bloomberg School of Public Health, said at a press conference.

Dalton said they also observed many patient benefits from therapy-dog visits, including decreased stress levels and fewer reports of anxiety and pain. Because of the positive results, Dalton and her colleagues have received additional funding for a larger study involving multiple hospitals.
IDWeek 2018 abstract #160

 

Gene study supports multiple Candida auris introductions into US

Whole-genome sequencing of Candida auris isolates from patients in 10 US states suggests that the fungal strain came from four different global regions, reflecting multiple introductions into the country. A team led by researchers from the US Centers for Disease Control and Prevention's mycotic diseases branch reported its findings yesterday in The Lancet Infectious Diseases.

The group examined isolates collected from May 2013 through August 2017 from 133 cases, 73 of them clinical specimens and 60 screening samples. Of the clinical isolates, sequencing found that 90% were related to South Asian, 7% to South American, 1% to African, and 1% to East Asian isolates. Most isolates were from New York and New Jersey, and though they were related to South Asian C auris strains, most were genetically distinct.

Genetic comparison suggested that only 5 clinical case-patients (7%) likely contracted the fungus during healthcare exposure abroad. Genetic diversity within a patient was similar to that seen in facilities during outbreaks.

The investigators concluded that the findings shed light on fungus introduction and how it can occur following travel. They added that the genetic diversity among isolates from patients, states, and facilities adds evidence of local and ongoing transmission.

In a commentary in the same issue, Jacques Meis, MD, PhD, a mycologist from the Netherlands, and Anuradha Chawdhary, MD, PhD, a mycologist from India, wrote that the findings confirm earlier work that the global C auris population consists of four different clades that harbor nearly identical strains within each clade. They said the US cases don't represent a fifth clade but instead represent several introductions into the US healthcare system. They note that the travel-related cases identified in the study weren't the outbreak index cases, suggesting previous unrecognized presence and transmission of the fungus.

A major unanswered question is the reservoir for C auris outside hospitals, they note. Though the drivers of the spread are elusive, the two wrote that demographics, extensive fluconazole use in intensive care units, poor infection control, international travel, and medical tourism likely play a role in ongoing outbreaks.

"The stringent recognition of the problem and simultaneous implementation of precautions to prevent the spread of C auris among patients should be taken as seriously as in bacterial pathogens," they wrote.
Oct 4 Lancet Infect Dis abstract
Oct 4 Lancet Infect Dis commentary

 

Study finds stewardship intervention early in hospital stay may pay off

A single-center study in Japan determined that an intervention from an antimicrobial stewardship team earlier in a hospital stay was associated with significantly fewer antibiotics prescribed, a lower incidence of antimicrobial resistance, and reduced costs, according to a study yesterday in the International Journal of Infectious Diseases.

The retrospective study was conducted at Fukuoka University Hospital from April 2013 through March 2016. The researchers compared data among three study periods (SPs): SP1 (patients receiving antibiotics against methicillin-resistant Staphylococcus aureus and carbapenems for 14 or more days), SP2 (patients receiving specific antimicrobials for 14 or days), and SP3 (patients receiving specific antimicrobials regardless of the duration of treatment). The average timing of stewardship interventions ranged from 15.5 days after hospital admission in SP1 to 4.2 days in SP3.

The investigators determined that the antimicrobial use density of carbapenems and piperacillin-tazobactam decreased significantly (SP2 vs. SP3, P < 0.05), and the costs of specific antimicrobials decreased (SP1, $1,080,000; SP2, $944,000; SP3, $763,000). The rates of carbapenem resistance among Pseudomonas aeruginosa isolates showed a significant reduction from 16.2% in SP2 to 8.7% in SP3 (P < 0.05). The mortality rate and length of stay did not change during the study period.
Oct 4 Int J Infect Dis abstract

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