Stewardship / Resistance Scan for Nov 15, 2018

Antibiotic use in Scotland
Drug-resistant malaria in India

Scottish officials report human antibiotic use down slightly

Health Protection Scotland (HPS) this week released its One Health antimicrobial resistance (AMR) report, which found decreases in antibiotic use overall and in primary care but increases in acute care, with AMR levels in animals remaining fairly steady.

The report said the total use of antibiotics in people was 25.5 defined daily doses per day in 2017, a 3.0% decline since 2013. Antibiotic use in primary care declined 7.8% since 2013, but in acute hospitals it increased 18.0% in the same period.

Other findings in humans:

  • As part of Scotland's shift in healthcare roles, nurses are now responsible for the second-highest proportion of antibiotic prescribing in the community: 8.4%, up from 3.9% in 2013.
  • The proportion of Escherichia coli bacteremia isolates non-susceptible to commonly used antibiotics was generally stable in the last 5 years, but resistance to some antibiotics stayed high.
  • Officials reported 108 carbapenemase-producing organisms in 2017, a 39% increase since 2013.
  • The HPS recorded 2,610 gonorrhea cases in 2017. None were ceftriaxone non-susceptible, but high levels of azithromycin resistance were noted in 1.6%.

Professor Alistair Leanord, Director of Scottish Microbiology Reference Laboratories, said in an HPS news release, "It is reassuring that we have not seen any significant changes in resistance to antibiotics in the common organisms that cause the majority of infections."

In animals, data from veterinary clinics show that levels of non-susceptibility to antibiotics have remained stable from 2013 to 2017, though levels of non-susceptibility in E coli from poultry and pigs were greater than those from cattle and sheep.

Extended-spectrum beta-lactamases (ESBLs) were detected in an E coli isolate from a fecal sample from a single pig and also in the urine of a dog in 2017. That compares with five ESBLs detected from animal samples in 2016.

The report did not include antibiotic use data for animals.
Nov 13 HPS news release
Nov 13 HPS full report


Study shows evidence of artemisinin resistance in East India

A study today in the New England Journal of Medicine provides evidence of artemisinin-resistant Plasmodium falciparum malaria in Eastern India that may be spurred by a novel mutation.

The study was conducted in West Bengal, India, in 2013 and 2014, and involved 136 patients with uncomplicated malaria treated with artesunate-sulfadoxine-pyrimethamine. Therapeutic efficacy was monitored from day 1 to day 42, using thick blood smears that analyzed the clearance of the malaria parasite from the blood.

The authors followed World Health Organization (WHO) guidelines to define artemisinin resistance, which included the presence of parasitemia at 72 hours after treatment (with a parasite-clearance half-life of more than 5 hours), the persistence of a parasite survival rate greater than 10%, and the presence of a mutation in kelch13 distal to codon 440.

Increased parasite clearance half-lives longer than 5 hours were observed in 14% of the patients. 

"Among the 5 patients who were positive for parasites at day 3, the isolates from 4 patients had the kelch13 G625R mutation, and the isolate from the other patient had the R539T mutation. In accordance with the WHO criteria, these 5 isolates were thus identified as being artemisinin-resistant," the authors said. "We identified G625R as a potential novel mutation that, along with R539T, is associated with artemisinin resistance."

The authors concluded the study by calling for increased surveillance of drug resistance.
Nov 15 N Engl J Med

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