CDC records 3 more acute flaccid myelitis cases, 196 total

The US Centers for Disease Control and Prevention (CDC) today recorded 3 new cases of acute flaccid myelitis (AFM), bringing the total for 2018 to 196 confirmed cases. The confirmed cases are among the 357 reports that CDC received of patients under investigation. 

2018 has seen the most AFM cases of any year since the CDC began tracking the mysterious illness in 2014.

Thirty-nine states have recorded cases, a number that has not changed in weeks. Texas has reported the most cases, 25, followed by Colorado (16), and Ohio (13). Washington state recorded 1 new case, bringing the state's total to 11. Minnesota and New Jersey each have 10 cases. California, Illinois, Pennsylvania, and Wisconsin have each confirmed 9 cases.

AFM appears to follow a seasonal pattern, with activity spiking every other year in the fall. 2014 saw 120 cases, followed by 22 in 2015, 149 in 2016, and 35 in 2017.

More than 90% of patients report mild respiratory symptoms before AFM symptom onset, which typically involves limb weakness and paralysis.

The CDC has yet to establish a definitive cause for the 2018 cases, but some previous cases have been connected to enterovirus infections.
Jan 14 CDC update

 

CDC wraps up cake mix Salmonella probe after 7 cases confirmed

The CDC today posted a final outbreak update for a Salmonella Agbeni outbreak linked to certain Duncan Hines cake mix varieties.

In early November, ConAgra brands recalled four types of its cake mix after Oregon officials identified Salmonella Agbeni in a box of the company's classic white cake mix. The CDC has reviewed the PulseNet national subtyping network to identify recent Salmonella Agbeni infections matching the same strain as the cake mix.

Since its last update on Nov 7, the CDC has identified two more illnesses, raising the total to seven. The newly identified patients are from Florida and Missouri, raising the number of affected states to five: Florida, Maryland, Missouri, Ohio, and Wisconsin.

The CDC said there isn't enough epidemiologic and trace-back information to determine if the sick people have links to the contaminated cake mix. Two people reported eating cake the week before their symptoms began, including one who consumed raw batter, but information about the brand wasn't available. The close genetic match of Salmonella isolated from the sick patients, however, suggests a common source of infection, the CDC said.
Jan 14 CDC final outbreak notice
Nov 7, 2018, CIDRAP News scan "Feds share more details about cake mix Salmonella outbreak

 

Frequent upper respiratory infections tied to sinusitis in kids

A study today in Clinical Infectious Diseases looks at the differences between uncomplicated upper respiratory infections (URIs) and those that precede sinusitis in children, and finds that children with sinusitis have more frequent URIs and are more likely to test positive for respiratory syncytial virus (RSV).

The 5-year prospective study followed children ages 4 to 8 years from two pediatric practices in Wisconsin, for a total of 519 URIs. Study subjects provided nasal samples on days 3, 4, and 10 of a URI, and when sinusitis was diagnosed. Thirty-seven illnesses in 31 patients met the study criteria for sinusitis.

According to the study, RSV was detected more frequently in URI visits that led to sinusitis compared with uncomplicated URIs (10.8% vs. 3.4%, P = .05). The median number of URIs per subject per year was 1 (range, 0-9) in patients with uncomplicated URIs, and 3 (range, 1-9) in those with sinusitis.

Most important, the authors said that 30% of nasal samples taken on the day of sinusitis diagnosis actually identified a new virus, which suggests the children were experiencing sequential viral URIs. 

"We found that using the criteria of persistent or worsening symptoms, 71% of patients had the same or no virus detected on the 10-day nasal sample supporting the diagnosis of bacterial sinusitis in these patients. However, nearly 30% had a new virus identified suggesting that sequential viral infection may be the explanation for the symptoms," the authors wrote.
Jan 14 Clinical Infect Dis study

 

Lone star ticks prefer females' breath over males', study says

The lone star tick exhibited a clear preference for human female breath over the breath of males, according to a new study in Experimental and Applied Acarology. The findings suggest either that chemical compounds in female breath attract the disease-carrying vectors, or that male breath repels the bugs, the authors say.

To conduct the study, researchers at Oklahoma State University had 20 mean and 20 women breathe into tubes containing 10 Amblyomma americanum ticks. An average of 42.5% of ticks chose a female host, 18% chose a male host, and 39.5% did not make a choice, the authors said.

This is the first study to demonstrate human sex preferences for lone star ticks, which can transmit diseases such as ehrlichiosis, Rocky Mountain spotted fever, and tularemia.

"Understanding what causes individual variation in attractiveness to ticks can lead to a better assessment of what aspects make one person more susceptible to tick bite and which individuals may be at higher risk for exposure to a tick-borne disease," the authors concluded.
Jan 10
Exp Appl Acarol study

 

Severe flu outcomes tied to immune deficiency, advanced age

In separate studies published late last week, Spanish researchers determined that the comorbidity most closely associated with severe outcomes with flu infection was immune deficiency, with older age also a factor, while scientists in Turkey reported that the death rate of H3N2 flu was significantly higher than H1N1 in the 2015-16 flu season.

In the first study, which appeared in PLOS One, researchers conducted an observational study of adult patients in 12 Catalonian hospitals from 2010 through 2016 that included 1,726 hospitalizations. Of the total, 595 patients (34.5%) were admitted to the intensive care unit (ICU), and 224 (13.0%) died.

The researchers found that the 65-to-74 and 75 and older age-groups were associated with an increased risk of death in all types and subtypes, especially for influenza type B, for which the adjusted odds ratio (aOR) reached 27.4 for the younger age-group and 16.0 for the oldest group. In contrast, older age was associated with a lower rate of ICU admission.

The comorbidity most closely associated with severe outcomes, however, was immune deficiency, which was associated with death for influenza type B (aO,R 9.0) and 2009 H1N1 (aOR, 3.16). The authors conclude, "Although possible explanations are not always available, our results suggest that predictors of poor outcomes of influenza may vary by type/subtypes."
Jan 11 PLOS One study

Results also varied  by subtype in second study, published in the International Journal of Infectious Diseases, which highlighted higher death rates in those infected by the H3N2 strain in Turkey, findings that have been noted in other countries.

Investigators included 222 cases of lab-confirmed flu in hospital patients, of whom 25 (11.2%) died. The fatality rate was significantly higher among patients older than 65 and those with chronic heart or kidney diseases.

They determined a 4.2 times higher risk of dying for those infected with H3N2 compared with other strains. And the OR of dying was 6.9 for those 65 and older and infected with any flu strain, compared with their younger counterparts.
Jan 11 Int J Infect Dis abstract

 

Russia, Taiwan report more high-path avian flu at poultry farms

Russia and Taiwan reported new highly pathogenic H5 avian flu detections, according to recent notifications from the World Organization for Animal Health (OIE).

In Russia, an outbreak that began on Jan 4 at a commercial turkey farm in Rostov oblast in the far west of the country killed 6,355 of 17,211 susceptible birds. The surviving birds were slated for culling, and so far the source of the virus hasn't been determined.

The country has been reporting a small but steady number of H5 outbreaks since last June, the last of which occurred in November. European health officials have said that the Russian outbreaks mainly involve H5N8.

Elsewhere, Taiwan reported another H5N2 outbreak, part of a string of similar detections involving the virus that began in early 2015. The latest outbreak began Dec 25 at a commercial duck farm in Yunlin County that had early been placed under movement restriction. Authorities culled all 2,139 birds at the location and have intensified surveillance at poultry farms within 3 kilometers of the affected farm.
Jan 11 OIE report on H5 in Russia
Jan 11 OIE report on H5N2 in Taiwan

Stewardship / Resistance Scan for Jan 14, 2019

News brief

Study evaluates stewardship uptake, antimicrobial usage in England

Researchers with Public Health England (PHE) report that a survey of England's National Health Service (NHS) hospitals found that the vast majority have made progress in establishing antimicrobial stewardship programs (ASPs), but many lack senior leadership and dedicated funding, and there was no significant correlation between stewardship scores and antimicrobial usage.

In an article published in the Journal of Antimicrobial Chemotherapy, the researchers evaluated ASP structures and processes through an online survey of 152 NHS hospitals. Scores were assigned to quality indicators based on resource- and labor-intensiveness, and the investigators analyzed the association between stewardship scores and prescribing, with a particular focus on World Health Organization–categorized Access, Watch, and Reserve (AWaRe) antibiotics.

Overall, 148 of 152 hospitals responded to the survey, and over 80% had high scores on antimicrobial policies, stewardship team structure, designated stewardship leads and antimicrobial pharmacists, and policies and access to outpatient parenteral antimicrobial therapy. But less than 50% had senior clinical leadership support and dedicated program funding. High-process performance (above 80%) was observed for antimicrobial pre-authorization, prescribing review and feedback, restricted susceptibility reporting, antimicrobial consumption monitoring, adherence to guidelines, and junior doctor training, while less than 50% of hospitals distributed resistance surveillance data and educated senior clinicians on appropriate prescribing.

From 2016 through 2017, there was no significant change in mean total antimicrobial prescribing (incidence rate ratio [IRR], 1.02; 95% confidence interval [CI], 1.00 to 1.05, P = 0.116) for all participating hospitals, and there were no major changes in the prescribing of antimicrobials from the AWaRe categories. But there were some noteworthy associations. While carbapenem prescribing fell by 7% (IRR, 0.93; 95% CI, 0.88 to 0.98) in non-teaching hospitals, prescribing of Watch antibiotics increased for specialist hospitals (odds ratio [OR], 1.10; 95% CI, 1.01 to 1.20), as did Reserve category prescribing for teaching (OR, 1.58; 95% CI 1.23 to 3.02) and specialist hospitals (OR 3.09; 95% CI, 2.02 to 4.74). A higher process score was associated with lower baseline prescribing of Reserve antimicrobials (OR, 0.82; 95% CI, 0.67 to 1.01).

The authors of the study say further studies are needed with better defined primary outcomes such as burden of disease or attributable mortality due to antimicrobial resistance to assess the true impact of ASP interventions over time.
Jan 11 J Antimicrob Chemother study

 

Chinese study identifies cats, dogs as potential C diff sources

A new study by Chinese scientists suggests that companion animals could be a source of pathogenic Clostridioides difficile. The findings appear in BMC Infectious Diseases.

To assess the burden of C difficile carriage and shedding by household pets, researchers from Xuzhou Medical University collected fecal samples of adult pets in pet shops in Xuzhou City in China's Jiangsu province, then identified and isolated C difficile strains. They used multilocus sequence typing (MLST) to identify sequence types and assess the possibility of transmission between pets and humans, employed multiplex polymerase chain reaction to detect toxin genes, and performed antimicrobial susceptibility testing.

A total of 175 fecal samples were collected from 146 healthy dogs and 29 cats, and C difficile was isolated from only 3 samples (1.7%)—2/29 cat samples (7.0%) and 1/146 (0.7%) dog samples.

The isolates were categorized into three MLST sequence types that have been identified in patients in eastern China and belong to the clade that contains most human C difficile sequence types. They were susceptible to chloramphenicol, tetracycline, metronidazole, and moxifloxacin and resistant to ampicillin, clindamycin, and cefoxitin. Notably, one strain recovered in the feces of a healthy dog, D141–1, carried toxin genes, implying a potential association between pets and pathogenic C difficile infections in humans.

"Since there is intimate contact between humans and their pets, the isolation of C. difficile from pets in this study suggests a possibility that humans may be colonized by C. difficile carried by pets, although faecal shedding of pathogenic C. difficile was not common among healthy dogs and cats," the authors write.
Jan 11 BMC Infect Dis study

 

Trial will evaluate safety, efficacy of fecal transplant for recurrent C diff

The National Institute of Allergy and Infectious Diseases announced today that a research consortium has begun enrolling patients in a clinical trial to determine whether fecal microbiota transplantation (FMT) delivered by enema is a safe and effective treatment for recurrent C difficile infection (CDI).

FMT for recurrent CDI has produced strong results in several small clinical trials in recent years, with cure rates as high as 90%, but the long-term safety has not been established. Although the US Food and Drug Administration still considers FMT an investigational treatment, physicians are allowed to perform the procedure using screened stool if recurrent CDI patients aren't responding to antibiotic treatments. According to the Centers for Disease Control and Prevention, roughly 20% of CDI patients treated with antibiotics experience a recurrence of symptoms.

The multicenter randomized controlled trial will enroll 162 adult volunteers who've had at least two episodes of CDI within the previous 6 months. One group of patients will take anti-diarrheal medication and receive FMT via enema, while the other group will take anti-diarrheal medication and receive a placebo solution via enema. The trial is part of a larger effort to gather data on how to standardize FMT, which can be delivered by several methods, including enema, upper gastrointestinal endoscopy, colonoscopy, or pill.

Trial sites include Emory University, Duke University Medical Center, and Vanderbilt University Medical Center.
Jan 14 NIAID news release

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