Stewardship / Resistance Scan for Jan 11, 2019

US XDR typhoid cases
ICU Klebsiella stewardship
Antimicrobials in European chickens

CDC reports 5 US cases of XDR typhoid infections

Enhanced surveillance has identified five US cases of extensively drug-resistant (XDR) typhoid infections associated with travel to Pakistan, according to a report today from the Centers for Disease Control and Prevention (CDC).

In Morbidity and Mortality Weekly Report (MMWR), the researchers report that, from 2016 through 2018, 29 patients with typhoid fever—a highly infectious illness caused by Salmonella enterica serotype Typhi—reported travel to or from Pakistan and had isolates tested for antimicrobial susceptibility. Five of those patients had XDR Salmonella Typhi, which is resistant to five classes of antibiotics (chloramphenicol, ampicillin, trimethoprim-sulfamethoxazole, fluoroquinolones, and third-generation cephalosporins). All patients were children aged 4 to 12 years and had traveled to or from Pakistan from late 2017 through mid-2018.

The World Health Organization recently reported that an XDR Salmonella Typhi outbreak that began in Pakistan's Sindh province in 2016 has now affected 5,372 people in Pakistan. It's the first widespread outbreak of an XDR Salmonella Typhi strain to be reported. The WHO has warned that the risk of acquiring XDR typhoid in Pakistan is high because of poor sanitation and hygiene and insufficient access to clean water.  

In March 2018, the CDC enhanced surveillance for typhoid fever in the United States by asking state and local health departments to interview every patient with typhoid fever about travel to or from Pakistan and to expedite submission of Salmonella Typhi isolates from these patients to CDC.

The report says clinicians should be aware that the XDR Salmonella Typhi outbreak strain associated with travel to and from Pakistan is only susceptible to azithromycin and carbapenems. Providers caring for patients with suspected typhoid fever should obtain a travel history and report confirmed cases to their local health departments. Travelers to Pakistan are advised to get vaccinated against typhoid fever and to follow safe food and water practices.
Jan 11 MMWR report
Dec 28, 2018, CIDRAP News story "WHO: XDR typhoid outbreak in Pakistan tops 5,200 cases"


Multipronged steps helped curb ICU Klebsiella, Chinese researchers say

Infection prevention and control (IPC) enhancements, plus modified treatment de-escalation and targeted bundle interventions, appeared to have played a key role in controlling an outbreak of carbapenem-resistant Klebsiella pneumoniae (CRKP) in an intensive care unit (ICU) at a teaching hospital in Shanghai.

Researchers from the hospital described their findings yesterday in Antimicrobial Resistance and Infection Control. The hospital's CRKP incidence had increased markedly, from 7.3% in 2011 to 25% in 2015. Their study included clinical data from 629 patients admitted to the ICU consecutively from January 2013 through June 2016. A total of 87 patients had CRKP, of whom 69 acquired their infections in the ICU and 18 were infected before admission.

The study had four stages: baseline, IPC interventions that included de-escalation of treatment based on culture results and targeted bundle interventions, modified IPC interventions for the next year, and a follow-up period.

Incidence of ICU-acquired CRPK was 10.08 (range, 4.43 to 16.43) per 1,000 ICU patient-days during baseline, but it significantly decreased during the early stages of IPC interventions. Colonization testing showed that the infections reappeared in April 2014, suggesting that other factors were involved. When the team modified the interventions during the third stage, colonizations dropped to 5.62 (0.69 to 6.34), then to 2.84 (2.80 to 2.89), during follow-up, even though colonized patients continued to be admitted to the hospital.

The authors wrote that the decrease they saw when modified steps were taken in the third study phase were done according to monitoring and analysis of screening results, with promptly applied measures including, for example, non-ICU medical staff education, contact precautions for shared equipment, and multiple rigorous cleaning and disinfection interventions.

"The integration of epidemiological and microbiological data and the strict application of infection-control measures played a decisive role in preventing against the spread of CRKP in our hospital," they wrote.
Jan 10 Antimicrob Resist Infect Control study


Survey profiles antimicrobial use at European broiler chicken farms

A study designed to gauge antimicrobial usage in broiler farms and flocks in nine European countries found that raising the chickens without the drugs is feasible, but there was wide variation in amount, administration, and antimicrobial classes, signs that more work is needed to reduce the practice. A team from Belgium and the Netherlands reported its finding yesterday in the Journal of Antimicrobial Chemotherapy.

The team notes that European efforts have harmonized the collection and reporting of European veterinary antimicrobial sales data, which is useful, but results don't show what's happening at the farm or flock level.

The cross-sectional survey, done as part of the European Union Ecology from Farm to Fork Of microbial drug Resistance and Transmission (EFFORT) project, was conducted at about 20 conventional, comparable farms in each of the nine countries: Belgium, Bulgaria, Denmark, France, Germany, Italy, Poland, Spain and the Netherlands. The study included 181 broiler farm tota.

The researchers visited the farms from May 2014 to June 2016, and poultry producers completed a questionnaire that asked about farm technical and antimicrobial use data. The investigators focused on substance administered or bought and assessed three parameters: defined daily dose, defined course dose, and used daily dose.

Polymyxins (colistin), extended-spectrum penicillins (amoxicillin and ampicillin), and fluoroquinolones were the most often-used classes, but drugs and their usage varied among countries. Intestinal disorders were the most common treatment indication (45%), followed by colibacillosis (16%), and omphalitis (12%).

Overall, broilers were treated with antimicrobials during 9% of their rearing period, though that percentage varied from 3.3% to 36.7% between countries. Each country, however, had at least one untreated flock. Timingwise, 26% of farms started treatment on day 1 of production, and 49% of them began treatment within the first week.

The authros said the wide variation calls for more research into what drives the differences, which would be useful for devising additional steps to curb antimicrobial use on broiler farms.
Jan 10 J Antimicrob Chemother abstract

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