Stewardship / Resistance Scan for Feb 05, 2019

News brief

Report describes Candida auris fungemia cases in Brooklyn hospital

In a paper published yesterday in Emerging Infectious Diseases, a team of clinicians, infection control specialists, and pharmacists at a community hospital in Brooklyn described the management of patients with Candida auris bloodstream infections (fungemia).

Of the nine cases of C auris fungemia reported at the hospital since 2016, most involved patients in the their 70s who had come from nursing homes and had multiple concurrent conditions. Half of the patients had invasive devices. In addition, each patient had a recent history of broad-spectrum antimicrobial use, and many had concomitant antibiotic-resistant organisms—including Pseudomonas aeruginosa and Klebsiella pneumoniae—isolated during the treatment for C auris.

All patients were given micafungin as first-line therapy for an average duration of 22 days, and two of the patients received liposomal amphotericin B after failing micafungin therapy. Average hospitalization was 65 days. Two of the patients died, and 3 of the 7 discharged patients were sent to palliative care.

Although antifungal susceptibility results were not available at the time of treatment, analysis of test results showed that all isolates were markedly resistant to fluconazole, and 40% were resistant to liposomal amphotericin B. The authors of the paper recommend that physicians treating invasive C auris infections consider combination therapy with micafungin plus liposomal amphotericin B in patients who fail monotherapy with micafungin.

Since its identification in Japan in 2009, C auris has caused outbreaks in healthcare facilities in more than 20 countries. The fungus, which has shown resistance to the three major classes of antifungal drugs, can cause serious invasive infections in patients who have compromised immune systems, with an estimated mortality of between 30% and 60%.

Of the 551 invasive C auris infections reported to the Centers for Disease Control in Prevention since 2016, 280 have been in New York.
Feb 4 Emerg Infect Dis research letter

 

Norwegian hospital study finds suboptimal use of microbiology tests

A multicenter study by Norwegian researchers has found that despite large numbers of microbiology test orders, few tests are used to inform antibiotic prescribing. The results appeared yesterday in Antimicrobial Resistance and Infection Control.

The study, conducted over a 5-month period in 2014 at three hospitals in western Norway, analyzed data on patients who had been prescribed antibiotics for sepsis, urinary tract infections (UTIs), skin and soft tissue infections, lower respiratory tract infections (LRTIs), or acute exacerbations of chronic obstructive pulmonary disease (COPD). The primary outcome measures were the degree of microbiology test ordering, compliance with microbiology testing recommendation in the national antibiotic guideline, and the proportion of test results used to inform antibiotic prescribing.

Of the 1,731 patient admissions analyzed, mean compliance with microbiology testing recommendations in the antibiotic guideline was 89%, ranging from 81% in patients with acute exacerbations of COPD to 95% in patients with sepsis. Substantial additional testing was performed beyond the recommendations, however, with 49% of LRTI patients having urine cultures and 22% of UTI patients having respiratory tests. Microbiology test results from one of the hospitals showed that 18% (120/672) of patient admissions had applicable test results, but only half of them were used for therapy guidance, resulting in 9% (63/672) of patient admissions having         test results that informed antibiotic prescribing. 

The authors of the study say the findings indicate that current use of microbiology lab services in Norway is suboptimal, with diagnostic uncertainty and clinicians' insufficient knowledge of microbiology contributing to excessive testing, and long turnaround times reducing the usefulness of certain tests.

"There is a need both for tests with better performance characteristics and improved test ordering practices," they write. "Furthermore, use of microbiology test results to inform antibiotic decision-making needs to be optimized in order to ensure adequate patient treatment and more targeted therapy."
Feb 4 Antimicrob Resist Infect Control study

News Scan for Feb 05, 2019

News brief

With three more Ebola cases, DRC remains entrenched in outbreak

Today the Democratic Republic of the Congo's (DRC's) health ministry reported three more cases and two new deaths in an ongoing Ebola outbreak. The outbreak now stands at 788 cases, including 486 deaths, and 191 suspected cases are still under investigation.

The new cases were reported in recent outbreak hotspots, including one each in Katwa, Kyondo and Oicha. The deaths occurred in Katwa and Kyondo, with the Kyondo fatality listed as a community death. So far, the virus has remained in DRC's North Kivu and Ituri provinces.

Officials also said a total of 74,096 people have been vaccinated with the VSV-ZEBOV vaccine, manufactured by Merck. Beni has seen the most vaccinations, with 20,473, followed by 18,362 in Katwa, 8,126 in Butembo, 6,008 in Mabalako, and 2,686 in Kalunguta.
Feb 5 DRC update

 

Two more MERS infections reported in Saudi Arabia

Today Saudi Arabia's ministry of health (MOH) recorded two more MERS-CoV cases, both of which appear to be part of an ongoing outbreak in Wadi ad-Dawasir.

The patients are men ages 42 and 41. The 42-year-old is listed as a secondary household contact, and the 41-year-old is a secondary healthcare contact. Both men are hospitalized for their MERS-CoV (Middle East respiratory syndrome coronavirus) infections.

Over the weekend, the MOH reported at least 5 cases of MERS in Wadi ad-Dawasir, and the country has seen 24 cases since the first of the year. The cases suggest a healthcare-associated outbreak. Along with camel transmission, healthcare-associated outbreaks are a hallmark of MERS-CoV.

Yesterday, Avian Flu Diary, an infectious disease blog, reported that agriculture officials in Oman have tested local camels for MERS-CoV, and the animals are negative for the virus.  The testing was prompted by 5 recent cases of MERS in Oman, including 2 deaths. Oman has now reported 19 MERS-CoV infections since 2013.
Feb 5 MOH report
Feb 4 Avian Flu Diary post 

 

Five cases reported in Texas measles cluster; Washington outbreak grows by 8

Texas health officials are reporting five confirmed measles cases in three neighboring counties in the region around Houston, according to official statements and media reports.

Three of the cases are from Harris County, according to a statement yesterday from Harris County Public Health (HCPH). The patients are two boys who are younger than 2 years old and a woman between ages 25 and 35. All live in the northwestern part of Harris County.

Umair Shah, MD, MPH, executive director at HCPH, said measles is highly contagious and spreads to others through coughing and sneezing. "However, it is easily preventable. Parents and caregivers have the power to protect their children and themselves from this disease by getting vaccinated," he said.

Also, the Galveston County Health District (GCHD) yesterday reported one case involving a boy ages 12 to 24 months who was tested Jan 28 and is part of a measles cluster in the region. And the Associated Press (AP) reported today that Montgomery County, on Harris County's northern border, has confirmed one case and that a possible sixth case in Texas has been identified with testing underway.
Feb 4 HCPH statement
Feb 4 GCHD statement
Feb 5 AP story

Elsewhere, health officials battling a measles outbreak in Washington state since early January have reported 8 more confirmed cases over the past few days, all from Clark County, the area around Vancouver. An update yesterday from Clark County Public Health (CCPH) said there are 9 more suspected cases under investigation.

All but two of the 49 confirmed cases are children age 18 or younger, and 42 patients were unimmunized, 6 have an unverified immunization status, and 1 had received the measles, mumps, and rubella (MMR) vaccine.

Earlier in the outbreak, 2 confirmed cases linked to the outbreak were reported, one from neighboring Multnomah County in Oregon and one Seattle-King County. No new cases have been reported from those two locations. The CCPH said its cases include two people who traveled to Hawaii, one who traveled to Bend, Ore., and two who moved to Georgia.
Feb 4 CCPH update

 

Bat Zika virus study finds possible animal model and ecological role

Jamaican fruit bats—one of the most common bat species in the Caribbean region, Central America, and Mexico—may be a useful animal model for studying Zika virus and may play a role in virus ecology, according to experiments conducted by researchers from Colorado State University.

Their two-part study was designed to gauge the susceptibility of the bats to Zika infection and to follow the disease course with tests to assess viremia, tissue tropism, replication, and shedding. The team reported their findings yesterday in PLOS Neglected Tropical Diseases. They noted that experiments in the 1950s and 1960s showed that several bat species were naturally and experimentally susceptible to Zika virus, with some developing neurological disease.

In the new experiments, Jamaican fruit bats infected in the lab mounted an antibody response. In some of the bats during 28-day follow up, researchers found evidence of viral replication and pathologic findings in the brain, testes, lungs, and salivary glands. They didn't find any blood brain barrier disruption and raised the possibility that microglial cells might be the Zika virus entry route to bat brains.

They concluded that bats might be a suitable animal model for studying Zika pathogenesis, including the assessment of sexual transmission, in-utero transmission, birth defects, and neurologic derangements. They also note that Zika could be a wildlife disease that affects bat populations, and more study is needed to fully understand the role bats might play in maintaining the virus.
Feb 4 PLOS Negl Trop Dis abstract

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