ASP Scan (Weekly) for Mar 22, 2019

New asymptomatic bacteriuria guidance
Resistant Enterococcus in wastewater
Stewardship in pet care
Fewer antibiotics in Salmon
Gloves, gowns, and MDROs
WHO drug-resistant TB guidelines
Antibiotic development partnership
Lung disease bacteria in tap water
Drop in US prescribing
Short course for Pseudomonas
Antibiotic cardiac device 'envelope'

IDSA updates guidelines for asymptomatic bacteriuria

Originally published by CIDRAP News Mar 21

The Infectious Diseases Society of America (IDSA) today issued updated guidelines on the management of asymptomatic bacteriuria (ASB) that reinforce previous recommendations to avoid overdiagnosis of urinary tract infection and unnecessary antibiotic treatment.

Its previous guidelines, issued in 2005, recommended that only pregnant women and individuals undergoing an invasive urologic procedure should be screened and treated for ASB—the presence of bacteria in the urine without symptoms of an infections—and that screening and treatment should be avoided in healthy non-pregnant women, the elderly, people with diabetes, and patients with spinal cord injuries. ASB occurs in 3% to 7% of healthy women, 50% of people with spinal cord injuries, and 30% to 50% of nursing home residents.

The new guidelines, published in Clinical Infectious Diseases, add infants and children and people who've had non-urologic surgery, joint replacement, or organ transplants to the list of those who should not be screened or treated for ASB unless they show signs of an infection.

"Screening these patients is far too common and leads to the inappropriate prescribing of antibiotics, which some studies suggest may actually increase the risk of a UTI, as well as contribute to other serious infections such as Clostridioides difficile," Lindsay Nicolle, MD, FIDSA, chair of the committee that developed the guidelines, said in an IDSA press release. "Generally, physicians should not obtain urine cultures unless patients have symptoms consistent with an infection, such as burning during urination, frequent urination or abdominal pain or tenderness on the back near the lower ribs."

Since the publication of the 2005 guidelines, antibiotic stewardship programs have identified ASB as important contributor to inappropriate antibiotic use.
Mar 21 Clin Infect Dis paper
Mar 21 IDSA press release


Study finds drug-resistant bacteria in English wastewater treatment plants

Originally published by CIDRAP News Mar 21

An epidemiologic and genomic analysis of wastewater in England has found widespread dissemination of hospital-adapted lineages of antibiotic-resistant Enterococcus faecium, a team of researchers reported today in Genome Research.

The researchers began by collecting treated and untreated wastewater from 20 wastewater treatment plants in the East of England and culturing the samples for E faecium, ampicillin-resisant E faecium(AREfm), and vancomycin-resistant E faecium (VREfm), which is a leading cause of healthcare-associated infections. They found AREfm and VREfm in all 20 samples of untreated water, and in 18 and 17 treated samples, respectively. The only negative samples were from plants that used terminal ultraviolet light contamination.

The bacterial counts of AREfm and VREfm were significantly higher in the 10 treatment plants that received wastewater from hospitals.

The researchers then compared the genomes of 423 E faecium isolates from the wastewater plants with 187 E faecium isolates associated with bloodstream infections diagnosed in patients in the East of England from 2010 through 2016. That comparison revealed that the resistant E faecium isolates were in two major lineages, the hospital-adapted clade A1 and the animal-associated clade A2, with AREfm residing in A1 and A2 and VREfm exclusive to A1.

Among the 481 isolates in clade A1, the researchers observed genetic intermixing between wastewater and bloodstream infection, with highly related isolates shared between a major teaching hospital and 9 of the 20 treatment plants. They also found that 23 of 28 detected antibiotic, metal, and biocide resistance genes were represented in bloodstream, hospital sewage, and municipal wastewater isolates.

"In conclusion, our findings highlight the challenges of controlling healthcare-associated dissemination of VREfm," the authors of the study write. "The extent to which isolates from humans and wastewater were related indicates that wastewater could be used for the surveillance of circulating VREfm lineages."

They add that the risk posed to human health by the release of VREfm into the environment, and the benefit derived from preventing it, is uncertain and needs to be studied further. 
Mar 21 Genome Res study


Group publishes recommendations for stewardship in pet care industry

Originally published by CIDRAP News Mar 21

The Pet Industry Joint Advisory Council (PIJAC) today released an industry-wide, comprehensive set of recommendations for antibiotic stewardship and combatting antimicrobial resistance in companion animals. It announced the guidelines during the Global Pet Expo trade show at the Orange County (Florida) Convention Center, according to a PIJAC news release.

The recommendations encompass a set of principles for all sectors of the pet care community, with an emphasis on those involved in the breeding, raising, transport, and sale of pets as well as those who work with products containing antibiotics. The guidelines cover the use of antibiotics, sanitation, hygiene, veterinary oversight, and zoonotic disease prevention, among other topics.

Sections of the report include key elements of stewardship, best practices for preventing and managing disease, recommendations for antibiotic stewardship, and guidance for specific segments of the industry.

"Antibiotic resistant germs are a growing and serious health risk to both humans and animals," said Savonne Caughey, PIJAC director of government affairs. "Last year, PIJAC committed to work with the pet care community to create best management practices to combat AMR as part of our participation in the U.S. government's Antimicrobial Resistance (AMR) Challenge."
Mar 21 PIJAC news release
Mar 21 full PIJAC report


Chilean fish farmers pledge to cut antibiotics in salmon

Originally published by CIDRAP News Mar 21

Companies representing about 80% of Chile's salmon industry pledged this week to cut antibiotics in farmed salmon in half over the next 6 years, Seafood Source reported.

The companies, which are members of the Chilean Salmon Marketing Council (CSMC), pledged at Seafood Expo North America on Mar 18 to reduce antibiotic use by 50% by 2025 and seek a "Good Alternative" rating from the Monterey Bay Aquarium's Seafood Watch program.

The partnership among CSMC, SalmonChile, and the Monterey Bay Aquarium will formally be known as the Chilean Salmon Antibiotic Reduction Program (CSARP). The Chilean operations of Mowi, a seafood company based in Norway, will also participate in the initiative, SalmonChile CEO Arturo Clement said.

In 2018 the United States imported about $1.4 billion worth of farmed salmon and farmed salmon products from Chile, not including smoked or canned salmon, according to data from the US National Marine Fisheries Service.
Mar 19 Seafood Source story


Contamination with MDROs after patient interaction common, study finds

Originally published by CIDRAP News Mar 20

Researchers at a large tertiary-care teaching hospital in Chicago reported today in Infection Control and Epidemiology that more than a third of healthcare workers were contaminated with a multidrug-resistant organism (MDRO) after caring for patients infected or colonized with the bacteria, and that errors in doffing personal protective equipment increased the risk of contamination.

The study, conducted at Rush University Medical Center in Chicago, enrolled 125 healthcare workers (mainly physicians and nurses) who were caring for patients on contact precautions for methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococci, and multidrug-resistant gram-negative pathogens. The researchers took swab samples from the healthcare workers' hands, clothes, gloves, gowns, and other equipment before and after patient interactions, and observed how the healthcare workers removed gowns and gloves after caring for patients. They also took samples from patients and environmental sites.

Of the 125 healthcare workers, 43 (34.4%) acquired the MDRO that was colonizing or infecting a patient during the patient encounter, with 38 acquiring the target MDRO on gloves and gowns and 4 acquiring it on their hands. Target MDROs were also found on healthcare worker clothing and equipment. Healthcare worker contamination was more common in settings of higher patient and environmental contamination. In addition, more than a third of healthcare workers (37.6%) made multiple doffing errors, including touching the inside of the gown or glove with a gloved hand, or touching the outside of the glove or gown with a bare hand.

Healthcare workers who made multiple doffing errors were more likely to have contaminated clothes after a patient encounter (odds ratio [OR], 13.23; 95% confidence interval [CI], 1.31 to 133.26, P = 0.26). There was also a higher risk of hand contamination when gloves were removed before gowns (OR, 5.56; 95% CI, 1.07 to 28.80, P = .052).

The authors of the study suggest that reinforcing the preferred order of doffing gloves and gowns—gloves and gowns removed together, or separately, with gloves first—could reduce healthcare worker contamination.
Mar 20 Infect Control Hosp Epidemiol abstract


WHO issues consolidated guidelines for MDR-TB treatment, care

Originally published by CIDRAP News Mar 20

The World Health Organization (WHO) today announced new consolidated guidelines aimed at improving treatment for multidrug-resistant tuberculosis (MDR-TB).

The consolidated guidelines incorporate all previous WHO guidance on treating drug-resistant TB dating back to 2011, including the most recent guidance issued in December 2018. The most significant change in the December 2018 guidance was the recommendation of a fully oral regimen for longer MDR-TB treatments, which last 18 to 20 months. The regimen no longer includes the injectable drugs kanamycin and capreomycin, which have been associated with increased risk of treatment failure and relapse and severe side effects, including hearing loss.

The consolidated guidelines also include treatment recommendations for isoniazid-resistant TB, a shorter treatment regimen for certain MDR-TB patients, policy recommendations for culture monitoring and surgery in MDR-TB patients, and optimal models of patient support and care.

The guidelines were released in advance of World TB Day on Mar 24.
Mar 20 WHO consolidated drug-resistant TB guidelines


New antibiotic development partnership formed

Originally published by CIDRAP News Mar 20

The Global Antibiotic Research and Development Partnership (GARDP) announced yesterday that it will partner with German drug maker Evotec AG to establish a joint pipeline of new antibiotics for hard-to-treat bacterial infections.

GARDP said the strategic partnership will focus on accelerating the discovery and development of antibiotics for infections caused by the WHO's priority pathogens by building a platform that spans the length of the drug development value chain. The two organizations also aim to ensure that the novel antibiotics produced through the partnership are sensibly priced and available to all patients who need them.

"Working with Evotec will undoubtedly strengthen GARDP's efforts to develop new antibiotics, while addressing the need for their sustainable access," Seamus O'Brien, PhD, research and development director at GARDP, said in a press release. "Evotec's expertise complements GARDP's approach, which allows both partners to develop a drug from early exploratory to preclinical and clinical studies all the way to patients."
Mar 19 GARDP press release


Sampling finds LegionellaMycobacterium in home and office tap water

Originally published by CIDRAP News Mar 20

Year-long sampling of cold water taps from offices and residences across the United States for two organisms known to cause two lung diseases—legionellosis and pulmonary nontuberculosis mycobacterium disease—revealed sporadic detections, according to researchers from the US Environmental Protection Agency (EPA).

The taps were monitored from January 2009 through November 2014, and, of the 108 taps, 65 were in offices and 43 were in residences. The locations spanned 31 states, 1 federal territory, and 1 federal district. Water was collected from the same tap at three specific times in 1 year. The team reported its findings today in the Journal of Applied Microbiology.

The investigators tested for Legionella pneumophiliaL pneumophilia serogroup 1, and Mycobacterium avium. The organisms were detected in 41%, 25%, and 45% of the structures, respectively. The team looked for two occurrence patterns, sporadic (a single detection) and persistent (positive tests in at least two of the three samples).

Microbe occurrence was mainly sporadic, with persistence seen more often in office buildings, independent of building age and square footage. For residences, the researchers saw microbial persistence in structures older than 40 years for L pneumophilia, but rarely for M avium. Lack of consistent detections reduces the potential to trigger an outbreak among a family or group of workers, the group concluded.

Maura Donohue, PhD, a study coauthor who works with the EPA in Cincinnati, said in a press release from Wiley, the journal's publisher, that residences are often suspected as the bacteria source when an illness involving one of the two organisms is reported, but the study shows that this may not be the case for sporadic incidence. The group notes that the results show exposure is occasional but that other factors involving aerosols and the host are needed for disease transmission.

"Data from this study can help public health officials pinpoint locations of disease transmission, inform decisions on detection or recovery of the causative agent, and improve public health protection," she said.
Mar 20 J Appl Microbiol abstract
Mar 20 Wiley press release


US data show overall drop in antibiotic prescribing, but not for adults

Originally published by CIDRAP News Mar 18

US nationwide prescribing data show that oral antibiotic prescription rates dropped 5% from 2011 to 2016, and the ratio of broad- to narrow-spectrum antibiotics decreased 8% in that span, but prescribing rates in adults rose slightly, according to a new study in Clinical Infectious Diseases.

The investigators, from the Centers for Disease Control and Prevention, used prescription information from the IQVIA Xponent database over the 6-year study period. They used Poisson models to estimate prevalence ratios to compare 2011 and 2016 antibiotic prescription rates and linear models to evaluate temporal trends.

The researchers found that oral antibiotic prescription rates decreased 4.7%—from 877 prescriptions per 1,000 people in 2011 to 836 per 1,000 people in 2016. Prescription rates for pediatric patients (19 and younger) fell 13.0%, while adult rates actually increased a bit, by 1.7%. The ratio of broad- to narrow-spectrum antibiotics dropped from 1.62 to 1.49, or 8.0%, driven by reductions in macrolides and fluoroquinolones.

The proportion of prescriptions written by nurse practitioners and physician assistants increased by 95.0% and 58.5%, respectively, during the study period, and these professionals accounted for more than a fourth of all antibiotic prescriptions by study's end.

The authors conclude, "Although overall and broad-spectrum antibiotic prescriptions decreased during the study period, there are likely further opportunities to improve prescribing, especially to adults, and additional stewardship interventions are needed." They add that antimicrobial stewardship efforts need to include nurse practitioners and physician assistants.
Mar 16 Clin Infect Dis abstract


Support for shorter antibiotic course for Pseudomonas in bloodstream

Originally published by CIDRAP News Mar 19

Patients receiving short-course antibiotic therapy for uncomplicated Pseudomonas aeruginosa bloodstream infection (BSI) had similar odds of recurrent infection or death as those receiving longer courses, and spent fewer days in the hospital, researchers from Johns Hopkins University School of Medicine reported today in Clinical Infectious Diseases.

Overall, 361 patients treated in the Johns Hopkins Health System for P aeruginosa BSI from July 2016 through October 2018 were evaluated, and 249 met the eligibility criteria for the study. Sixty-nine patients (28%) received short-course therapy (median duration, 9 days) and 180 (72%) received long-course therapy (median, 16 days). Sixty-five percent of the cohort consisted of severely immunosuppressed patients. Antibiotics prescribed included piperacillin/tazobactam, cefepime, ciprofloxacin, meropenem, and ceftazidime.

In the propensity-score weighted cohort, the primary outcome of recurrent P aeruginosa infection or mortality within 30 days of completing therapy occurred in 10 (14%) of patients in the short-course group and 24 (13%) of patients in the long-course group (odd ratio, 1.06; 95% confidence interval [CI], 0.42 to 2.68, P = 0.91). On average, patients who received short-course therapy spent 4 fewer days in the hospitals compared with patients receiving longer courses (4.04 days; 95% CI, 1.25 to 6.83, P = 0.005).

The authors of the study say further interventional studies are needed to evaluate the reproducibility of the findings
Mar 18 Clin Infect Dis abstract


Antibiotic-releasing 'envelope' for cardiac devices tied to less infection

Originally published by CIDRAP News Mar 18

A study yesterday in the New England Journal of Medicine showed that an added antibacterial mesh envelope led to 40% fewer infections related to major cardiac implantable electronic devices (CIEDs) than did standard infection-prevention strategies alone.

The researchers used an absorbable TYRX envelope designed to hold a CIED—such as a pacemaker—when the device is implanted in the body. The envelope, made by Medtronic, consists of a multifilament knitted mesh coated with an absorbable polymer mixed with minocycline and rifampin, which releases the antibiotics into surrounding tissue for at least 7 days. The envelope is fully absorbed by the body in about 9 weeks, the authors said.

The scientists randomized 3,495 patients to the envelope group and 3,488 patients to the control (standard treatment) group. After 1 year, 6.0% of patients in the envelope group and 6.9% of patients in the control group had infections, for a hazard ratio (HR) of 0.87 (95% confidence interval [CI], 0.72 to 1.06; P < 0.001 for non-inferiority). The mean follow-up was 20.7 months, and major CIED-related infections through the entire follow-up period occurred in 32 patients in the envelope group and 51 patients in the control group (HR, 0.63; 95% CI, 0.40 to 0.98).

The authors conclude, "Adjunctive use of an antibacterial envelope resulted in a 40% lower incidence of major CIED infection than standard-of-care infection-prevention strategies alone. Patients who received the envelope did not have more procedure-related or system-related complications than those who did not receive it."
Mar 17 N Engl J Med study

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