Food Outbreak Scan for May 24, 2019

News brief

CDC reveals latest details on tahini Salmonella probe

The US Centers for Disease Control and Prevention (CDC) yesterday provided new details in the investigation into a Salmonella Concord outbreak linked to imported tahini. No new illnesses have been reported, and the total stands at four infected people in three states. One patient has been hospitalized. The latest illness onset was Mar 23.

Interviews with three sick patients revealed that all had eaten tahini or hummus made with tahini. Records from restaurants where the people ate showed that the tahini used was the Karawan brand. Genetic sequencing has tied the strain found in the tahini samples to isolates from patients, and tests on four clinical isolates didn't suggest resistance to any antibiotics.

Brodt Zenatti Holdings, based in Jupiter, Florida, recalled its Karawan brand tahini imported from Palestine on May 15. On May 20 it recalled its SoCo brand tahini. The outbreak is not related to an event earlier this year linked to a different brand of tahini.
May 23 CDC outbreak announcement
May 16 CIDRAP News scan "Imported tahini tied to Salmonella cases in 3 states"

 

Precut melon Salmonella investigation concludes after 137 cases

Today the CDC said it has received reports of 20 more illnesses in a Salmonella Carrau outbreak linked to precut melon and has wrapped up its investigation.

In a final outbreak notice, the CDC said 137 cases have been reported, with the number of affected states holding steady at 10. Six more people were hospitalized, raising that total to 38. No deaths were reported. The latest illness onset was May 1.

Epidemiologic and trace-back investigations suggested that precut melon from Caito Foods based in Indianapolis was the source of the outbreak, and on Apr 12, the company issued a recall.

Interviews with 83 sick patients found that 53 (64%) reported eating precut melon bought at grocery stores. Five more reported eating it outside the home. Information from stores where the customers shopped revealed that Caito Foods supplied the precut melon, which included watermelon, honeydew melon, cantaloupe, and precut fruit medley products containing one of these melons.
May 24 CDC final outbreak update
Apr 25 CIDRAP News scan "CDC: Precut melon Salmonella outbreak sickens 24 more, 117 total

News Scan for May 24, 2019

News brief

WHA adopts resolution to combat antimicrobial resistance

Yesterday member states at the World Health Assembly (WHA)—the annual meeting of the decision-making body of the World Health Organization (WHO)—adopted a resolution calling for continued high-level commitments to implement and adequately fund multisectoral national action plans addressing antimicrobial resistance, the WHO said in a news release.

The resolution urges countries to strengthen infection prevention and control measures, including water sanitation and hygiene; enhance participation in the Global Antimicrobial Surveillance System; ensure prudent use of antimicrobials; and support multisectoral annual self-assessment surveys.

The resolution acknowledges the work of the Interagency Coordination Group on Antimicrobial Resistance to provide practical guidance to enhance global action to address antimicrobial resistance, and stresses the importance of addressing antimicrobial resistance to the achievement of the 2030 Agenda for Sustainable Development. 

It requests the WHO director-general to significantly enhance support to countries in implementing their national action plans and help mobilize needed financial resources, in collaboration with other United Nations agencies and partners. It also calls on the WHO director-general to maintain the WHO list of critically important antimicrobials for human medicine.
May 23 WHO news release

 

FDA OKs marketing of first test for detecting Zika virus antibodies

The US Food and Drug Administration (FDA) yesterday authorized the marketing of a diagnostic test to detect Zika virus immunoglobulin (IgM) antibodies in human blood, the agency said in a news release.

The ZIKV Detect 2.0 IgM Capture ELISA is the first Zika diagnostic test the FDA has allowed to be marketed in the United States. Other tests for detecting Zika virus IgM antibodies—including the ZIKV Detect 2.0 IgM Capture ELISA—had been approved only for emergency use under the FDA's Emergency Use Authorization.

The newly approved test is designed to identify IgM antibodies to Zika virus, which indicate an early immune response, in the blood. The FDA reviewed data from a clinical study of 807 test samples and a variety of analytical studies, which demonstrated that the ZIKV Detect 2.0 IgM Capture ELISA was safe and effective at identifying IgM antibodies against Zika virus in blood.

"At the onset of the Zika virus outbreak, when little was known about the disease or how to diagnose it, the FDA worked quickly with manufacturers to encourage the development of diagnostic tests and ensure they were available using our emergency use authorities," said FDA Acting Commissioner Ned Sharpless, MD. "Today's marketing authorization is a great demonstration of the FDA's work to protect the public health in emergency response situations."
May 23 FDA news release

 

CDC reports 3 new pediatric flu deaths, 111 for the season

Although US flu activity continues at only low levels now that the flu season is over, the Centers for Disease Control and Prevention (CDC) today reported two new flu-related deaths in children for 2018-19, raising the season's total equal to or higher than several other recent seasons. The agency also confirmed a pediatric death from the 2017-18 season.

The two latest flu-related deaths in children were caused by an influenza A virus that was not subtyped and occurred in January and late April. The 2017-18 death was caused by the H3N2 strain.

This season has now reached 111 pediatric flu deaths, compared with the same number in 2013-14, 148 in 2014-15, 95 in 2015-16, 110 in 2016-17, and 187 last season.

The proportion of outpatient visits for influenza-like illness (ILI) last week remained at 1.5%, well below the national baseline of 2.2%. All regions reported ILI below their region-specific baseline levels. ILI activity was low in Louisiana, Minnesota, and Puerto Rico and was minimal everywhere else. Massachusetts was the only state reporting widespread flu activity.

While influenza A(H1N1) viruses predominated from October to mid-February, influenza A(H3N2) viruses have been more common since then. Also, the typical late-season surge of influenza B strains has been muted this year. Last week clinical labs reported that they made up 44.7% of all flu viruses tested, while public health labs reported a 35.7% prevalence.
May 24 CDC FluView report

 

Pakistan reports 2 more polio cases; experts update eradication progress

Pakistan has reported two more wild poliovirus type 1 (WPV1) cases in separate provinces, and Niger reported circulating vaccine-derived poliovirus type 2 positives in a case contact, according to an update today from the Global Polio Eradication Initiative (GPEI).

Of the two WPV1 cases in Pakistan, one is in Karachi district in Sindh province and the other is in North Waziristan in Khyber Pakhtunkhwa province. Patients' paralysis onsets were Apr 29 and Apr 26, respectively. The country has now reported 17 cases in 2019 compared with 3 at this point last year and 12 for all of 2018.

In related news, the WHO today provided more details about a recent positive WPV1 environmental sample in Iran, first reported by the GPEI on May 17. The WHO said the sample was from sewage collected on Apr 20 in Sistan-Baluchistan province.

No related paralysis cases have been detected, and follow-up testing of sewage samples at the location on May 4 were negative for the virus. The area borders Pakistan and Afghanistan, two countries in which the virus is still endemic, with the other being Nigeria. Genetic tests suggest the virus found in Iran is most closely linked to WPV1 circulating in Pakistan's Sindh province. Iran's last indigenous WPV case was reported in 1997.

In Niger, cVDPV2 was found in an isolated collected on Mar 16 from a healthy community contact of an earlier confirmed case-patient in Zinder state, where an outbreak has been linked to one in Nigeria's Jigawa state.
May 24 GPEI update
May 24 WHO statement

Meanwhile, no WPV cases have been detected in the WHO's African region in 30 months, and continued improvements in surveillance and vaccinating children in Nigeria and the Lake Chad Basin may have interrupted WPV transmission, experts said today in Morbidity and Mortality Weekly Report (MMWR). A team from the CDC and the WHO published an assessment of eradication progress from January 2017 to March 2019.

In Afghanistan and Pakistan, the number of WPV cases in 2018 rose for the first time since 2014, and genetic sequencing of patient and environmental samples suggests persistent transmission along two common corridors due to transborder population movements. Efforts are under way to enhance vaccination at border points, and the group wrote that a ban on house-to-house vaccination in Kandahar province since the middle of 2018 has hindered immunization campaign effectiveness.
May 24 MMWR report

ASP Scan (Weekly) for May 24, 2019

News brief

Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans

WHA adopts resolution to combat antimicrobial resistance

Yesterday member states at the World Health Assembly (WHA)—the annual meeting of the decision-making body of the World Health Organization (WHO)—adopted a resolution calling for continued high-level commitments to implement and adequately fund multisectoral national action plans addressing antimicrobial resistance, the WHO said in a news release.

The resolution urges countries to strengthen infection prevention and control measures, including water sanitation and hygiene; enhance participation in the Global Antimicrobial Surveillance System; ensure prudent use of antimicrobials; and support multisectoral annual self-assessment surveys.

The resolution acknowledges the work of the Interagency Coordination Group on Antimicrobial Resistance to provide practical guidance to enhance global action to address antimicrobial resistance, and stresses the importance of addressing antimicrobial resistance to the achievement of the 2030 Agenda for Sustainable Development. 

It requests the WHO director-general to significantly enhance support to countries in implementing their national action plans and help mobilize needed financial resources, in collaboration with other United Nations agencies and partners. It also calls on the WHO director-general to maintain the WHO list of critically important antimicrobials for human medicine.
May 23 WHO news release 

 

Study links lower triage scores to delayed sepsis antibiotics

Originally published by CIDRAP News May 23

Sepsis patients who received a slightly higher emergency department (ED) triage score received antibiotics faster, a crucial step for survival, researchers from Intermountain Medical Center reported yesterday at the American Thoracic Society annual meeting under way in Dallas.

For the study, the team looked at adult sepsis patients who were treated at four Intermountain EDs in Utah from July 2013 to January 2017, according to an Intermountain press release. The EDs use a common five-point acuity score, with one being most in need of immediate care and five the least. They focused on patients with mid-range scores of 2 (emergent) and 3 (urgent) who had abnormally low blood pressures. Of 799 patients, 591 has a score of 2 and 208 had a score of 3. Then they gauged how quickly the patients received antibiotics.

Those who had triage scores of 3 had door-to-antibiotic times that were 32 minutes longer than those assigned a score of 2.

Ithan D. Peltan, MD, MSc, the study's senior author and attending physician in the Intermountain Medical Center Shock Trauma Intensive Care Unit and Intermountain Healthcare Telecritical Care, said in the statement that federal and international standards encourage starting broad-spectrum antibiotics within 3 hours of a sepsis patient's ED arrival. "Those 32 minutes can make a major difference in a patient's chances for survival."
May 22 Intermountain Medical Center press release

 

Report on superbugs from Mexico highlights medical tourism dangers

Originally published by CIDRAP News May 23

Officials from the Centers for Disease Control and Prevention (CDC) and seven state health departments today provided new details on 12 US patients who contracted Verona integron–encoded metallo-beta-lactamase–producing carbapenem-resistant Pseudomonas aeruginosa (VIM-CRPA) tied to medical procedures in Mexico—and how the infections could pose a risk to US hospitals.

Reporting in Morbidity and Mortality Weekly Report (MMWR), the investigators say the CDC received 31 reports of VIM-CRPA through its Antibiotic Resistance Laboratory Network from Sep 18 through Nov 19, 2018. Six of those cases were tied to invasive medical procedures in Mexico. After the CDC alerted healthcare professionals about the risk, six more cases came to light.

The 12 patients were from seven states: Utah, Washington, Arizona, Arkansas, Oregon, Texas, and West Virginia. Specimen collection ranged from November 2015 through December 2018. Eleven of the patients were medical tourists—they had traveled to Mexico specifically for bariatric surgery—and the 12th underwent endoscopic cholangiopancreatography in September 2018 after falling ill while traveling. Six patients were hospitalized in the United States for their VIM-CRPA infections, and one who developed a bloodstream infection died. Previous reports have noted that the infections have been tied to Grand View Hospital in Tijuana.

"This investigation highlights the potential for acquiring infections with highly antibiotic-resistant organisms not commonly found in the United States when receiving health care abroad that, once imported into this country, can spread within U.S. health care facilities," the authors write.

They add, "Any patient with an overnight stay in a health care facility outside the United States in the preceding 6 months should undergo rectal screening for carbapenemases on admission to a U.S. health care facility."

On Mar 5, the WHO said 20 people in nine states were tied to the outbreak.
May 24 MMWR report
Mar 5 CIDRAP News scan

 

Letter to 'nudge' high antibiotic prescribers linked to drop in prescribing 

Originally published by CIDRAP News May 21

A letter sent to the highest antibiotic-prescribing General Practitioners (GPs) in Northern Ireland was tied to a nearly 5% reduction in prescribing in those practices over the course of a year, researchers reported yesterday in the Journal of Antimicrobial Chemotherapy.

The letter, signed by Northern Ireland's chief medical officer, was sent to 221 GPs in 67 practices in Northern Ireland in October 2017, on the basis of those practices being in the top 20% of highest prescribers by standardized total antibiotic prescribing rate. The idea behind the behavioral intervention was that providing a descriptive social norm feedback "nudge" could get prescribers to change their prescribing practices. A similar intervention conducted in England in 2014 was associated with 3.3% relative reduction in antibiotic prescribing in targeted practices.

The outcomes measured in the study were the standardized total antibiotic prescribing rates in the four calendar quarters following the intervention (October 2017 through September 2018).

The greatest change occurred in the first quarter following the intervention, when there was a change of – 25.7 (95% confidence interval [CI], – 42.5 to – 8.8) antibiotic items per 1,000 Specific Therapeutic group Age-sex Related Units (STAR-PU) associated with the intervention. But with each subsequent quarter, the coefficient increased by a diminishing amount, to – 58.7 antibiotic items per 1,000 STAR-PU (95% CI, – 116.7 to – 0.7) after 1 year. In the final three quarters of the intervention, none of the individual quarters showed a significant change in antibiotic prescribing from the pre-intervention period.

Still, approximately 18,900 fewer antibiotic items were prescribed than if the intervention had not been made, representing a 4.6% reduction in antibiotic prescribing in those practices and a 1% reduction in overall primary care antibiotic prescribing in Northern Ireland.

The authors of the study conclude, "This intervention is an example of a low-cost, simple behavioural 'nudge' that policymakers can use to effectively meet their goals without introducing new policies or rules."
May 20 J Antimicrob Chemother abstract 

 

Study finds diagnostic testing and antibiotic use is high in kids with CAP

Originally published by CIDRAP News May 21

A study by a team of US pediatric emergency medicine and infectious disease experts has found that diagnostic testing and antibiotic use in children with community-acquired pneumonia (CAP) in outpatient settings remain high, despite recommendations against their routine use. The findings appeared yesterday in the Journal of Pediatric Infectious Diseases.

Because CAP in most young children is viral, the 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America pediatric CAP guidelines recommend against routinely performing these diagnostic tests and prescribing antibiotics. To evaluate the use of diagnostic testing and antibiotics before and after publication of these guidelines, the researchers used data from the 2008-2015 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to determine the proportion of visits in which chest radiography (CXR) was performed, a complete blood count (CBC) or blood culture was obtained, and antibiotics were prescribed for children aged 1 to 6 years with CAP.

The results showed that in an estimated 6.3 million pediatric visits for CAP from 2008 through 2015, a CBC was obtained in 8.6% of visits, blood culture in 11.1%, CXR was performed in 43%, and antibiotics were prescribed in 73.9%. In addition, when antibiotics were prescribed, most of them were macrolides or cephalosporins, which is inconsistent with the guideline recommendations to use narrow-spectrum penicillins as first-line treatment. No difference was found in CBC, blood culture, CXR, and antibiotic orders overall between the pre-guideline and post-guideline periods. 

The authors of the paper suggest the high rates of testing and treatment in children with CAP could be attributable to diagnostic uncertainty and the lack of objective, easily obtained tests to determine CAP etiology. They conclude, "Effective interventions are needed to decrease potentially unnecessary diagnostic testing and treatment."
May 20 J Pediatric Infect Dis Soc abstract

 

Trial supports shorter antibiotic therapy for orthopedic implant infections

Originally published by CIDRAP News May 20

The results of a randomized clinical trial conducted by Swiss researchers suggest that 4 weeks of antibiotic therapy is non-inferior to 6 weeks in patients with orthopedic implant infections. The findings appear in the Journal of Antimicrobial Chemotherapy.

In the single-center trial, researchers with Geneva University Hospitals analyzed 123 patients who had an infected implant surgically removed. The patients were randomized 1:1 to receive either 4 or 6 weeks of systemic antibiotic therapy. The most common type of infection included orthopedic plate infection (44), prosthetic joint infection (38), and infected nail implants (11). The antibiotic regimen for each patient was selected by the treating surgeon in consultation with an infectious diseases expert.

The primary outcome was remission of infection at the operative site, and the secondary endpoint was the occurrence of any adverse events related to antibiotic therapy. The non-inferiority margin was 10%.

Of the 123 cases in the intention-to-treat population, 120 episodes (98%) were cured microbiologically and 116 (94%) clinically after a median follow-up period of 2.2 years. Recurrence of clinical infection occurred in four patients in the 4-week arm and three patients in the 6-week arm (Pearson X² test; P = 0.74); in all cases, this occurred at around 2 months following the end of antibiotic treatment. These results were formally in line with the non-inferiority hypothesis, as the two-tailed 95% confidence intervals [CIs] largely excluded the 10% margin (1.5%, 95% CI, −9.8% to 6.8%). The study could not meet the non-inferiority hypothesis in terms of adverse events, however.

The authors of the study conclude, "Our randomized trial confirms the opinion of several experts who have suggested that results are likely similar for patients with surgically debrided OM [osteomyelitis] treated with 4 versus 6 weeks of antibiotic therapy.As there are many advantages, and apparently no disadvantages, patients with orthopaedic implant infections might benefit from this shorter antibiotic treatment."
May 18 J Antimicrob Chemother study

 

Australian researchers to use artificial intelligence against AMR

Originally published by CIDRAP News May 20

A multidisciplinary team of scientists and medical researchers in Australia has launched a new project to put artificial intelligence (AI) to work against antimicrobial resistance (AMR).

Combining machine learning with data streams from people, animals, and the environment, the OUTBREAK (One-health Understanding Through Bacterial REsistance to Antibiotics Knowledge) project will create a spatial and temporal map of AMR in Australia, using a One Health approach. The ultimate aim of the technology is to predict possible AMR outbreaks, trace the origins of outbreaks, and evaluate the risks and cost-effectiveness of treatments and intervention strategies.

"Every city, town, region and country will have a different AMR fingerprint and therefore different risks," chief investigator Steven Djordjevic, PhD, said in a press release from the University of Technology Sydney (UTS), one of 14 institutions collaborating on the project. "Our vision, ultimately, is a worldwide AI-powered network for AMR surveillance and mitigation, led by Australian research and industry."

The team will include experts in genomics and metagenomics, microbiome and computational biology, zoonotic diseases, biosecurity, pharmacy, risk management, and machine learning.

The project is supported by a $1 million grant from the Medical Research Future Fund, with the possibility of $5 million in additional funding.
May 17 UTS press release

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