Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans
ECDC surveillance report shows high level of antibiotic resistance in ICUs
The burden of antibiotic resistance in European intensive care units (ICUs) remains high, according to a surveillance report today from the European Centre for Disease Prevention and Control (ECDC).
The report on healthcare-associated infections (HAIs) in ICUs, based on 2016 data from 1,159 hospitals and 1,451 ICUs in 14 countries, revealed that 30% of Staphylococcus aureus isolates were resistant to oxacillin, and resistance to third-generation cephalosporins was detected in 18.1% of Escherichia coli isolates, 32.1% of Enterobacter isolates, and 37.8% of Klebsiella isolates. In addition, carbapenem resistance was reported in 10.7% of Klebsiella isolates, 26.4% of Pseudomonas aeruginosa isolates, and 66.1% of Acinetobacter baumannii isolates. Those percentages are comparable to the 2015 report.
"The high percentages of resistance to carbapenems of P. aeruginosa, A. baumannii, and K. pneumoniae isolates reflect the challenges in the treatment of ICU patients, a highly vulnerable patient population. . . . Moreover, the burden of antimicrobial resistance is high in ICUs, due to the severity of the clinical condition of the patients, the frequent use of antibiotics, and varying infection prevention and control practices," the authors write. "Strengthening infection prevention and control practices and implementing antimicrobial stewardship are essential to prevent HAIs and counteract the emergence and spread of antimicrobial resistance in ICUs."
Overall, the report found that, of 151,709 patients staying in an ICU for more than 2 days, 12,735 patients (8.4%) presented with at least one HAI. The most common HAI was pneumonia, reported in 6.3% of patients; bloodstream infections occurred in 3.7% of patients, and 1.9% acquired urinary tract infections.
May 4 ECDC report
Survey notes possibilities, barriers in nurses' stewardship role
Originally published by CIDRAP News May 3
An online survey of 180 nurses found that nursing professionals are well positioned to be integrated into antibiotic stewardship programs, but clinical practice and hospital culture influence perceptions of their role—and barriers include nurses not included in rounds, interdisciplinary power differentials, and nursing input not actively sought—according to a study yesterday in the American Journal of Infection Control.
The survey assessed 10 practices that fall within the responsibility of inpatient nurses and contribute to stewardship efforts.
Nurses were highly confident assessing for an adverse drug reaction history, obtaining cultures before antibiotic prescribing, and participating in patient education. They were less confident in reviewing microbiology results to determine antibiotic appropriateness. Clinical practice and hospital culture influenced perceptions of their stewardship role. Reported barriers to stewarding included exclusion from rounds, power differentials, and lack of coworkers not seeking their input.
The authors conclude, "Barriers to nurse engagement were identified and could be addressed by improving education in microbiology and principles of antibiotic use along with more consistent inclusion of nurses in bedside rounds while also cultivating an environment where nurse contribution is actively sought."
May 2 Am J Infect Control study
Study analyzes snapshot of K pneumoniae isolates in Germany
Originally published by CIDRAP News May 3
Whole-genome sequencing (WGS) of K pneumoniae isolates from German hospital patients suggests the prevalence of classical K pneumoniae strains with widely distributed carbapenemase genes, researchers reported yesterday in Antimicrobial Resistance and Infection Control.
For the study, researchers with the Robert Koch Institute in Berlin compiled a representative subset of 107 carbapenemase-producing K pneumoniae isolates collected from 2008 through 2014 at hospitals throughout the country. The isolates possessed the four most prevalent carbapenemase types in Germany—KPC-2, KPC-3, OXA-48, and NDM-1.
WGS data showed that the isolates belonged to 21 different sequence types (STs) of K pneumoniae, with 27 of 34 (80%) KPC-2-producing isolates belonging to ST258—a prominent lineage in healthcare settings—and 21 of 26 (81%) KPC-3-producing isolates belonging to ST512 (a variant of ST258). The most prevalent carbapenemase type, OXA-48 (42 isolates), revealed 15 different STs, and the 5 NDM-1 producers were assigned to 4 STs.
One OXA-48 isolate in the collection contained an almost complete set of virulence genes and belonged to ST23, a hypervirulent strain which is frequently found in Asia. That strain appeared to be representative of an entire cluster of infections in a single German healthcare center in 2012.
"The finding of a supposed hypervirulent and OXA-48-producing ST23 K. pneumoniae isolate outside Asia is highly worrisome and requires intensive molecular surveillance," the authors write.
May 2 Antimicrob Resist Infect Control study
FDA panel OKs plazomicin for complicated urinary tract infections
Originally published by CIDRAP News May 3
A US Food and Drug Administration (FDA) advisory committee has voted unanimously in favor of Achaogen's plazomicin, an intravenous antibiotic, for the treatment of adults who have complicated urinary tract infections but not for the treatment of bloodstream infections.
San Francisco–based Achaogen said the FDA Antimicrobial Drugs Advisory Committee voted 15-0 that the company had "provided substantial evidence of the safety and effectiveness of plazomicin for the treatment of complicated urinary tract infections," but 11-4 against the same criterion for bloodstream infections in patients with limited or no treatment options.
"We are encouraged by the Committee's unanimous vote in favor of plazomicin for complicated urinary tract infections (cUTI). The discussion underscored the real-world challenges that healthcare providers face every day given limited or inadequate treatment options for certain pathogens," said CEO Blake Wise in the company release.
The FDA is not bound by the committee's votes but takes its input into consideration when reviewing marketing applications. Plazomicin has a Prescription Drug User Fee Act date of Jun 25. If the FDA approves the drug by this date, Achaogen expects to launch plazomicin in the United States soon thereafter, the company said.
Achaogen announced on Jan 2 that the FDA had accepted its New Drug Application for priority review for plazomicin.
May 2 Achaogen news release
Jan 2 Achaogen press release
Strain of hypervirulent, carbapenem-resistant Klebsiella found in China
Originally published by CIDRAP News May 2
Scientists in China are reporting the emergence of a new strain of hypervirulent, carbapenem-resistant of K pneumoniae.
In a study published in Antimicrobial Agents and Chemotherapy, researchers from Sichuan University report that the strain, WCHKP13F2, was isolated in 2015 from a patient who had severe burns and a healthcare-associate bloodstream infection. The K pneumoniae isolate was resistant to several antibiotics, including imipenem and meropenem. The patient discharged himself in spite of unsolved critical illness.
Whole-genome sequencing revealed that the isolate belonged to sequence type 36, a known hypervirulent K pneumoniae (hvKP) strain with a worldwide distribution, and testing confirmed hypervirulence. Further analysis identified several plasmid-mediated hypervirulence genes and antibiotic resistance genes, including the carbapenemase gene blaKPC-2.
"The combination of carbapenem resistance and hypervirulence significantly compromises options of antimicrobial agents for treating the life-threatening infections caused by carbapenem-resistant hvKP and therefore represents a major urgent challenge for clinical treatment, infection control, and public health," the authors write. "Surveillance of carbapenem-resistant hvKP is urgently required to generate essential information for preventing their spread."
Apr 30 Antimicrob Agents Chemother abstract
Spanish study shows long-term impact of prescribing intervention
Originally published by CIDRAP News Apr 30
Six years after it was first implemented, a multifaceted, practice-based intervention among Spanish primary care physicians continued to keep antibiotic prescribing levels down for respiratory tract infections (RTIs), researchers report in the Journal of Antimicrobial Chemotherapy.
In 2008 and 2009 The HAPPY AUDIT project, a study aimed at strengthening the surveillance of RTIs and developing interventions to reduce prescribing, demonstrated a 50% reduction in antibiotic prescriptions by participating physicians 1 to 3 months after the intervention was implemented. The intervention involved individual prescriber feedback and discussion of the first registration of results in 2008, a training course on the appropriate use of antibiotics for RTIs, clinical guidelines for diagnosis and treatment of RTIs, brochures and handouts to patients about prudent use of antibiotics, and access to rapid point-of-care tests (POCTs).
A follow-up study in 2015 aimed to see if the intervention continued to have an impact. A total of 121 of the 210 physicians who registered in the initial study agreed to participate in the follow-up study, and their prescribing habits were compared with 117 physicians who had not been exposed to interventions on antibiotic prescribing.
The 238 physicians combined treated 22,247 patients with RTIs and prescribed antibiotics to 5,325 of them (23.9%). After adjustment for covariables, compared with the antibiotic prescribing observed just after the intervention was initially implemented in 2008, the 121 physicians in the intervention group prescribed slightly more antibiotics in 2015, although the difference was not statistically significant (odds ratio [OR], 1.08). But the physicians in the control group prescribed significantly more antibiotics (OR, 2.74).
The authors of the study conclude, "Changing clinicians' prescribing behaviour is a complex matter. Several strategies such as the provision of guidelines, poster display in the waiting rooms and even leaflets have limited effect. When active strategies are added to these passive educational sessions, such as the feedback and discussion of previous results, training in enhancing communication skills in the consultation and the provision of POCTs, the effect is much greater."
Apr 27 J Antimicrob Chemother study
Researchers identify variant MCR-3 colistin resistance gene in Brazil
Originally published by CIDRAP News Apr 30
Researchers analyzing E coli isolates from Brazilian pigs have identified a new variant MCR-3 colistin resistance gene, according to a study today in Antimicrobial Agents and Chemotherapy.
Scientists from Switzerland, Brazil, and France screened samples from 126 Brazilian pigs for colistin resistance. They identified eight colistin-resistant E coli isolates, including one from a pig in Minas Gerais state that contained an MCR-3 variant that they named MCR-3.12. It was carried by an IncA/C2 plasmid and had a similar function as MCR-1 and MCR-2.
Since the colistin resistance gene MCR-1 was first identified in E coli samples from pigs, pork products, and humans in China in 2015, it has been detected in more 30 countries, and MCR-2 through MCR-7 genes have been identified. Colistin is considered a last-resort antibiotic for treating infections caused by multidrug-resistant bacteria, and the plasmids containing MCR genes can transfer among different bacterial species, another cause for concern.
Apr 30 Antimicrob Agent Chemother abstract
Apr 18 CIDRAP News scan "New colistin resistance gene identified in Chinese poultry"
Africa analysis finds high levels of antibiotic-resistant H pylori
Originally published by CIDRAP News Apr 30
A study designed to provide a clearer picture of the burden of Helicobacter pylori antibiotic resistance, which is increasing worldwide, found that levels in Africa are high, an international team of researchers reported in a recent edition of BMC Infectious Diseases.
They noted that the prevalence of H pylori infection, which can cause peptic ulcers and gastric cancer, varies by geographic region and quantity of antibiotics used, with seropositive levels much higher in developing countries than in their developed counterparts.
In their meta-analysis, the team looked at 26 studies on H pylori resistance from 14 African countries that were published from 1986 to 2017. Their goal was to estimate the extent of resistance to macrolides, quinolones, amoxicillin, tetracycline, and metronidazole. In total, 2,085 isolates were tested for metronidazole, 1,530 for amoxicillin, 1,277 for tetracycline, 1,752 for clarithromycin, and 823 for quinolones.
Pooled proportion of H pylori resistance was 17.4% for quinolones, 29.2% for clarithromycin, 48.7% for tetracycline, 75.8% for metronidazole, and 72.6% for amoxicillin.
The authors wrote that treatment guidelines for managing H pylori infections in developing countries have recommended first, second, and rescue therapy based on local susceptibility patterns, but poor resources make following them a challenge, and eradication rates have been found to be lower than 80%. They noted that the metronidazole resistance they found in Africa was significantly higher than in Europe and America, and the use of the drug for treating endemic diarrheal and protozoal diseases might explain the high resistance rate seen in Africa.
The investigators said the level of clarithromycin resistance in Africa, which was similar to some other regions of the world, could be related to high used of macrolides for communicable diseases. The overall resistance they saw for amoxicillin was much higher than in other regions, which the team said might be related to ampicillin's role as one of the most abused antibiotics in rural and urban African areas, because oral formulations are cheap and available.
They added that there's a need to conduct standard surveillance of H pylori susceptibility patterns in Africa to yield data that can help establish effective empirical treatment.
Apr 24 BMC Infect Dis abstract
