ASP Scan (Weekly) for May 10, 2019

News brief

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

Computer model shows potential of automated registry for CRE carriers

A computer modeling study suggests that implementing a registry that tracks patients with extensively drug-resistant organisms (XDROs) could reduce the spread of carbapenem-resistant Enterobacteriaceae (CRE) in a regional healthcare network, researchers reported yesterday in Clinical Infectious Diseases.

Using Regional Healthcare Ecosystem Analyst software, researchers from Johns Hopkins Bloomberg School of Public Health and elsewhere developed a model of all inpatient healthcare facilities (90 acute care hospitals, 9 long-term acute care hospitals, 351 skilled nursing facilities, and 12 ventilator-capable skilled nursing facilities) in the Chicago metropolitan area to simulate what would happen to CRE prevalence with the introduction and use of an electronic XDRO registry that tracks all patients carrying CRE  and automatically alerts facilities to help guide infection prevention and control efforts. The researchers then compared the impact of the registry with having no registry.

The results predicted that when all Illinois facilities participated (n=402), the registry reduced the number of new CRE carriers by 11.7% and CRE prevalence (compared to baseline) by 7.6% over a 3-year period. When 75% of the largest Illinois facilities participated (n=304), registry use resulted in an 11.6% relative reduction in new carriers (16.9% and 1.2% in participating and non-participating facilities, respectively) and 5.0% relative reduction in prevalence. When 50% participated (n=201), there were 10.7% and 5.6% relative reductions in incident carriers and prevalence, respectively. And when only 25% participated (n=101), there was a 9.1% relative reduction in incident carriers (20.4% and 1.6% in participating and non-participating facilities, respectively) and a 2.8% relative reduction in prevalence

"Our results show that an XDRO registry may be an effective tool in combating XRDO spread between facilities in a region," the authors of the study write. "Appropriately identifying patients allows for prompt use of contact precautions, which may save resources and time if known carriers do not need to be reidentified."
May 9 Clin Infect Dis abstract

 

ExPEC vaccine candidate shows promise in phase 2 trial

An extra-intestinal pathogenic Escherichia coli (ExPEC) vaccine candidate was well tolerated and elicited robust and functional responses across all serotypes, doses, and age groups in a phase 2 trial, researchers from Janssen Pharmaceuticals reported yesterday in The Lancet Infectious Diseases.

The randomized, double-blind placebo-controlled trial, designed and funded by Janssen, involved 848 healthy adults who were randomly assigned to receive a single dose of one of five ExPEC4V formulations or placebo. ExPEC4V is a four-valent vaccine comprised of the E coli O1A, O2, O6A, and O25B antigens bioconjugated to the protein carrier Pseudomonas aeruginosa exoprotein A. The primary objectives were the evaluation of safety, tolerability, and immunogenicity of ExPEC4V and determination of its dose-dependent immunogenicity 15 days after vaccination in individuals who had received at least one dose. On the basis of day 15 immunogenicity and day 30 safety data, two ExPEC4V doses were selected for assessment up to day 360. 

Overall, 843 participants were included in the safety analysis; of these, 757 received the vaccine and 86 received the placebo. Of 757 participants vaccinated with ExPEC4V, 222 (29%) had a solicited local adverse event and 325 (43%) had any solicited systemic adverse event, compared with 11 (13%) and 30 (35%) of 86 participants in the control group. Symptoms were mild-to-moderate. The most frequently reported solicited local adverse event was pain or tenderness (205 of 757 [27.1%] in combined ExPEC4V groups) and the most frequently reported solicited systemic adverse event was fatigue (208 of 757 [27.6%]). Only 13 of 843 (2%) had a grade 3 event.

At day 15, 80% or more of all participants achieved a two times or greater increase in serotype-specific IgG antibodies (except O25B at the lowest dose, 103 of 144 [72%]). Durable serotype-specific antibody responses were observed in groups 2 and 4 up to day 360, with 65% or more in group 2 and 71% or more in group 4 maintaining a two times or greater increase in IgG from baseline.

ExPEC is the most common Gram-negative bacterial pathogen in humans, causing diverse and serious invasive diseases across all age groups, including urinary tract infections (UTIs), bacteremia, neonatal meningitis, surgical site infections, abdominal and pelvic infections, and nosocomial pneumonia. The expansion of multidrug-resistant ExPEC clones, such as E coli sequence type 131, has contributed to increased treatment failure and mortality.
May 9 Lancet Infect Dis study

 

Review supports shorter antibiotic prophylaxis after head, neck surgery

A systematic review and meta-analysis suggests that short-course antibiotic prophylaxis should be used after ear, nose, and throat (ENT) or oral and maxillofacial (OMF) surgery, Dutch researchers reported yesterday in JAMA Otolaryngology-Head & Neck Surgery.

Even though current evidence favors short-course treatment after ENT and OMF surgery, post-operative antibiotic prophylaxis regimens are often prolonged because of fear of surgical site infections (SSIs). To further explore the issue, researchers from Radboud University Medical Center in the Netherlands reviewed studies comparing antibiotic prophylaxis courses of 24 hours or less after ENT or OMF surgery with antibiotic course of 72 hours or more. The main outcomes were the relative risk (RR) of SSIs, microbial origins of surgical site infections, adverse events, duration of hospital stay, and treatment costs.

The meta-analysis included 21 studies, with a total of 1,974 patients. In patients receiving 24 hours or less vs 72 hours or longer antibiotic prophylaxis regimens, no significant difference was found in the occurrence of postoperative infections in the pooled population (RR, 0.90; 95% CI, 0.67 to 1.19), or in the ENT (RR, 0.89; 95% CI, 0.54 to 1.45), and OMF populations (RR, 0.88; 95% CI, 0.63 to 1.21), separately. No heterogeneity was observed overall or in the subgroups. However, patients receiving extended-course antibiotic prophylaxis were more than twice as likely to develop adverse events unrelated to the surgical site (RR, 2.40; 95% CI, 1.20 to 3.54).

"These results suggest that short-course antibiotic prophylaxis is recommended unless risk groups are found to benefit from an extended course," the authors of the study write. "In the future, placebo-controlled randomized clinical trials need to be conducted to identify these risk groups who might benefit from different protocols."
May 9 JAMA Otolaryngol Head Neck Surg study

 

Study finds high probability of antibiotic use over time in insured patients

Originally published by CIDRAP News May 9

Research today in the New England Journal of Medicine shows that nearly two-thirds of Americans enrolled in health insurance plans filled a prescription for an antibiotic over a 4-year period.

In a letter to the journal, researchers from Harvard and the University of Toronto report that an analysis of the Truven Health MarketScan Research Databases for 2011 through 2014 found that the probability of filling an antibiotic prescription at an outpatient pharmacy was 33% over 1 year, 47% over 2 years, 55% over 3 years, and 62% over 4 years. The analysis also found that demographic groups with a higher annual volume of antibiotic consumption had a higher cumulative probability of antibiotic use at all time points.

The study is limited by the population sample, which covers 62 million Americans (roughly 20% of the population), and by the fact that it did not address whether the antibiotics prescribed were appropriate.

"Because antibiotic use is widespread, with nearly two thirds of enrollees in U.S. health insurance plans filling an antibiotic prescription during a 4-year period, it may be important to reduce inappropriate prescribing among all patients, not just the most intense antibiotic users, to effectively combat antibiotic resistance," the author's write.
May 9 N Engl J Med letter

 

IV antibiotics linked to longer hospital stays in heart failure patients

Originally published by CIDRAP News May 9

Researchers from the University of Tennessee reported yesterday in Open Forum Infectious Diseases that unnecessary intravenous (IV) antibiotic use in patients with heart failure was associated with longer hospital stays and other potential harms.

In the single-center study, the researchers analyzed data on patients admitted and discharged with acute decompensated heart failure (ADHF), a condition that is sometimes mistaken for community-acquired pneumonia (CAP). ADHF patients are often simultaneously treated for CAP with IV antibiotics, even when evidence of infection is lacking. To determine whether this treatment has any potentially adverse effects, the researchers compared the length of stay in patients who had ADHF and were given IV antibiotics with ADHF patients who received no antibiotics. Secondary outcomes included mortality, readmission rates, amount of diuretic received, and fluid volume and quantity of sodium administered as part of IV antibiotic therapy.

Of the 144 patients in the study, none of whom had radiographic documentation suggesting pneumonia, 56 (39%) received IV antibiotics and 88 (61%) did not. Length of stay was significantly longer in the antibiotic arm (6.6 days) compared with the non-antibiotic arm (3.0 days).

Patients in the antibiotic arm also received higher total doses of furosemide than those who didn't receive antibiotics (mean total dose of 930 milligrams [mg] vs 320 mg), along with approximately 1.7 liters of additional fluid and 9,311 mg of additional sodium. Patients who received IV antibiotics were 2.2 times more likely to be readmitted to the hospital than those who did not.

The authors note that the additional fluid and sodium received by the IV antibiotic patients is important, because ADHF patients typically have volume and sodium restrictions.

"Giving patients at low risk of infection antibiotic therapy 'just to be safe' may not actually be the safest option," they conclude.
May 8 Open Forum Infect Dis abstract

 

Australian report highlights antibiotic use, resistance concerns

Originally published by CIDRAP News May 9

A report today from Australian health officials has found that community antibiotic use in the country is falling but overprescribing continues to be an issue, and that common bacterial pathogens are becoming increasingly resistant.

The third report on antimicrobial use and resistance in Australia (AURA 2019) found that the overall rate of antibiotic dispensing in the community declined from 2015 through 2017, representing the first downward trend in community antibiotic use in Australia since the 1990s. But Australia remains in the top 25% of countries with the highest community antibiotic use. In 2017, 41.5% of the population was prescribed at least one systemic antibiotic. And a large percentage of patients in 2017 were prescribed antibiotics inappropriately, including 52.2% of influenza and 92.4% of acute bronchitis patients.

Total antibiotic use in hospitals, meanwhile, rose for the first time since 2013, while inappropriate prescribing in hospitals remained static in 2017, at 23.5%. Nursing homes were found to have high levels of inappropriate prescribing, as well.

"While the downward shift in prescribing will help to slow the spread of resistance, these latest AURA findings indicate that the levels of inappropriate prescribing of antibiotics in hospitals and the community are still too high and there is more work to be done," AURA clinical director Kathryn Daveson, MBBS, MPH, said in a press release from the Australian Commission on Safety and Quality in Health Care (the Commission).

The report also found that although national rates of resistance have not substantially changed from those reported in 2016 and 2017, increased resistance to common agents has been observed in E coli, Salmonella, Neisseria gonorrhoeae, and Neisseria meningitidis, and patterns of methicillin resistance continue to evolve in Staphylococcus aureus. The prevalence of vancomycin resistance in Enterococcus faecium remains higher in Australia than in any European country. 
May 9 AURA report
May 8 Commission press release

 

MCR-9 gene discovered in Salmonella Typhimurium strain

Originally published by CIDRAP News May 8

Researchers from Cornell University have discovered another variant of the mobile colistin-resistance gene MCR, according to a study yesterday in mBio.

The MCR-9 gene was identified in a multidrug-resistant (MDR) Salmonella enterica serotype Typhimurium strain isolated from a patient in Washington state in 2010. The strain was tested for phenotypic resistance to colistin and was found to be sensitive at the 2-milligrams-per-liter (mg/L) European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoint. However, when the MRR-9 gene was cloned and transferred to colistin-susceptible E coli, it conferred resistance to colistin at levels up to 5 mg/L.

Further analysis revealed that the amino acid sequence of MCR-9 most closely resembled that of the MCR-3 gene, and pairwise comparisons of the predicted protein structures of all MCR genes showed that MCR-9, MCR-3, MCR-4, and MCR-7 share a high degree of similarity at the structural level. A search of the National Center for Biotechnology Information's non-redundant protein sequence database found that MCR-9 was present in multiple genera of Enterobacteriaceae.

Colistin is considered a "last resort" drug for MDR infections.

"These results indicate that mcr-9 has the potential to reduce susceptibility to colistin, up to and beyond the EUCAST breakpoint, and can be found extrachromosomally in multiple species of Enterobacteriaceae, making it a relevant threat to public health," the authors of the study write. "Future studies querying the plasmids that harbor mcr-9 (e.g., transferability, stability, and copy number variation) will offer further insight into the potential role that mcr-9 plays in the dissemination of colistin resistance worldwide."
May 7 mBio study

 

Study: Carbapenem de-escalation doesn't compromise clinical outcomes

Originally published by CIDRAP News May 8

Researchers at a university hospital in Spain report that a carbapenem de-escalation strategy was safe in patients with severe infections, regardless of microbiological results. The findings appeared yesterday in the International Journal of Infectious Diseases.

In the prospective observational study, conducted from August 2013 through July 2014, researchers evaluated the de-escalation strategy in all patients who started treatment with carbapenems at admission for intra-abdominal, respiratory, urinary, skin, or soft-tissue infections. De-escalation was defined as the discontinuation of carbapenems, or substitution with narrower-spectrum agents, during the first 96 hours of treatment. The primary outcomes were in-hospital morality, mortality at 30 days after carbapenem prescription, and infection-related readmission within 30 days.

The study included 1,161 patients, and de-escalation was performed in 667 (57.5%) of these. In the de-escalation group, 54.9% of cultures were positive. After propensity score matching, 30-day mortality was lower (17.4 vs 25.7%, P = 0.036), carbapenem treatment was 4 days shorter (4 vs 8 days, P < 0.001), total antibiotic therapy duration was 2 days longer (12 vs 10 days, P = 0.003) and the length of hospital stay was 5 days shorter (8 vs 13 days, P = 0.008) in the de-escalated patients versus the not-de-escalated patients. In-hospital mortality and 30-day readmission rates did not significantly differ between these groups.

The authors conclude, "Carbapenem de-escalation is a safe strategy that does not compromise the prognosis of severely ill hospitalized patients. There appeared to be no increase in 30-day mortality, 30-day re-admission rate, or length of hospital stay in these patients."
May 7 Int J Infect Dis abstract

 

Pakistani study finds high mortality rate in patients with Candida auris

Originally published by CIDRAP News May 7

A study yesterday in BMC Infectious Diseases by Pakistani researchers describes the wide range of invasive infections and high mortality rate associated with the multidrug-resistant fungus Candida auris.

The retrospective study, conducted at a university hospital in Karachi, included 92 patients who had C auris strains isolated from September 2014 through March 2017. Overall, 193 C auris strains were collected; 65 of the patients were infected and 27 were colonized.

Among the infected patients, bloodstream infections (candidemia) accounted for 38 cases (58%), most of them central line-associated bloodstream infections, followed by urinary tract infections (19 cases, 29%). Other infections included peritonitis, empyema, nosocomial ventriculitis, otitis externa, and surgical site infections. Antifungal susceptibility testing on 63 isolates found resistance to fluconazole in all isolates, voriconazole resistance in 18 isolates (28.6%), and amphotericin resistance in 5 isolates (7.9%). No isolates were resistant to all classes tested.

The crude in-hospital mortality rate among the patients was 42.4%, with 19 deaths directly related to C auris, while 14-day mortality was 31.5%. Mortality was similar among infected and colonized patients (46.2% vs 33.3%) and higher in candidemia patients than non-candidemia patients (60.5% vs 25.9%). On multivariate analysis, candidemia (adjusted odds ratio [AOR], 4.2%; 95% confidence interval [CI], 1.09 to 16.49, P = 0.037) and older age (AOR, 4.5; 95% CI, 1.09 to 18.9, P = 0.038) were associated with greater mortality. Source control was found to be a protective factor (AOR, 0.22; 95% CI, 0.05 to 0.92, P = 0.038).

The mortality figures are in line with previous C auris studies, which have found mortality rates ranging from 30% to 60%.
May 6 BMC Infect Dis study

 

Study supports shorter antibiotic treatment for UTIs in men

Originally published by CIDRAP News May 7

The findings from a multi-clinic study support shorter antibiotic therapy for men with uncomplicated urinary tract infections (UTIs) in outpatient settings, researchers from Baylor College of Medicine and elsewhere reported yesterday in Open Forum Infectious Diseases.

In the retrospective cohort study, the researchers examined the administrative and billing records of adult men who were diagnosed as having a UTI and prescribed an antibiotic at three different types of outpatient clinic from January 2011 through September 2015. For eligible visits in which an antibiotic was prescribed, the team extracted data on the antibiotic used, the treatment duration, recurrent UTI episodes, and patient medical and surgical history. The primary exposure was treatment duration, characterized as short (7 days or less) or long (more than 7 days) based on expert recommendation.

Overall, 637 visits were included for 573 unique patients with a mean age of 53.7 years. Fluoroquinolones were the most commonly prescribed antibiotics (69.7%), followed by trimethoprim-sulfamethoxazole (21.2%), nitrofurantoin (5.3%), and beta-lactams (3.8%). Thirty-two patients had UTI recurrence, with 7 having early recurrence and 25 having late recurrence. Antibiotic choice was not associated with UTI recurrence.

In the overall cohort, longer treatment duration was not significantly associated with UTI recurrence (odds ratio [OR], 1.95; 95% CI, 0.91 to 4.21). But an assessment of the association between treatment duration and recurrence in four subgroups found that longer treatment was associated with more than twice the risk of recurrence in the group that excluded men with urologic abnormalities, immunocompromising conditions, prostatitis, pyelonephritis, nephrolithiasis, and benign prostatic hyperplasia (OR, 2.62; 95% CI, 1.04 to 6.61).

Although the authors note that the results need to be interpreted with caution, they say the study adds to evidence that men with UTIs and no additional complications can be treated with a 7-day antibiotic course. "Shorter duration of antibiotic treatment for male UTI may lead to decreased risk of antibiotic resistance, fewer adverse effects, and lower costs," they write. 
May 6 Open Forum Infect Dis abstract

 

Nursing home stewardship intervention shows mixed results

Originally published by CIDRAP News May 6

Implementation of an antimicrobial stewardship program intervention at 27 nursing homes in North Carolina was associated with reductions in urine culture and culture-positive rates, according to a study today in Infection Control and Hospital Epidemiology. But high proportions of antimicrobial resistance were still observed among common urinary pathogens.

The intervention, which was implemented in June 2015, was designed to optimize antibiotic use and improve knowledge and understanding of UTIs among staff, resident, and families, with training sessions on causes of antimicrobial resistance, urine culture reports, asymptomatic bacteriuria, and UTI management. To investigate the impact of the program, researchers collected and analyzed urine culture results before and after implementation, comparing culture rates, culture positive rates, and antimicrobial resistance patterns in urinary pathogens.

Of the 6,718 urine cultures studied, 68% were positive, 18% were negative, and 14% were recorded as polymicrobial. Both the urine and urine positive culture rates per 1,000 resident-days showed a decrease from baseline through the active antimicrobial stewardship intervention period, with low "P" values for both the urine culture rate (= .014) and the positive culture rate (P ≤ .001). Most of the identified potentially uropathogenic isolates were E coli (38%), Proteus spp (13%), and Klebsiella pneumoniae (12%).

While resistance varied, a significant decrease was observed during the intervention period in nitrofurantoin resistance among E coli (P ≤ .001) and ciprofloxacin resistance among Proteus spp (P ≤ .001). But carbapenem resistance increased for Proteus spp (P ≤ .001). Multidrug resistance also increased for Proteus spp compared to the baseline. In addition, the high baseline resistance of E coli to the commonly prescribed antimicrobials ciprofloxacin and trimethoprim-sulfamethoxazole did not change during the intervention.

The authors note that while some downward reductions in resistance were observed, they were too small and scattered to conclude that the intervention significantly changed resistance patterns.
May 6 Infect Control Hosp Epidemiol abstract

 

NY senator urges CDC to declare Candida auris a public emergency

Originally published by CIDRAP News May 6

US Senator Chuck Schumer yesterday urged the Centers for Disease Control and Prevention (CDC) to declare a public emergency over C auris.

Schumer, D-NY, said in a press release that declaring a public emergency over the multidrug-resistant fungal infection would help New York, the state with the most cases, gain access to millions of dollars in public health crisis response funding. Schumer said the money would be available if the agency qualified "superbugs" as eligible for official emergency response funding, as it has done with Zika and Ebola. 

"While the CDC is doing a fine job honing in on the threat this superbug presents to New York and the country, with the wave of a pen, they can help beat back the wave of this fungus' spread across New York in an even tougher way," Schumer said. "And that is what they should do: deliver a new raid of resources to stop this superbug from spreading even more across New York, Long Island and Upstate."

Of the 643 confirmed and probable C auris cases in the United States, 323 are in New York. C auris can spread easily in hospitals and cause serious invasive infections in patients who have compromised immune systems. The CDC has estimated that 30% to 60% of patients with infections have died.

Schumer said the money could be used to boost state and local testing capacity, invest in more rapid detection technology, fund surveillance efforts, and develop a public awareness campaign.
May 5 Senator Schumer press release

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News Scan for May 10, 2019

News brief

Tainted oysters from Mexico linked to multistate outbreak

A gastrointestinal illness outbreak involving several different pathogens linked to oysters imported from Mexico has sickened 16 people in 5 states, the US Centers for Disease Control and Prevention (CDC) announced today.

Two people have been hospitalized, and no deaths have been reported. The illnesses began Dec 16, 2018, and Apr 4 was the most recent onset.

Lab testing of samples from patients has revealed multiple pathogens, with some patients infected with more than one. They include Shigella flexneri, Vibrio parahaemolyticus, Shiga toxin-producing Escherichia coli non-O157, Campylobacter lari, Vibrio albensis, norovirus genogroup 1, and Vibrio of unknown species. Four people were sick without a pathogen identified.

The epidemiologic and traceback investigations found that raw oysters harvested from Estero El Cardon in Baja California Sur in Mexico are the source of the outbreak. Patients sickened in the outbreak ate raw oysters at restaurants in California and Nevada. The CDC said investigations are still underway and it will provide further updates when more information is available.
May 10 CDC outbreak notice

 

US flu activity drops, but official note 5 new deaths in kids

Influenza-like illness (ILI) represented just 1.6% of outpatient clinic visits last week, a sure sign seasonal flu activity is dwindling in the United States, the Centers for Disease Control and Prevention (CDC) said in its weekly FluView update.

But, as in last week’s report, the CDC recorded 5 new pediatric flu deaths, raising this year's total to 106. The fatal flu infections occurred in March, April, and May. All but one were associated with influenza A strains.

Only Massachusetts and New York reported widespread flu activity, and no states experienced high ILI activity, the CDC said.

The flu-associated hospitalization rate rose slightly, to 65.7 per 100,000 population. The highest rate was among patients over the age of 65 (221.5 hospitalizations per 100,000 people).

As has been the case in the last 3 weeks, most current flu activity is caused by influenza A (H3) viruses. Of all lab-tested samples collected last week, 66% were influenza A, and 34% were influenza B.
May 10 CDC FluView

 

Pakistan reports three more polio cases

Over the past week, Pakistan has reported three more wild poliovirus type 1 cases, according to the latest weekly update from the Global Polio Eradication Initiative (GPEI).

Two of the cases are from Lahore district in Punjab province and one is from Bannu district in Khyber Pakhtunkhwa province. Patient paralysis onsets were Apr 2, 17, and 19, respectively. The country has now reported 11 WPV 1 cases for 2019.

Elsewhere, Niger has reported that circulating vaccine-derived poliovirus type 2 (cVDPV2) has been detected in a healthy community contact in Magaria in Zinder state. The sample was collected on Mar 16. The country is experiencing an outbreak linked to an event originating in Nigeria's Jigawa state.
May 10 GPEI update

In other polio developments, the GPEI said yesterday that it and Gavi, the Vaccine Alliance, have successfully achieved a goal they set in 2013 of having 126 countries that use oral polio vaccine (OPV) incorporate at least one dose of inactivated polio vaccine (IPV) in their immunization campaigns. They noted that the last two countries—Mongolia and Zimbabwe—added the vaccine to their programs in April. Introducing one dose of IPV is part of the phased removal of OPV.
May 9 GPEI statement

Stewardship / Resistance Scan for May 10, 2019

News brief

Computer model shows potential of automated registry for CRE carriers

A computer modeling study suggests that implementing a registry that tracks patients with extensively drug-resistant organisms (XDROs) could reduce the spread of carbapenem-resistant Enterobacteriaceae (CRE) in a regional healthcare network, researchers reported yesterday in Clinical Infectious Diseases.

Using Regional Healthcare Ecosystem Analyst software, researchers from Johns Hopkins Bloomberg School of Public Health and elsewhere developed a model of all inpatient healthcare facilities (90 acute care hospitals, 9 long-term acute care hospitals, 351 skilled nursing facilities, and 12 ventilator-capable skilled nursing facilities) in the Chicago metropolitan area to simulate what would happen to CRE prevalence with the introduction and use of an electronic XDRO registry that tracks all patients carrying CRE  and automatically alerts facilities to help guide infection prevention and control efforts. The researchers then compared the impact of the registry with having no registry.

The results predicted that when all Illinois facilities participated (n=402), the registry reduced the number of new CRE carriers by 11.7% and CRE prevalence (compared to baseline) by 7.6% over a 3-year period. When 75% of the largest Illinois facilities participated (n=304), registry use resulted in an 11.6% relative reduction in new carriers (16.9% and 1.2% in participating and non-participating facilities, respectively) and 5.0% relative reduction in prevalence. When 50% participated (n=201), there were 10.7% and 5.6% relative reductions in incident carriers and prevalence, respectively. And when only 25% participated (n=101), there was a 9.1% relative reduction in incident carriers (20.4% and 1.6% in participating and non-participating facilities, respectively) and a 2.8% relative reduction in prevalence

"Our results show that an XDRO registry may be an effective tool in combating XRDO spread between facilities in a region," the authors of the study write. "Appropriately identifying patients allows for prompt use of contact precautions, which may save resources and time if known carriers do not need to be reidentified."
May 9 Clin Infect Dis abstract

 

ExPEC vaccine candidate shows promise in phase 2 trial

An extra-intestinal pathogenic Escherichia coli (ExPEC) vaccine candidate was well tolerated and elicited robust and functional responses across all serotypes, doses, and age groups in a phase 2 trial, researchers from Janssen Pharmaceuticals reported yesterday in The Lancet Infectious Diseases.

The randomized, double-blind placebo-controlled trial, designed and funded by Janssen, involved 848 healthy adults who were randomly assigned to receive a single dose of one of five ExPEC4V formulations or placebo. ExPEC4V is a four-valent vaccine comprised of the E coli O1A, O2, O6A, and O25B antigens bioconjugated to the protein carrier Pseudomonas aeruginosa exoprotein A. The primary objectives were the evaluation of safety, tolerability, and immunogenicity of ExPEC4V and determination of its dose-dependent immunogenicity 15 days after vaccination in individuals who had received at least one dose. On the basis of day 15 immunogenicity and day 30 safety data, two ExPEC4V doses were selected for assessment up to day 360. 

Overall, 843 participants were included in the safety analysis; of these, 757 received the vaccine and 86 received the placebo. Of 757 participants vaccinated with ExPEC4V, 222 (29%) had a solicited local adverse event and 325 (43%) had any solicited systemic adverse event, compared with 11 (13%) and 30 (35%) of 86 participants in the control group. Symptoms were mild-to-moderate. The most frequently reported solicited local adverse event was pain or tenderness (205 of 757 [27.1%] in combined ExPEC4V groups) and the most frequently reported solicited systemic adverse event was fatigue (208 of 757 [27.6%]). Only 13 of 843 (2%) had a grade 3 event.

At day 15, 80% or more of all participants achieved a two times or greater increase in serotype-specific IgG antibodies (except O25B at the lowest dose, 103 of 144 [72%]). Durable serotype-specific antibody responses were observed in groups 2 and 4 up to day 360, with 65% or more in group 2 and 71% or more in group 4 maintaining a two times or greater increase in IgG from baseline.

ExPEC is the most common Gram-negative bacterial pathogen in humans, causing diverse and serious invasive diseases across all age groups, including urinary tract infections (UTIs), bacteremia, neonatal meningitis, surgical site infections, abdominal and pelvic infections, and nosocomial pneumonia. The expansion of multidrug-resistant ExPEC clones, such as E coli sequence type 131, has contributed to increased treatment failure and mortality.
May 9 Lancet Infect Dis study

 

Review supports shorter antibiotic prophylaxis after head, neck surgery

A systematic review and meta-analysis suggests that short-course antibiotic prophylaxis should be used after ear, nose, and throat (ENT) or oral and maxillofacial (OMF) surgery, Dutch researchers reported yesterday in JAMA Otolaryngology-Head & Neck Surgery.

Even though current evidence favors short-course treatment after ENT and OMF surgery, post-operative antibiotic prophylaxis regimens are often prolonged because of fear of surgical site infections (SSIs). To further explore the issue, researchers from Radboud University Medical Center in the Netherlands reviewed studies comparing antibiotic prophylaxis courses of 24 hours or less after ENT or OMF surgery with antibiotic course of 72 hours or more. The main outcomes were the relative risk (RR) of SSIs, microbial origins of surgical site infections, adverse events, duration of hospital stay, and treatment costs.

The meta-analysis included 21 studies, with a total of 1,974 patients. In patients receiving 24 hours or less vs 72 hours or longer antibiotic prophylaxis regimens, no significant difference was found in the occurrence of postoperative infections in the pooled population (RR, 0.90; 95% CI, 0.67 to 1.19), or in the ENT (RR, 0.89; 95% CI, 0.54 to 1.45), and OMF populations (RR, 0.88; 95% CI, 0.63 to 1.21), separately. No heterogeneity was observed overall or in the subgroups. However, patients receiving extended-course antibiotic prophylaxis were more than twice as likely to develop adverse events unrelated to the surgical site (RR, 2.40; 95% CI, 1.20 to 3.54).

"These results suggest that short-course antibiotic prophylaxis is recommended unless risk groups are found to benefit from an extended course," the authors of the study write. "In the future, placebo-controlled randomized clinical trials need to be conducted to identify these risk groups who might benefit from different protocols."
May 9 JAMA Otolaryngol Head Neck Surg study

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