ASP Scan (Weekly) for Nov 23, 2018

News brief

CDC investigating multidrug-resistant Pseudomonas outbreak in Texas

Originally published by CIDRAP News Nov 21

The City of Lubbock, Tex., Health Department and the Centers for Disease Control and Prevention (CDC) are investigating an outbreak of multidrug-resistant Pseudomonas aeruginosa in multiple healthcare facilities.

To date, 27 cases of Verona integron-encoded metallo-beta-lactamase (VIM)-producing P aeruginosahave been identified since the outbreak was discovered in October. The cases were identified by the CDC's Antibiotic Resistance Laboratory Network.

"The cases are not associated with a single facility and there is no obvious epidemiologic link," Katherine Wells, MPH, City of Lubbock director of public health, told CIDRAP News. "We are currently working with CDC to complete PFGE [pulsed-field gel electrophoresis] and WGS [whole-genome sequencing] to look for links. We are also working with acute care hospitals and long-term care facilities to do additional point-prevalence surveys."

VIM is a mobile resistance mechanism that confers resistance to carbapenems and several other classes of antibiotic and can be transferred between bacterial species. VIM-producing P aeruginosawas first reported in France in 1996 and has been documented in other countries, but it is less common in the United States. The organism can cause severe healthcare-associated infections, is difficult to treat, and is associated with high morbidity and mortality.
City of Lubbock VIM resources page


Endoscope linked to hospital outbreak of multidrug-resistant organisms

Originally published by CIDRAP News Nov 21

An epidemiologic investigation by researchers from the University of Pittsburgh has found that an outbreak of multidrug-resistant organisms (MDROs) in hospital patients was linked to contamination of a single, defective bronchoscope, according to a study in Infection Control and Hospital Epidemiology.

The outbreak was discovered in November 2014, when a cluster of patients with bronchoscopically obtained clinical cultures positive for carbapenem-resistant Klebsiella pneumoniae (CR-KP) and multidrug-resistant P aeruginosa (MDR-PA) was identified in the medical intensive care unit (MICU) at University of Pittsburgh Medical Center-Presbyterian Hospital. Of the nine bronchoscopes used in the MICU, only one (named B1) was positive for CR-KP and MDR-PA. To determine the link between bronchoscope B1 and the outbreak, investigators performed molecular typing and WGS on isolates from the patients and the device.

A total of 33 case patients with cultures positive for CR-KP and MDR-PA were identified from July 2014 to December 2014; of these patients, 23 (69.7%) were exposed to bronchoscope B1. Molecular testing and WGS confirmed that isolates from bronchoscope B1 and 19 of the patients were genetically related, providing strong evidence for horizontal bacterial transmission. Ten of the 19 patients were classified as belonging to a "pseudo-outbreak" that occurred because of contamination of patient specimens as they were being withdrawn from the bronchoscope.

Upon removal of B1 from service, the number of patients with newly detected CR-KP or MDR-PA decreased. Borescopy revealed a luminal defect that may have contributed to the establishment of biofilm and subsequent contamination, despite compliance with the manufacturer's recommended reprocessing procedures.

The authors of the study conclude, "In addition to adhering to endoscope reprocessing guidelines, hospital epidemiology programs should prioritize thorough periodic maintenance of endoscopic devices and emphasize scrutiny of endoscopic-derived culture data as an important intervention to hasten recognition of endoscope-associated outbreaks." 
Nov 19 Infect Control Hosp Epidemiol abstract


High rate of multidrug-resistant bacteria reported in Ethiopian hospital

Originally published by CIDRAP News Nov 20

In a study yesterday in Antimicrobial Resistance and Infection Control, Ethiopian researchers reported an alarming level of multidrug resistance among patients with healthcare-associated infections (HAIs) at a university hospital.

The cross-sectional study was carried out by researchers at Jimma University Medical Center from May through September 2016. A total of 1,015 patients were admitted during this period, and microbiologic investigation was conducted for 192 patients who were suspected of having an HAI. Investigators collected different clinical specimens (blood, urine, wound swab, pus, and sputum) from the patients, identified the bacterial pathogens, and performed antibiotic susceptibility testing.

Overall, 126 bacterial pathogens were isolated from 118 patients with culture-confirmed HAIs. The most commonly isolated bacteria were Escherichia coli (31 isolates, 24.6%), Klebsiella pneumoniae (30 isolates, 23.8%), and Staphylococcus aureus (26 isolates, 20.6%), all of which showed very high resistance patterns. Among the 126 isolates, 38 (30.2%), 52 (41.3%), and 24 (19%) were multidrug-resistant (MDR), extensively drug resistant (XDR), or pan-drug resistant (PDR), respectively. More than half of the gram-negative bacterial isolates (51%) were positive for extended-spectrum beta-lactamase (ESBL) or AmpC enzymes, and 25% were resistant to carbapenems.

The investigators found that the observed MDR rate was significantly associated with prolonged hospital stays. In addition, all 13 patients who died during the study period were infected with MDR bacteria.

The authors of the study suggest the high rate of XDR and PDR bacteria could be linked to a lack of antimicrobial resistance surveillance or an antibiotic stewardship program at the hospital, as well as to the absence of national antibiotic policies in Ethiopia, where purchasing antibiotics without a prescription is common practice. The country also lacks a system to assess the quality of imported antibiotics, they note, and it is likely that some are sub-standard.

"Coordinated effort is needed from all stakeholders working in [the] health system in Ethiopia to tackle this important public health problem," the authors wrote. "An immediate action should be taken at the hospital to start [an] antibiotic stewardship program to reduce the observed antibiotic resistance and prevent further complications."
Nov 19 Antimicrob Resist Infect Control study  


Study finds low adherence to CDC stewardship elements in NICUs

Originally published by CIDRAP News Nov 20

A baseline assessment of a sample of the nation's neonatal intensive care units (NICUs) has found low compliance with CDC recommendations to improve antibiotic use in newborns and a wide variation in antibiotic usage rates. The findings appear today in Pediatrics.

The one-day cross-sectional quality audit, conducted in February of 2016, involved 143 NICUs enrolled in the Vermont Oxford Network internet-based quality improvement collaborative, an effort to decrease antibiotic overuse during the newborn period. The first part of the audit was a structured, unit-level self-assessment of policies, procedures, and guidelines related to antibiotic stewardship, based on compliance with the CDC's Core Elements of Hospital Antibiotic Stewardship Programs: leadership commitment, accountability, drug expertise, action, tracking, reporting, and education.

For the second part of the audit, auditors conducted patient-level assessments, looking at patient demographics, antibiotic use, reason for antibiotic therapy, and what appropriate cultures were obtained before therapy. Results were used to calculate the antibiotic use rate (AUR), defined as the number of infants who were on antibiotic therapy divided by the total census for the day, for each participating NICU.

The results of the unit-level assessment showed that none of the NICUs addressed all seven of the CDC core elements, and only two elements—accountability (55%) and drug expertise (62%)—had more than 50% compliance. Only 15% of NICUs said they tracked AURs, and only 6% said they reported information on antibiotic use and resistance to clinicians.

Of the 4,127 infants audited for antibiotic exposure, 725 received antibiotics, for a median hospital AUR of 17% (interquartile range, 10% to 27%).  Of the 412 infants who received antibiotics for more than 48 hours, only 26% had positive culture results, 17% had no culture obtained, and 69% had at least 1 negative culture result.

"There are significant gaps between the CDC recommendations and current antibiotic stewardship capacity and practices in newborns," the authors of the study write. "Systemic quality improvements can be used to address these deficiencies and should be tested for their ability to be used to promote adherence to the CDC core elements and the appropriate use of antibiotics in the newborn period."
Nov 20 Pediatrics abstract


Antibiotic use declining in UK livestock

Originally published by CIDRAP News Nov 19

A new report from the Responsible Use of Medicines in Agriculture Alliance (RUMA) says the UK livestock industry is making progress in efforts to meet antibiotic use targets, but a group of leading British clinicians warns that progress could be threatened if the government doesn't commit to changes in the way antibiotics are used in food-producing animals.

According to RUMA's "One Year On" report, the industry overall is making headway in its efforts to reduce antibiotic use. Sales of antibiotics to the livestock industry fell by 40% from 2013 through 2017, including a 52% decrease in sales of the most critical antibiotics for human health, and antibiotic use in food-producing animals is among lowest in the European Union. But progress in reaching 2020 targets varies among different animal sectors.

The report shows that the pig sector in the United Kingdom is on track to meet the 2020 target for reducing antibiotic use, the poultry meat sector is already under the targets set for both chickens and turkeys, the laying hen sector is below its target, and the gamebird sector hit its target 2 years early and is now considering new targets. But the cattle and sheep industries have had issues with data collection that have made it difficult to assess progress, and progress in the fish sector (farmed trout and salmon) has been mixed.

The targets were established in 2017 by RUMA's Targets Task Force, a group that included a specialist veterinary surgeon and a leading farmer for each of the sectors covered.

"Some species have met their targets already but now, with a measure of what's happening in their sector, they know they can go further and are working on new goals," RUMA secretary general Chris Lloyd said in a press release. "For others at or around their optimal level of use, progress is about animal health, continual refinements to what they do and working to overcome new diseases threats as they emerge."

Meanwhile, the Guardian reports that the leaders of the UK's main medical associations have signed a joint letter to the secretaries of state for health and the environment calling on the British government to commit to a ban on the use of antibiotics to prevent diseases in groups of animals. In October, members of the European Parliament voted to limit the use of antibiotics to prevent disease to individual animals (rather than entire herds or flocks), and only in cases where a veterinarian believes there is a high risk of infection.

But that legislation will not become law until 2022, and with the United Kingdom scheduled to leave the European Union in 2019, that means the British government won't be bound by it. The letter asks the government to commit unequivocally to banning preventive antibiotic group treatments.

"If the government allows group prevention to continue, the UK will have some of Europe’s weakest regulatory standards," the letter states. "This could seriously undermine progress being made in reducing UK farm antibiotic use."
Nov 16 RUMA report
Nov 16 RUMA press release
Nov 16 Guardian story


PAHO issues guidance for antibiotic stewardship in Latin America

Originally published by CIDRAP News Nov 19

The Pan American Health Organization (PAHO) has published a new set of recommendations to help governments and healthcare providers in Latin America and the Caribbean set up antimicrobial stewardship programs (ASPs).

The manual, published in conjunction with the Global Health Consortium at Florida International University, aims to provide practical guidelines on implementing ASPs for national health authorities in the region and recommendations for hospital managers and healthcare workers on cost-effective interventions to reduce inappropriate antibiotic use. The recommendations focus on stewardship in acute care and ambulatory settings

"Antibiotics are responsible for having saved millions of lives all over the world, but we are currently experiencing unprecedented rates of resistance to some of the most common treatments,” Marcos Espinal, MD, MPH, director of the Communicable Diseases and Environmental Determinants of Health unit at PAHO, said in a press release. "It is vital that efforts are stepped up to preserve these achievements, reduce the impact of resistance and ensure continued treatment and prevention of infectious disease."

ASPs are a critical part of the World Health Organization (WHO) Global Action Plan on Antimicrobial Resistance and the PAHO Regional Action Plan, but hospitals in the region have been slow to adopt them. According to a 2012 survey, only 46% of hospitals in Latin America and the Caribbean have an ASP in place, compared to 58% in the rest of the world (and 66% and 67% in Europe and North America, respectively.)

Observational studies estimate that the misuse of antibiotics by healthcare providers in Latin America and the Caribbean is around 50%, but there have been no regional studies on antibiotic use in hospitals. The authors of the manual say that standardized systems and indicators are needed at different health care levels in the region to promote benchmarking, guide policy-making, and implement effective strategies to change antibiotic behavior.
Nov 16 PAHO press release
Nov 16 PAHO manual


FDA approves new antibiotic for travelers' diarrhea

Originally published by CIDRAP News Nov 19

The US Food and Drug Administration (FDA) approved a new antibiotic for adults with uncomplicated travelers' diarrhea caused by non-invasive strains of E coli.

Aemcolo (rifamycin), developed by Cosmo Pharmaceuticals, is an orally administered, minimally absorbed antibiotic that releases its active ingredient in the colon. It was approved based on results from two randomized, controlled phase 3 clinical trials of adult patients with travelers' diarrhea, which showed that Aemcolo significantly reduced symptoms compared to a placebo and was well-tolerated, with headache and constipation being the most common adverse events.

Aemcolo was not shown to be effective in patients with diarrhea complicated by fever and/or bloody stool or diarrhea caused by pathogens other than non-invasive strains of E coli. It should not be used by patients with a known sensitivity to rifamycin.

Travelers' diarrhea affects an estimated 10% to 40% of travelers worldwide each year and is commonly caused by bacteria found in food or water. The highest-risk destinations are in Asia, the Middle East, Africa, Mexico, and Central and South America.

Aemcolo was granted priority review under the FDA's Qualified Infectious Disease Product designation, given to antibacterial and antifungal drug products that treat serious or life-threatening infections. It will be available in pharmacies in the first quarter of 2019.
Nov 19 Cosmo Pharmaceuticals press release
Nov 16 FDA press release

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