News Scan for Aug 19, 2020

News brief

Clinical support tool linked to better antibiotic prescribing for cystitis

The inclusion of a clinical decision support system (CDSS) and order set within the electronic medical record, in combination with the use of local urine antibiograms, was associated with improved antibiotic prescribing for acute cystitis at a veterans' health system in North Carolina, researchers reported today in Infection Control & Hospital Epidemiology.

In the quasi-experimental, interrupted time-series analysis, researchers from Duke University School of Medicine and the Durham Veterans' Affairs Health Care System analyzed treatment of outpatient urinary tract infections from April 2016 through October 2019.

The study period consisted of the pre-intervention phase, an intervention period when the CDSS highlighting nitrofurantoin and beta-lactams as preferred agents over fluoroquinolones for uncomplicated acute cystitis was integrated within the electronic medical record, and a post-intervention phase. The primary outcomes measured were changes in monthly proportions of antibiotic classes prescribed for cystitis.

Prior to the intervention, monthly fluoroquinolone prescriptions accounted for 45% of all outpatient prescriptions of cystitis. After the intervention, fluoroquinolone prescriptions accounted for a median of 32% of antibiotics prescribed monthly for cystitis. Conversely, prescriptions for beta-lactams increased from a monthly median of 14% in the pre-intervention phase to 24.5%. Nitrofurantoin and trimethoprim/sulfamethoxazole prescribing was unaltered by the intervention.

In the interrupted time series analysis, CDSS implementation resulted in a −20.7% level change (95% CI, −33.8% to −7.5%; P = .002) and −1.4% change in slope (95% CI, −3.0% to 0.2%; P = .09) in fluoroquinolone prescribing for cystitis, and a 28.5% level change (95% CI, 15.5% to 41.7%; P < .001) and 1.2% change in slope (95% CI, −0.3% to 2.8%; P = .13) in beta-lactam prescriptions.

"In summary, CDSS combined with local urine antibiograms, even without prescriber education or audit and feedback, can be an effective tool for antimicrobial stewardship," the authors concluded.
Aug 19 Infect Control Hosp Epidemiol abstract


Salmonella outbreak linked to onions grows by more than 200 cases

A multistate Salmonella Newport outbreak linked to onions grew in the past week, with 229 new cases, according to the Centers for Disease Control and Prevention (CDC). According to the CDC, officials have confirmed 869 cases in 47 states, including 116 hospitalizations. No deaths have been recorded.

Thomson International, Inc. of Bakersfield, California, is the likely source of potentially contaminated red onions, which were used in a variety of food products, according to a list of recalled produces from the Food and Drug Administration (FDA). In addition to onions, cheese dips, salsa, and pre-diced onions have all been recalled. The products have been sold at retailers throughout the country, including Aldi, Public Super Market, Walmart, and Kroger.

According to the CDC, illness-onset dates range from Jun 19 to Aug 4, and the median age of sick people is 40. The most-affected state is California, with 115 cases, followed by Utah (105), Oregon (94), Montana (63), and Washington state (50).

"Eighty-eight percent of people reported eating onions or dishes likely containing onions in the week before their illness started," the CDC said. "Of the 68 cases who were asked what types of onions they ate, 46 (68%) ate any white onions, 45 (66%) ate any red onions, and 33 (49%) ate any yellow onions in the week prior to illness. Most ill people ate more than one type of onion in the week before illness."
Aug 18 CDC update
Aug 19 FDA recall notice

COVID-19 Scan for Aug 19, 2020

News brief

Report lays out ethical guidance for COVID vaccine allocation

The Johns Hopkins Center for Health Security today released an ethical framework for how to allocate and distribute a COVID-19 vaccine once it's been approved but is in limited supply.

While the decision about who gets the initial doses of the first approved vaccine in the United States is currently being discussed by the US Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) and the National Academy of Medicine, the paper offers suggestions for groups that, based on publicly available information, would be ethically defensible to include as candidates for high-priority access.

The framework emphasizes three broad ethical values: promoting public health and economic and social well-being; justice, fairness, and equality; and legitimacy, trust, and a sense of community ownership of vaccine policy.

Based on these principles, the authors suggest two tiers of candidates to consider for high-priority access. Tier 1 includes those most essential for maintaining the COVID-19 response, those at greatest risk for severe illness and death and their caregivers, and those most essential to maintaining core societal functions.

Tier 2—for when more vaccine supply becomes available—includes healthcare workers involved in broader health provision, people who face greater barriers to care if they become severely ill, those contributing to maintenance of core societal functions, and people whose living or working conditions put them at greater risk of infection.

The authors say several uncertainties about key issues will also need to be taken into account, including how well-contained the pandemic is when a vaccine becomes available, how many doses of the vaccine are expected, and how the vaccine performs in different population groups.

"We hope that our framework will serve as a conceptual resource to inform public dialogue and deliberation about vaccine allocation," the authors write. "Using this framework can help decision makers assess which population groups have the strongest claims to limited doses of vaccine on the basis of greatest need, greatest overall benefit, or presence of multiple strong claims related to individual and public health."
Aug 19 Johns Hopkins Center for Health Security report


Iranian clinical trials assess hepatitis C combo drug for COVID-19

The results from two randomized, controlled clinical trials published today in the Journal of Antimicrobial Chemotherapy suggest the hepatitis C combination drug sofosbuvir/daclatasvir has potential as a treatment for COVID-19.

In one of the trials, 66 adults with moderate or severe COVID-19 at four university hospitals in Iran were randomized 1:1 into a treatment arm receiving sofosbuvir/daclatasvir plus standard care or a control arm receiving standard care alone from Mar 26 to Apr 26. The primary endpoint was clinical recovery within 14 days of treatment. The results showed that recovery within 14 days was achieved in 29 of 33 patients (88%) in the treatment arm and 22 of 33 patients (67%) in the control arm (P = 0.076). Patients in the treatment arm also had a significantly shorter median duration of hospitalization (6 days) than the control group (8 days).

Fewer deaths were observed in the treatment arm (3 vs 5), but the difference was not statistically significant.

In the other trial, 62 Iranian patients with a positive nasopharyngeal swab for SARS-CoV-2 (the virus that causes COVID-19) on reverse transcription polymerase chain reaction or bilateral multi-lobar ground-glass opacity on their chest exam and signs of COVID-19 were randomized into two treatment arms: one receiving sofosbuvir/daclatasvir and the other the antiviral ribavirin.

All patients also received the national standard treatment at the time (Mar 19 to Apr 16), which was lopinavir/ritonavir plus hydroxychloroquine. The primary endpoint was time from starting medication until discharge from the hospital, with a secondary endpoint of mortality.

The results showed a median hospitalization duration of 5 days for the sofosbuvir/daclatasvir patients, compared with 9 days for the ribavirin group. Death rate in the sofosbuvir/daclatasvir group was 6% (2 of 35 patients) versus 33% (9 of 27) for the ribavirin group, and the relative risk of death for patients treated with sofosbuvir/daclatasvir was 0.17 (95% confidence interval [CI], 0.04 to 0.73, P = 0.02).

The authors of both studies say the results, while promising, need to be confirmed in additional, larger trials.

A third trial in the same journal, in which 48 Iranian COVID-19 patients received either sofosbuvir/daclatasvir plus ribavirin or standard care, was too small to make definitive conclusions.
Aug 19 J Antimicrob Chemother study
Aug 19 J Antimicrob Chemother study
Aug 19 J Antimicrob Chemother study

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