News Scan for Feb 02, 2021

News brief

VHA hospital study shows benefits of carbapenem-specific stewardship

An assessment of 90 Veterans Health Administration (VHA) hospitals found that carbapenem-specific stewardship strategies were associated with a lower volume of carbapenem use and more appropriate carbapenem prescribing, researchers reported yesterday in the Journal of Antimicrobial Chemotherapy.

In the study, researchers from the University of Iowa Carver College of Medicine and the Iowa City Veterans Affairs Health Care System analyzed all acute care admissions at VHA hospitals in 2016 and used a national VHA survey to categorize each hospital's carbapenem-specific antibiotic stewardship strategy into one of three types: no strategy (NS), prospective audit and feedback (PAF), and restrictive policies (RP).

They then calculated overall carbapenem use and days of therapy (DOT) per 1,000 days present and compared strategy effectiveness using risk-adjusted generalized estimating questions that accounted for clustering within hospitals. Auditors assessed carbapenem appropriateness with an assessment score on day 4 of therapy.

Overall, there were 429,062 patient admissions across 90 hospitals in 2016, and at least one inpatient carbapenem dose was administered during 8,566 patient admissions (20.0%). Median carbapenem use across hospitals was 17.4 DOT/1,000 days present. In the adjusted analysis, carbapenem use was lower at PAF than NS sites (rate ratio [RR], 0.6; 95% confidence interval [CI], 0.4 to 0.9) but similar between RP and NS sites (RR, 0.8; 95% CI, 0.5 to 0.12).

Carbapenem prescribing was considered appropriate in 215 (50.6%) of the reviewed cases. Assessment scores were significantly lower (ie, better) in hospitals with an RP strategy compared with NS hospitals (mean 2.3 versus 2.7) but did not differ significantly between PAF and NS sites (mean 2.5 vs 2.7). Across all three strategies, infectious disease (ID) consultations—which were more common at PAF/RP than NS sites—were associated with better assessment scores.

The authors concluded that antibiotic stewardship strategies and ID consultations appear to be complementary and that hospitals should leverage both to optimize carbapenem use.
Feb 1 J Antimicrob Chemother abstract

Antibiotic use declined during Spain's COVID-19 lockdown

Data from Andalusia, Spain, show antibiotic use in the community declined during the pandemic compared with the pre-COVID period, according to a study yesterday in Clinical Microbiology and Infection.

To assess the impact of the pandemic on community antibiotic use in a region with an existing antibiotic stewardship program (ASP) for hospitals and primary care clinics, a team of Spanish researchers conducted a before and after cross-sectional study comparing outpatient antibiotic prescribing in Andalusia in the first two quarters of 2019 and the same quarters in 2020, when a regional lockdown was in force. Data were collected from a pharmacy database containing records of reimbursed and dispensed drugs.

The analysis found that overall community antibiotic consumption in Andalusia fell by 7.6% between the first quarter of 2019 and the first quarter of 2020, and by 36.8% between the second quarters of 2019 and 2020. Larger reductions were found between the second quarters for most antibiotic classes studied as well as four antibiotics used for respiratory infections (amoxicillin, amoxicillin-clavulanate, cefuroxime, and levofloxacin).

The analysis also revealed a concomitant reduction in primary care consultations in the region.

The authors say the question is how much the reduction in community antibiotic use was linked to the lockdown, limited access to the healthcare system and antibiotic prescriptions, and how much can be attributed to Andalusia's ASP.

"Gaining access to that information may be useful to improve ASPs in primary care," they wrote. "If these results are confirmed in other health systems, further studies are needed to determine whether this reduction in antibiotic use in the community during the pandemic has resulted in a favourable ecological impact."
Feb 1 Clin Microbiol Infect study

H5N8 avian flu strikes poultry in Nepal, Europe, China

Nepal became the latest country to report highly pathogenic H5N8 avian flu in poultry, with more detections reported in France and Germany, according to the latest notifications from the World Organization for Animal Health (OIE).

Nepal reported an H5N8 outbreak in backyard poultry in Bagmati, which began on Jan 21, killing 32 of 2,576 birds. The event marks the country's first appearance of the virus in poultry since 2019. Though the source of the outbreak isn't known, wild birds were seen in the area where the outbreak occurred.

Elsewhere in Asia, China reported H5N8 detections in wild swans in Beijing, according to the Global Times. The country recently reported an H5N8 outbreak involving mute swans in Shandong province.

In Europe, France reported 11 more H5N8 outbreaks, mostly in its hard-hit southwest. Of the five departments reporting recent outbreaks, only one, which involved backyard birds, is in the northeast: Ardennes. The latest outbreaks began from Jan 9 to Jan 28, and taken together, the virus killed 1,070 of 66,458 birds.

Elsewhere on the continent, Germany reported an H5N8 outbreak at a turkey farm in Mecklenburg-Vorpommern state, which began on Jan 28 killing 1,532 of 19,479 susceptible birds.

In outbreaks involving other highly pathogenic strains, Taiwan reported another H5N5 outbreak in poultry, which began on Jan 15 at a chicken farm in Pingtung County and killed 1,679 of 9,222 birds. Also, Romania reported H5N5 in two wild swans found dead on Jan 25 in Constanta County in the far southeast.
Jan 30 OIE report on H5N8 in Nepal
Feb 2 Global Times story
Feb 2 OIE report on H5N8 in France
Feb 1 OIE report on H5N8 in Germany
Feb 1 OIE report on H5N5 in Taiwan
Feb 2 OIE report on H5N5 in Romanian wild birds

In low-pathogenic avian flu developments, South Africa reported two more H7 outbreaks on commercial ostrich farms. The outbreaks began in early November at facilities in Western Cape province. Between the two events, the virus killed 9 of 194 susceptible birds.
Feb 1 OIE report on low-path H7 in South Africa

COVID-19 Scan for Feb 02, 2021

News brief

Just 1 vaccine dose may protect recovered COVID patients from new infection

Recovered COVID-19 patients given a single dose of a currently authorized mRNA vaccine had a robust immune response equal to or exceeding that reached by their coronavirus-naïve peers after the second dose, according to a non–peer reviewed study published yesterday on the medRxiv preprint server.

Currently, the recommended dosing schedule for the two authorized mRNA vaccines, manufactured by Pfizer/BioNTech and Moderna, is two doses given 3 or 4 weeks apart. But the study researchers at Mount Sinai's Icahn School of Medicine say their findings suggest that the current policy could be amended to include only one dose in recovered coronavirus patients, sparing them from side effects and freeing up urgently needed doses.

Of the 68 coronavirus-naïve vaccine recipients given the first dose, 51 had mixed, relatively low immune responses by 9 to 12 days after vaccination. In contrast, within days of vaccination, all 41 vaccinees with antibody evidence of previous COVID-19 infection mounted antibody responses 10 to 20 times higher than did vaccinees who were seronegative, or had no coronavirus antibodies. In fact, their antibody levels, or titers, were 10 times higher than those in seronegative vaccinees after they received the second dose.

While seronegative vaccine recipients experienced only mild side effects after the first dose, the most common of which were pain, swelling, and redness at the injection site, seropositive vaccine recipients had significantly more side effects, including fatigue, headache, chills, fever, and muscle or joint pain.

"These observations are in line with the first vaccine dose serving as boost in naturally infected individuals, providing a rationale for updating vaccine recommendations to considering a single vaccine dose to be sufficient to reach immunity," the authors said.

They suggested using serological tests to measure antibody levels to the coronavirus spike protein to screen vaccine candidates before vaccination if they don't know whether they've had COVID-19. "Such policies would allow not only expanding limited vaccine supply but also limit the reactogenicity experienced by COVID-19 survivors," the researchers concluded. "Ongoing follow-up studies will show whether these early differences in immune responses are maintained over time."
Feb 1 medRxiv study

Extracorporeal membrane oxygenation may help with severe COVID-19

Intensive care unit (ICU) patients with severe COVID-19 who received extracorporeal membrane oxygenation (ECMO) within the first 7 days had a mortality rate of 34.6%, 12.8 percentage points lower than those who didn't, according to a study today in Intensive Care Medicine. ECMO exchanges carbon dioxide for oxygen in the blood outside the body and is given to those with severe respiratory failure.

The primary results showed that 130 patients treated with ECMO had an adjusted hazard ratio of 0.55 compared with the 1,297 who were not (95% confidence interval, 0.41 to 0.74), meaning a 45% lower death rate.

Using a target trial emulation approach, which is meant to act as a pseudo randomized, controlled trial, the researchers pulled data from 55 hospital ICUs with ECMO capabilities across the United States from Mar 1 to Jul 1, 2020. In the original data pool, 190 of 5,122 patients (3.7%) received ECMO. After 60 days, most of those who received ECMO were still alive, either discharged (49.5%) or still hospitalized (17.4%).

Patients who received ECMO were started on it a median of 3 days after ICU admission. The most frequent complications from ECMO were bacterial pneumonia (34.7%), bleeding (27.9%), thrombotic events (22.9%), and acute kidney injury that needed renal replacement therapy, which can include dialysis (21.8%).

"ECMO gives patients' lungs time to heal when we've exhausted every other aspect of care for these patients—it can be a bridge to recovery," said Shahzad Shaefi, MD, corresponding author, in a Beth Israel Deaconess Medical Center (BIDMC) press release. "But ECMO's efficacy in the context of COVID-19 remains unclear. This work sheds new light on that question in the most robust way possible during the COVID-19 pandemic."
Feb 2 Intensive Care Med study
Feb 2 BIDMC press release

Study: COVID-19 ICU death rates fell steadily but may have plateaued

Mortality rates in intensive care units (ICUs) have dropped globally since the start of the pandemic, but the reduction is slow and may be plateauing, according to a study yesterday in Anaesthesia.

Previous analyses showed ICU mortality rates fell by one-third from 60% at the end of March to 42% at the end of May in 2020. In this new study, which included data through October 2020, ICU mortality rates fell to 36%.

The authors based their study on 52 observational studies, which included more than 43,000 patients in Europe, North America, China, South Asia, the Middle East, and Australia.

The Middle East and Australia represented the two outliers: Regions of Australia boasted an ICU mortality rate of 11%, while the rate in certain parts of the Middle East rose above 62%. In most geographic regions, though, ICU COVID-19 mortality has remained between 30% and 40% throughout 2020.

"After our first meta-analysis last year showed a large drop in ICU mortality from COVID-19 from March to May 2020, this updated analysis shows that any fall in mortality rate between June and October 2020 appears to have flattened or plateaued," the authors concluded in a news release from the Association of Anaesthetists (in full the Association of Anaesthetists of Great Britain and Ireland [AAGBI]).

The authors also noted that ICU mortality rates would likely change again, both as new, more contagious variants of the virus circulate, and more people receive vaccination against the coronavirus.
Feb 1 Anaesthesia study
Feb 1 AAGBI news release

Sweden reports lower COVID-19 ICU rates than rest of Europe

Mortality rates in Swedish intensive care units (ICUs) were lower during the first wave of the COVID-19 pandemic compared with other European countries, according to a new study in the European Journal of Anaesthesiology.

As in other countries, mortality in Sweden from COVID-19 was driven by several predictable factors: age, severity of disease, and the presence of organ failure. But unlike other countries, Sweden did not commit to a society-wide lockdown during the first wave of the pandemic.

"Coupled with what is widely perceived to be a 'relaxed' national pandemic strategy, results for ICU care in Sweden are understandably under scrutiny," the authors said in a European Society of Anaesthesiology and Intensive Care (ESAIC) press release.

The data comes from 1,563 adult admissions to Swedish ICUs from Mar 6 to May 6, 2020. Thirty-day all-cause mortality was 27%, and mortality within the ICUs was 23%. Chronic lung disease was the only comorbidity to be associated with increased mortality, and it carried a 50% increased risk of death.

Other European countries with data from roughly the same period show higher rates of ICU mortality, with Italy reporting the highest rate, at 49%. A French-Belgian-Swiss study showed ICU mortality rates from 26% to 30%, and various North America studies show a 35% mortality rate in ICUs during the first pandemic wave.

"We believe that process and organisational factors have likely contributed to the relatively good outcomes seen in Swedish ICUs as staffing, protective equipment, availability of drugs, medical and technical equipment were considered at an early stage at hospital and regional levels," the authors concluded in the press release.
Jan 28 Eur J Anesthesiol study
Feb 1 ESAIC press release