News Scan for Jun 11, 2020

News brief

Study supports shorter antibiotic course for pneumonia in children

A study of children hospitalized for community-acquired pneumonia (CAP) found that a shorter course of antibiotics did not increase the odds of treatment failure compared with a longer course, US researchers reported today in the Journal of the Pediatric Infectious Diseases Society.

The retrospective cohort study looked at children older than 6 months who were hospitalized with CAP at the Johns Hopkins Hospital from 2012 through 2018. Guidelines at the hospital have recommended 5 days of antibiotics for children with CAP since 2012, based on published data in the adult population, but variability in prescribing still exists.

To evaluate whether children who received a shorter course of antibiotics are at increased risk of treatment failure, the researchers compared their outcomes with those of children who received a prolonged course. Treatment failure was a composite of unanticipated emergency department visits, outpatient visits, hospital readmissions, or death within 30 days of discontinuing antibiotics.

Of the 439 patients included in the study, 168 (38%) received short-course therapy (median, 6 days), and 271 (62%) received prolonged-course therapy (median, 10 days). Overall, 20 children (4%) experienced treatment failure, and there was no difference in treatment failure between the children who received short-course (3%) versus prolonged-course (6%) therapy (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.18 to 1.30).

Three patients (2%) in the short-course group compared with 8 patients (3%) in the prolonged-course group experienced an unplanned emergency department or outpatient visit related to CAP (OR, 0.54; 95% CI, 0.14 to 2.07), and 2 patients (2%) and 7 patients (3%) in the short- and prolonged-course groups, respectively, required hospital readmission (OR, 0.43; 95% CI, 0.11 to 1.74).

Although they acknowledge that a multicenter randomized controlled trial would provide the best evidence for evaluating antibiotic therapy for CAP in children, the authors of the study say the findings provide additional evidence for the "less-is-more" approach to antibiotic treatment for bacterial infections.

"We believe that the results of our study, when combined with the abundant randomized, controlled trial data in adults, suggest that hospitalized children with uncomplicated CAP can be safely and effectively treated with approximately 5 days of antibiotics," they write. "Because CAP is one of the most common causes of hospitalization and antibiotic prescription in children, decreasing the duration of therapy could have an important public health impact."
Jun 11 J Pediatric Infect Dis Soc abstract

Heartland virus illness probe finds tick carriers in northern Illinois

An investigation into two Heartland virus infections in Illinois patients in 2018 that found ticks at exposure sites about 273 miles apart suggests widespread distribution in the state. Researchers from the University of Illinois at Urbana-Champaign and the US Centers for Disease Control and Prevention (CDC) reported their findings yesterday in Emerging Infectious Diseases.

Heartland virus infections, spread by Amblyomma americanum lone star ticks and first found in humans in 2009, have been reported from 10 states, mostly in the Southeast and Midwest. Symptoms include fatigue, fever, leukopenia, and thrombocytopenia, and patients are often hospitalized. Some deaths have been reported.

The first Illinois patient described in the study was exposed in July while camping on residential property in Kankakee County in the northeastern part of the state. The second patient was exposed at a campground near their home in Williamson County, located in southern Illinois.

After interviewing the patients, researchers collected ticks from exposure locations and sorted them by species, life stage, and sex. Scientists at the CDC's Arboviral Diseases Branch tested pooled samples for Heartland and Bourbon viruses. A single pool of male A americanum ticks from each country was positive for Heartland virus, and none of the samples yielded Bourbon virus. Detection of the virus in adult ticks suggests they may have overwintered in the area.

More tick collection and animal serosurvey studies are needed to see if transmission cycles are active in Illinois, but researchers' detection of the ticks in the northern edge of their distribution range in Kankakee County was surprising, and the study suggests that they are established there at high densities. "Consequently, diseases associated with A. americanum ticks must be on the radar of physicians and public health officials throughout Illinois," the authors wrote.
Jun 10 Emerg Infect Dis report

Study links cases of Legionnaires' disease to toilet flushing

Yesterday in a separate Emerging Infectious Diseases report, French researchers describe two cases of healthcare-associated Legionnaires' disease linked to flushing toilets, writing that it could be a transmission route for the Legionella pneumophila bacteria.

The patients were an 18-year-old woman and a 51-year-old man, both hospitalized in the same room of a hematology unit in France, 5 months apart. Samples from the patients showed they had the same bacterial infection, but water from the sink in each room and from the shower, shared by all of the unit's patients, was filtered through 0.1-micrometer pore filters. Both patients also drank only bottled water and did not take showers during their hospital stay, and there was no cooling tower within the hospital, the authors said.

"However, sampling of the water from the toilet bowl in room 1 showed contamination," the authors said. The authors concluded that the infections were probably caused by L. pneumophila transmitted through contaminated toilet water that became aerosolized during flushing.

"We reached this conclusion because we found little to no detectable difference between whole genomes in isolates obtained from 2 patients hospitalized 5 months apart in the same room and those from the toilet in that room," they wrote. "The other commonly suspected sources, in this case the shower and the sink, tested negative for L. pneumophila."
Jun 10 Emerg Infect Dis study

COVID-19 Scan for Jun 11, 2020

News brief

Risks, benefits weighed of reopening different businesses amid COVID-19

For maximum benefit relative to risk amid the COVID-19 pandemic, banks, dentists, colleges, places of worship, auto dealers, and repair shops should be reopened first, followed by gyms, cafes, juice bars, and dessert parlors, according to a study published yesterday in the Proceedings of the National Academy of Sciences (PNAS).

Researchers from the Massachusetts Institute of Technology used mobility data from 47 million smartphones, consumer preference surveys, and economic statistics to measure the infection risk against the consumer and economic value of 26 types of US businesses employing 32 million people, paying $1.1 trillion in yearly payroll, and taking in $5.6 trillion each year.

By store type, those that sell electronics and furniture should be opened before stores that sell liquor, tobacco, or sporting goods, the study found.

The 26 locations of interest accounted for about 57% of all unique visits from January 2019 to March 2020. There was a 24.9% drop in total visits to all locations in the analysis from February to March 2020, when shutdowns and physical distancing began.

Sit-down restaurants had large numbers of both visits and unique visitors. The authors noted that the biggest outliers were colleges and universities and hardware stores. While colleges offer a relatively good trade-off, most shut down, resulting in 61% fewer visits. In contrast, visits to liquor and tobacco stores fell only 5%, despite the authors deeming them poor trade-offs because of their mediocre economic importance and elevated likelihood of transmission.

Hardware stores saw the largest increase in visits as consumers sought personal protective equipment and home supplies.

The largest declines in visits occurred at locations that the study findings indicated should be closed first from February to March, indicating that consumers, businesses, and policy makers are doing their own risk-benefit analyses.

The authors said that governments should use the study findings, as well as their own region-specific research, to guide reopenings while working toward the public health goal of slowing coronavirus spread.
Jun 10 PNAS study

A quarter of COVID-19 diagnostic tests inaccurate, researchers find

Seven of 27 COVID-19 diagnostic tests studied (26%) had potential genomic sequence mismatches that may lead to underperformance or false-negative results, a study published yesterday in Royal Society Open Science has found.

Because viruses mutate, researchers at York University in Toronto tested the accuracy of polymerase chain reaction (PCR) tests using genetic variations in more than 17,000 publicly available PCR tests from around the world, some of them recommended by the World Health Organization (WHO).

Rapid sequencing of SARS-CoV-2, the virus that causes COVID-19, by national organizations led to early publication of the genome by the WHO but may have inadvertently led to the development of tests that don't account for variations and mutations, the authors said.

Test-viral genome mismatches are not uncommon, having been reported in the flu, HIV, respiratory syncytial virus, and dengue, rabies, hepatitis B viruses. In addition, tests for COVID-19 were rapidly deployed with limited regulatory approval amid a public health emergency.

Early diagnostic testing is a public health priority because it can lead to quarantine of infected people, but false-negative test results can lead to further spread of the coronavirus by people with mild illness or no symptoms. The study findings highlight the need to update COVID-19 diagnostic tests by regularly checking sequence variations in the PCR primer/probe binding regions, the authors said.

"These findings are potentially important for clinicians, laboratory professionals and policy-makers as it gives them a better idea of which tests may deliver the best results and how to ensure the tests they are using are properly matched to the virus genome," lead author Kashif Aziz Khan, PhD, said in a press release.
Jun 10 R Soc Open Sci study
Jun 9 York University press release

Research identifies GI symptoms, fecal viral RNA in COVID-19 patients

About 12% of COVID-19 patients have gastrointestinal (GI) symptoms, and 41% of patients shed viral RNA in their feces, according to a systematic review and meta-analysis published by international researchers today in JAMA Network Open.

In the meta-analysis of 23 published and 6 preprint studies involving 4,805 COVID-19 patients from Nov 1, 2019, to Mar 30, 2020, the most common reported GI symptoms were diarrhea (7.4%) and nausea or vomiting (4.6%). Eight studies that provided data on fecal virus RNA shedding yielded a rate of 40.5%. It is important to note that the presence of virus RNA does not necessarily indicate live (infectious) virus.

Abnormal levels of the liver enzymes aspartate aminotransferase and alanine aminotransferase, indicating organ damage, were seen in 14.6% and 20% of patients, respectively. Mean patient age was 52 years, and 1,598 of 4,805 patients (33.2%) were women.

The authors noted that the first US coronavirus patient reported loose bowel movements and abdominal pain and had PCR test results indicating viral RNA in fecal and respiratory specimens.

"This raises the question of inadvertent human-to-human transmission via the fecal route despite public health emphasis on droplet transmission and precautions for contact with respiratory secretions," the authors wrote. "Particularly concerning is the presence of detectable RNA in the GI tract, making the use of optimal personal protective equipment and following up-to-date national infection control guidelines highly prudent."
Jun 11 JAMA Netw Open study