Italian study finds daily ID consults linked to reduced hospital antibiotics

Daily infectious disease (ID) consultation in an Italian hospital was associated with reduced antibiotic consumption compared with weekly ID consultation, Italian researchers reported late last week in BMC Infectious Diseases.

The 2-year retrospective observational analysis of all ID consults at a large tertiary hospital in Milan, conducted by researchers at the University of Milan, compared a year of weekly ID consults (September 2016 through August 2017) with a year of ID consults provided on a daily basis (September 2017 through September 2018). The process outcomes included the number of ID consults per 100 bed-days, the time from admission to first ID consults, and the type of antibiotic intervention. The primary outcomes were the reduction of overall antibiotic consumption and the reduction of antibiotic consumption by department and antibiotic class, as expressed by defined daily dose (DDD) per 100 bed-days.

Overall, 2,552 ID consults were performed in 1,111 patients (18.6% weekly vs 81.4% daily). In the daily service, compared with the weekly service, patients were seen by the ID consultant earlier (6 days vs 10 days), and the number of ID consults increased from 0.4 per 100 bed-days to 1.5 per 100 bed-days, with the greatest increase seen in the emergency department. Total antibiotic consumption decreased from 64 to 60 DDD/100 bed-days, with the greatest reduction observed in the emergency department (132 DDD/100 bed-days with weekly consults vs 107 DDD/100 bed-days with daily consults).

According to antibiotic classes, glycopeptides consumption declined from 3.1 to 2.1 DDD/100 bed-days, while carbapenem use decreased from 3.7 to 3.1 DDD/100 bed-days. No changes in overall mortality (5.2% in 2017 vs 5.2% in 2018) and sepsis-related mortality (19.3% in 2017 vs 20.9% in 2018) were observed among the two periods.

"In our study, the availability of daily ID-consultations was associated with a global reduction in antibiotic consumption in the whole hospital in spite of a similar distribution of infections among the two time periods," the authors wrote. "This reduction was not accompanied by a worsening of clinical outcomes."
Nov 7 BMC Infect Dis study


MERS sickens Saudi man in Riyadh

Marking the first known MERS-CoV since May, Saudi Arabia's ministry of health (MOH) yesterday reported an infection in a man from Riyadh who had contact with camels.

The man is 51 years old, but few other details were available, other than the is case is classified as primary, meaning it likely didn't contract MERS-CoV (Middle East respiratory syndrome coronavirus) from another patient, and he is not a healthcare worker.

The country's last cases were reported in April and May, six of which were part of a hospital outbreak in Riyadh. Its latest infection would lift the global total reported to the World Health Organization since 2012 to 2,562 cases, 881 of them fatal. The vast majority of the cases have been reported in Saudi Arabia.
Nov 8 Saudi MOH update
Jul 6 CIDRAP News scan on earlier Saudi cases


Parental flu vaccine hesitancy leads to less coverage, study finds

In a national survey about child flu vaccinations, one in five children had a parent who had vaccine hesitancy (VH), which is tied to lower flu vaccination coverage.

The study, published today in Pediatrics, found that, among parents with VH, flu vaccination coverage for their children was 25.8 percentage points lower than other children's coverage during the 2017-18 flu season and 25.6 percentage points lower in the 2018-19 flu season.

Parents were contacted April through June of 2018 and 2019 as part of the National Immunization Survey-Flu and asked about their hesitancy toward childhood shots, concerns about side effects and the amount of shots at one time, and trust in their health provider. In 2018, 36,184 people responded, reporting 25.8% at least somewhat hesitant, and in 2019, 39,617 responded, with 19.5% identifying as at least somewhat hesitant.

Some of the larger opinion differences lay between parents of black children and parents of white children. VH differed from 29.4% for parents of black children to 17.5% for parents of white children; concern about the number of vaccines per one appointment was 22.1% vs 18.0%, concerns about serious long-term side effects was 29.8% vs 19.9%, and relative mistrust in their health provider was 15.5% vs 14.1%, respectively.

Despite this, only 5.5% of parents with black children chose nonstandard flu vaccine schedules (eg the Sears schedule), compared with 5.9% of parents with white children. Hispanics, while self-reporting the highest non-standard vaccine schedule (7.1%), had the lowest mistrust in their healthcare providers regarding vaccine information (13.1%).

Higher VH was also correlated with parents living in rural areas, lower education, and having a lower income than the highest bracket. Concern declined as children grew older, with 20.3% of parents with children 6 to 23 months old being hesitant compared with 17.7% of parents with children 13 to 17 years old. The data suggested that geographical pockets of VH existed, but further research is needed for more conclusive results.
Nov 9 Pediatrics study


Three European countries report avian flu detections in wild birds

In the latest highly pathogenic avian flu developments, Denmark reported an H5N5 outbreak in wild birds, and Germany and the Netherlands reported more events involving both H5N8 and H5N5 in wild birds, according to the latest notifications from the World Organization for Animal Health (OIE).

In Denmark, animal health officials found H5N5 in a peregrine falcon found on Oct 30 near the city of Guldborgsund in the southernmost region of the country.

Meanwhile, in five different OIE reports, Germany reported H5N8 in wild birds in Brandenburg state in an event that began on Nov 6, one that began on Nov 3 in Hamburg state, and four that began on Nov 4 in Mecklenburg-Vorpommern state. It also reported H5N5 outbreaks that began on Nov 3 in Schleswig-Holstein state and on Nov 4 in Mecklenburg-Vorpommern state.
Nov 6 OIE report on H5N5 in Denmark
Nov 9 report on H5N8 in Germany
Nov 6 OIE report on H5N8 in Germany (Hamburg)
Nov 6 OIE report on H5N5 in Germany (Schleswig-Holstein)
Nov 6 OIE report on H5N5 in Germany (Mecklenburg-Vorpommern)
Nov 6 OIE report on H5N8 in Germany (Mecklenburg-Vorpommern)

In other developments, the OIE added virus subtypes on outbreaks reported earlier by the Netherlands and Japan. In the Netherlands, a recent suspected H5 outbreaks at a poultry farm in Puiflijk was confirmed as H5N8, and an outbreak at a farm in Japan's Kagawa prefecture was confirmed as H5N8.
Nov 7 OIE report on H5N8 in the Netherlands
Nov 6 OIE report on H5N8 in Japan
Nov 5 CIDRAP News scan

Our underwriters

COVID-19 Scan for Nov 09, 2020

News brief

At least 9% of COVID-19 patients readmitted within 2 months, study finds

In a Mortality and Morbidity Weekly Report (MMWR) study today, data from the Premier Healthcare Database showed that, of 106,543 patients who survived after being admitted for COVID-19 from March through July, 9,504 (8.9%) were readmitted to the same hospital within 2 months of discharge for any condition, infectious disease–related or not.

Indeed, 1,667 (1.6%) of patients recorded more than a single readmission within this timeframe.

Same-hospital readmissions occurred more often among patients discharged to a skilled nursing facility (15% return rate, 1.4 odds ratio [OR]) or home health organization support (12%, 1.3 OR) as opposed to those who were discharged to home or self-care (7%). Other factors that increased readmission likelihood included chronic conditions (1.2 to 1.6 OR), those who had a prior hospitalization within the last 3 months (2.6 OR), or those who were 65 years or older (1.2 to 1.4 OR).

The most common reason for readmission was infectious or parasitic disease such as COVID-19 (45%), but 11% reported circulatory diseases and 7% reported digestive diseases. White people were most likely to be readmitted, but no possible reasons for this are offered by the study.

"Understanding frequency of, and potential reasons for, readmission after a COVID-19 hospitalization can inform clinical practice, discharge disposition decisions, and public health priorities, such as health care resource planning," the Centers for Disease Control and Prevention (CDC) researchers write.

Study limitations include how patients and their diagnoses were coded, how COVID-19 sequelae is not fully integrated into data interpretation, how patients may not have gone to the same site for prior hospitalizations or readmissions, and how readmissions after 2 months were not included.
Nov 9 MMWR study


Shortages, lack of clear guidance hinders COVID-19 care providers

A new JAMA Network Open study found that institutional planning efforts failed to anticipate a number of challenges faced by frontline clinicians treating COVID-19 patients, leading to difficult allocation decisions and a lack of clarity regarding acceptable standards of care.

The researchers interviewed 61 US clinicians in 15 states from Apr 9 to May 26 who had cared for COVID-19 patients and were involved in planning institutional responses to potential resource limitations. The participants were mainly attending physicians who practice in large academic centers and representing areas that were hardest hit with COVID-19 cases at the time of the interviews.

Clinicians described a variety of resource limitations that severely compromised care, led to difficult bedside decisions, and took a significant emotional toll on providers, even in the absence of formal declarations of crisis capacity.

While providers described feeling strong institutional support for their efforts to develop protocols, many acknowledged the challenges and moral weight of adapting existing guidelines to resource limitations. Developing triage algorithms was a particularly weighty task, with clinicians describing explicit attempts to avoid bias by minimizing information about individual patients when making decisions.

Clinicians identified resource limitation (dialysis machines, staff, routine supplies, etc) as a source of frustration, as well as feeling unsupported. Some reported unorthodox attempts to obtain healthcare equipment through personal contacts or by fabricating it themselves.

The authors highlight the need to develop guidelines, protocols, and defined standards of care in advance of crises. Greater collaboration is needed between triage team members and frontline clinicians, as well as bioethics training for clinical teams navigating the conflicts of resource limitation, they wrote.

"Expanding the scope of institutional planning to address a broader spectrum of resource limitation may help to support clinicians, promote equity, and optimize care during the pandemic," the authors wrote.
Nov 6 JAMA Netw Open study


More data for no hydroxychloroquine benefit in hospital COVID-19 patients

The results of a robust, randomized clinical trial today show no benefit for hospitalized COVID-19 patients treated with hydroxychloroquine. The latest in a series of studies of the drug, the JAMA study shows no significant improvement in clinical status for COVID-19 patients at day 14 and no benefit over placebo.

Early enthusiasm for the use of hydroxychloroquine stemmed from in vitro studies showing that it might limit viral entry into human cells and reduce inflammatory factors, as well as a small observational study in March. Widespread availability of the drug and a history of safety based on its use as an anti-malarial and rheumatologic treatment added to the drug's early appeal. Many high-quality studies since have found no benefit for hospitalized patients.

Today's study of 479 COVID-19 ethnically and racially diverse patients at 34 US hospitals included rigorous monitoring for safety and adverse events. Patients were assigned to hydroxychloroquine (242) and placebo groups (237), with treatment participants receiving 400-milligram (mg) of hydroxychloroquine twice daily for two doses, then 200-mg twice daily for eight doses. The primary outcome was clinical status at day 14, measured on a 7-point scale ranging from 1 (death) to 7 (discharged and performing normal activities).

Study authors found no significant difference in clinical status between the hydroxychloroquine and placebo groups (mean clinical status score of 6 for both groups [4 to 7]; odds ratio [OR], 1.02; 95% confidence interval [CI], 0.73 to 1.42) and no difference in mortality at 28 days (OR, 1.07; 95% CI, 0.54 to 2.09), providing conclusive evidence of no benefit over placebo.  

"The clear, unambiguous, and compelling lesson from the hydroxychloroquine story for the medical community and the public is that science and politics do not mix," said Michael Saag, MD, of the University of Alabama at Birmingham, in an editorial in the same journal. "The number of articles in the peer reviewed literature over the last several months that have consistently and convincingly demonstrated the lack of efficacy of a highly hyped 'cure' for COVID-19 represent the consequence of the irresponsible infusion of politics into the world of scientific evidence and discourse."
Nov 9 JAMA study
Nov 9 JAMA editorial 

This week's top reads