Stewardship / Resistance Scan for Apr 01, 2019

News brief

New rapid diagnostics partnership announced

A new public-private partnership to address inappropriate antibiotic use and antimicrobial resistance (AMR) through wider use of rapid diagnostics was launched today at an event in Madrid.

VALUE-Dx, a project of the Innovative Medicines Initiative, brings together six in vitro diagnostics companies with 20 non-industry partners to "generate evidence on the medical, economic, and public health value of diagnostics in tackling AMR," according to a news release from project partner, the University of Edinburgh. The project will focus on acute respiratory tract infections acquired in community care settings, one of the most frequent causes of inappropriate prescribing.

"This is an exciting and groundbreaking opportunity to address one of the greatest barriers to adoption of rapid diagnostics," Till Bachman, PhD, deputy head of infection medicine at the University Edinburgh, said in a statement. "It will shift the focus from the cost to the added value diagnostics provide in the fight against AMR."

Other partners include bioMerieux, Accelerate Diagnostics, the University of Antwerp, and the European Society of Clinical Microbiology and Infectious Diseases. The project is co-funded by the European Commission, Wellcome Trust, and private companies, with a budget of €14 million ($15.7 million) over 4 years.
Apr 1 University of Edinburgh news release

Chinese study finds many diverse resistance genes in live poultry

A new study in the Journal of Infection suggests that live poultry markets in China are a significant reservoir for antibiotic resistance genes (ARGs).

In the study, Chinese researchers used large-scale metagenomic sequencing to explore the diversity and abundance of ARGs in the gut microbiomes of poultry in live-poultry markets (LPMs). Because these markets are known to be a high-risk environment for the spread of avian flu to people, the researchers theorized they may also be a potential site for the dissemination of animal-origin ARGs. For their analysis, the authors collected 753 poultry fecal samples from 22 cities in 18 provinces, sequenced the genomes of 130 representative samples to create a catalogue of gut microbial genes, and compared the genes with genes from the pig gut and human gut microbiomes.

Overall, the analysis revealed the presence of 539 ARGs in live poultry that could be classified into 235 different ARG types. Both the number of ARGs and ARG types in live poultry were significantly higher than they were in humans and pigs, suggesting a greater diversity and enrichment of ARGs in live poultry. The overall abundance of ARGs was also highest in live poultry, followed by pigs and then humans. A total of 65 ARG types were shared among the three groups. Mapping of the ARG types to their corresponding antibiotics showed that tetracycline-resistance genes were the most abundant in all three groups.

Using polymerase chain reaction and Sanger sequencing, the researchers then investigated the distribution of the MCR-1 gene in all 753 live poultry fecal samples, finding it in 449 samples (59.6%). The MCR-1 gene was present in samples from all 18 provinces, and positive rates were similar in chickens, ducks, pigeons, and geese. The gene was also found in seven wild birds, and the researchers also identified MCR-3 and MCR-5 genes.

"The LPM is a special environment in China, where city dwellers have the opportunity to contact live animals and the viruses and bacteria carried by them," the authors of the study write. "We propose that LPMs represent a high-risk environment for the dissemination of animal-origin ARGs to public health."
Mar 29 J Infect study

Illegal antibiotic prescribing in Sri Lanka

An experimental study involving fake patients revealed a high level of illegal antibiotic prescribing in community pharmacies in Sri Lanka, according to a new study in Antimicrobial Resistance and Infection Control.

The cross-sectional study involved visits to 242 community pharmacies by 32 trained "pseudo-patients" (pharmacy school students or recent graduates) who pretended to have a relative with clinical symptoms of four randomly selected common infections. Three of the infections were viral (acute sore throat, common cold, acute diarrhea) and one was bacterial (uncomplicated urinary tract infection [UTI]). Each pseudo-patient requested an unspecified medicine for the condition, and a research assistant recorded the interaction. Sri Lankan law prohibits the supply of an antibiotic without a prescription.

In 41% (99/242) of visits, antibiotics were sold illegally without a prescription in response to the reported clinical symptoms, with two-thirds (65/99) being sold for underlying viral infections. Antibiotics were provided for 55% of uncomplicated UTIs, 50% of acute diarrhea cases, 42% acute sore throat cases, and 15% of common colds. Patient history was obtained in less than a quarter of interactions, and pharmacy staff recommended a visit to a physician in only 18% (44/242) of cases; yet in 25% (11/44) of those interactions, an antibiotic was still obtained. Roughly half of the pseudo-patients were advised on how and how often to take the antibiotics, and less than a quarter were advised on when to stop taking them. In nearly two thirds of instances, antibiotics were sold by a staff member other than a qualified pharmacist.

While the availability of a pharmacist reduced the likelihood of illegal antibiotic sales (odds ratio, 0.53; 95% confidence interval, 0.31 to 0.89, P = 0.016), it did not appear to reduce inappropriate prescribing.

"In addition to strict implementation of policies, awareness and educational interventions must be implemented to improve appropriate antibiotic dispensing practice among pharmacists and their staff," the authors of the study conclude.
Mar 29 Antimicrob Resist Infect Control study

News Scan for Apr 01, 2019

News brief

Secondary exposure noted in latest Saudi MERS case

Saudi Arabia's Ministry of Health (MOH) has reported another MERS-CoV case, marking the second recent case from Khafji in the country's northeast, according to its epidemiologic week 14 report.

The patient is a 25-year-old man who was found to have secondary exposure, meaning he likely had contact with an earlier confirmed MERS-CoV (Middle East respiratory syndrome coronavirus) case. On Mar 29, the health ministry reported an earlier case in Khafji, that of a 75-year-old man who had contact with camels.

The new case boosts Saudi Arabia's MERS-CoV total for the year to 114, of which 57 are linked to a large outbreak in Wadi ad-Dawasir, with most of the illnesses linked to healthcare spread.
Mar 31 MOH report

CDC reports 73 new measles cases as US total tops 2018 levels

In less than 3 months, the United States has already surpassed the number of measles cases logged for all of 2018, the Centers for Disease Control and Prevention (CDC) said today as it confirmed 73 new infections.

In its weekly update, the CDC said officials in 15 states reported a total of 387 measles cases from Jan 1 to Mar 28—the second-highest total since measles was declared eliminated in 2000. In 2014 the agency recorded 667 measles cases, including at least 383 cases in an unvaccinated Amish community in Ohio. Last year saw 372 cases, now the third-most since 2000.

The CDC said six outbreaks, which it defines as 3 or more related cases, are ongoing, the same number it reported a week ago. The outbreaks are in New York City (214 confirmed cases); Rockland County, New York (157); Washington state (74); New Jersey (10); Butte County, California (6); and Santa Cruz County, California (3).

"These outbreaks are linked to travelers who brought measles back from other countries such as Israel, Ukraine, and the Philippines, where large measles outbreaks are occurring," the CDC said. "Make sure you are vaccinated against measles before traveling internationally."

Besides the states noted above, Arizona, Colorado, Connecticut, Georgia, Illinois, Kentucky, Michigan, Missouri, New Hampshire, Oregon, and Texas have recorded cases this year.
Apr 1 CDC update

Seven more acute flaccid myelitis cases noted in US

In a separate update, the CDC late last week reported 5 new cases of acute flaccid myelitis (AFM) in 2018 and 2 new cases this year, bringing last year's total to 228 and this year's to 4.

The 228 cases in 41 states—which are by a large margin the most US cases in 1 year—were confirmed from 378 reports of patients under investigation (PUIs). The CDC said no deaths have been attributed to AFM in 2018 or 2019.

The 2019 AFM cases have been diagnosed in Nebraska, North Carolina, Utah, and West Virginia, with Nebraska and West Virginia reporting cases for the first time this year. The 4 cases are among 25 PUIs. The CDC's previous update was on Mar 3.

Texas has reported the most AFM cases in 2018, with 31, which is 2 more than in the previous update. Colorado has 16 cases, California 15 (1 new case), Ohio 14, and Pennsylvania (1 new case), New Jersey, and Washington state have 11.

AFM affects the spinal cord, leaving patients—almost always children—with partial or total limb paralysis or muscle weakness. The cause of the disease is unknown, but 90% of patients report upper respiratory virus symptoms in the weeks before limb weakness. In previous years the syndrome has been tied to enterovirus infections. So far, the condition has peaked in even-numbered years since 2014.
Mar 29 CDC update

UK study highlights varying degrees of vaccine hesitancy

UK scientists who adapted a 10-item vaccine hesitancy scale found that 90% of British citizens were hesitant on at least 1 item and 4% on all 10, according to a new study in Vaccine.

The original 10-item scale targeted parental attitudes toward childhood vaccines. The UK researchers adapted it toward a more generic version that captures general attitudes toward vaccination among all ages. They surveyed 1,402 UK citizens.

Some sample statements to which respondents answered from "strongly disagree" to "strongly agree" were:

"Vaccines are important for my health."
"All vaccines offered by the government program in my community are beneficial."
"Generally I do what my doctor or health care provider recommends about vaccines."
"I am concerned about serious adverse effects about vaccines."

The authors found that 90.2% were vaccine-hesitant for at least 1 item and 4.4% were hesitant about all 10. Some factors associated with lower confidence in vaccines were being 20 to 29 years old, living in a rural area, being male, and having children 20 years old or older.
Mar 30 Vaccine study