Stewardship / Resistance Scan for Apr 04, 2018

News brief

Defensive medicine found common when prescribing antibiotics

A study group with the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) reports that 45% of specialists in infectious diseases and clinical microbiology sometimes worried and 29% often worried about malpractice implications when prescribing or advising on antibiotic prescriptions, and 85% reported defensive behaviors when prescribing, according to a study today in the Journal of Antimicrobial Chemotherapy.

The experts report on their experience with AntibioLegalMap, an international Internet-based survey targeting those two specialties. The survey included 830 professionals in 74 countries.

When asked about the fear of liability, 164 of 774 respondents (21.2%) said they never worried, 349 of 774 (45.1%) sometimes worried, and 221 of 774 (28.6%) frequently worried when prescribing or advising on antibiotic prescriptions. Being female, 35 years or younger, and aware of previous cases of litigation were independently associated with such concerns.

In addition, 525 of 618 respondents (85.0%) reported some defensive behavior in antibiotic prescribing and 505 of 661 (76.4%) reported defensive behaviors in advising. The preferred measures to reduce fear and defensive behaviors were having local guidelines and sharing decisions through teamwork, the scientists reported.
Apr 4 J Antimicrob Chemother abstract

Diagnostic stewardship tied to lower hospital rates of Clostridium difficile

A new study in Infection Control and Hospital Epidemiology describes how University of California-Los Angeles researchers achieved a two-fold reduction of Clostridium difficile rates after implementing diagnostic stewardship and provider education programs.

The study took place over a 12-month period at the Los Angeles County and University of Southern California Medical Center. The stewardship program began with provider education on how to properly collect and include stool samples as diagnostic criteria.

Before the program was implemented, researchers found that more than 50% of admitted patients with positive C difficile tests lacked symptoms of colitis and had at least one confounding factor at the time of stool collection, such as laxative use. The rate of false-positives was estimated to be 70%. This is because a positive C difficile NAAT does not distinguish between infection and colonization, the authors said.

The hospital implemented a two-step C difficile testing program that required a confirmatory test with a toxin-specific enzyme-linked immunosorbent assay (ELISA) assay after a positive C difficile nucleic acid amplification tests (NAAT).

"Starting in January 2017, after implementing the diagnostic and education interventions, the average number of tests ordered fell to 85 per month (a 43% reduction), of which 7 per month were positive (36% reduction)," the authors said.

C difficile infections are the most common healthcare-associated infections in the United States, resulting in 44,500 deaths and $5.4 billion in healthcare expenses.
Apr 3 Infect Control Hosp Epidemiol study

Study finds high antimicrobial resistance levels in Cambodian kids

A 9-year analysis of bacteria samples from hospitalized children in Cambodia found high rates of antibiotic resistance, especially among gram-negative organisms, an international research group reported yesterday in Emerging Infectious Diseases.

The samples were from Angkor Hospital for Children in Siem Reap. From 39,050 bacterial cultures collected from 2007 to 2016, they identified 1,371 target pathogens. Multidrug-resistance rates were 82% each for Escherichia coli and Klebsiella pneumoniae. In addition, 62.1% of K pneumoniae isolates and 47.2% of E coli isolates were resistant to ampicillin and gentamicin. Third-generation cephalosporin resistance was seen in 78.8% of K pneumoniae, 49.5% of E coli, and 93.3% of Acinetobacter baumannii isolates.

For Salmonella, the team found that resistance patterns varied by subtype, with the proportion highest for Salmonella Typhi—85% of them fluoroquinolone and multidrug resistant—and lowest for Salmonella Paratyphi A, of which only 22.7% were resistant to fluoroquinolone or other drugs.

The researchers found that resistant K pneumoniae was more common in infants, which they said might be the result of acquisition of gram-negative organisms from hospital surfaces. And Salmonella Typhi was more often resistant in kids younger than age 5, which the team said could be related to their exposure to more antimicrobial drugs.

In patients who had community-associated gram-negative bacteremia, resistance to third-generation cephalosporins was associated with more deaths, intensive care unit admissions, and a 2.26-fold greater healthcare costs in survivors.

The team concluded that the surveillance findings fill a gap in the understanding of antimicrobial resistance in Cambodian kids and shows that tracking the patterns is feasible in similar low-resource settings.
Apr 3 Emerg Infect Dis study

News Scan for Apr 04, 2018

News brief

Saudi Arabia records 2 new MERS cases

The Saudi Arabian Ministry of Health (MOH) has confirmed two new cases of MERS-CoV, including a household contact in Riyadh.

On Apr 2, a 58-year-old Saudi man from Najran was diagnosed as having an asymptomatic MERS-CoV (Middle East respiratory syndrome coronavirus) infection. He is in stable condition, and the source of his infection is listed as "primary," meaning it's unlikely he contracted the disease from another person.

Today the MOH recorded the case of a 57-year-old female expatriate from Riyadh, who is listed as a household contact of a previously recorded patient. She is in stable condition. On Mar 23, the MOH said a male expatriate in Riyadh had been diagnosed as having MERS. Neither of the two newly reported patients is a healthcare worker.

Saudi Arabia's MERS-CoV total cases since 2012 have now reached 1,830, including 739 deaths. Nine people are still being treated for their infections.
Apr 2 MOH update
Apr 4 MOH update

Flu retreats throughout most of Northern Hemisphere

According to the latest global flu update from the World Health Organization (WHO), flu is declining everywhere in the Northern Hemisphere except Eastern Europe, where case counts are still rising.

Globally, influenza strains are almost evenly divided among types A and B, with 46.8% of laboratory specimens typed as influenza A and 53.2% as influenza B. Of the sub-typed influenza A viruses, 64% were influenza 2009 H1N1 and 36% were influenza H3N2. Of the characterized B viruses, 91% belonged to the Yamagata lineage and 9% to the Victoria lineage.

"In Eastern Europe, influenza activity continued to increase with influenza A virus most frequently detected followed by influenza B virus. In particular, influenza activity was still increasing in the Russian Federation, with all seasonal influenza subtypes co-circulating," the WHO said.

Flu declined in the United States, Canada, Mexico, and all Asian regions. In the temperate zones of the Southern Hemisphere, flu remained at typical inter-seasonal levels.
Apr 2 WHO update

Lassa fever kills 2 more in Nigeria, including doctor

The Nigerian Centre for Disease Control (NCDC) reported six new confirmed cases of Lassa fever last week, including two deaths. One of those deaths, in Abia state, involved a doctor who was in close contact with at least 30 patients, according to Nigerian news sources.

From Jan 1 to Apr 1, the NCDC has confirmed 400 cases of Lassa fever, including 97 deaths. The case-fatality rate is 24.3%. Twenty-five healthcare workers have been infected since the onset of the outbreak, with five of them dying.

Lassa fever is endemic in Nigeria, but the current outbreak is one of the largest in history. The virus is transmitted mostly by rats, but human transmission can occur when a person comes into contact with infected bodily fluids.

The vast majority of cases are in the south central part of the county, with 81% of all confirmed cases from Edo (42%), Ondo (23%), and Ebonyi (16%) states.
Apr 1 NCDC update
Apr 4 All Africa story

South Africa's lab reiterates Listeria source evidence amid political claims

South Africa's National Institute for Communicable Diseases (NICD) reiterated its evidence linking a company's contaminated ready-to-eat polony meat products to a large Listeria outbreak, pushing back against political claims that the source was still unknown and that the health ministry has backed down on its earlier assessment about the link.

In an Apr 2 statement, the NICD said it was concerned about confusion that came from statements at a parliament agriculture hearing, which implied that the NICD misled the health ministry and the public. "Furthermore, we condemn the statement made that the government prematurely scapegoated 'Enterprise and Rainbow' without sufficient evidence," the NICD said. The agency said the doubts raised in the hearing are not a small matter, given that the NICD's lab expertise plays a key role in global health matters in South Africa and across the globe. "Therefore, the work of the NICD is scientifically sound and evidence-based," the agency said.

In reiterating the evidence, NICD described how whole-genome sequencing showed that the clinical isolates from patients suggests that a single Listeria monocytogenes strain is involved in the outbreak and tests on samples from an Enterprise Foods production facility yielded the outbreak strain in the postcooking production environment and on final polony products. That the patient and facility strains were 99.99% related "means there can be no doubt that these L. monocytogenes ST6 strains are all linked, and that there is certainty that products manufactured at Enterprise Polokwane are the source of the outbreak."

Also, interviews with sick patients have found that 86% ate polony, a meat product similar to bologna, during the month before they became ill.

The NICD also said new test results from polony samples from the same facility sold at its factory store in Germiston tested positive for the outbreak strain. "This means that the outbreak strain has been found inside the ready-to-eat processed meat products manufactured at Enterprise Foods' Polokwane production facility, dispelling claims made to the contrary."

The outbreak, the world's largest involving Listeria, has resulted in at least 978 lab-confirmed cases, 183 of them fatal. The World Health Organization (WHO) has raised concerns about the potential scope of the outbreak, because the company's products, which have been recalled, were exported to 15 African countries.
Apr 2 NICD statement