Stewardship / Resistance Scan for Apr 15, 2019

News brief

European analysis links antimicrobial resistance to climate change

New research presented at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) annual meeting suggests an association between antimicrobial resistance (AMR) and climate change.

Using statistical analysis and computer modeling, a team of German researchers looked at more than 900,000 bacterial isolates collected from 30 European countries over a 6-year period and found significant associations between the warm-season mean temperature and methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant Escherichia coli, and carbapenem-resistant Klebsiella pneumoniae.

The researchers also observed that the warm-season mean temperature was a stronger predictor of MRSA variation than outpatient antibiotic use, and that carbapenem-resistant Pseudomonas aeruginosa (CRPA) was significantly associated with a warm-season change in temperature of 0.5°C (0.9°F).

The authors of the study conclude, "These results reveal two aspects: climatic factors significantly contribute to the prediction of AMR in different types of healthcare systems and societies, while climate change might increase AMR transmission, in particular CRPA."

The study builds on research published in 2018 by a team of US scientists that found that an increase in the average minimum temperature across US regions was associated with higher levels of AMR in E coli, K pneumoniae, and S aureus.
Apr 14 ECCMID abstract
Apr 14 ECCMID poster
May 23, 2018, CIDRAP News story "Study finds antibiotic resistance tied to hotter temps"

Study identifies petting zoos as potential source of MDR pathogens

A study presented at ECCMID by Israeli scientists suggests that petting zoos could be a reservoir for multidrug-resistant (MDR) pathogens, potentially posing a threat to people who visit the facilities.

The prospective cross-sectional study was performed in eight petting zoos throughout Israel from December 2016 to May 2018, with researchers collecting fecal and body-surface samples from 228 animals belonging to 42 different species. They identified the bacteria, susceptibility profile, and sequence type (ST) in each sample and used polymerase chain reaction and whole-genome sequencing to identify extended-spectrum beta-lactamase (ESBL) and AmpC-carrying Enterobacteriaceae (AmpC-E). They also analyzed questionnaires filled out by zoo owners to determine risk factors for carriage of drug-resistant pathogens.

Analysis of 382 samples revealed that 12% of the animals (28 of 228) carried at least one ESBL/AmpC-producing bacterial strain, with 35 different types of bacteria identified. Seventy-seven percent of the recovered bacterial types were from fecal samples, and 23% were from skin/fur/feathers. Twenty-five percent of the animals carrying ESBL/AmpC-E were co-colonized with more than one strain.

The main bacteria recovered were Enterobacter spp (55%), E coli (31%), and Citrobacter spp (14%). Among the strains identified were the highly virulent enterotoxigenic E coli ST 656, a known cause of traveler's diarrhea, and E coli ST127, which causes urinary tract infections in people.

Analysis of risk factors found that animals treated with antibiotics were more than seven times more likely to carry an MDR pathogen (odds ratio, 7.34).

"Our findings demonstrate that animals in petting zoos can result in shedding and transmission of MDR pathogens that may cause illness for human visitors, even when the animals appear healthy," lead study author Shiri Navon-Venezia, PhD, a microbiologist at Ariel University, said in an ECCMID press release. She and her colleagues suggest petting zoos should implement strict hygiene and infection-control policies to reduce the risk of animal-visitor transmission.
Apr 14 ECCMID abstract
Apr 14 ECCMID poster
Apr 13 ECCMID press release

Study: Bloodstream infection mortality rate varies by organism

In another abstract presented at ECCMID, a retrospective analysis of hospitalized patients from 10 New York healthcare facilities found a wide range of mortality rates associated with bloodstream infections (BSIs) caused by different antibiotic-resistant pathogens.

The researchers sought to evaluate the association between different microorganisms and in-hospital mortality in patients with BSIs by analyzing patients discharged from the 10 facilities over 12 months (January to December 2018). For suspected BSI patients who'd had blood cultures taken, the investigators sent the cultures for molecular analysis to identify the species of microorganism present in the blood. They then grouped the discharged patients by organism type and discharge disposition to assess in-hospital mortality rates by organism.

Overall, 212,257 patients were discharged during the study period, and 4,133 (2%) involved the death of a patient. Of the 6,149 patients who were found to have a BSI caused by one or more microorganism, 744 (12%) died in the hospital. The mortality rate for BSI patients ranged from 8% to 46%, with the highest mortality rates associated with Acinetobacter baumannii (46%), vancomycin-resistant Enterococcus (36%), carbapenem-resistant K pneumoniae (35%), and Candida species (30%). The analysis also found that illicit drug use, pressure ulcers, and acute kidney injury were strongly associated with BSIs, and that coagulase-negative Staphylococcus, typically considered to have low virulence, was associated with a 13% mortality rate.

The authors of the study conclude that molecular identification of organisms with high mortality rates could be crucial in helping clinicians identify the right antibiotic to treat the infection.
Apr 13 ECCMID abstract
Apr 13 ECCMID poster

Study finds drug-resistant pathogens fairly common on patients' hands

A study of patients in two Michigan hospitals reveals that 14% were colonized with a multidrug-resistant organism (MDRO), 10% had an MDRO on their hands, 29% of rooms harbored an MDRO, and 6% of patients acquired a new MDRO on their hands while in the hospital, according to the findings, which appear in Clinical Infectious Diseases.

University of Michigan researchers analyzed data on 399 patients who were enrolled in the study within 24 hours of arrival to their hospital room and had swabs taken from their nostrils, dominant hand, and six high-touch surfaces in their room on admission and weekly until discharge. The authors note that the role of healthcare worker hand contamination in MDRO spread has been well studied, but not the role of patient hand contamination.

The team found that 56 of 399 patients (14.0%) were colonized with MDROs at baseline, 40 of them (10.0%) on their hands. They also discovered that 29% of rooms harbored MDROs, and 14 of 225 patients who had at least two visits (6.2%) had newly acquired MDROs on their hands during their stay. Genetic typing also determined a high correlation between acquiring MRSA on patients' hands and MRSA on room surfaces.

The authors conclude, "Patient hand hygiene protocols should be considered to reduce transmission of pathogens and healthcare-associated infections."
Apr 13 Clin Infect Dis abstract

European, Duke University researchers join efforts to combat resistance

European researchers and a group based at Duke University announced a new joint effort to tackle antibiotic resistance issues, according to a news release from the Duke Clinical Research Institute (DCRI).

The US-based Antibacterial Resistance Leadership Group (ARLG), part of the DCRI, and the University Medical Center (UMC) in Utrecht, the Netherlands, which manages the COMBACTE (Combatting Bacterial Resistance in Europe) consortium, "will work together to solidify a comprehensive global community to combat the threat of antibiotic resistance around the world," according to the release.

The collaboration will include jointly designing and conducting clinical research, holding working meetings at conferences like ECCMID, exchanging data and protocols, and other cooperative efforts. It will also help avoid duplication of efforts.

"We at the ARLG have long admired the work being done by COMBACTE to increase the efficacy of antimicrobial drug development," said Vance Fowler, MD, an investigator at the DCRI and co-principal investigator of the ARLG. "Combining our efforts will allow us to maximize the work we both do to stop the advancement of antibacterial resistance."

"We have already made efforts to expand our reach across Europe, where an increasing number of people suffer from infections caused by antibiotic-resistant bacteria," said Marc Bonten, MD, coordinator of COMBACTE and a professor at UMC Utrecht. "But by collaborating and sharing our progress with the ARLG, we can make a truly global impact beyond this population—an important consideration in a globally connected era in which epidemics travel across oceans quickly."
Apr 13 DCRI news release

News Scan for Apr 15, 2019

News brief

Two new MERS cases reported in Saudi Arabia

Saudi Arabia's Ministry of Health (MOH) reported a new MERS-CoV case over the weekend in an update to its epidemiologic week 15 report.

On Apr 13, the MOH noted that a 75-year-old woman from Khafji had contracted MERS-CoV (Middle East respiratory syndrome coronavirus) as a secondary case, meaning likely not from another MERS patient. It's unknown if she had camel contact.

This is the 11th case reported from that city since Mar 29. Her illness lifts Saudi Arabia's total since the first of the year to 130 cases, including 57 linked to a large outbreak in Wadi ad-Dawasir.
Apr 13 MOH update

CDC ties pre-cut melon to 93-case multistate Salmonella outbreak

The Centers for Disease Control and Prevention (CDC) announced late last week a Salmonella outbreak tied to pre-cut watermelon, honeydew melon, cantaloupe, and fruit medley products sold by Caito Foods LLC of Indianapolis.

So far 93 people in nine states have been sickened in the outbreak, caused by Salmonella Carrau. There have been no deaths, but 23 patients have required hospitalization. Illnesses started on dates ranging from Mar 4 to Mar 31, and most of the patients are over the age of 50—the median age is 53, with patients' ages ranging from less than 1 to 93 years.

According to an Apr 12 CDC notice, 30 of 39 people interviewed reported eating pre-cut melons bought from grocery stores in the week prior to illness. Four additional people reported eating pre-cut melon outside the home.

Ohio has reported the most cases, with 27, followed by Michigan (19), Indiana (18), Kentucky (16), and Illinois (5). Both Minnesota and Missouri have three cases, and Alaska and Wisconsin have one case each.

On Apr 12 Caito recalled products produced at an Indianapolis facility. According to the Food and Drug Administration (FDA), "The products were packaged in clear, plastic clamshell containers and distributed in Illinois, Indiana, Iowa, Kansas, Kentucky, Michigan, Minnesota, Missouri, Nebraska, New York, North Carolina, Ohio, Pennsylvania, Tennessee, West Virginia, and Wisconsin."

Both retailers and consumers are urged to toss the fruit, and Caito has halted production on these types of fruit products until further notice.
Apr 12 CDC notice
Apr 12 FDA notice

H5 avian flu poultry outbreaks strike Iran, Nigeria, and Nepal

Three countries reported more highly pathogenic avian flu outbreaks in poultry, with Iran and Nigeria grappling with H5N8 and Nepal with H5N1, according to the latest notifications from the World Organization for Animal Health (OIE).

In Iran, the country's veterinary ministry reported two H5N8 outbreaks, one involving a large flock of village birds in Tehran province and the other affecting a layer farm in East Azarbayejan province. Between the two events, the virus killed 4,278 of 75,000 susceptible birds. Authorities culled the remaining ones to curb the spread of the virus. The outbreaks began on Apr 8 and are now considered resolved.

So far, the source of the virus isn't known. Iran reported its last H5N8 outbreak about a month ago.

Nigeria reported an H5N8 outbreak at a farm housing cockerels and layers in Edo state in the country's southwest. The event began on Apr 5, killing 250 of 1,500 birds. The surviving ones were destroyed as part of the outbreak response. Nigeria's last H5N8 detection in poultry occurred in late January.

And Nepal's agriculture ministry reported another H5N1 outbreak, part of sporadic detections since March. The latest outbreak began on Apr 12 at a layer farm in Bagmati zone, killing 123 of 1,000 birds.
Apr 14 OIE report on H5N8 in Iran
Apr 15 OIE report on H5N8 in Nigeria
Apr 13 OIE report on H5N1 in Nepal

Experts warn of climate-related vectorborne disease spread in Europe

Speakers at a symposium on climate change at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) in Amsterdam yesterday warned that the geographic range of mosquito and tickborne diseases is expanding quickly, fueled by multiple factors, including climate change.

The experts predicted that vectorborne disease outbreaks will increase across many parts of Europe over the next few decades, even at previously unaffected higher latitudes and altitudes in Northern Europe, according to an ECCMID news release. They warned that actions are needed to improve surveillance and data sharing and to monitor environmental and climate precursors to outbreaks.

Climate change is only one of many factors, which include globalization, socioeconomic development, urbanization, and changes in land use, said Jan Semenza, PhD, MPH, with the European Centre for Disease Prevention and Control.

Giovanni Rezza, MD, PhD, who directs the department of infectious diseases at the Instituto Superiore di Sanita in Rome, said the stark reality is that longer hot seasons will enlarge the seasonal window for the potential spread of vector-borne outbreak, favoring larger events. "We must be prepared to deal with these tropical infections. Lessons from recent outbreaks of West Nile virus in North America and chikungunya in the Caribbean and Italy highlight the importance of assessing future vector-borne disease risks and preparing contingencies for future outbreaks."

The experts noted that the interplay between multiple drivers makes projecting disease burden challenging, but they said climate change has allowed mosquitoes and ticks to adapt, proliferate, and broach new areas, with examples including dengue outbreaks in France and Croatia, malaria in Greece, West Nile fever in southeast Europe, and chikungunya in Italy and France.
Apr 13 ECCMID press release