Stewardship / Resistance Scan for Apr 19, 2017

News brief

Study finds ID consultation helps patients with S aureus bacteremia

Adding infectious disease consultation to antimicrobial stewardship review in the management of patients with Staphylococcus aureus bacteremia (SAB) can ensure adherence to recommended treatment and improve clinical outcomes, according to a study yesterday in the American Journal of Infection Control.

In the retrospective cohort study, investigators at University of Chicago Medicine, an academic medical center, evaluated adult patients with SAB who were admitted for treatment from December 2012 through October 2014. The investigators were looking to see whether the inclusion of ID consultation (IDC) in the management of SAB, which has been shown to improve cure rates and reduce rates of recurrence in previous studies, would have an impact in a setting where SAB patients are already evaluated by an antimicrobial stewardship program (ASP).

The primary end point of the study was the incidence of complete adherence to a composite of SAB treatment guidelines from the Infectious Diseases Society of America (IDSA). The composite included at least one echocardiogram, daily blood cultures until at least 72 hours of negative cultures, removal of prosthetic devices, initiation of appropriate antibiotics with activity against methicillin-resistant S aureus (MRSA) if necessary, and de-escalation to beta-lactams if MRSA was not present. Secondary outcomes included length of stay, recurrence of SAB within 8 weeks, and all-cause mortality.

Of the 154 patients included in the study, 115 received IDC, and 39 did not. The investigators found that adherence to the composite of IDSA guidelines was 78% in the patients who received IDC, compared with 46% in the patients who received no consultation, with significantly more IDC patients receiving echocardiograms (91% vs. 67%) and daily blood cultures (92% vs. 64%) than non-IDC patients. In addition, mortality was much lower in the IDC group than in the non-IDC patients (5% vs. 23%).

Although there were no differences in initiation of appropriate antimicrobial therapy or de-escalation, the authors of the study say that finding is likely a result of the hospital's ASP, which already provides recommendations on antimicrobial therapy.

"These results provide supporting evidence for requiring automatic consult with ID specialist physicians for patients with SAB," the authors write.
Apr 18 Am J Infect Control study

Oral steroid without antibiotic might aid in sore throat relief

In a JAMA study yesterday that has potential antibiotic-sparing implications, a single dose of the oral steroid dexamethasone provided symptom relief for sore throat in 48 hours but not within 24 hours, and the difference between the drug and placebo was modest.

The clinical trial involved 565 UK adults who visited acute care clinics with sore throats that did not require immediate antibiotics. Of the total, 293 patients received 10 milligrams of dexamethasone and 283 received a placebo, with the patients and physicians not knowing which they received. Sore throat imposes a substantial burden on primary care and is a frequent source of inappropriate antibiotic prescribing.

Twenty-four hours after taking the pills, 65 patients in the treatment group (22.6%) and 49 in the placebo group (17.7%) reported complete resolution of symptoms, a statistically non-significant difference. At 48 hours, however, the percentages rose to 35.4% and 27.1%, respectively, which reflected a statistically significant difference.

The rate of complete symptom relief was about 31% higher in the dexamethasone group after 48 hours, and the difference was seen whether the patients were offered a delayed antibiotic prescription or not.
Apr 18 JAMA study

Study details MRSA glove, gown contamination in VA nursing homes

A study involving seven Veterans Administration (VA) nursing homes in four states and Washington, DC, found a 20% rate of MRSA glove contamination and an 11% rate of gown contamination in healthcare workers, with certain high-risk activities increasing the odds of gown contamination.

VA researchers in Maryland, New York, Massachusetts, Texas, and Washington, DC, enrolled 200 residents in the study, which was published yesterday in the American Journal of Infection Control. Of those residents, 94 (46%) were found to be colonized with MRSA.

The team then determined that 20% of healthcare workers contacting the colonized patients had glove contamination, compared with 11% for gown contamination, with transmission varying from 7% to 37% for gloves and from 0% to 19% for gowns. The authors identified changing wound dressing, providing hygiene such as brushing teeth, and bathing as high-risk activities for gown transmission.

The authors conclude, "Transmission to gloves varies by type of care, but all care had a risk of contamination, demonstrating the importance of hand hygiene after all care. . . . Optimizing gown and glove use by targeting high-risk care activities could improve resident-centered care."
Apr 18 Am J Infect Control study

Daily ICU chlorhexidine baths tied to low rates of MDR microbes

Daily chlorhexidine bathing in the intensive care unit (ICU) was associated with low levels of multidrug-resistant (MDR) organisms, according to a third study yesterday in the American Journal of Infection Control.

Although patients colonized with MDR microbes can spread worrisome disease, few studies have examined the effect of daily chlorhexidine gluconate (CHG) bathing as part of routine care, the authors, from the University of Wisconsin, said. From May 2010 through January 2011, they screened patients admitted to a 24-bed ICU for MRSA, vancomycin-resistant enterococci, and fluoroquinolone-resistant gram-negative bacilli. They then plotted the monthly incidence and prevalence of colonization of these MDR pathogens.

The scientists found that prevalence of the pathogens decreased immediately after implementing daily CHG bathing and generally remained at that level throughout the study period. Monthly prevalence of colonization with the three MDR organisms ranged from 1.9% to 27.9%.
Apr 18 Am J Infect Control study

Candida bloodstream infections in Peru at times resistant, often deadly

A multicenter study of Candida bloodstream infections in Lima, Peru, yesterday discovered a very high proportion of non-albicans Candida species, a 13% incidence of decreased susceptibility or resistance to fluconazole, and high mortality.

Reporting in PLoS One, Peruvian investigators analyzed data from 158 Candida isolates obtained from 157 patients in three hospitals in Lima from November 2013 to January 2015. Candidemia, or bloodstream infections involving Candida yeast, have been increasing in developing countries, and US officials have recently warned about C auris, an often-resistant and potentially deadly strain that has been increasingly detected.

In the current study, patients' median age was 55, and 24% of infections were in children. Although C albicans typically causes more than half of invasive Candida infections, 72.1% of candidemia in this study was caused by non-albicans strains. Frequency was as follows: C albicans (27.8%), C parapsilosis (25.3%), C tropicalis (24.7%), and C glabrata (9.5%).

Only 4 isolates were resistant to fluconazole and 17 had reduced susceptibility, for a total of 13.3%.

The researchers also noted that only 28% of patients received appropriate antifungal treatment within 72 hours of diagnosis. The 30-day survival rate was only 60.4%, with treated subjects reaching a 67.4% survival rate and untreated patients a 50.9% rate.

The authors wrote, "It is possible, that the delay in initiating antifungal treatment contributed to the elevated mortality rate, in spite of low antifungal resistance."
Apr 13 PLoS One report

News Scan for Apr 19, 2017

News brief

MERS hospitalizes another in Saudi Arabia

Saudi Arabia's Ministry of Health (MOH) today announced a new MERS-CoV case, involving a 55-year-old expat man from Wadi Aldwasir who is hospitalized in critical condition. It's not clear if his illness is part of a recent hospital cluster reported from Wadi Aldwasir; he is not a healthcare worker and his infection source is listed as primary, meaning he didn't likely contract the virus from another person.

Ten MERS-CoV (Middle East respiratory syndrome coronavirus) cases were recently linked to a dialysis unit at a hospital in Wadi Aldwasir, located in Riyadh province, about 420 miles south of the city of Riyadh.

The man's MERS-CoV infection lifts Saudi Arabia's overall total to 1,592 cases, 659 of them fatal. Six people are still being treated for their illnesses.
Apr 19 Saudi MOH statement

In MERS-CoV research developments, a team from South Korea yesterday described patterns they observed with outbreaks reported from two hospitals in Daejeon that occurred in May through July of 2015. One is a 300-bed general hospital and the other is an 800-bed university hospital. The group published its findings in Emerging Infectious Diseases.

The index patient in Daejeon was a 41-year-old man who had undergone surgery and then a follow-up colonoscopy at the hospital in Pyeongtaek, the facility where South Korea's outbreaks originated. He got sick with fever and chills in Daejeon, where he was treated at the general hospital then sent to the emergency department of the university hospitals when his symptoms didn't improve.

Those around him didn't use protective equipment during his first 10 days of illness. A total of 26 cases were confirmed at the two hospitals, and 11 of them died. Incubation period was about 6.1 days, similar to 2013 outbreaks in Saudi Arabia.

Officials ordered cohort quarantine at the two hospitals to prevent spread the local community, which the team said had its advantages and disadvantages. It prevented transmission to the community but may have increased transmission within the hospital, they wrote.
Apr 18 Emerg Infect Dis report

Wolbachia mosquito trial launches in Florida Keys

The Florida Keys Mosquito Control District (FKMCD) yesterday launched a field trial of Wolbachia-infected male Aedes aegypti mosquitoes on Stock Island near Key West, which it is conducting with MosquitoMate, the Lexington, Ky., company that produces the mosquitoes.

Males infected with the naturally-occurring Wolbachia bacteria do not bite and when they mate with female Aedes aegypti mosquitoes, the eggs do not hatch. The strategy is part of the battle against mosquitoes that spread Zika virus and other related diseases.

The initial release involved 20,000 mosquitoes that were freed from cardboard tube carriers at 20 locations, and additional releases will take place twice a week for about the next 12 weeks, according to the FKMCD, which said it is always looking for and evaluating new ways to prevent mosquito-borne diseases from entering the island communities.

The Florida Keys release is MosquitoMate's second field trial in the United States; the first one took place last year in Clovis, Calif., according to a report on the release yesterday in the Orlando Sentinel. The company's Web site said it expects to receive US Environmental Protection Agency (EPA) approval this spring.

A World Health Organization expert group that met last year to discuss what new methods might be useful in battling mosquitoes to curb the spread of Zika virus recommended Wolbachia as one of only two methods for careful pilot testing.
FKMCD Wolbachia field trial information
FKMCD Facebook page
MosquitoMate Web site

Feds conduct interagency large-scale biocontainment evacuation drill

The US State Department and the Department of Health and Human Services (HHS) last week conducted an unprecedented inter-agency drill to test the ability to airlift clusters of infected patients to hospitals with special biocontainment units, the Associated Press (AP) reported yesterday.

The drill involved flying 11 patients in specially designed biocontainment containers on two 747 airliners and three smaller Gulfstream jets from Sierra Leone, to Dulles International Airport in Washington, D.C., and to five medical facilities. They included Bellevue Hospital in New York City, Johns Hopkins University in Baltimore, the University of Minnesota Medical Center in Minneapolis, the Denver Health Medical Center in Denver, and the University of Nebraska Medical Center in Omaha.

At a telebriefing yesterday, State Department and HHS officials said the State Department maintains all-hazard biohazard containment transport capability through a contract with Phoenix Air Group in Cartersville, Ga., which they said performed flawlessly during dozens of evacuations during the Ebola outbreak, but it became clear that a larger transport capability was needed.

The Containerized BioContainment System tested last week, the third such exercise since last August, is the result of a $5 million public-private partnership between the State Department and the Paul G. Allen Foundation. The system is designed as a first-responder to manage clusters of patients during the first days of an outbreak, allowing international responders to focus immediately on containment. It is a 40-foot container that can be loaded onto a number of different aircraft, containing three chambers: a patient-care area, a space for donning and doffing personal protective equipment, and a space where medical workers can rest and prepare for crew rotation.

According to a briefing transcript, William Walters, MD, managing director for operational medicine with the State Department's bureau of medical services, said, "Tranquil Shift prepares us today for what we were largely unprepared for in 2014. This is not about Ebola. This is about the Middle East respiratory syndrome coronavirus, MERS-CoV, in Qatar, with outbreaks every month for the past several months; Lassa fever in Benin, Togo, and Burkina Faso from February of this year; plague in Madagascar in December of last year." He said infectious disease outbreaks happen all the time and that the US has a responsibility globally and to American citizens to continue to support ongoing efforts to prevent future catastrophes.

During the Ebola outbreak, Donald Trump criticized the Obama Administration for bringing Ebola patients to the United States, and when pressed by reporters, Walters said he couldn't speak for the Trump White House on whether it supported the exercise, but added that what officials have learned going forward is that transport can be done safely as long as exercises take place, that stakeholders are identified early, and that there's careful coordination.
Apr 18 AP story
Apr 18 State Department/HHS telebriefing transcript