Stewardship / Resistance Scan for Apr 23, 2018

News brief

Global hospital survey highlights antibiotic Rx, high guideline compliance

The first data published by the Global Point Prevalence Survey reveal that penicillins with beta-lactamase inhibitors, third-generation cephalosporins, and fluoroquinolones were the most frequently prescribed antibiotics, and guideline compliance was 77.4%. The data, from 2015, were published Apr 19 in The Lancet Global Health.

The researchers used a standardized web-based surveillance method to gather data from 303 hospitals treating adults in 53 countries, including 8 lower-middle-income and 17 upper-middle-income nations. Of the 86,776 patients, 29,891 (34.4%) received at least one antimicrobial. Of the 41,213 prescriptions for antimicrobials, 36,792 (89.3%) were for systemic use. In addition to the data on the three most popular antibiotics, the authors reported that carbapenems were most frequently prescribed in Latin America and west and central Asia.

Of patients who received at least one antimicrobial, 5,926 (19.8%) received a targeted antibacterial for systemic use, and 1,769 (5.9%) received a treatment for multidrug-resistant organisms. The reason for treatment was recorded for 31,694 antimicrobial prescriptions (76.9%), and a stop or review date was specified in 15,778 (38.3%). Local antibiotic guidelines were missing for 7,050 (19.2%) of the 36,792 systemic antibiotic prescriptions, and guideline compliance was 77.4%.

The authors conclude, "The Global Point Prevalence Survey complements WHO's [World Health Organization's] Global Antimicrobial Surveillance System (which provides a standardised approach for collection, analysis, and sharing of data for antimicrobial resistance) by providing a validated method for measuring the quality of antimicrobial prescribing and the effect of interventions to improve prescribing."

They add, "These data will help to improve the quality of antibiotic prescribing through education and practice changes, particularly in low-income and middle-income countries that have no tools to monitor antibiotic prescribing in hospitals."

The study was funded by France-based biotechnology company bioMerieux.
Apr 19 Lancet Glob Health study


Study: Nitrofurantoin beats fosfomycin for uncomplicated UTI

A 5-day course of nitrofurantoin resolved a higher rate of uncomplicated urinary tract infections (UTIs) than one dose of fosfomycin, according to a new study published in the Journal of the American Medical Association (JAMA). Both antibiotics are first-line therapies for UTIs.

In the multicenter international study, 377 women with a confirmed UTI were randomly dosed with either a 5-day course of nitrofurantoin (100 mg three times a day) or one, 3-gram dose of fosfomycin. The primary outcome was clinical resolution at day 28. Seventy percent of patients who received nitrofurantoin were clinically cleared of their UTIs by day 28, compared with 58% of patients who received fosfomycin.

Nitrofurantoin was particularly effective in treating infections caused by Escherichia coli, with 78% of patients being cured by day 28, compared with 50% in the fosfomycin group.

An accompanying editorial in JAMA said the study uses a rigorous study design to reaffirm nitrofurantoin's place as the preferred first-line choice in treating UTIs, which accounts for approximately 10 million ambulatory visits and an estimated $2 billion in total costs each year in the United States.
Apr 22 JAMA
Apr 22 JAMA editorial


French case study shows evolution of colistin-resistant bacteria

French researchers tracked the evolution of a Klebsiella pneumoniae carbapenemase (KPC) strain of bacteria for more than 4.5 years in a patient who ultimately died from sepsis. The case study, published in Clinical Infectious Diseases, shows the bacteria is capable of several genomic and phenotypic diversifications and mutations in a relatively short period, even from drug resistance to susceptibility.

The patient contracted the bacterium via a contaminated endoscope at a French tertiary care hospital in 2009. The patient was seeking treatment from chronic infection in the liver's bile ducts.

Researchers collected 17 isolates until the patient died in 2014. All 17 isolates were subjected to whole-genome sequencing. During the study period, a total of 98 genetic events occurred, and the average evolutionary rate of the KPC strain was 7.5 single nucleotide polymorphisms per year per genome.

Most interestingly, the researchers reported, "The contaminating strain was colistin resistant but after two years of carriage, all isolates became susceptible to colistin."
Apr 21 Clin Infect Dis study  


Study finds regional antibiograms may benefit community hospitals

A study of 20 community hospitals in North Carolina and Virginia determined that a regional antibiogram can provide useful information to these hospitals even for low-prevalence pathogens, according to a study today in Infection Control and Hospital Epidemiology.

Antibiograms are profiles of antimicrobial susceptibility testing results of a specific pathogen to a battery of antimicrobial drugs. To determine the feasibility and value of developing a regional antibiogram for community hospitals, Duke University scientists analyzed data on 69,778 bacterial isolates across 13 gram-negative pathogen-antibiotic combinations. Combinations ranged from 174 to 27,428 results, for a median of 1,100.

The team found that, across all pathogen-antibiotic combinations, 69% of local susceptibility rates fell within 1 standard deviation (SD) of the regional mean, and 97% fell within 2 SDs. But no individual hospital had more than 1 pathogen-antibiotic combination with a local susceptibility rate of more than 2 SDs of the regional mean, and all local susceptibility rates were within 2 SDs of the regional mean for low-prevalence pathogens.

The authors conclude, "Small community hospitals frequently cannot develop an accurate antibiogram due to a paucity of local data. A regional antibiogram is likely to provide clinically useful information to community hospitals for low-prevalence pathogens."
Apr 23 Infect Control Hosp Epidemiol abstract

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News Scan for Apr 23, 2018

News brief

HHS buys more anthrax antitoxin for Strategic National Stockpile

The office of the Assistant Secretary for Preparedness and Response (ASPR) at the Department of Health and Human Services (HHS) today announced that it will purchase $25.2 million worth of anthrax antitoxin from Elusys Therapeutics for the Strategic National Stockpile (SNS).

Robert Kadlec, MD, who leads ASPR, said that protecting Americans from current threats such as anthrax remains a high priority for the department. "This procurement under Project BioShield ensures we continue to have treatment options for people exposed to anthrax and increases the number of courses available in an emergency."

The funds, from the Biomedical Advanced Research and Development Authority (BARDA), part of ASPR, cover continued manufacturing and purchase of the company's obiltoxaximab (Anthim). The drug can be used alongside antibiotics to neutralize toxins produced by Bacillus anthracis, the bacterium that causes anthrax. Eulasys developed the drug though a partnership with BARDA, which got early research funding from the National Institute of Allergy and Infectious Diseases.

In March 2016 the Food and Drug Administration approved Anthim for use in patients with inhalational anthrax, and the first delivery of the drug was made to the SNS the same year.
Apr 23 HHS press release


Hungarian lab worker isolated after exposure to Ebola

A Hungarian lab worker is isolated and under observation at a Budapest hospital a week after accidental exposure to Ebola virus, Reuters reported on Apr 20, citing the country's health officials.

The World Health Organization (WHO) told the news service that the patient was immediately isolated, based on standard procedures and hasn't shown any symptoms. The agency added that it sent an experimental vaccine and other treatments, which the patient has received.

The risk of spread from worker's exposure is negligible, the WHO said. Hungary's National Institute of Environmental Health said there was no threat to other workers or the public.

The vaccine is likely VSV-EBOV, which was shown to be highly effective in ring vaccine trials during Guinea's outbreak. The vaccine hasn't been licensed but is available for experimental and investigational use by the WHO and Doctors Without Borders.
Apr 20 Reuters story


ECDC reports teen, young adult vaccination gaps, threats to young kids

An analysis of measles activity in European countries in 2017 by the European Centre for Disease Prevention and Control (ECDC) found that up to 80% of teens and young adults who had the disease that year were unvaccinated. In a press release today, the ECDC went on to warn that there can be pockets of unvaccinated people, even in countries that have high overall coverage.

Andrea Ammon, MD, ECDC director, said in the press release, "It is essential that teenagers and young adults check their vaccination status, as we are seeing a recurring pattern in measles outbreaks where they are being affected." She added that countries may need to consider catch-up campaigns to close the vaccination gaps in those two groups.

For 2017, European nations reported 14,600 measles cases, more than triple the number reported in 2016. The hardest-hit countries were Romania, Italy, Greece, and Germany. Thirty-seven deaths from the disease were reported in eight countries, though most were in Romania.

In its most recent monthly monitoring report for measles and rubella, the ECDC said measles infections are on the rise in a number of countries, especially Romania, Greece, France, and Italy, which together have reported 13 deaths so far this year. The ECDC said it was especially concerned about cases in France, which tripled over the last month, and Italy, where infections more than doubled.

In a related development, a study by ECDC researchers of measles cases from 2013 through 2017 presented at the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) in Barcelona this weekend found that, of 37,365 cases, 81% involved unvaccinated people. The greatest number of deaths were in the youngest patients, and 1-year-old children were six times more likely to die from the disease compared with those ages 2 and older. Babies younger than 1 year were seven time more likely to die.
Apr 23 ECDC press release
Apr 13 ECDC measles and rubella monitoring report for April
Apr 21 ECCMID press release

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