Stewardship / Resistance Scan for Aug 20, 2020

News brief

Study finds antibiotic time-outs not tied to lower overall antibiotic use

Implementation of a pharmacist-led antibiotic time-out (ATO) at an academic medical center was feasible and well-accepted, but did not change overall antibiotic use, researchers from the University of Nebraska Medical Center reported today in Infection Control & Hospital Epidemiology.

In the two-phased cluster-randomized study, three academic inpatient medical teams were randomly selected in the first phase (ATO-A) to implement the pharmacist-led time-out, in which initial antibiotic therapy in a patient is reassessed, and three teams maintained usual care (UC-A). In phase B, the usual-care teams implemented the ATO process (UC ATO-B), while ATO use continued in the other group (ATO-B).

The study, conducted from November 2014 through February 2015, included all patients who were treated by the teams and received antibiotics. The researchers targeted two ATO points: early (less than 3 days after antibiotics were initiated) and late (from 3 to 5 days after antibiotics were started).

In total, 290 ATOs were documented (181 early, 87 late, and 22 subsequent) among 538 admissions. The most common ATO recommendations were narrow therapy (148 of 290), no change (124 of 290), and change to oral (30 of 290).

Measured in days of therapy (DOT) per 1,000 patient-days (PD), overall antibiotic use was not different between any of the groups (P = .51), although intravenous (IV) levofloxacin use decreased in the UC group after ATO implementation (49 DOT/1,000 PD vs 20 DOT/1,000 PD; P = .022). The ratio of oral to IV DOT was lower in the UC group than in any of the ATO groups (P = .032). The researchers detected no differences in mortality, length of stay, readmission, Clostridioides difficile infection, or antibiotic adverse events.

While email surveys indicated the ATO process was well-accepted, the authors of the study say the findings mirror those of other studies that have found that ATOs have no impact on overall antibiotic use. But they also said that not that all studies of ATOs have been conducted in hospital with active antibiotic stewardship programs (ASPs).

"An ATO may be beneficial when an active ASP is absent or the program lacks [infectious disease] expertise, although ATOs have not been studied in these situations," they wrote.
Aug 20 Infect Control Hosp Epidemiol abstract

Use of common antibiotics linked to resistant bacteria colonization

A nationwide case-control study in Denmark found that the risk of colonization with multidrug-resistant bacteria (MRB) was associated with consumption of commonly used antibiotics for at least 2 years after treatment, Danish researchers reported today in the Journal of Antimicrobial Chemotherapy.

Using data from the AB-RED (Antibiotic Resistance in Emergency Departments in Denmark) study and from a national register of antibiotic consumption, researchers from the University of Southern Denmark and Odense University Hospital compared 256 patients colonized with MRB—including extended-spectrum beta-lactamase–producing Enterobacteriaceae (ESBL-E), carbapenemase-producing Enterobacteriaceae, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus—based on throat, nose, and rectum swabs and 4,763 control patients. They performed multivariate analyses to examine the association between antibiotic consumption and MRB colonization, with a subgroup analysis of ESBL-E-colonized patients.

In the 2 years prior to study inclusion, 77% of patients colonized with MRB and 68% of control patients had at least one antibiotic prescription (P = 0.002). The multivariate analysis showed a significant increase in risk of colonization with ESBL-E if penicillins (odds ratio [OR], 1.58 to 1.65) or fluoroquinolones (OR, 2.25 to 6.15) were prescribed. Analysis of all MRB-colonized patients showed similar results. An assessment of the timeline showed a significant increase in risk of colonization up to 2 years after exposure to penicillins, fluoroquinolones, and macrolides, with no association observed for other antibiotics.

"The findings of our study draw a clear link between more commonly used antibiotics such as macrolides and penicillins, especially amoxicillin, and an increased risk of MRB colonization, particularly ESBL-E colonization," the authors of the study wrote. "This indicates that more restricted antibiotic stewardship might be needed to reduce the prevalence of ESBL-E, and maybe all MRB, in the future."
Aug 20 J Antimicrob Chemother abstract

News Scan for Aug 20, 2020

News brief

COVID-19 not likely passed from moms to babies through breast milk

University of California researchers studying the breast milk of 18 women with COVID-19 found coronavirus RNA—but not live virus—in 1 of 64 samples, suggesting that babies aren't likely to be infected through that route.

The research letter, published yesterday in JAMA, described studying self-collected and mailed samples and clinical data gathered through phone interviews from Mar 27 to May 6. The mothers' babies ranged in age from newborn to 19 months, and each mother provided 1 to 12 breast milk samples.

All but one woman had COVID-19 symptoms. The one sample with coronavirus RNA tested positive only on the day of symptom onset; the ones tested 2 days before and 12 and 41 days later tested negative. The researchers were unable to culture live virus from the positive sample.

To reproduce the conditions of the Holder pasteurization method commonly used to ensure sterilization of human donor milk in banks, the investigators spiked breast milk samples from two different, uninfected donors with the coronavirus. After heating the samples to 62.5°C (144.5°F) for 30 minutes and then cooling them to 4°C (39.2°F), live virus was not found in either sample.

The authors noted that 24 case reports have described the detection of viral RNA in 10 samples from 4 women but cautioned that RNA does not equate with infectiousness; rather, it has to be able to grow and multiply to be transmissible. "These findings are reassuring given the known benefits of breastfeeding and human milk provided through milk banks," they wrote.

In the future, the researchers said they will study whether breast milk from women with COVID-19 contains antibodies that could, in theory, protect their infants from coronavirus infection. Current recommendations to prevent spread of COVID-19 during breastfeeding include handwashing and sterilization of pumping equipment after each use.
Aug 19 JAMA research letter

More teens got routine vaccines in 2019, but doctor orders dropped amid COVID

More US teens received at least one dose of two of the three vaccines recommended for their age-group in 2019 than in 2018, but vaccination orders dropped after the COVID-19 pandemic hit, according to a study by researchers from the Centers for Disease Control and Prevention (CDC) published today in Morbidity and Mortality Weekly Report (MMWR).

The CDC's Advisory Committee on Immunization Practices recommends that 11- and 12-year-old children be vaccinated against pertussis (whooping cough); meningitis (swelling of the membranes covering the brain and spinal cord) types A, C, W, and Y (MenACWY); and human papillomavirus (HPV)-related cancers. Teens 16 years and older are urged to receive a booster dose of the meningococcal vaccine, and those 16 to 23 years old can be vaccinated against meningitis B (MenB), if appropriate.

The researchers found that 71.5% of adolescents received at least one dose of HPV vaccine in 2019, up from 68.1% in 2018. Likewise, the percentage of teens up to date with the two-dose HPV series rose from 51.1% in 2018 to 54.2% in 2019. Rates of vaccination improved in both boys and girls.

The percentage of adolescents vaccinated with at least one dose of MenACWY increased from 86.6% in 2018 to 88.9% in 2019, and more teens began HPV vaccination by the recommended age of 13 years. While the percentage of 17-year-olds receiving the booster dose of MenACWY didn't change significantly over the year, the percentage receiving one or more doses of MenB rose from 17.2% in 2018 to 21.8% in 2019.

Fewer teens living at or above the poverty level outside of a city received at least one dose of HPV and MenACWY vaccines or were up to date on their HPV vaccine series than those living in a city.

When the investigators reviewed Vaccines for Children provider ordering data, they found that vaccine orders for HPV; tetanus, diphtheria, and pertussis (Tdap); and MenACWY dropped in mid-March 2020, after the pandemic arrived. "The COVID-19 pandemic has the potential to offset historically high vaccination coverage with Tdap and MenACWY and to reverse gains made in HPV vaccination coverage," the authors wrote.
Aug 20 MMWR study

Ebola infects 7 more in DRC outbreak; total climbs to 96 cases, 42 deaths

Seven more Ebola cases have been confirmed in the Democratic Republic of the Congo (DRC) outbreak in Equateur province, raising the total to 96, the World Health Organization (WHO) African regional office said on Twitter today.

Also, 5 more deaths were reported, raising the fatality count to 42.

The outbreak has been growing at a slow but steady pace of about one or two cases a day, and it's unclear if the spurt of cases today reflects increased activity or the result of a recent 3-day strike by health workers in the region. The WHO, however, raised concerns about several aspects of the outbreak, including its wide geographic spread and that confirmed case-patients have remained in the community.

The outbreak has been under way since early June and is occurring in the same area where an event in 2018 resulted in 54 cases, 33 of them fatal.
Aug 20 WHO African regional office tweet

CDC warns of 9-state Salmonella outbreak linked to peaches

Late yesterday the CDC announced a new outbreak of Salmonella Enteritidis infections linked to bagged peaches sold at Aldi stores in nine states. Aldi has recalled the fruit from Wawona Packing, LLC.

So far 68 people in nine states have been sickened, and 14 have been hospitalized. There have been no deaths. Illness -onset dates range from Jun 29 to Aug 3, and patients range in age from 1 to 92 years, with a median age of 39.

The bagged peaches were bought at Aldi stores in Connecticut, Illinois, Iowa, Kentucky, Massachusetts, Michigan, Minnesota, New Hampshire, New York, North Dakota, Ohio, Rhode Island, South Dakota, Vermont, West Virginia, and Wisconsin between Jun 1 and Aug 19. Minnesota has the most cases, with 23, followed by Michigan (17) and Iowa and New York (8 each).

"Many ill people report purchasing bagged peaches sold at certain ALDI stores in several states. This investigation is ongoing to identify other retailers that might have sold contaminated peaches," the CDC said.
Aug 19 CDC notice

Global flu still low; CDC updates flu vaccine recommendations

In its latest global flu update that covers the last half of July, the WHO said flu levels are lower than expected for this time of year and noted that COVID-19 activity and response measures may be affecting the usual flu patterns.

Though the Southern Hemisphere's flu season generally runs from May through October, the season hasn't started. Sporadic detections were reported in a few parts of the world, including the Caribbean, Central America, and tropical parts of South America and Africa.

Of about 205,000 flu specimens tested in the last half of July, only 40 were positive for flu, and half were influenza A and half were influenza B. Of the subtyped influenza A viruses, 75% were H3N2.
Aug 17 WHO global flu update

In a related development, the CDC today published in MMWR the latest flu vaccination recommendations for the upcoming season from its Advisory Committee on Immunization Practices (ACIP), which covers updates based on discussions at ACIP's last three meetings.

The CDC has urged all people who are recommended to receive the flu vaccine to be immunized to help reduce symptoms that might be confused with COVID-19 and to reduce the overall burden on the healthcare system over the fall and winter.

The updated recommendations cover two new flu vaccines, both targeted to seniors. One is FluZone high-dose quadrivalent (four-strain), and the other is Fluad Quadrivalent. Other updates include a discussion of using live attenuated influenza vaccine (LAIV) when patients are taking antiviral medications, which might interfere with the actions and effectiveness of the vaccine.

The recommendations note that the newer antivirals peramivir and baloxavir have longer half-lives than other antivirals and could interfere with LAIV replication if given more than 48 hours before vaccination. People who receive LAIV—the nasal spray vaccine—during certain periods may need to be revaccinated with a different type of flu vaccine.

Also, the recommendations for people with egg allergy say that additional measures for people with a history of severe reactions to egg are needed only if a vaccine other than Flucelvax or Flublok are used.
Aug 21 MMWR report