Stewardship / Resistance Scan for Aug 24, 2020

News brief

CMS sepsis bundle linked to increased use of broad-spectrum antibiotics

Implementation of a core measure sepsis bundle by the Centers for Medicare and Medicaid Services (CMS) was associated with an immediate and long-term increase in the use of broad-spectrum antibiotics for hospital-onset multidrug-resistant (MDR) organisms, researchers reported late last week in Clinical Infectious Diseases.

In the study, a team led by researchers from Virginia Commonwealth University evaluated monthly antibiotic data for four categories of antibiotics at 111 US hospitals before and after the 2015 implementation of the Sepsis Bundle Core Performance Measure for hospitals participating in Inpatient Quality Reporting (SEP-1). One element of the bundle is initiation of broad-spectrum antibiotics within 3 hours of sepsis diagnosis. The four antibiotic categories evaluated included antibiotics for surgical prophylaxis, broad-spectrum agents for community-acquired infections, broad-spectrum antibiotics for hospital-onset/MDR organisms, and anti–methicillin resistant Staphylococcus aureus agents.

Using interrupted time series and negative binomial regression analyses, the researchers observed an immediate increase in the level of broad-spectrum agents for hospital-onset/MDR organisms (+ 2.3%, P = .0375) and a smaller long-term increase in trend (+ 0.4%, P = .0273) after the SEP-1 bundle was implemented. Overall antibiotic use also increased immediately following SEP-1 implementation (+ 1.4%, P = .0293). There was also an unexpected decrease of 7.3% in Clostridioides difficile infection (CDI) rates immediately following implementation.

When the analyses was limited to sepsis patients, there was a significant increase in the use of all antibiotic categories at the time of SEP-1 implementation.

The authors of the study say the findings are noteworthy because correctly diagnosing sepsis is challenging, and there are concerns that the aggressive timelines for antibiotic therapy in SEP-1 may result in overdiagnosis and inappropriate use of broad-spectrum agents, which could promote development of antibiotic resistance.

"These data suggest that antimicrobial stewardship programs should apply postprescription audit and feedback strategies among sepsis patients to ensure that antibiotic de-escalation is occurring appropriately," the authors wrote. "Further investigations regarding higher use of broad-spectrum antibiotics and impact on CDI and antibiotic resistance development are warranted."
Aug 22 Clin Infect Dis abstract

Antibiotic resistance likely not a major driver of gonorrhea spread in NYC

In a study yesterday in the same journal, an analysis of gonococcal isolates collected in New York City in 2012 and 2013 showed that all large transmission clusters were susceptible to current gonorrhea therapies.

In their analysis of genome sequences, antibiotic susceptibility, and patient data from 897 gonococcal isolates cultured by the New York City Public Health Laboratory from January 2012 through June 2014—a convenience sample that represents 1.5% of total gonorrhea infections in New York City during the period—the researchers found that the New York City gonococcal phylogeny reflected global diversity, with isolates from 22 of the 23 global Neisseria gonorrhea lineages.

They also observed that the isolates clustered on the phylogeny by sexual behavior (P < 0.001), with one lineage significantly associated with isolates from men who have sex with men (MSM) and another associated with isolates from heterosexuals. They also clustered based on race and ethnicity (P < 0.001).

Analysis of antibiotic susceptibility showed that 24.3% of isolates were resistant to ciprofloxacin, 0.9% had reduced susceptibility to azithromycin, and 0.3% had reduced susceptibility to ceftriaxione. Minimum inhibitory concentrations were higher across antibiotics in isolates from MSM compared with heterosexuals (P < 0.001) and white heterosexuals compared with black heterosexuals (P < 0.01). The largest transmission clusters were all susceptible to azithromycin, ceftriaxone, and ciprofloxacin and included isolates from across patient demographic groups.

The authors of the study say the findings indicate that antibiotic resistance was not a major driver of gonorrhea transmission in New York City during the study period, but note that, nationally, reduced susceptibility to azithromycin has increased from 0.6% in 2013 to 4.6% in 2018—after the study period.

"While resistance remains a major public health concern, strategies to reduce overall gonorrhea transmission are also needed as pre-existing transmission networks may present opportunities for rapid spread of resistant lineages," they wrote. "Greater understanding of the transmission dynamics of both susceptible and resistant infections can aid the design of effective intervention strategies for controlling gonorrhea, and further investment in sexual health services and interventions are critical."
Aug 23 Clin Infect Dis abstract

News Scan for Aug 24, 2020

News brief

40 million adults who work or live with children at risk for severe COVID-19

A research letter published late last week in the Annals of Internal Medicine has found that about 40 million US adults who work or live with school-aged children have definite or possible risk factors for severe COVID-19, carrying implications for fall school reopenings.

Researchers from Harvard Medical School and City University of New York at Hunter College who analyzed representative data from the 2018 National Health Interview Survey showed that 2.9 million of 5.8 million K-12 teachers (50.6%) had definite or possible risk factors for serious coronavirus illness, including obesity (32.1%), heart conditions (8.0%), and cancer (0.7%). Of nonteaching staff, 55.8% had definite or possible risk factors.

Of 69.7 million adults living with children 5 to 17 years old, 37.7 million (54.0%) had definite or possible risk factors, including age older than 64 (6.6%), heart disease (12.5%), type 2 diabetes (12.7%), and cancer (at least 1.6%). The prevalence of risk factors was similar for those living with children aged 5 to 10 years and with those aged 11 to 17 years.

Adult household members of children in low-income families were at higher risk for severe COVID-19 than those in high-income households. While adults living with black children were at elevated risk, those living with Asian children or those of other ethnicities were at lowest risk.

The authors noted that the study did not include the 4.4 million nonteachers working at schools or 1.6 million daycare workers, so the number of at-risk adults would be higher than 40 million.

They said that teachers' risks appear to be similar to those of other working adults, and while in-person school is better for children's intellectual and social development, mental health, food security, and safety, and children tend to have only asymptomatic or mild COVID-19, they do spread the virus.

"School leaders must weigh these undoubted benefits against the risk to the adults who care for children, particularly older children who commonly transmit the infection (younger children are about one third as likely to cause household spread)," the researchers wrote. "Both the risks and benefits of schools reopening are likely larger for poor and Black families."
Aug 21 Ann Intern Med research letter

Study suggests limited diagnostic value for repeat COVID-19 testing

Of 10,165 patients tested for COVID-19 at a large Los Angeles health system, 6.2% were positive, and only 1.9% tested positive after an initial negative result—calling into question the diagnostic value of repeat testing amid limited testing resources, according to a retrospective study published late last week in the International Journal of Infectious Diseases.

Researchers analyzed all test results for SARS-CoV-2, the virus that causes COVID-19, at the UCLA Health System from Mar 9 to Apr 29 to understand the diagnostic yield of repeat testing in view of scarce test supplies and personal protective equipment.

Of 904 patients with more than one test result, 808 (89.4%) were negative on the first test, while 96 (10.6%) were positive. Of the 808 patients with an initial negative result, 15 (1.9%) tested positive on the second test. The 904 patients accounted for 2,108 tests, with a positivity rate of 9.9%.

Tests were repeated once in 646 of the 808 patients (80.0%) with an initial negative result, twice in 110 (13.6%), three times in 39 (4.8%), and four times in 13 (1.6%). Of 11 patients with an initial negative test and with no known positive tests but clinical reasons to question the negative finding, 10 were positive on the second test, 6 of whom were healthcare workers.

Of the 96 patients with an initial positive result, 56 (58.3%) had one other test, while 24 (25.0%) had two, 8 (8.3%) had three, and 8 (8.3%) had four or more. Of patients with an initial positive result, 48 of 96 (50%) had a subsequent negative result. Median time between positive and negative results was 16 days.

"We found a low diagnostic yield of repeat testing for SARS-CoV-2 in our health system," the authors wrote. "Repeat testing might prove useful in certain clinical scenarios, such as in healthcare workers, when symptoms develop after a negative test, and in hospitalized patients with a high clinical suspicion for COVID-19."
Aug 21 Int J Infect Dis study

Ebola infects 2 more in DRC; cases rise to 102, 44 fatal

Tests confirmed Ebola infections in two more people in the Democratic Republic of the Congo (DRC) Equateur province outbreak, raising the total to 102, the World Health Organization (WHO) African regional office said today in a Twitter update.

Also, 1 more death was reported, lifting the fatality count to 44.

The outbreak, marking the DRC's 11th involving Ebola, began in early June, and has been challenging because of a steady rise in cases over a large geographic area, some of them very remote. Outbreak responders have also been grappling with the extra demands of the COVID-19 pandemic and sparse funding. A similar outbreak in the same province in 2018 resulted in 54 illnesses, 33 of them fatal.
Aug 24 WHO African regional office tweet

More peaches recalled in multistate Salmonella outbreak

Late last week the Centers for Disease Control and Prevention (CDC) said a nine-state outbreak of Salmonella Enteritidis infections linked to bagged peaches from Wawona Packing, LLC sold at Aldi stores now likely involves fruit distributed to Target, Kroger, and Wegmans stores, and includes both loose and bagged fruit.

So far at least 68 people 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.

Of 31 people interviewed about their illness, 87% said they ate peaches before symptom onset.

"Of the 12 people reporting pre-bagged peaches, 11 (92%) reported purchasing pre-bagged peaches from ALDI stores and 1 person (8%) reported purchasing from Target," the CDC said.

In related news, the Canadian Food Inspection Agency (CFIA) over the weekend issued a consumer advisory to avoid all fresh imported peaches recalled by Prima Wawona of Fresno, California. The advisory involves both loose and bagged white and yellow peaches sold by a number of national grocery chains. The CFIA did not report any cases in Canada.
Aug 21 CDC update
Aug 22 CFIA notice