Stewardship / Resistance Scan for Dec 11, 2017

News brief

Interventions to reduce overtreatment of asymptomatic bacteriuria noted

A paper today in JAMA Internal Medicine proposes an evidence-based implementation guide to help reduce inappropriate treatment of asymptomatic bacteriuria (ASB).

Despite efforts to reduce the practice, treatment of ASB—defined as isolation of bacteria in an uncontaminated urine specimen in the absence of urinary tract infection symptoms—remains prevalent across settings and frequently leads to inappropriate antibiotic prescribing. A multicenter retrospective review of three US hospitals found that 38% of in patients with ASB were treated with antibiotics the day of a positive urine culture report, and 43% were treated by the fourth day.

To come up with an implementation guide that could help clinicians reduce ASB overtreatment, a team of researchers from Johns Hopkins, Sinai Health System, and the University of Toronto first reviewed the evidence behind supporting reduced treatment of ASB. Based on that evidence, they determined that efforts to reduce inappropriate treatment of ASB in low-risk populations (excluding pregnant women and patients undergoing invasive urologic procedures) can reduce preventable harm from unnecessary antibiotic exposure.

The team then looked at safety and quality outcomes data for different interventions aimed at reducing ASB treatment. From those data, they determined that the most successful interventions used a multimodal approach that combined the following elements: education, audit and feedback, withholding routine urine culture reports, and clinical decision support tools and protocols.

"While the interventions described in this guide have proven efficacy in certain settings, we acknowledge the importance of context and encourage teams to select and adapt specific interventions that best suit the needs and resources specific to the institution," the authors write. "In reality, a bundle of interventions may be needed to address different contributors to the problem specific to the local setting."
Dec 11 JAMA Internal Med paper

New National Academies publication details AMR workshop proceedings

The National Academies of Sciences, Engineering, and Medicine (NAS) have released a new document summarizing the presentations and discussions at a 2-day workshop on antimicrobial resistance (AMR) held earlier this year.

The workshop, held Jun 20 and 21 in Washington, DC, brought together experts in infectious disease, microbiology, and human and animal health to explore the issue of AMR through the One Health lens, which views the health of humans, animals, and the environment as interconnected. The workshop was convened to examine short-term actions and research needs that are feasible and cost-effective and will have the greatest effect on reducing AMR.

Among the topics explored were the implications and effects on human health of the movement of resistance genes across different ecosystems; the expected effect of new US regulatory policies regarding the use of antibiotics in food animals; the role and effectiveness of antibiotic stewardship programs in reducing and preventing AMR, and the importance of data availability and data sharing for evaluating stewardship strategies; strategies for maintaining the effectiveness of existing drugs, for developing new drugs and diagnostics, and for implementing disease prevention steps; and the need for national and international collaboration.

The document contains the opinion of the presenters, but it does not reflect the conclusions of the Health and Medicine Division of the NAS.
Dec 8 National Academies proceedings of AMR workshop

News Scan for Dec 11, 2017

News brief

Report: Philippines rushed into Dengvaxia immunization program

A new report from Reuters concerning previously unreleased documents shows that the Philippines Department of Health (DOH) implemented a childhood vaccine campaign with Dengvaxia despite warnings from the country's Formulary Executive Council (FEC) that the vaccine did not have enough long-term safety data.

Earlier this month, Sanofi, the maker of the vaccine, urged countries using Dengvaxia to restrict its use among people who are dengue-naive at the time of inoculation. These patients, including children, have more severe dengue infections post-immunization than people who were not dengue-naive upon immunization. The Philippines halted its immunization program in response to Sanofi's recommendation.

In an effort to inoculate 1 million children against the tropical disease, the Philippines DOH bought 3 million doses of Dengvaxia from Sanofi Pasteur in early 2016. The vaccine is administered in a series of three injections per child. Reuters obtained minutes from three meetings showing the FEC urged the DOH to hold off on wide immunization campaigns and buy small batches of the vaccine because long-term safety data on Dengvaxia were missing.

The DOH said it was following World Health Organization recommendations when officials began immunizing 830,000 children against the disease, endemic in many parts of Southeast Asia.

Late last week, Reuters and other news agencies reported that the death of one school-aged girl has been attributed to severe dengue infection after immunization.

In other news, the DOH announced the creation of a task force to investigate the Dengvaxia immunization program, Outbreak News Today reported today. Included in the task force is a legal team that will look into Sanofi's accountability. Sanofi originally said Dengvaxia was safe for all people between ages 9 and 45, despite previous dengue status or exposure.
Dec 10 Reuters story
Dec 11 Outbreak News Today story

Analysts see worrying signs of North Korea bioweapons build-up

Over the past decade, North Korea has apparently overcome technical challenges in putting together a bioweapons programs and now has key equipment and labs and is gaining the expertise to use them, according to a Washington Post report yesterday that cited both on-the-record experts and anonymous sources in the intelligence community.

US analysists have known since at least 2006 that North Korea was doing secret work on a biological weapon and has long held stocks of smallpox and anthrax, but at the time, experts didn't think the country had the technical skills to produce weapons with the pathogens.

Kim Jong Un is sending scientists overseas to get advanced degrees in microbiology, and in 2015 after news surfaced that the Pentagon had accidentally shipped live anthrax samples to a South Korean military base, North Korea's leader in TV footage showed off a biotechnology institute that makes biological pesticides. However, foreign observers saw expensive machines that could grow and process microbes, include many pieces of equipment that were banned under international sanctions.

US and South Korean intelligence agencies say North Korea has experimented with microbes including anthrax, cholera, and plague, and are thought to have had the smallpox virus since at least the mid-1990s, based on antibodies in the bloodstreams of North Korean soldiers who escaped decades ago, according to the Post.

A senior US official told the Post that military planners believe Kim is keeping his bioweapons care in reserve for now, as the country's scientists build the capacity to quickly make large quantities of pathogens quickly. So far there is no evidence that North Korean scientists are genetically engineering more lethal pathogens, but experts are seeing signs that it is working to get its scientists up to speed with schooling and seeking outside expertise.
Dec 10 Washington Post story

Saudi Arabia reports new MERS case, fatality

The Saudi Arabian Ministry of Health (MOH) reported a new case of MERS-CoV in Riyadh late on Dec 8 and the death of a previously confirmed patient today.

A 90-year-old Saudi man is in critical condition after presenting with symptoms of MERS-CoV (Middle East respiratory syndrome coronavirus) infection. The patient's source of infection is listed as "primary," meaning it's unlike he contracted the virus from another person.

Today the MOH reported that a previously described patient, a 71-year-old Saudi man from Buraydah, has died. He had preexisting conditions at the time of his MERS diagnosis.

Saudi Arabia's MERS-CoV case count since 2012 has now reached 1,754, including 710 deaths. Three patients are still being treated, according to the MOH.
Dec 8 MOH report
Dec 11 MOH report

Harnessing math and modeling for early vaccine scare identification

Analyzing tweets and Google searches can help predict vaccine scares, giving public health officials a potential new tool to intervene and help prevent disease outbreaks, researchers from Canada's University of Waterloo reported today in Proceedings of the National Academy of Sciences (PNAS).

The team collected geocoded tweets that mentioned measles, mumps, and rubella (MMR) vaccine, then used artificial intelligence computer programs to classify message sentiments. Researchers also collected data on measles-related Google searches, using mathematical theory to look for early warning signals.

They looked for a tipping point, which reflected when vaccine coverage declines due to spreading fears, which could contribute to disease outbreaks with waning population immunity. Similar mathematical theories have been used to predict tipping points with other phenomena, such as changing climate patterns.

Researchers found early warning signs of a tipping point 2 years before a measles outbreak occurred in 2014 and 2015 that was linked to exposure at Disneyland. Also, the mathematical model predicted how the Disneyland outbreak helped California back away from the tipping point, as parents became more afraid of the disease than the vaccine.

Chris Bauch, PhD, study coauthor and professor of applied mathematics at the University of Waterloo, said in a press release from the school that by monitoring people's attitudes towards vaccination on social media, public health groups may be able to focus their resources on areas most likely to experience a vaccine scare and prevent it before it starts.

"Knowing someone is a smoker cannot tell us for sure whether someone will have a heart attack, but it does tell us that they have increased risk of heart attack," said Bauch. "In the same way, detecting these early warning signals in social media data and Google search data can tell us whether a population is at increased risk of a vaccine scare, potentially years ahead of when it might actually happen.
Dec 11 PNAS abstract
Dec 11 University of Waterloo press release