Stewardship / Resistance Scan for Jan 25, 2018

News brief

Officials in Pakistan announce world's first drug-resistant typhoid outbreak

In what is being called the world's first outbreak of drug-resistant typhoid, more than 100 children are sick and dozens have died in Hyderabad, Pakistan, the country's The News International reported yesterday.

"Typhoid cases resistant to third-generation antibiotic Ceftriaxone have been reported from different areas of Hyderabad, but so far we're unable to find its source," Health Services Sindh Director General Dr Muhammad Akhlaq Khan said.

"Children in the age group of 2-10 years are being affected by this type of disease, but so far we don't have any exact data on the deaths caused by this lethal disease." Scientists at Aga Khan University (AKU) in Karachi, Pakistan, blamed the outbreak on contaminated water, but the Sindh Health Department has ruled that cause out, the story said.

No official case count has been cited, but the city's health department and local gastroenterologists have said more than 100 drug-resistant cases have been reported since November 2016, compared with only 6 cases from 2009 to 2014. The health department, in collaboration with AKU, has launched a mass vaccination campaign aimed at immunizing 250,000 children in the district.

Typhoid is mainly cause by Salmonella enterica serotype Typhi bacteria. About 1.7 million people live in Hyderabad.
Jan 24 News International story

Bowel disease, antibiotics tied to fecal transplant for recurrent C difficile

A single-center study in Rhode Island found several risk factors, including inflammatory bowel disease and the use of metronidazole, for fecal microbiota transplantation (FMT) to address recurrent Clostridium difficile infection (CDI), according to a study yesterday in Infection Control and Hospital Epidemiology.

The retrospective study compared 200 adults who underwent FMT for recurrent CDI to 75 patients who did not. The strongest risk factors for FMT for recurrent CDI were concomitant inflammatory bowel disease (P = .002), use of immunosuppressive therapy (P = .04), and use of metronidazole within 2 months before the first CDI (P = .02). The use of vancomycin for the first CDI was also a potential risk factor.

The authors concluded, "This study provides important insights into the factors predictive for FMT in patients with recurrent CDI and highlights the potential racial and medical characteristics that affect the access of the patients to FMT."
Jan 24 Infect Control Hosp Epidemiol study

News Scan for Jan 25, 2018

News brief

CDC declares investigation into leafy green E coli outbreak over

The US Centers for Disease Control and Prevention (CDC) today said an Escherichia coli outbreak tied to leafy greens appears to be over after 25 cases in 15 states and 1 death.

The CDC in its update reported 1 new case—in New York state—since its last update on Jan 10. California has reported the most cases, 4, and Maryland has confirmed 3. The other 13 states reported either 1 or 2 cases.

Of the outbreak patients, 9 were hospitalized, including 1 from California who died. Two people developed hemolytic uremic syndrome, a potentially fatal kidney complication. Illness-onset dates range from Nov 5 to Dec 12, 2017. Fourteen of 15 patients who were interviewed reported eating various types of leafy greens before they fell ill.

"The likely source of the outbreak in the United States appears to be leafy greens, but the investigation did not identify a specific type of leafy greens as the source of the outbreak," the CDC said. "Leafy greens typically have a short shelf life, and since the last illness started a month ago, it is likely that contaminated leafy greens linked to this outbreak are no longer available.

"No common supplier, distributor, or retailer of leafy greens had been identified as a possible source of the outbreak and the investigation continued," the CDC added.

On Jan 10, Canadian officials declared a similar 42-case E coli outbreak in that country to be over. Authorities there had specifically identified romaine lettuce as the culprit. The CDC said today that three isolates from US patients were closely related genetically to an E coli isolate from a patient in Canada's outbreak.
Jan 25 CDC statement

CDC details yellow fever vaccination errors in the United States

The CDC today urged vaccine providers to closely follow instructions on yellow fever vaccine packages, following a recent report of four people at a military clinic who were inadvertently immunized with a five-dose vial.

The people were vaccinated at a single clinic in March 2017, according to a brief report today in Morbidity and Mortality Weekly Report (MMWR). None of the patients experienced adverse events, and all were seen in the emergency department. Health workers reported the errors to the CDC's Vaccine Adverse Event Reporting System (VAERS).

Sanofi's yellow fever vaccine is the only one of its kind licensed in the United States, and about 500,000 doses are given each year, mostly to military members and people traveling to yellow fever risk areas. The vaccine is available in packages containing five single-dose vials with five 0.6-milliliter (mL) vials of diluent (a dilution substance) provided separately, or a five-dose vial with a 3 mL vial of diluent provided separately. The package says the vaccine should be used within 60 minutes of reconstituting the single-dose or five-dose vial.

A review of the VAERS database for similar errors found 11 since 2007, including a cluster of 7 at another military clinic in 2007. Of 15 people affected, only 1 had symptoms, which included intermittent upper abdominal and arm pain the next day that resolved with intravenous treatment.

The CDC said reports of yellow fever dosing errors are rare. The report noted sporadic results from Brazil in which patients received even larger doses in error, most of which didn't involve adverse events but were costly regarding follow-up and vaccine waste. The authors added that other measures to prevent errors could include more distinctive packaging and more training for clinics that stock both sizes of vials.
Jan 26 MMWR report