Stewardship / Resistance Scan for Jul 13, 2017

News brief

Study finds high resistance to first-line MDR-TB drug in Georgia

More than half of the multidrug-resistant tuberculosis (MDR-TB) isolates tested in the Republic of Georgia were resistant to one of the first-line treatments for the disease, researchers reported yesterday in BMC Infectious Diseases.

In the study, researchers tested a collection of TB isolates to assess their resistance to the fluoroquinolone antibiotic pyrazinamide (PZA), one of the drugs recommended for first-line treatment of TB and MDR-TB. The isolates were collected as part of a larger study on TB in Georgia, which is recognized as one of the high-burden MDR-TB countries. According to the study, 16.6% of all laboratory-confirmed pulmonary TB patients in Georgia in 2014 were diagnosed with MDR-TB.

Of the 57 isolates tested for PZA susceptibility, 33 (57.9%) were resistant to PZA and 24 (42.1%) were susceptible. All 33 PZA-resistant isolates were MDR-TB strains, and 4 of the 57 isolates were identified as extensively drug-resistant (XDR)-TB. Mutations in the pncA gene, which are largely responsible for conferring resistance to PZA, were found in all 33 PZA-resistant isolates.

Molecular typing identified two major MDR-TB clusters (94-32 and 100-32) in which 67% and 93% of isolates, respectively, were PZA-resistant. Researchers also identified a member of the potentially highly transmissible clade A strain, along with a strain that was distantly related to the clade A strain, suggesting that different branches of the lineage have been introduced to the region.

"Our data contribute to the rising pool of evidence showing the high incidence of PZA resistance among MDR-TB isolates," the authors write. "Health authorities and TB control programs should consider prospective genotyping and PZA testing to assure current effective MDR-TB treatment and to inform the design of new MDR-TB treatment trials."
Jul 12 BMC Infect Dis study

Barriers, solutions for antibiotic stewardship in emergency departments

A study yesterday in the American Journal of Infection Control suggests that antibiotic stewardship in emergency departments (EDs) is hampered by a combination of technological and social factors, but that these barriers could be minimized by using electronic health record–based clinical decision support (EHR CDS) guided by a set of principles and practices.

In the study, researchers conducted interviews and focus groups with hospital and ED leadership, attending ED physicians, nurse practitioners, physician assistants, and residents at Children's Hospital Colorado Health System. The purpose was to elicit a range of information on factors that influence antibiotic prescribing in the ED, provider experience with EHR CDS, and the potential barriers to implementing antibiotic stewardship in the ED using EHR CDS. Data were reviewed and coded using constant comparative analysis and framework analysis until a final set of themes emerged.

The answers from participants revealed that two dominant beliefs framed their perception of antibiotic stewardship in the ED. The first was that efficiency was a core principal guiding antibiotic prescribing practices, as the volume and pace of the ED necessitated that providers manage their time efficiently. The second was autonomy in antibiotic prescribing is often constrained by external influences, including parents or a family's primary care provider (PCP).

These beliefs were reflected in the barriers to stewardship identified by the participants: the rapid pace of the ED, the limited time to interact with the patient and the family, the need to manage parental expectations about antibiotic use, and the need to support the prescribing decisions of the family's PCP.

The participants identified three principles and practices to guide and support antibiotic stewardship in the ED using EHR CDS. The principles included integrating EHR CDS into the existing workflow to support efficiency, maintaining a balance between provider autonomy and standardization, and using antibiotic prescribing data to communicate the scope of the issue to providers. Practices included designing a simple yet flexible EHR CDS user interface, providing performance data to providers regularly, and developing brief communications scripts about antibiotics that providers can use with patients.
Jun 24 Am J Infect Control abstract

News Scan for Jul 13, 2017

News brief

CDC: total in backyard poultry Salmonella outbreaks rises by 418

The Centers for Disease Control and Prevention (CDC) released new numbers on current outbreaks of Salmonella illnesslinked to backyard poultry. Since the last update on Jun 1, there have been 418 more cases, raising the total number of cases this year to 790, reported in 10 multistate outbreaks. The outbreaks involve 10 different Salmonella subtypes.

A total of 48 states have reported cases of Salmonella tied to backyard poultry, with 174 hospitalizations; 103 of those hospitalizations have occurred within the last month. The latest illness onset was Jun 20. About one-third (31%) of the patients are under the age of 5. So far, there have been no deaths.

Most people who become ill from Salmonella recover within 1 week, but sometimes diarrhea and vomiting is so severe it requires hospitalization. The CDC said they expect the outbreaks to continue through the summer.

Salmonella infections have risen as the trend of urban or backyard gardening grows. The CDC cautions the public to remember that healthy poultry can carry Salmonella, and live birds should not be allowed in the home, especially if young children are present. The CDC also emphasizes proper hand washing after handling birds.
Jul 13 CDC update
Jun 1 CIDRAP News story "Salmonella tied to live poultry sickens 372 in 47 states"

More than 2,700 cases of chikungunya reported in Bangladesh

Dhaka, the capital of Bangladesh is reporting the country's largest ever chikungunya outbreak, with more than 2,700 cases reported since May, Indo-Asian News Service (IANS) reported yesterday.

The disease is spread by the Aedes aegypti mosquito, the same vector that spreads Zika virus and dengue. Officials in Dhaka are warning citizens that the mosquitos will be active for another few months. Monsoon season, and its accompanying heavy rains help create standing pools of water where the Aedes like to breed. The disease can spread quickly in densely populated urban settings, such as Dhaka.

Though chikungunya was first detected in Bangladesh in 2008, this is the first major outbreak of the disease. Chikungunya can cause fever, muscle ache, chills, rashes and nausea. It is sometimes misdiagnosed as dengue.
Jul 12 IANS story

Minnesota measles outbreak began with unvaccinated toddlers at daycare

A new report on the Minnesota measles outbreak in April and May of this year in Morbidity and Mortality Weekly Report said the disease began to spread among unvaccinated toddlers who attended the same childcare facilities. The children were part of Minneapolis' Somali-American community, and belonged to a cohort of children who were unvaccinated due to parental concerns over autism.

The outbreak began on Apr 8, and by May 31, there were 65 confirmed cases reported to the Minnesota Department of Health (MDH). Of the 65 cases, 62 were in unvaccinated patients. Fifty-five of the cases, or 85%, were in Somali-American children. Among the 65 confirmed cases, the median patient age was 21 months. An estimated 8,250 people were exposed to the disease at 5 schools, 12 child care centers, and 3 health care facilities. No deaths were reported, but 30 patients were hospitalized due to measles complications.

The authors explain that before 2008, the vaccination coverage rate for Somali-Americans was well over 90%. But after the community became concerned that the measles, mumps, and rubella (MMR) vaccine was linked to autism, vaccination rates dropped precipitously.

To help staunch the outbreak, the MDH recommended an accelerated vaccination schedule for all children older than 1 year who lived in a county reporting measles. Health officials also began outbreak programs to reach the Somali community and accurately describe the risk of the MMR vaccine and autism. To date, no studies have showed a link between autism and childhood vaccines.
Jul 13 MMWR study

Taiwan and Belgium report more avian flu outbreaks

In the latest highly pathogenic avian influenza outbreak developments, Taiwan and Belgium reported more H5N8 detections, while Taiwan also reported H5N2 at four more locations, according to separate notifications from the World Organization for Animal Health (OIE).

Taiwan's H5N8 outbreak began on Jun 29 at a duck farm in Pingtung county on the southwest side of the island. The report said samples from the farm were sent for testing, which turned up both H5N8 and H5N2. Authorities have placed movement restrictions around the farm, ordered enhanced surveillance, and culled 2,732 birds there.

Meanwhile, H5N2 was found at three more farms and a slaughterhouse in Taiwan. The outbreaks began between Jun 28 and Jul 6, killing 4,050 of 29,658 susceptible birds. Locations included Pingtung and Yunlin counties and the cities of Taipei and Taichung. Authorities culled the remaining birds to curb the spread of the virus.

In Belgium, animal health officials today reported two more H5N8 outbreaks, one in Hainaut province that began on Jun 29 and one in Liege province that began Jul 7. The specify what types of birds or what kinds of facilities or settings were involved. Taken together, the virus killed 17 of 97 susceptible birds, and authorities destroyed the remaining ones as part of the response.
Jul 13 OIE report on H5N8 in Taiwan
Jul 13 OIE report on H5N2 in Taiwan
Jul 13 OIE report on H5N8 in Belgium