Stewardship / Resistance Scan for Jul 14, 2020

News brief

Survey highlights antifungal stewardship in pediatric hospitals

The results of a survey sent to pediatric antimicrobial stewardship program (ASP) physicians and pharmacists indicate that most pediatric ASPs conduct antifungal stewardship but many don't feel confident about making antifungal recommendations, US researchers reported today in Infection Control & Hospital Epidemiology.

The electronic survey, which included 17 close-ended questions about institutional antifungal stewardship practices, was sent to 74 hospitals participating in the Sharing Antimicrobial Reports for Pediatric Stewardship collaborative, 68 of which responded.

Overall, 63 of the 68 hospitals (93%) responded that they conduct one or more antifungal stewardship activities, with 43 (63%) performing prospective audit and feedback and 52 (76%) requiring preauthorization for one or more antifungal agents. The most commonly restricted antifungals were isavuconazole (42 of 52 hospitals [80%]) and posaconazole (39 of 52 hospitals [75%]).

Although 33 ASPs (48%) agreed or strongly agreed that antifungals are used inappropriately at their institution, only 25 (37%) felt very confident making recommendations about antifungals. Respondents reported that having clinical guidelines specific to antifungal use in children (31 of 68 [46%]) and better diagnostics (25 of 68 [37%]) would improve their level of confidence in making antifungal recommendations.

"Although implementing antifungal stewardship has challenges, it has the potential to decrease unnecessary and suboptimal antifungal use, to reduce toxicities associated with inappropriate antifungal use, and to prevent the emergence of antifungal resistance," the authors of the study wrote. "Currently, [prospective and adult feedback] and preauthorization are the main strategies used by pediatric ASPs to perform antifungal stewardship. Future studies should evaluate the effectiveness and clinical impact of such interventions."
Jul 14 Infect Control Hosp Epidemiol abstract

Stewardship program tied to less carbapenem resistance in Australian hospitals

Implementation of a computer-assisted stewardship program at healthcare facilities in an Australian local health district and a reduction in carbapenem use were associated with a decline in carbapenem-producing Enterobacteriaceae (CPE) isolates, according to a new study in JAC-Antimicrobial Resistance.

For the study, researchers analyzed CPE isolates collected from hospitals in the Illawarra Shoalhaven Local Health District from 2008 through 2018. In particular, they were looking to see whether the 2012 introduction of a district-wide stewardship program supported by a computerized clinical decision support system had any impact on carbapenem use and detection of CPE isolates.

They also looked at microbiological and demographic data, CPE risk factors and outcomes, and hand hygiene compliance rates among healthcare workers. Bivariate relationships were examined using Pearson's r, and predictors of CPE isolates were assessed using time series linear regression.

In total, 120 CPE isolates from 110 patients were identified. Most isolates (61%) were urinary and primarily categorized as hospital acquired. The numbers of CPE isolates and carbapenem use both showed a strong downward trend during the study period, and the decreases were strongly correlated (r = 0.80; P = 0.006).

Hand hygiene compliance remained at high levels throughout the study period and was negatively correlated with the numbers of CPE isolates (r = –0.70; P < 0.038). The time series regression analysis showed that the positive relationship between CPE isolation and carbapenem use was maintained while adjusting for time (b = 0.05; P < 0.001).

The average yearly consumption of carbapenems fell from 18.4 defined daily doses (DDDs) per 1,000 occupied bed days (OBDs) in the years before implementation of the ASP to 14.7 DDDs/1,000 OBDs in the years after implementation.

"In conclusion, we demonstrated a reduction in CPE isolates in conjunction with reduced carbapenem use in an Australian setting, longitudinally consolidated by a comprehensive district-wide AMS [antimicrobial stewardship] programme," the authors wrote. "Prospective studies are needed to confirm the influence of the AMS-driven carbapenem use reduction on carbapenemase prevalence, as well as the effect in high-prevalence settings."
Jul 13 JAC-Antimicrob Resist study

News Scan for Jul 14, 2020

News brief

Pandemic could set back decades of HIV, TB, malaria advances, experts say

Some low- and middle-income countries could see deaths due to HIV, tuberculosis, and malaria spike by as much as 10%, 20%, and 36%, respectively, over the next 5 years because of health service disruptions amid the COVID-19 pandemic and response, according to a modeling study published yesterday in The Lancet Global Health.

The researchers' models estimate that, in a worst-case scenario, heavily affected areas may expect that the impact of COVID-19 disruption on years of life lost could be similar to the direct impact of the coronavirus pandemic itself.

Substantial progress has been made against HIV, tuberculosis, and malaria in the last 2 decades, but the pandemic could cause significant disruptions in already-fragile health systems, limited routine program activities and care seeking, and broken medical supply chains. But the researchers said that the situation could be mitigated by prioritizing critical services, particularly antiretroviral therapy for HIV, rapid tuberculosis diagnosis and treatment, and resumption of distribution of durable, insecticide-treated mosquito nets for malaria.

Coauthor Timothy Hallett, PhD, of Imperial College London, said in a Lancet news release that the study results highlight the difficult decisions confronting policymakers. "Well managed, long-term suppression measures could avert the most COVID-19 deaths," he said. "But if these interventions are not well managed, they could cause people to stay away from hospitals and clinics and force public health programmes to be cancelled, leading to a large spike in deaths from other major infectious diseases that had been coming under control."

In a commentary in the same journal, Peter Sands, MPA, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria in Geneva, said that his organization is working to ensure the continuity of antiretroviral therapy and deliver it to immunocompromised patients through multimonth dispensing, home delivery, and remote consultations.

"We need more resources and decisive action, and we must measure success not just in terms of minimising the direct impact of COVID-19, but in terms of minimising its total impact, including the knock-on impact on HIV, tuberculosis, and malaria," he wrote.
Jul 13 Lancet Glob Health study, commentary, and news release

Analysis: Infants, kids with underlying illness fare worse with COVID-19

An epidemiologic and clinical study of 3,836 COVID-19 pediatric cases in Italy has described less serious disease than in adults, with 4% of all children—but 11% of those 6 years and younger—becoming seriously ill.

The Rome-based researchers analyzed the Italian national case-based surveillance system of confirmed coronavirus cases until May 8, according to the study today in Pediatrics. Children made up 1.8% of 216,305 total infections, while they account for 16% of the country's population.

Median pediatric patient age was 11 years, and 51% were boys. Of 3,836 children, 511 (13%) were hospitalized; 4% required intensive care; 5% had underlying conditions such as respiratory disease, heart disease, and cancer; and 4 patients (0.1%) died, all of them younger than 6 years and having serious underlying conditions.

Illness was mild in 32% of children. Infections tended to be less severe in older children, while high risk of serious disease was tied to infection in the first year of life and underlying conditions (odds ratio, 2.80; 95% confidence interval, 1.74 to 4.48). Patients 1 year and younger had the highest hospitalization rate (13.3%), followed by those 2 to 6 years (12.8%), 13 to 17 years (8.9%), and 7 to 12 years (8.8%). Intensive care unit admission rates were highest in children 2 to 6 years (9.5%).

Most COVID-19 infections occurred in pediatric patients aged 13 to 17 years (40.1%), followed by 7- to 12-year-olds (28.9%), 2- to 6-year-olds (17.2%), and those 1 year and younger (13.8%).

The authors called for implementation of effective infection-control measures to prevent COVID-19 spread in hospitals and among all patients with serious underlying conditions. "A widespread availability of testing may allow to better understand the infection in children, giving important insights into disease pathogenesis, health care practices, and public health policies," they wrote.
Jul 14 Pediatrics study

More polio cases reported in 4 countries

For the week ending on Jul 7, four countries—Afghanistan, Pakistan, Chad, and Ivory Coast—reported new polio cases, according to an update from the Global Polio Eradication Initiative (GPEI) posted today.

Afghanistan reported 3 more wild poliovirus type 1 (WPV1) cases, 2 in Hilmand province and 1 in Kandahar province, raising its total for the year to 29. It also reported 8 more vaccine-derived circulating poliovirus type 2 (cVDPV2) cases, 2 in Laghman and 6 in Nangarhar province, putting the country's cVDPV2 total at 25.

In Pakistan, health officials reported 1 more WPV1 case, in Khyber Pakhtunkhwa, bringing the year's total to 56. Also, there are 3 more cVDPV2 cases, including 1 each in Khyber Pakhtunkhwa, Punjab, and Sindh provinces, raising that number to 72 for the year.

In Africa, Chad reported 4 more cVDPV2 cases, 2 in Tandjile prefecture and 1 each in Logone Occidental and Mayo Kebbi Est prefectures. The GPEI said the country now has 50 cases from two different outbreaks, one linked to Nigeria's Jigawa state outbreak.

Ivory Coast reported 1 more cVDPV2 case, in Loh-Djiboua province, lifting the country's 2020 number to 19.
Jul 7 GPEI update

Meta-analysis finds HPV might be linked to prostate cancer

A meta-analysis published today in Infectious Agents and Cancer suggests human papillomaviruses (HPVs) may have a causal role in prostate cancer in addition to their commonly known role in causing cervical and other cancers.

"Although HPVs are only one of many pathogens that have been identified in prostate cancer, they are the only infectious pathogen which can be prevented by vaccination," the authors wrote.

The study, a literature review of 26 case-control studies, found that high-risk HPV types 16 and 18—which cause the majority of cervical cancers—have been found in normal, benign, and malignant prostate tissue. High-risk HPVs were identified in 325 (22.6%) of 1,284 prostate cancers and in 113 (8.6%) of 1,313 normal or benign prostate controls.

The study also showed that transmission in men was most likely sexual.

In a news release from BMC, which publishes the journal, lead author James S. Lawson, MD, said, "As high risk HPV infections are associated with the majority of cervical cancers and the most frequent means of HPV transmission is probably by sexual activity, the data may indicate that HPV infection may be transmitted during sexual activity and play causal role in prostate cancer, as well as cervical cancer."

The authors suggest a possible inflammatory role the HPV can cause in prostate cancers, and they say this is likely very different from the role the viruses play in cervical cancers. They conclude, "It is 'highly likely' that high risk HPVs have causal roles in prostate cancer. This evidence is sufficiently sound to justify its use in encouraging universal vaccination against HPV infections."
Jul 14 Infect Agents Cancer study