Stewardship / Resistance Scan for Jul 22, 2019

News brief

Survey: Antibiotic stewardship often lacking for end-of-life care

A survey of 36 hospitals discovered that about two-thirds had antimicrobial stewardship programs (ASPs) that monitored antimicrobial use in patients during end-of-life care, but only a third had ASPs that offered guidance for patients receiving comfort care only, according to a study today in Infection Control & Hospital Epidemiology.

Yale University investigators conducted an electronic survey of ASPs from the Society for Healthcare Epidemiology of America (SHEA) Research Network, a consortium of hospitals collaborating on multicenter projects in healthcare epidemiology. Members of 36 of the 94 hospitals completed the survey in May and June of 2018.

In addition to finding that 23 hospitals (64%) had ASPs that monitored antimicrobial use during end-of-life care and 13 (36%) had ASPs offering comfort-care antimicrobial use guidance for patients, the survey results showed that recommendations for intravenous antimicrobials were more common than recommendations for oral antimicrobials in 86% of programs.

The researchers also found that approval of antimicrobials in the ASPs was often influenced by patients' goals, with 15 ASPs (42%) having antimicrobials restrictions affected by comfort measures only, 9 (25%) having them affected by no-escalation-of-care status, and 4 (11%) affected by do-not-resuscitate/intubate orders.

Free-text responses indicated that ASPs should support end-of-life clinical decisions in four ways: (1) discerning adverse events, (2) supporting palliative care providers, (3) refining guidelines specific to end-of-care issues, and (4) educating physicians.
Jul 22 Infect Control Hosp Epidemiol study

Study: Molecular test for group A strep could lead to overprescribing

Researchers in Chicago report today that the illumigene test, a molecular-based assay for group A Streptococcus (GAS), is significantly more likely than throat culture to yield positive results in patients without GAS pharyngitis, a finding they say could have an impact on outpatient antimicrobial stewardship efforts.

In a study published in The Pediatric Infectious Disease Journal, researchers from Northwestern University Feinberg School of Medicine and Lurie Children's Hospital of Chicago enrolled children between the ages of 3 and 17 who visited the hospital's pediatric clinic for health supervision or follow-up of a non-infectious condition and had no signs or symptoms of pharyngitis. They then performed the illumigene test and blood agar plate throat cultures on duplicate throat swabs to compare the proportion of positive tests.

The illumigene test replaced throat cultures at the hospitals for diagnosis of GAS pharyngitis in 2014, and since then hospital records have detected an increase in positive GAS tests. The researchers hypothesized that asymptomatic carriers may be testing positive and receiving unnecessary antibiotics.

Among the 385 enrolled children, significantly more illumigene tests (78/385, 20.3%) than throat cultures (48/385, 12.5%) were positive. Three swabs yielded an "indeterminate" illumigene test result (all 3 paired swabs were culture-negative), leaving 382 pairs for analysis. Results were discordant for 32 of 382 pairs (8.4%), of which 31 of 32 (97%) were illumigene-positive/culture-negative. A positive result was significantly more likely with the swab chosen for the illumigene test than with the one used for culture. In a small subset of 13 illumigene-positive lysates tested by polymerase chain reaction, 4 (31%) were negative, and the paired cultures were negative in all four.

"The results of the present study are consistent with the hypothesis that the sensitivity of the illumigene test is such that it can identify GAS more readily than occurs with standard throat culture, especially in patients with very low streptococcal burden," the authors of the study write.

They conclude that additional studies of GAS molecular tests are needed, and that new clinical guidelines are needed to define the role of these tests in clinical care.
Jul 22 Pediatr Infect Dis J study

News Scan for Jul 22, 2019

News brief

CDC: 25 new measles cases as number of outbreaks grows to 5

The Centers for Disease Control and Prevention (CDC) today recorded 25 new measles cases in an outbreak that has affected 30 states. The total number of cases in 2019 is now 1,148.

"This is the greatest number of cases reported in the U.S. since 1992 and since measles was declared eliminated in 2000," the CDC said.

The 25 cases show a slight uptick from recent weeks, as the agency had recorded 14 cases in each of the previous 2 week. In addition, the CDC is now tracking five outbreaks of three or more related cases, adding to ongoing outbreaks in New York and Washington states an outbreak in El Paso, Texas, and one in Los Angeles County, California.

According to the California Department of Public Health (CDPH), Los Angeles County has had 16 cases this year, part of 60 confirmed cases across the state.

The two outbreaks in New York City and Rockland County are the nation's largest, with 282 cases in Rockland and 623 in parts of Brooklyn. Both of those outbreaks have been linked to international travel.
Jul 22 CDC update
Jul 17 CDPH update

MERS sickens 1 more in Saudi Arabia; WHO details June cases, deaths

Saudi Arabia's ministry of health (MOH) reported another MERS-CoV case, which involves a 58-year-old man from Najran in the country's southwest, according to a Jul 20 statement.

The man's history of contact with camels isn't known, and health officials are classifying his MERS-CoV (Middle East respiratory syndrome coronavirus) exposure as primary, meaning he wasn't likely exposed by another known patient.

The latest illness marks the country's fifth case recorded for July.
Jun 20 Saudi MOH statement

In other MERS-CoV developments, the World Health Organization (WHO) Eastern Mediterranean regional office (EMRO) recently posted a snapshot of seven Saudi Arabia infections reported in June. One of the patients died from his or her illness, and one more fatality was reported in an earlier reported case.

No new cases were reported in Khafji, and the outbreak seems to be over after Saudi Arabia's response steps, the WHO said. No clusters were reported in June, though one of the month's cases is in a healthcare worker who had a secondary infection linked to an illness reported in May. In May, Khafji reported a string of cases involving two different clusters, one linked to a hospital.

Since the virus was first detected in humans in April 2012, the WHO has now received reports of 2,449 confirmed cases, at least 845 of them fatal. Though 27 countries have reported cases, the vast majority have been from Saudi Arabia.
EMRO MERS-CoV situation update for June

Flu still rising in Australia, other Southern Hemisphere countries

Flu activity in Australia, which was already high, increased further, with H3N2 as the dominant strain and variable patterns seen in different parts of the country, the World Health Organization (WHO) said today in its latest global flu update, which includes data up to Jul 7 from reporting countries.

Severity markers were low, and influenza B was the next most commonly detected virus. In New Zealand over the same period, flu activity declined to just above seasonal baseline.

Elsewhere in the Southern Hemisphere, flu activity reflects a mixed picture, with levels on the rise in Argentina and Uruguay, with decreases in such countries as Brazil, Chile, Paraguay, and South Africa. Overall, H3N2 has been the main virus in Oceania and South Africa, and 2009 H1N1 has been predominant in temperate South American countries.

Southern Asia experienced mostly low flu activity, except Bangladesh, which is still reporting high activity, with H3N2 as the main strain. Myanmar is experiencing high flu activity from 2009 H1N1.

In tropical locations in Central America, the Caribbean, and South America, Cuba and French Guiana reported increases in flu detections, with flu activity in Costa Rica rising to high levels and both H3N2 and 2009 H1N1 circulating. Panama's flu activity remained high, with 2009 H1N1 as the predominant strain.

In Africa, H3N2 detections increased in Guinea and Nigeria.

Globally from Jun 24 to Jul 7, testing by WHO-affiliated laboratories revealed that 67.7% of specimens were influenza A and 32.3% were influenza B. Of subtyped influenza A strains, 62.7% were H3N2 and 37.3% were 2009 H1N1. Of the characterized influenza B strains, 95.6% were from the Victoria lineage and 4.4% belonged to the Yamagata lineage.
Jul 22 WHO global flu update