Stewardship / Resistance Scan for Jun 13, 2019

News brief

Canada's public health chief offers prescription for preserving antibiotics

Canada's chief public health officer, Theresa Tam, BMBS, issued a report this week aiming to raise awareness among both the public and healthcare professionals about the needless use of antibiotics and how to preserve the drugs' effectiveness.

The avowed goal of the "public health spotlight" report is "to describe why unnecessary antibiotic use sometimes happens and what we can do about it." The report is presented online in a single 24-page document and separately in a set of six chapters with larger type and graphics. The focus is on antibiotic use and prescribing in the community (non-hospital settings), where 92% of antibiotic prescriptions are written.

"When we better understand the many social and cultural reasons behind why unnecessary antibiotic use happens, we can begin to see some of the actions that each of us can take to help fight antibiotic resistance," Tam said in a statement about the report. "Canadians can help by keeping their vaccinations up to date, protecting themselves from infection, speaking to their health care providers before using antibiotics, and taking their antibiotics as prescribed."

Healthcare providers can help by talking with their patients about antibiotics, staying current on prescribing guidelines, and promoting appropriate use of antibiotics through tools like delayed prescriptions, meaning ones intended to be used only if symptoms don't improve within a few days, Tam added.

The report says that antibiotic resistance rates in Canada are lower than in many other countries, but not all is well. For two examples, cases of carbapenem-resistant bacteria in people without infections have quintupled, suggesting that those bacteria are becoming more common, and more than 50% of gonorrhea cases now involve bacteria with resistance to at least one antibiotic.

Included in the report are several real-life stories about patients' and providers' experiences with the prescribing and use of antibiotics.

In the conclusion, Tam says, "I look forward to using the findings from this Spotlight Report and the forthcoming Pan-Canadian Action Plan to work with leaders across the country" to preserve the effectiveness of antibiotics.
Jun 11 Tam statement
Full report in one document
First part of chapter-by-chapter version

Study reveals snapshot of carbapenem-resistant Pseudomonas burden

A surveillance study based in five United States metropolitan areas to flesh out the epidemiology of carbapenem-resistant Pseudomonas aeruginosa (CRPA) in the United States found that the burden is high, but carbapenemase-producing CRPA were rare. A team from the Center for Disease Control and Prevention (CDC) Emerging Infections Programs (EIP) sites reported their findings yesterday in Emerging Infectious Diseases.

From July to October of 2015 they began lab surveillance for CRPA at sentinel sites in Georgia, New Mexico, Oregon, Tennessee, and Monroe County, N.Y. They defined a case as the first P aeruginosa isolate resistant to carbapenems in a patient in a 30-day period from any source except for the nares, rectum or perirectal area, or feces.

Overall, they found 384 (9.1%) CRPA cases among 4,243 P aeruginosa isolates. The team identified 294 incident cases among 274 patients, with isolates most commonly found in respiratory sites (40.8%) and urine (37.8%). CRPA—an opportunistic pathogen—was found mainly in patients with underlying health conditions. Nearly 80% occurred in patients who had been hospitalized in the previous year. They found genes encoding carbapenemases in only 2.3% of 129 isolated tested.

Of 280 cases with available healthcare exposure history, 91.8% were healthcare-associated and 8.2% were community linked. And of cultures collected in acute care settings, most (83.5%) were from short-stay hospitals and 16.5% were from long-term care facilities. Of 155 hospitalized patients with information available, 65.2% had received antimicrobial drugs within 14 days of culture collection, and of those, 82.2% had received one or more β-lactam antimicrobial drug.

Resistance testing found one-third were not multidrug-resistant, and more than half were susceptible to ceftazidime or cefepime. The authors said the surveillance findings provide a snapshot of CRPA epidemiology and that based on the findings, surveillance at eight EIP sites began in 2016 to monitor changes in CRPA incidence and carbapenemase-producing CRPA strains.
Jun 12 Emerg Infect Dis report

In a related research development, researchers from California who looked at antimicrobial susceptibility test results from California hospitals between 2014 and 2017 found 3.2% of Enterobacteriaceae were resistant to carbapenems and 26.9% were resistant to cephalosporins. They reported their findings yesterday in Emerging Infectious Diseases.

Also, they found that the proportion of cephalosporin-resistant Escherichia coli increased 7% per year during the study period. They said some decreasing trends in carbapenem resistance, often the focus of containment efforts, affirm the potential effectiveness of prevention strategies. "Nonetheless, increases and regional variation in carbapenem-resistant and ESCR E. coli highlight the urgent need for ongoing, local infection prevention and antimicrobial stewardship efforts."
Jun 12 Emerg Infect Dis report

News Scan for Jun 13, 2019

News brief

Salmonella outbreak tied to live poultry swells to 279 cases in 41 states

The Centers for Disease Control and Prevention (CDC) today confirmed 227 new cases of Salmonella infection tied to backyard poultry such as chicks and ducklings, swelling the outbreak to 279 cases in 41 states.

Forty people have required hospitalization for their illnesses. When the CDC first reported this outbreak on May 16, it involved only 52 cases in 21 states. In interviews, 118 (77%) of 153 case-patients reported recent contact with chicks or ducklings. "People reported obtaining chicks and ducklings from several sources, including agricultural stores, websites, and hatcheries," the CDC said.

Illness-onset dates range from Jan 1 to May 24, and patients range in age from less than 1 year to 92 years, with a median age of 25. No deaths have been reported.

Ohio has the most cases, with 32, followed by Tennessee and Texas (26 each), Pennsylvania (18), and Virginia (16).

Outbreak strains are Salmonella Agona, Anatum, Braenderup, Infantis, Montevideo, and Newport. Officials have identified one of these strains in samples collected from backyard poultry in Ohio, the CDC said.

The outbreak is the latest in a series of Salmonella outbreaks tied to live poultry, the most recent of which happened last year and eventually affected at least 334 people, 56 of whom were hospitalized.

The CDC recommends a variety of steps to prevent disease for poultry owners, stores, and mail-order hatcheries.
Jun 13 CDC update

Italian researchers detail pair of related cutaneous anthrax infections

Researchers from Italy detailed two epidemiologically linked cutaneous Bacillus anthracis infections, in patients who had both been exposed to the blood of a cow that died from the disease at a farm near Rome in 2017. The group reported the findings today in the latest issue of Eurosurveillance.

The first patient was a 50-year-old male veterinarian who developed an eschar and lesion after contaminating his hand while removing a glove after inspecting a cow that died from digestive hemorrhage. When four more cows died at the farm and were confirmed as having anthrax, the patient sought specialist care and was hospitalized for treatment. He received intravenous ciprofloxacin and was discharged 4 days later with a prescription for oral ciprofloxacin.

Meanwhile, the second patient—a male farm worker in his 40s—sought care at a different city near Rome for several lesions on his arm and was admitted the same day to a hospital for treatment of ulcerated and necrotizing skin symptoms and upper-extremity edema.

He initially didn't report any exposure to sick animals, but had worked on a horse farm bordering the one where the cows had died from anthrax. Upon further questioning by his clinical team, the man remembers that he had been exposed to the blood of the dead cow that was evaluated by the first patient, the veterinarian. He was treated with intravenous ciprofloxacin and was discharged 2 weeks later.

Researchers said the two cases highlight the importance of a concerted One Health response between clinicians and veterinarians, the healthcare system and public health officials. They also note that anthrax should be included in the differential diagnosis of skin lesions, especially during dry seasons where B anthracis has been detected before.
Jun 13 Eurosurveill report

Mouse findings show favipiravir as potential Bourbon virus treatment

Experiments on mice suggest the antiviral drug favipiravir might be a useful treatment for deadly tickborne Bourbon virus infections. Researchers based at Washington University School of Medicine published their findings today in PLOS Pathogens.

Bourbon virus was first identified in Bourbon County, Kansas, in 2014, and of the handful of human cases that have been detected, most have been fatal. There are no treatments or vaccines for the disease.

According to a press release from the school, given that Bourbon virus is a distant relative of influenza, researchers have been examining if any current or candidate drugs for flu could be used to treat Bourbon virus. They narrowed the list to favipiravir, because it inhibits a protein that the virus needs to multiply. Favipiravir is approved in Japan but hasn't yet been cleared by US regulators.

For the study, they experimentally infected mice, then treated them with favipiravir or placebo. Of those treated within a day of infection, all given the antiviral at the time of infection or within 1 day after survived without becoming visibly sick, while all of the placebo-treated mice died. Mice who got favipiravir 3 days after infection when they showed signs of infection recovered.

Jacco Boon, PhD, assistant professor of medicine and the study's first author, said in the press release, "Up until now, doctors have not had any way to treat Bourbon virus. We’ve found something that works, at least in mice, and it suggests that antivirals for flu are a good place to start looking for a treatment for Bourbon."
Jun 13 PLOS Pathog abstract
Jun 13 Washington University School of Medicine press release