Stewardship / Resistance Scan for Jun 26, 2017

News brief

Study finds increase in C difficile in cancer patients

Researchers with the University of Texas at Austin report that the incidence of Clostridium difficile infection (CDI) is increasing among cancer patients, according to a new study in BMC Infectious Diseases.

Using data from the US National Hospital Discharge Surveys, the researchers identified more than 30 million cancer discharges from US hospitals from 2001 to 2010. CDI was present in 260,219 (0.9%) of cancer patients. The overall CDI incidence for the study period was 8.6 per 1,000 adult discharges, with incidence increasing from 6.8 per 1,000 cancer discharges in 2001 to 12.8 in 2010. Incidence peaked in 2008 at 17.2 per 1,000 discharges. Increases were seen in both principal CDI and secondary CDI.

Patients with CDI were more likely to be older, male, residents of the Northeast, and Medicare users, and CDI was found to be over 2.5 times more common among patients with blood cancers than those with solid-organ cancers.

Death occurred in 7.4% of cancer patients during the study period. The mortality rate was significantly higher for cancer patients with CDI compared with those without (9.3% vs 7.4%). In addition, the median length of hospital stay was significantly longer for CDI patients compared with those without (9 days vs 4 days).

The authors of the study say that knowing the burden of CDI among cancer patients is important because cancer patients can now be identified as a high-risk population and a target for antimicrobial stewardship and infection control efforts.
Jun 23 BMC Infect Dis study


Editorial urges narrower use of contact precautions with MRSA, VRE

An editorial today in JAMA is calling for a rethinking of the use of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus.

Under 2007 guidance from the US Centers for Disease Control and Prevention (CDC), which recommends the use of gloves and gowns for patients with target multidrug-resistant organisms (MDROs) and those who have previously been identified as colonized with target MDROs, patients infected or colonized with MRSA and VRE have become the most common focus of contact precautions. In addition, many states have passed laws mandating active culturing and contact precautions for MRSA patients.

But the authors of the editorial argue that no strong clinical trial evidence supports this policy. Observational data suggesting that contact precautions prevent MRSA or VRE infections, they say, come from reports of bundled approaches to outbreaks and not endemic MRSA or VRE, which are the more significant concern for hospitals. In addition, they cite higher-quality studies that have found no reduction in MRSA or VRE transmission rates associated with glove and gown use.

Furthermore, the authors argue that contact precautions can be burdensome when applied to an entire hospital, slowing the time it takes to move patients from the emergency room to hospital inpatient services and prolonging discharge time for patients being transferred to long-term care facilities, and result in less-satisfied patients. They also suggest that having to wear gloves and gowns for every patient visit could divert attention from other infection control activities, such as hand hygiene and chlorhexidine bathing.

One potential solution they offer is more selective use of contact precautions, given that MRSA or VRE contamination are more common when healthcare workers are performing high-risk patient care activities, such as bathing patients or dressing wounds, and caring for patients with clinical infections. Hospitals that have used such an approach, they say, have found no adverse effects on infection rates.

"Contact precautions are of unproven benefit and, at best, are low-value interventions that require significant personnel engagement," the authors write. "Reports of successful, alternative uses of gloves and gowns to prevent all infections while decreasing the health care worker, institutional, and environmental burden of personal protective equipment use are encouraging."
Jun 26 JAMA viewpoint


Antibiotic resistance in acne

A synopsis of clinical evidence suggests that the use of topical and systemic antibiotics for acne is associated with the formation of resistance in Propionibacterium acnes and other bacteria, with clinical consequences.

The synopsis, published in JAMA Dermatology, encompasses five trials conducted from 1987 to 2002 and 2007 to 2008 and including more than 120,000 patients in the United States, United Kingdom, Greece, Hungary, Italy, Spain, and Sweden. The primary outcomes were prevalence of antibiotic-resistant P acnes among patients and untreated contacts, nasal/pharyngeal colonization with S aureus, diagnosis of upper respiratory or urinary tract infection, and self-reported pharyngitis.

A summary of the findings showed that multiple countries have reported resistance in more than half of P acnes isolates, predominantly to topical erythromycin and clindamycin, and that resistant P acnes is found on the skin of untreated contacts of acne patients prescribed antibiotics. In addition, the reviewers found that use of topical antibiotics is associated with resistance in S aureus, that acne patients treated with topical and/or oral antibiotics for at least 6 weeks were more likely to develop upper respiratory infections during 1 year of follow-up than those who had not received antibiotics, and that university students receiving oral antibiotics for acne were four times more likely to report pharyngitis during 1 year of follow-up.

To reduce resistance, current guidelines from the American Academy of Dermatology recommend benzoyl peroxide, a topical bactericidal agent not reported to cause resistance, alongside topical and oral antibiotics. Benzoyl peroxide is thought to impede the formation of resistance, but evidence of its ability to limit resistance is stronger with topical antibiotics than with oral antibiotics.

The authors say additional studies are needed to address multiple evidence gaps.
Jun 21 JAMA Dermatol clinical evidence synopsis

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News Scan for Jun 26, 2017

News brief

Two new MERS cases reported in Saudi Arabia

The Saudi Arabian Ministry of Health (MOH) updated its MERS-CoV statistics for the first time in more than a week, noting two new cases not related to current hospital outbreaks in Riyadh.

On Jun 22, the MOH said an 85-year-old Saudi man from Yanbu died from MERS-CoV (Middle East respiratory syndrome coronavirus). The source of infection was listed as "primary," meaning it's unlikely he contracted the disease from another person.

Yesterday, the MOH said a 30-year-old Saudi woman from Dammam was in critical condition after presenting with symptoms of MERS-CoV. She had indirect contact with camels, a known risk factor for the coronavirus. Neither patient is a healthcare worker.

The new cases bring Saudi Arabia's MERS-CoV cases since 2012 total 1,667, including 680 deaths. Thirteen people are still being treated for their infections.
Jun 22 MOH report

Jun 25 MOH report


WHO: Flu continues slow rise in Southern Hemisphere countries

Flu activity in the Southern Hemisphere continues to increase and has passed the seasonal threshold in some South American countries such as Chile and Paraguay, where H3N2 is the dominant strain, the World Health Organization (WHO) said today in a global flu update, which includes activity through Jun 11.

In more tropical areas of South America, flu activity remained low, with a slight increase in Brazil that is still below the alert level. In Australia and New Zealand, flu has increased from baseline to average levels, with the region experiencing a mix of influenza A and B. Southern Africa is also reporting a rise in flu activity, with H3N2 as the predominant strain.

A few other regions of the world reported increasing flu levels, including the East African nations of Madagascar and Mauritius, as well as Hong Kong, where H3N2 is the main strain and Vietnam, where 2009 H1N1 and influenza B are predominant. Also, a few West Asian nations including Oman and Qatar reported slight increases.

At the global level, among recent specimens that tested positive for flu, 68.2% were influenza A and 31.8% were influenza B. Of the subtyped influenza A viruses, 68.5% were H3N2.
Jun 26 WHO global flu update


New study details pediatric symptoms of Lyme disease

A new study presented at the Pediatric Academic Societies meeting described the range of symptoms associated with Lyme disease in children, in an effort to help providers understand what can be expected after a course of antibiotic treatment for the tick-borne disease.

Prompt treatment with antibiotics is considered the gold-standard for Lyme disease. Most symptoms develop after a tick has been attached to a child for 36 or more hours—enough time to sufficiently transmit the Lyme disease spirochete. The "bulls-eye" rash, which occurs with most but not all infections, usually appears within 7 to 10 days of a bite. Fever, body aches, headache, and musculoskeletal pain are all known symptoms of Lyme.

The study was based on the electronic medical records of 79 children admitted to the Children's National Health System with laboratory-confirmed diagnosis of Lyme disease from June 2008 to May 2015. The researchers looked at how long certain symptoms lasted, including headache (usually present at disease onset) and knee pain (apparent weeks after diagnosis). Headaches tended to dissipate within 3 days of antibiotic treatment and did not return, no matter how long a child had been reporting them before beginning antibiotic therapy. Knee pain, however, took 2 to 4 weeks to resolve.

Only 2 of the 79 children included in the study had symptoms 6 months after diagnosis, a phenomenon known as post-treatment Lyme disease syndrome.
Jun 26 Children's National Health System press release

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