Stewardship / Resistance Scan for May 09, 2019

News brief

Study finds high probability of antibiotic use over time in insured patients

Research today in the New England Journal of Medicine shows that nearly two-thirds of Americans enrolled in health insurance plans filled a prescription for an antibiotic over a 4-year period.

In a letter to the journal, researchers from Harvard and the University of Toronto report that an analysis of the Truven Health MarketScan Research Databases for 2011 through 2014 found that the probability of filling an antibiotic prescription at an outpatient pharmacy was 33% over 1 year, 47% over 2 years, 55% over 3 years, and 62% over 4 years. The analysis also found that demographic groups with a higher annual volume of antibiotic consumption had a higher cumulative probability of antibiotic use at all time points.

The study is limited by the population sample, which covers 62 million Americans (roughly 20% of the population), and by the fact that it did not address whether the antibiotics prescribed were appropriate.

"Because antibiotic use is widespread, with nearly two thirds of enrollees in U.S. health insurance plans filling an antibiotic prescription during a 4-year period, it may be important to reduce inappropriate prescribing among all patients, not just the most intense antibiotic users, to effectively combat antibiotic resistance," the author's write.
May 9 N Engl J Med letter

IV antibiotics linked to longer hospital stays in heart failure patients

Researchers from the University of Tennessee reported yesterday in Open Forum Infectious Diseases that unnecessary intravenous (IV) antibiotic use in patients with heart failure was associated with longer hospital stays and other potential harms.

In the single-center study, the researchers analyzed data on patients admitted and discharged with acute decompensated heart failure (ADHF), a condition that is sometimes mistaken for community-acquired pneumonia (CAP). ADHF patients are often simultaneously treated for CAP with IV antibiotics, even when evidence of infection is lacking. To determine whether this treatment has any potentially adverse effects, the researchers compared the length of stay in patients who had ADHF and were given IV antibiotics with ADHF patients who received no antibiotics. Secondary outcomes included mortality, readmission rates, amount of diuretic received, and fluid volume and quantity of sodium administered as part of IV antibiotic therapy.

Of the 144 patients in the study, none of whom had radiographic documentation suggesting pneumonia, 56 (39%) received IV antibiotics and 88 (61%) did not. Length of stay was significantly longer in the antibiotic arm (6.6 days) compared with the non-antibiotic arm (3.0 days).

Patients in the antibiotic arm also received higher total doses of furosemide than those who didn't receive antibiotics (mean total dose of 930 milligrams [mg] vs 320 mg), along with approximately 1.7 liters of additional fluid and 9,311 mg of additional sodium. Patients who received IV antibiotics were 2.2 times more likely to be readmitted to the hospital than those who did not.

The authors note that the additional fluid and sodium received by the IV antibiotic patients is important, because ADHF patients typically have volume and sodium restrictions.

"Giving patients at low risk of infection antibiotic therapy 'just to be safe' may not actually be the safest option," they conclude.
May 8 Open Forum Infect Dis abstract

Australian report highlights antibiotic use, resistance concerns

A report today from Australian health officials has found that community antibiotic use in the country is falling but overprescribing continues to be an issue, and that common bacterial pathogens are becoming increasingly resistant.

The third report on antimicrobial use and resistance in Australia (AURA 2019) found that the overall rate of antibiotic dispensing in the community declined from 2015 through 2017, representing the first downward trend in community antibiotic use in Australia since the 1990s. But Australia remains in the top 25% of countries with the highest community antibiotic use. In 2017, 41.5% of the population was prescribed at least one systemic antibiotic. And a large percentage of patients in 2017 were prescribed antibiotics inappropriately, including 52.2% of influenza and 92.4% of acute bronchitis patients.

Total antibiotic use in hospitals, meanwhile, rose for the first time since 2013, while inappropriate prescribing in hospitals remained static in 2017, at 23.5%. Nursing homes were found to have high levels of inappropriate prescribing, as well.

"While the downward shift in prescribing will help to slow the spread of resistance, these latest AURA findings indicate that the levels of inappropriate prescribing of antibiotics in hospitals and the community are still too high and there is more work to be done," AURA clinical director Kathryn Daveson, MBBS, MPH, said in a press release from the Australian Commission on Safety and Quality in Health Care (the Commission).

The report also found that although national rates of resistance have not substantially changed from those reported in 2016 and 2017, increased resistance to common agents has been observed in Escherichia coli, Salmonella, Neisseria gonorrhoeae, and Neisseria meningitidis, and patterns of methicillin resistance continue to evolve in Staphylococcus aureus. The prevalence of vancomycin resistance in Enterococcus faecium remains higher in Australia than in any European country.
May 9 AURA report
May 8 Commission press release

News Scan for May 09, 2019

News brief

Ebola response in Butembo resumes after 5 days; 4 new cases noted

The Democratic Republic of the Congo's (DRC's) ministry of health confirmed that Ebola outbreak response activities partially resumed today in Butembo, after being suspended for 5 days due to several acts of violence.

Four cases of Ebola were confirmed, and 5 new deaths were recorded, raising the outbreak's total to 1,604 cases, including 1,074 deaths. A total of 264 suspected cases are still under investigation. The low number of reported cases, after a month of increased activity, likely reflects a lag in reporting caused by the security incidents.

Yesterday, DRC officials said two Katwa health workers—including one who had been vaccinated—had contracted Ebola, raising the number of health workers infected in this outbreak to 97.

In an update today, the World Health Organization (WHO) said more violent attacks will likely expand the outbreak beyond North Kivu and Ituri provinces. In the past 21 days, 93% of cases have originated in Katwa, Butembo, Mandima, Mabalako, Musienene, Beni, and Kalunguta health zones.

"The ongoing violent attacks sow fear, perpetuate mistrust, and further compound the multitude of challenges already faced by frontline healthcare workers," the WHO said.
May 8 DRC update
May 9 DRC update
May 9 WHOupdate

WHO profiles recent Saudi MERS cases as country notes new one

The WHO today provided more details on 36 MERS-CoV cases, 12 of them fatal, reported from Saudi Arabia between Mar 1 and Apr 8 that weren't part of a large outbreak in Wadi ad-Dawasir.

Of the 36 cases, 10 were in Khafji and 6 in Riyadh. Nine patients had a history of exposure to camels or camel milk, and 12 had been exposed to another MERS-CoV (Middle East respiratory syndrome coronavirus) patient. Five involved healthcare workers, all from Eastern region, presumably linked to the illnesses in Khafji.

Patient ages ranged from 22 to 80, and all but 8 of them were male. Three apparently had asymptomatic infections, and 24 had underlying medical conditions.

The WHO said the new cases don't change its overall MERS-CoV risk assessment. The agency added that it expects cases to continue to be reported in the Middle East, along with possible exported cases involving people who contract the virus from camels, animal products such as camel milk, and humans, especially those in healthcare settings.

Since 2012 when the virus was first detected in humans the WHO has been notified of 2,419 MERS-CoV cases, at least 836 of them fatal. The vast majority are from Saudi Arabia.
May 9 WHO update

Meanwhile, Saudi Arabia's Ministry of Health (MOH) reported a new illness in a 31-year-old man from Riyadh, according to a May 7 update to its epidemiologic week 19 report. It's not known if the man had contact with camels, and the source of his exposure is listed as primary, meaning he probably wasn't exposed to sick patients. The case raises the 2019 Saudi total to 137 infections.
May 8 Saudi MOH epi week 19 report

CWD confirmed on deer farm in Crow Wing County, Minnesota

The Minnesota Board of Animal Health (MBAH) announced yesterday that at least seven animals at Trophy Woods Ranch, a captive deer farm in Crow Wing County, Minnesota, suffered from chronic wasting disease (CWD) in the last 2 years, and the animals likely spread the prion disease to deer in the wild.

On Apr 16, animals at Trophy Woods Ranch were depopulated and tested for CWD after the ranch closed when a wild female deer near the property was found dead from CWD. A total of 102 deer were removed from the farm, and all viable samples were sent to the National Veterinary Services Laboratory for CWD testing.

Seven animals tested positive for CWD, which raised the total number of CWD-infected animals associated with Trophy Woods to 14, the Minneapolis Star Tribune reported. Thirteen animals were too decomposed for testing.

"The results give us a clearer picture of the disease prevalence on the farm as we continue our efforts to contain and eliminate any remaining infectious CWD prions in the enclosed property," said Linda Glaser, DVM, the assistant director of MBAH, in an MBAH news release.

CWD is a fatal prion disease in cervids, and has been documented across the United States, and in Canada, Scandinavia, and South Korea. The disease likely spreads when infected animals shed prions in saliva, feces, urine, and other fluids or tissues. No human cases have been recorded, but eating contaminated meat is not advised.
May 8 MBAH news release
May 8 Star Tribune article

H9N2 avian flu infection reported in Oman

Oman has detected H9N2 avian flu in a 13-month-old baby girl from South Batinah governorate, according to a post yesterday from ProMED Mail, the online reporting system of the International Society for Infectious Diseases.

The post cited a WHOvirus traceability notification that said H9N2 had been obtained from a nasopharyngeal swab, as well as a mention in a May 7 Hong Kong Centre for Health Protection weekly avian flu report that noted the baby's infection and said the illness onset was Mar 17.

No information on the source of the virus or the patient's clinical details were available. A moderator's comment on the post noted a 2015 medical literature report of low-pathogenic H9N2 in mynah birds in Oman.
May 8 ProMED Mail post

Singapore sees first monkeypox case — in Nigerian national

Singapore's ministry of health confirmed the countrys first case of monkeypox, in a Nigerian man who traveled to Singapore for a workshop last week.

As of yesterday the man, 38, was hospitalized and in stable condition in an isolation ward at the National Centre for Infectious Diseases. An additional 22 case contacts are under quarantine, health officials said.

The Singapore Times reported the man had attended a wedding in Nigeria shortly before his trip, and may have consumed bush meat during the celebration. Monkeypox is often transmitted from animals to humans via contaminated meat or rodents who have come into contact with infected animals.

Though human-to-human transmission is possible, it requires very close contact. Monkeypox is a self-limiting disease, with most symptoms resolving within 3 weeks.
May 9 Singapore Times story