Stewardship / Resistance Scan for May 24, 2018

News brief

Scottish stewardship program helps reduce use of powerful antibiotics

A paper today in the Journal of Antimicrobial Chemotherapy reports that a Scottish stewardship program resulted in decreasing use of carbapenems and piperacillin/tazobactam and could be generalized to other antibiotics.

In response to rising use of the antibiotics in Scottish hospitals, the Scottish Antimicrobial Prescribing Group (SAPG) introduced guidance in 2013 that emphasized optimizing the use of carbapenems and piperacillin/tazobactam in patients with multidrug-resistant gram-negative bacteria infections and considering the use of carbapenem-sparing antibiotics. Using an online survey, researchers with SAPG aimed to evaluate how the guidance had been implemented by local health boards and translated into clinical practice. They also conducted a point prevalence survey (PPS) to evaluate prescribing and analyzed national prescribing data to assess the impact of the guidance.

The results of the survey showed that meropenem was subject to restrictions in 13 boards (87%), while piperacillin/tazobactam was restricted in 7 boards (47%), with an infection specialist authorizing use. In addition, compliance with local guidelines was good for meropenem but lower for piperacillin/tazobactam. The PPS data showed that carbapenem use was less than 2% of all antibiotics in all boards, while piperacillin/tazobactam use varied from 1% to more than 6%. Over the course of a 2-year improvement program that involved two interventions (introduction of the guidance and a subsequent quality improvement program), use of carbapenems and piperacillin/tazobactam decreased.

"Comparison with other countries suggests that Scotland is 'bucking the trend' of stable or increasing rates of carbapenem and piperacillin/tazobactam use," the authors write. "We consider this three-part improvement project will be of interest to stewardship colleagues as it can be applied to other antimicrobials to investigate and inform safe and effective clinical practice."
May 26 J Antimicrob Chemother abstract

Hypervirulent XDR Klebsiella pneumoniae strain identified in Taiwan

In another study today in the Journal of Antimicrobial Chemotherapy, scientists in Taiwan report the identification of a strain of extensively drug-resistant (XDR), carbapenemase-producing, and hypervirulent Klebsiella pneumoniae.

For the study, researchers analyzed K pneumoniae carbapenemase (KPC)-producing K pneumoniae isolates from clinical specimens collected at Taipei Veterans General Hospital from January 2012 through December 2014. They investigated the isolates for capsular types and the presence of the virulence genes rmpA and rmpA2, and conducted molecular and genomic testing to identify sequence types and resistance elements.

A total of 62 KPC-2-producing K pneumoniae strains were identified, all of which belonged to sequence type ST11 and capsular genotype K47. But an additional strain, isolated from a fatal case with intra-abdominal abscess, was found to harbor rmpA and rmpA2 and did not belong to the major cluster associated with the other KPC-2-producing strains. In addition to carbapenems, the strain was also resistant to tigecycline and colistin, which has not been previously reported in carbapenem-resistant hypervirulent K pneumoniae strains. The strain exhibited high in vivo virulence in a mouse infection model.

Whole-genome sequencing identified two plasmids containing KPC-2 and several other antibiotic resistance genes, along with a novel hybrid plasmid harboring rmpA/rmpA2 and additional virulence genes not found in the classic ST11 KPC-2-producing strains.

The convergence of hypervirulence and carbapenem resistance in K pneumoniae is considered a significant health threat. In August 2017, Chinese researchers reported an outbreak of ST11 hypervirulent carbapenem-resistant K pneumoniae at a Chinese hospital where all five patients died.

"Active surveillance focusing on both the antimicrobial resistance and virulence characteristics of K pneumoniae strains is necessary, as the threat to human health is imminent," the authors write. "Further studies regarding carbapenem-resistant hypervirulent K pneumoniae worldwide to explore the evolutionary relationship between virulence and resistance in K pneumoniae are encouraged."
May 24 J Antimicrob Chemother abstract

Groups urge McDonald's to cut antibiotics from beef supply

A coalition of advocacy groups today called on McDonald's to do more to address antibiotic resistance.

In an event held outside McDonald's headquarters in Chicago during the company's annual shareholder meeting, representatives from U.S. PIRG Education Fund, Consumer's Union, Food Animal Concerns Trust, and CREDO Action delivered 160,000 petition signatures from consumers urging the company to eliminate beef raised with antibiotics from its supply chain. The fast-food giant stopped selling chicken raised with medically important antibiotics in 2016 and has laid out a vision for phasing out antibiotics in beef and pork, but has not made any specific commitments.

According to estimates, approximately 70% of all medically important antibiotics sold in the United States are used in poultry and livestock production. Although medically important antibiotics can no longer be used for growth promotion, they are still routinely used for disease prevention. Infectious disease and public health experts are concerned that this practice contributes to antibiotic resistance.

"We must end the routine use of antibiotics in animals in order to preserve these drugs for curing human disease," Jean Halloran of Consumer's Union said in a press release from US PIRG. "McDonald's is in a unique position to lead the industry by prohibiting antibiotic use in the production of its burgers."

McDonald's is the largest beef purchaser in the United States.
May 24 U.S. PIRG press release

News Scan for May 24, 2018

News brief

WHO, World Bank unveil new global health security monitoring board

In a major development today on the sidelines of the World Health Assembly under way in Geneva, the World Health Organization (WHO) and the World Bank Group announced the launch of a new mechanism to firm up global health security, an independent monitoring board to regularly assess country preparedness to handle outbreaks, pandemics, and other health emergencies.

The new Global Preparedness Monitoring Board (GPMB) will be cochaired by Gro Harlem Brundtland, Norway's former prime minister, and Elhadj As Sy, secretary general of the International Federation of the Red Cross and Red Crescent Societies.

In a WHO news release, WHO Director-General Tedros Adhanom Ghebreyesus, PhD, said, "The ongoing Ebola outbreak in the Democratic Republic of the Congo is a stark reminder that outbreaks can happen anywhere, at any time." He added that part of being prepared is assessing progress made at all levels to identify gaps, including financing.

Jim Yong Kim, MD, PhD, World Bank president, said the cycle of panic and neglect has continued for too long, and the GPMP marks a big step toward breaking the pattern. "The GPMB will help save lives, prevent economic damage, and ensure that we keep pandemic preparedness at the top of the global agenda," he said.

The new board's activity will cover emergency preparedness across national governments, United Nations agencies, civil society, and the private sector. Each year it will issue a report on financing, research and development, and health crisis preparedness at the global, regional, and national levels. According to the WHO, a UN global health crisis task force formed in 2016 in the wake of West Africa's Ebola outbreak recommended robust ongoing monitoring of global health emergency preparedness which led to the establishment of the GPMB. The new board will be housed at WHO headquarters in Geneva.
May 24 WHO press release

ECMO does not significantly reduce mortality in ARDS patients: study

Venovenous ECMO, or extracorporeal membrane oxygenation, is becoming an increasingly common intervention in intensive care units, but a study today in the New England Journal of Medicine (NEJM) shows it does not significantly reduce mortality for patients with severe acute respiratory distress syndrome (ARDS).

The international randomly controlled trial measured mortality outcomes at 60 days after intervention with either ECMO or traditional mechanical ventilation on patients who had undergone endotracheal intubation and had been receiving ventilation for less than 7 days.

Researchers stopped the trial after 60 days because no significant reduction in mortality was found in the ECMO group; 44 patients (35%) in the ECMO group and 57 (46%) in the control group had died (relative risk, 0.76), while the hazard ratio for death within 60 days after randomization in the ECMO group, as compared with the control group, was 0.70.

Throughout the study, 28% of the control group patients crossed over to using ECMO because of severe hypoxia.

"This crossover rate makes it difficult to draw definitive conclusions regarding the usefulness of ECMO for severe forms of ARDS," the authors explained. "We were aware of this potential problem when we started the trial, but many investigators felt that it would have been unethical to prohibit crossover to ECMO in patients with very severe hypoxemia."

In an accompanying editorial, experts from Massachusetts General Hospital in Boston suggest that the results of this trial mean clinicians should reserve ECMO for patients whose life-threatening hypoxemia persists despite traditional interventions.
May 24 NEJM study
May 24 NEJM editorial