Stewardship / Resistance Scan for Nov 27, 2017

News brief

Activated charcoal may help protect gut microbiome from antibiotics

The results of a small phase 1 clinical trial show that an activated charcoal product helped protect the gut microbiome in volunteers treated with moxifloxacin, French researchers report in the Journal of Infectious Diseases.

The product, called DAV132, was developed as a potential strategy to protect the gut microbiome from the deleterious effects of non-absorbed antibiotics, which can wipe out beneficial bacteria in the gut and result in Clostridium difficile infection and the selection of antibiotic-resistant bacteria. It contains 5.11 grams of activated charcoal as the active absorbing ingredient. A previous phase 1 trial had shown that DAV132 could deliver a powerful non-specific absorbent to the late ileum of healthy volunteers and did not affect the plasma pharmacokinetics of the antibiotic amoxicillin.

For the randomized controlled trial, investigators recruited 28 healthy volunteers and randomized them to receive moxifloxacin alone or with DAV132 for 5 days. Two control groups of 8 volunteers, each receiving either DAV132 alone or a non-active substitute, were added. The primary objective was to evaluate the influence of DAV132 on free fecal moxifloxacin concentrations.

The investigators found that the combination of moxifloxacin and DAV132 reduced free moxifloxacin fecal concentrations by 99% compared with moxifloxacin alone, without affecting the plasma pharmacokinetics of the antibiotic or causing serious adverse effects. In addition, co-administration of DAV132 largely protected the richness and composition of the intestinal microbiota of the moxifloxacin-treated volunteers. DAV132 also showed it could absorb a wide range of antibiotics in ex vivo tests.

The authors conclude, "DAV132 may constitute a breakthrough product to prevent short- and long-term detrimental effects of antibiotic treatments." They say further studies are under way to evaluate DAV132's clinical potential.
Nov 23 J Infect Dis abstract

US pediatric C diff cases in hospitals cost thousands, study finds

Using a large US pediatrics database, researchers determined that the cost of a Clostridium difficile infection (CDI) in a hospitalized child ranged from almost $2,000 to over $8,000, depending on the length of stay, according to a study today in Infection Control and Hospital Epidemiology.

The investigators used a logistic regression model to predict CDI during hospitalization based on data from 8,527 pediatric hospitalizations with a diagnosis of CDI and 1,597,513 discharges of patients who did not have a CDI diagnosis. They found that that the cost attributed to CDI ranged from $1,917 to $8,317, depending on whether the team used a model adjusted for length of stay or not. The average hospital stay for CDI was about 4 days.

The authors concluded, "Clostridium difficileinfection in hospitalized children is associated with an economic burden similar to adult estimates. This finding supports a continued focus on preventing CDI in children as a priority."
Nov 27 Infect Control Hosp Epidemiol abstract

Report finds MDR-TB burden low in European children

European scientists reported late last week in Eurosurveillance that the burden of multidrug-resistant tuberculosis (MDR-TB) appears to be low in European children but could be underestimated because of challenges with lab confirmation.

From surveillance data from 2007 through 2015, the researchers reported 18,826 pediatric TB cases, of which 4,129 (21.9%) were lab-confirmed. Of the 3,378 cases for which drug-susceptibility data were available, 249 (7.4%) were single-drug-resistant TB, 64 (1.9%) were poly-resistant TB, 90 (2.7%) were MDR-TB, and 8 (0.2%) were extensively drug-resistant.

Children with a foreign background had almost double the risk of MDR-TB, while those with previous TB treatment had a more than sixfold-higher risk. Successful treatment outcome was reported for 58 (78.4%) of 74 pediatric MDR-TB cases that had outcome information available. Children aged 5 to 9 years old were the only group significantly associated with unsuccessful treatment outcome.

The authors concluded, "The burden of MDR TB in children in the EU/EEA appears low, but may be underestimated owing to challenges in laboratory confirmation. Diagnostic improvements are needed for early detection and adequate treatment of MDR TB."
Nov 23 Eurosurveill study

News Scan for Nov 27, 2017

News brief

Saudi Arabia reports 2 new MERS cases

The Saudi Arabian Ministry of Health (MOH) reported two new cases of MERS-CoV over the past week, according to its daily updates on the disease.

On Nov 20, a 63-year-old Saudi man from Bisha in the country's southwest was diagnosed as having a MERS-CoV (Middle East respiratory syndrome coronavirus) infection after presenting with symptoms. He is in stable condition. Investigators found that the man had a history of direct contact with camels.

Also, on Nov 24 the MOH reported an apparent fatal infection in a 64-year-old Saudi woman from Buraidah, which is located in the central Saudi Arabia. The ministry listed her condition as critical, but the report also suggests that she died from her illness. The source of her virus is reported as primary, meaning she didn't likely contract it from another person.

Saudi Arabia's MERS-CoV case count since 2012 has now reached 1,748, including 708 deaths. Three patients are still being treated, according to the MOH.
Nov 20 MOH update
Nov 24 MOH update

Review of oseltamivir for kids' flu finds shorter illness, fewer ear infections

Oseltamivir (Tamiflu) treatment for flu in children reduces the length of illness and reduces the risk of ear infection, according to a new meta-analysis that folded in results from the latest randomized placebo-controlled trials. A research team based at the University of Michigan reported their findings in the latest issue of Clinical Infectious Diseases.

The five trials they looked at included 2,561 patients in the intent-to-treat (ITT) and 1,598 in the intent-to-treat infected populations (ITTI). Oseltamivir shortened illness duration in the ITTI group by 17.6 hours (95% confidence interval -34.7 to -0.62 hours). The difference was even larger in the trials that enrolled children without asthma—a reduction of 29.9 hours (95% CI -53.9 to -5.8 hours).

The risk of otitis media was 34% lower in the ITTI population.

Researchers also examined complications and safety issues and found that vomiting was the only adverse event that was higher in the treatment group. They noted though the ITT population was relatively large, it might not be large enough to flag more infrequent adverse events.

"Our analysis is reassuring that in uncomplicated influenza oseltamivir appears to be as safe and effective in children as among adults," the team wrote, noting that the drug's role in preventing ear infection—a frequent flu complication—is also important. They said the findings support current policies and reinforce recommendations that treatment is most useful was started early after illness inset.
Nov 23 Clin Infect Dis abstract

Seven new vaccine-derived polio cases reported in Syria

There are seven new circulating vaccine derived poliovirus type 2 (cVDPV2) cases reported in Syria, all from the war-torn Deir Ez-Zor governorate. The Global Polio Eradication Initiative announced the cases in its most recent weekly report.

Syria now has 70 cases of cVDPV2 this year, with the most recent onset of paralysis reported on Sep 9. Last year, the country did not report any cases. The Syrian Ministry of Health requested 1 million doses of oral polio virus vaccine and 500,000 inactivated polio vaccine to conduct what will be the third immunization campaign in that country. The campaign, like the previous two, will target children under the age of 5.

The GPEI also said that the World Health Organization (WHO) polio emergency committee at a Nov 14 meeting that polio remains a global threat and is still a public health emergency of international concern (PHEIC). The committee, which has met 15 times before, reconvenes about every 3 months, or more often if needed, to reevaluate the global polio threat.

"The Committee was very concerned by the size of the outbreak in the Syrian Arab Republic, and the difficulty of reaching target populations because of the conflict," the WHO said. "As type 2 population immunity rapidly wanes, the risk of spread within the Syrian Arab Republic and beyond its borders will increase substantially, meaning urgent action is needed to stop transmission."
Nov 22 GPEI report
Nov 14 WHO statement

Two cases of yellow fever prompt vaccination campaign in Brazil

The WHO confirmed two cases of yellow fever in Brazil's Sao Paulo state, one of which was fatal.

Between August and October, a total of 71 suspected cases were reported in the state, which has also seen 120 epizootic cases of the flavivirus in recent months. The confirmed infections in non-human primates took place near Sao Paulo city, a large urban area that has previously not been the site of yellow fever activity.

The two human cases have prompted a mass vaccination campaign throughout Sao Paulo state, the WHO said. "Currently, the number of unvaccinated people in Sao Paulo City remains high at around 10 million. If yellow fever transmission continues to spread to areas that were previously considered not at risk for yellow fever, ensuring the availability of vaccine and implementing control measures would pose significant challenges."

The current yellow fever outbreak in Brazil began in late 2016 and reached its peak earlier this spring. Officials still do not believe the Aedes aegypti mosquito is transmitting the virus.
Nov 24 WHO report

Clinician suspicion proves poor predictor of Lyme disease

A new study published in Pediatrics showed that clinical suspicion was a minimally accurate diagnostic tool for detecting Lyme disease in children. The study highlights the need for laboratory testing to confirm infection with the tick-borne disease.

The study looked at the evaluations and diagnosis of 1,021 children in five emergency departments across the United States between 2015 and 2017. A total of 238 had Lyme disease as confirmed by blood testing.

Clinicians were asked to rank how likely a Lyme diagnosis was before the results of the patients' serology tests were returned. Of the 554 children who the treating clinicians thought were unlikely to have Lyme disease, 65 (12%) had the disease. Of the 127 children who the treating clinicians thought were very likely to have Lyme disease, 39 (31%) did not have Lyme disease.

Only children with the classic "bull's eye" rash should be treated for Lyme disease before serological tests are completed, the study authors concluded.

In other Lyme news, a recent study in BMC Public Health showed that that a minority of people (less than 30%) consistently performs tick checks on their bodies after being in nature. Frequent checking was associated with increased knowledge of tick-borne diseases.
Nov 27 Pediatrics study
Nov 25 BMC Public Health study