Stewardship / Resistance Scan for Nov 27, 2018

News brief

Study: Fluoroquinolone use common in patients at risk of aortic rupture

A study yesterday in Antimicrobial Agents and Chemotherapy found that patients at risk for aortic rupture are frequently exposed to fluoroquinolones during hospitalization, despite concerns that fluoroquinolone use may be associated with increased risk of aortic aneurysm and/or dissection (AAD).

In the study, investigators from Baylor College of Medicine analyzed hospital admissions data for the years 2009 through 2015 to explore how often patients with AAD or Marfan syndrome (a genetic disorder linked to increased risk of AAD) are being treated with fluoroquinolones in the acute care setting, given that these patients are already at increased risk of aortic rupture. Fluoroquinolones are among the most commonly prescribed antibiotics worldwide, but post-marketing and clinical surveillance studies have linked them with several adverse effects, and four recent observational clinical studies have suggested they may be associated with an increased risk of AAD.

Using the Advisory Board billing and administrative database, the investigators identified 136,789 admissions for AAD, which involved 99,818 unique patients, and 2,871 unique admissions for Marfan syndrome, involving 1,872 unique patients. Of the 19,818 patients with AAD, 20% were administered a fluoroquinolone during admission. Of the 7,045 patients with dissection, 18% were exposed to fluoroquinolones, and 19% of the patients who underwent aortic repair received fluoroquinolones before the surgery. In addition, 14% of the Marfan syndrome patients were exposed to fluoroquinolones.

Multi-level regression analysis to determine factors associated with fluoroquinolone use revealed that in patients with AAD, having a diagnosis of pneumonia or urinary tract infection (UTI) increased the likelihood of receiving a fluoroquinolone by 46% and 40%, respectively. Pneumonia and UTIs also increased the risk of fluoroquinolone use in Marfan syndrome patients as well.

"If the suspected deleterious effects of FQs [fluoroquinolones] on aortic integrity is substantiated, reducing FQ use in these patients should be a high priority for antibiotic stewardship and patient safety programs," the authors of the study write. "Our results help identify the patients who are most at risk of FQ exposure during hospitalization and, thus, provide a starting place for stewardship interventions."
Nov 26 Antimicrob Agents Chemother abstract

Advisory group seeks input on priorities for resistance action plan

The US Presidential Advisory Committee on Combating Antibiotic Resistant Bacteria (PACCARB) is seeking the public's input for an update on the US government's efforts to fight antibiotic resistance.

On Nov 23 PACCARB posted a Request for Information (RFI) in the Federal Register that will allow a wide range of stakeholders to suggest new priority areas within each of the five goals that were established in the first National Action Plan (NAP) for Combating Antibiotic-Resistant Bacteria, which covers the years 2015 to 2020. PACCARB posted the RFI in response to a request from Department of Health and Human Services (HHS) Secretary Alex Azar to identify significant areas that have emerged since the first NAP was published in 2015.

The goals of the initial NAP included slowing the emergence of resistant bacteria and preventing the spread of resistant infections; strengthening national One Health surveillance efforts; advancing development and use of rapid and innovative diagnostic tests; accelerating research and development for new antibiotics and other therapeutics; and improving international collaboration. Azar asked PACCARB to identify three to five areas within each of these goals that should be considered for the second iteration of the NAP, which will guide action against antibiotic resistance for the period 2020-2025.

The deadline for submitting comments in Jan 7, 2019. Priority areas will be explored at the next PACCARB public meeting, scheduled for Jan 30-31, 2019.
Nov 23 Federal Register notice
HHS online comment form

News Scan for Nov 27, 2018

News brief

Two more Ebola cases, 1 death recorded in DRC; total stands at 421

Today the ministry of health of the Democratic Republic of the Congo (DRC) reported two more Ebola cases in the ongoing outbreak in North Kivu and Ituri provinces. The outbreak total now stands at 421 cases (374 confirmed and 47 probable), including 241 deaths.

The two new cases are from Kyondo and Kalunguta, and one additional death was recorded in Beni. Seventy-four cases are still under investigation.

A ring vaccination campaign is still under way throughout the region. A total of 36,612 people have been vaccinated with Merck's unlicensed Ebola vaccine, including 17,465 in Beni.

If the outbreak reaches 426 Ebola cases—which is highly likely soon—it will become the second-largest in history, behind Uganda's 2000 outbreak (425 cases) and the massive 2014-2016 outbreak in West Africa (28,652 cases).
Nov 27 DRC update

CDC confirms 10 new acute flaccid myelitis cases, 116 total

In an update yesterday on the ongoing accuse flaccid myelitis (AFM) outbreak, the Centers for Disease Control and Prevention (CDC) confirmed 10 more cases, raising the outbreak total to 116 confirmed cases in 31 states.

The 116 confirmed cases are part of 286 reports CDC has received of patients under investigation in 2018. Colorado has reported the most confirmed cases, with 15, followed by Texas (14).

There is still no consensus on the cause of AFM. Though some cases have been linked to enteroviruses, the CDC said that virus is common in children and most often does not lead to AFM.

AFM is a rare, polio-like illness that affects the nervous system and causes muscles and limbs to weaken. Since 2014, the CDC has tracked AFM, which seems to operate on a cyclical seasonal schedule, with most outbreaks occurring every 2 years in the early fall.

In 2016, there were 149 confirmed cases of AFM in 39 states and Washington, D.C., the most of any year.
Nov 26 CDC update

New polio vaccine candidate requires no refrigeration

Scientists from the University of Southern California (USC) have developed a freeze-dried polio vaccine that could one day prove a useful tool in the endgame of the virus.

The thermostable lyophilized Sabin inactivated poliovirus vaccine (sIPV) is an injected vaccine that can be stored without refrigeration and reconstituted at the time of use. According to a study in mBio, the vaccine performed well in mice.

"The feasibility of the use of current IPV formulations in developing countries is limited, because IPV is insufficiently stable to be purified, transported, and stored under unrefrigerated conditions," the authors wrote. "We successfully designed the sIPV for use in the dry state that maintains the full vaccine potency in animal models after incubation at ambient temperature."

In the study, the freeze-dried sIPV was kept at 37°C (98.6°F) for 4 weeks before being reconstituted and injected into mice, where it induced an antipoliovirus immune response.

A temperature-stable vaccine could be useful in countries where refrigeration is unreliable. In recent weeks, Nigeria, the Democratic Republic of the Congo, and Papua New Guinea have all reported new polio cases.
Nov 27 mBio study

Report urges vigilance for Zika spread from India's outbreak hot spot

India is currently experiencing its largest Zika virus outbreak, with most cases reported from the Rajasthan state capital of Jaipur, and Indian cities and countries with close connections to the city should prepare for possible imported cases, a Canadian-led research team recently reported in a letter to the Journal of Travel Medicine.

By the end of October, 147 cases had been reported in Jaipur, a popular tourist destination, and as of Nov 2, neighboring Gujarat state reported 1 case and Madhya Pradesh state reported 3 infections.

To look at potential spread of the virus, the group analyzed the timing and volume of airline connections to Jaipur, along with the environmental suitability of populations of mosquitoes that can carry the virus in destinations cities within and outside of India. Based on airline data from November 2016 through January 2017, the investigators found there were 326 cities near areas that can support Zika transmission. Of passengers traveling out of Rajasthan, 94% traveled to Indian cities, mostly Mumbai, New Delhi, Bengaluru, and Kolkata. International cities in the top 20 destinations included Bangkok, Muscat, and Singapore.

The authors concluded that because there are so many regions that can support Zika transmission that have large populations with limited exposure and immunity to the virus, Indian cities and international locations with close travel ties to Jaipur should prepare for possible cases in upcoming months. They added that the risk of domestic spread is greater, especially in the city of Chennai, with its close ties to the outbreak hot spot, large population, and environment that could support year-round transmission by Aedes aegypti mosquitoes.
Nov 22 J Travel Med abstract