Stewardship / Resistance Scan for Oct 22, 2018

News brief

Financial incentives may cut antibiotic prescribing, with few unintended results

The antibiotic prescribing component of a financial incentive program to improve services at UK National Health Service (NHS) clinics found a significant reduction in both total and broad-spectrum antibiotic prescribing in primary care settings, with no link to unintended consequences, except for a few specific conditions.

A research team from Imperial College London reported its findings on Oct 18 in two separate reports in Clinical Infectious Diseases: one on the impact of the antimicrobial stewardship component of the Quality Premium (QP) program and the other on possible unintended consequences.

UK officials introduced the QP program in 2015, which included financial incentives for meeting different criteria, including reducing antibiotic prescribing by 1% and reducing broad-spectrum antibiotic prescriptions by 10%.

To gauge the impact of the program, the researchers analyzed national antibiotic prescribing data from April 2013 till February 2017 using a segmented regression analysis of interrupted time series data. They looked at the total number of items prescribed, the number prescribed per STAR-PU (specific therapeutic group age-sex related prescribing units), and number and percentage of broad-spectrum antibiotics prescribed.

More than 140 million antibiotic items were prescribed during the study period. After the quality premium was introduced, antibiotic prescribing decreased by 8.2%, reflecting more than 5.9 million fewer antibiotics prescribed in the 23 months after the QP went into effect compared with expected numbers based on trends found in the months before the intervention. The investigators also saw a relative decrease in antibiotics prescribed per STAR-PU, as well as a similar effect for broad-spectrum antibiotics, which were reduced by 18.9%.
Oct 18 Clin Infect Dis abstract

In the second study, which focused on potential unintended consequences of the reduced prescribing part of the quality premium incentive, the team looked at databases of general practitioner consultations and emergency department (ED) admissions for a set of pre-defined conditions. Their analysis covered 27,334 clinic visits and more than 5 million ED admissions.

Overall, the researchers didn't see any changes in rates for either measure. When they considered each condition separately, however, they found a significant increase in hospital admission for quinsy (peritonsillar abscess) and significant decreases for hospital-acquired pneumonia, scarlet fever, pyelonephritis, and complicated urinary tract infections. For clinic visits, the team focuses on empyema and scarlet fever and didn't observe any significant changes for either.
Oct 18 Clin Infect Dis abstract

Active surveillance for ESBL-E in neonatal intensive care found costly

A single-center study today in Infection Control and Hospital Epidemiology found that active surveillance to prevent extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) transmission may have contributed to a decline in incidence in a neonatal intensive care unit (NICU), but was too costly to continue.

The retrospective observational study was conducted at Children's National Health System in Washington, DC, where active surveillance for ESBL-E colonization has been performed in the NICU since the early 1990s, when a point prevalence study revealed a colonization rate of 30%. Researchers from the hospital and George Washington University School of Medicine and Health Sciences reviewed 19 years of data to evaluate the efficacy and financial impact of active surveillance on ESBL colonization and infection in the NICU and to assess the need for continuing the practice.

The study included patients admitted to the NICU from January 1999 through March 2018. Active surveillance using rectal swabs was conducted on all patients admitted to the unit until March 2017. Overall, 171 patients were found to have ESBL-E colonization or infection, and 150 of those patients (87.7%) were detected by active surveillance. The overall incidence rate of ESBL-E colonization or infection was estimated to be 1.4 per 100 patient admissions. The hospital-acquired incidence rate was 0.41 per 1,000 patient-days; this rate had declined since 2002, with an average of six cases detected annually, and declined significantly after the unit moved into a single-bed unit featuring private rooms in 2009. Of the 150 colonized patients, 14 (9.3%) subsequently developed an infection.

The researchers estimated that active surveillance resulted in a total of 50,950 specimens being collected and that the total direct cost of processing those specimens was $127,187—an average of $848 to detect one patient colonized with ESBL-E.

"Active surveillance for ESBL-E in this setting might have contributed to the prevention of ESBL-E transmission when used in conjunction with contact precautions and private rooms, but it became increasingly costly when incidence continued to decrease," the authors of the study write. "Thus, we have decided to discontinue the active surveillance, and we continue to emphasize the use of fundamental infection control strategies, including proper hand hygiene, contact precautions, and appropriate antibiotic use, to combat antimicrobial resistance, including that of ESBL-E pathogens, in our NICU."
Oct 22 Infect Control Hosp Epidemiol abstract

News Scan for Oct 22, 2018

News brief

CDC: Suspected acute flaccid myelitis cases rise to 155

In an update today, the US Centers for Disease Control and Prevention (CDC) said state and federal health partners are investigating 28 more suspected acute flaccid myelitis (AFM) cases, raising the overall number of patients under investigation to 155.

The number of confirmed cases remained at 62 in 22 states. The latest numbers reflect cases reported to the CDC as of Oct 19. Confirming an AFM requires a review of a patient's clinical syndrome based on a diagnostic algorithm and radiographic findings.

On Oct 16, the CDC announced that health officials are investigating a spike in AFM similar to increases seen in the late summer and fall of 2014 and 2016. Symptoms of AFM, which is still extremely rare, include a polio-like sudden onset of limb weakness and decreased muscle tone that results from inflammation of gray matter in the spinal cord.

Though a large AFM epidemic occurred in 2014 alongside a national outbreak of severe respiratory illness from enterovirus D68 (EV-D68), testing of patient samples hasn't consistently found a common cause. Last week CDC officials said that, besides infectious diseases, they are looking at other potential causes, such as environmental toxins.
Oct 22 CDC AFM investigation update
Oct 16 CIDRAP News story "CDC, partners probe 127 polio-like cases in 22 states"

New MERS case reported in Riyadh as study details testing protocol

Saudi Arabia’s Ministry of Health (MOH) today reported one new MERS cases for epidemiologic week 42, which was last week.

The patient is a 53-year-old man from Riyadh. The MOH said the man had camel contact, a known risk factor for MERS-CoV (Middle East respiratory syndrome) transmission. He is hospitalized for his infection.

Since 2012, at least 2,263 cases of MERS have been recorded, including 803 fatalities.

In other MERS news, the American Journal of Infection Control published a new study showing the need for at least two nasopharyngeal samples taken at different times to positively identify MERS patients.

The study used data from 408 patients who had positive MERS-CoV test results at a referring hospital in Saudi Arabia. Conversely, two negative nasopharyngeal samples at least 48 hours apart are needed to definitively say a patient does not have MERS, according to the study authors, led by Ziad Memish, MD, one of the first to identify the coronavirus.
Oct 22 MOH report
Oct 20 Am J Infect Control study

Canada, Washington state probe Salmonella cases tied to cucumbers

Cucumbers are suspected in Salmonella illnesses reported from Canada and Washington state, though it's not clear yet if the events are related.

The Public Health Agency of Canada (PHAC) said federal and provincial health officials are investigating 45 lab-confirmed Salmonella Infantis infections in five provinces, most of them in the west: British Colombia, Alberta, Saskatchewan, Manitoba, and Quebec. The patient from Quebec had traveled to British Columbia, which has reported 37 of the cases.

According to an Oct 19 notice, PHAC said the outbreak's source hasn't been identified, but many of the people who got sick reported eating cucumbers before their illnesses began. Symptom-onset dates range from the middle of June through late September, and so far, nine people have been hospitalized. No deaths have been reported.

A food safety investigation by the Canadian Food Inspection Agency is under way, and if contaminated food products are found, it will take further steps, which would include recalling the product. So far, there are no recalls associated with the outbreak.

Meanwhile, the Washington State Department of Health (WSDH) said it is working with state, local, and federal health partners to investigate six Salmonella infections in residents from five counties: King, Snohomish, Thurston, Yakima, and Pierce. The same (unspecified) strain of Salmonella is responsible for all of the illnesses, and the last confirmed patient's symptoms began on Sep 15.

Five of the six people bought and ate English cucumbers from various Costco stores in Washington. According to the WSDH, the cucumbers linked to the infections were sold in three-packs of individually wrapped cucumbers. It urges consumers who bought English cucumbers at Costco between Aug 18 and Sep 10 and still have them in their refrigerators to throw them away.
Oct 19 PHAC notice
Oct 19 WSDH news release