Stewardship / Resistance Scan for Oct 29, 2018

News brief

Study finds substantial decline in pediatric Staphylococcus infections

Staphylococcus aureus hospitalizations at US pediatric hospitals fell by 36% from 2009 to 2016, with methicillin-resistant S aureus (MRSA) declining by 52%, with a corresponding drop in antibiotic use, according to a study today in Infection Control and Hospital Epidemiology.

The retrospective cohort study was conducted at 39 US pediatric hospitals using the Pediatric Health Information Systems administrative database and was limited to patients under 18 years of age who had an S aureus infection indicated in the electronic medical record. Annual rates for S aureus overall, MRSA, and methicillin-susceptible S aureus (MSSA) were calculated per 1,000 admissions.

Among the 39 hospitals, investigators identified 116,152 S aureus hospitalizations from 2009 to 2016. During the period, the annual S aureus rate fell from 26.3 to 16.8 infections per 1,000 admissions (P < .001), with MRSA decreasing from 14.4 to 6.9 infections per 1,000 admissions (P < .001) and MSSA infections falling 17% (from 11.9 to 9.9 infections per 1,000 admissions; P < .001). The proportion of S aureus infections that were MRSA dropped from 55% in 2009 to 41% in 2016. In addition, days of therapy for anti-MRSA antibiotics declined from 38.0 to 24.4, with the most notable decreases for clindamycin (14.32 to 7.5) and vancomycin (16.6 to 10.8).

The authors of the study suggest that a number of factors may contribute to the decreases, including earlier recognition of S aureus infections and initiation of appropriate therapy in outpatient settings, but they say more research is needed to fully understand what's driving the epidemiologic changes.
Oct 29 Infect Control Hosp Epidemiol abstract


US Candida auris cases continue to rise

The number of confirmed and probable cases of Candida auris in the United States has jumped to 463, according to the latest update from the Centers for Disease Control and Prevention (CDC), up from 349 in July.

As of Sep 30, infections caused by the multidrug-resistant fungus have been identified in 11 states, with the vast majority of confirmed cases reported in New York (239), New Jersey (94), and Illinois (80). Cases have also been reported in Massachusetts (7), Florida (4), Maryland (3), Oklahoma (2), California (1), Connecticut (1), Indiana (1), and Texas (1). Of the 463 clinical cases identified, 433 are laboratory-confirmed and 30 are listed as probable.

The CDC also said that targeted screening in six states with clinical cases has identified an additional 801 patients who are colonized with C auris. The screening is being conducted as part of an effort to control the spread of the fungus, which can persist on surfaces in healthcare facilities and spread between patients.

Originally identified in Japan in 2009, C auris has caused outbreaks in healthcare settings in more than 20 countries and has shown resistance to the three major classes of antifungal drugs used to treat Candida infections. In patients with compromised immune systems, it can cause serious invasive infections affecting the bloodstream, heart, brain, ear, and bones. The CDC estimates that 30% to 60% of patients with invasive C auris infections have died.

C auris was made a nationally notifiable condition at the 2018 Council for State and Territorial Epidemiologists annual conference in August.
Oct 23 CDC C auris case count page

News Scan for Oct 29, 2018

News brief

New MERS case recorded in Saudi Arabia

Saudi Arabia's Ministry of Health (MOH) today reported one new MERS-CoV case for epidemiologic week 44. The MOH did not note any cases in epidemiologic week 43, which was last week.

The new case of MERS-CoV (Middle East respiratory syndrome coronavirus) occurred in a 74-year-old man from Riyadh who had contact with camels—a known risk factor for MERS transmission. The man is currently hospitalized.

Since 2012, at least 2,264 cases of MERS have been recorded, including 803 fatalities.
Oct 29 Saudi MOH report


New Jersey reports 9th pediatric adenovirus death as cases climb to 26

The New Jersey Department of Health (NJ Health) yesterday reported a new death in an at-risk child who had an adenovirus infection, bringing to nine the number of deaths in an outbreak that has now reached 26 cases.

"Another medically fragile child with respiratory illness at the Wanaque Center for Nursing and Rehabilitation in Haskell unfortunately passed away at a hospital late last night," NJ Health said in a news release. The child had become ill on Oct 22 and had a confirmed case of adenovirus 7, the outbreak strain.

The outbreak includes 25 cases involving residents of the facility, who range in age from toddlers to young adults, but the vast majority of them are children—plus 1 staff member at the center. The staff member has since recovered, NJ Health said. All the deaths have involved children.

The residents began developing symptoms from Sep 26 to Oct 22. All had severely compromised immune systems and respiratory problems before the outbreak began, NJ Health said.

"We are working every day to ensure all infection control protocols are continuously followed and closely monitoring the situation at the facility," said NJ Health Commissioner Shereef Elnahal, MD, MBA. On Oct 27 Elnahal said in a news release, "The type of adenovirus virus involved in this outbreak (#7) is associated with communal living arrangements and is known to cause severe illness—especially in those with compromised immune systems."
Oct 28 NJ Health news release
Oct 27 NJ Health news release


Study highlights flaws in California's vaccine exemption law

Although kindergarten vaccination coverage went up substantially after California in 2015 passed a law eliminating personal belief vaccine exemptions, medical exemptions since then have more than tripled and health officers have voiced frustration over the lack of authority to review such exemptions and other problems, according to a study today in Pediatrics.

California passed Senate Bill 277 (SB277) in 2015 to abolish all nonmedical exemptions to schoolchildren receiving vaccinations. For the 2014-15 school year, kindergarten vaccination coverage in the state was 90.4%, but by 2016 it rose to 95.1%, according to a commentary that accompanied the study.

For the study, researchers in August and September 2017 conducted 34 interviews with 40 health officers and immunization staff in 35 of California's 61 local health districts. Noting that the rates of medical exemptions in the state after the passage of SB277 increased 250% (from 0.2% in 2015-16 to 0.7% in 2017-18), the investigators wanted to dig deeper into the rise of medical exemptions and the ramifications.

They found several problems highlighted during the interviews, including a lack of authority to validate or question the growing number of medical exemptions—even those that seemed highly dubious—and the fact that only five local jurisdictions actively tracked medical exemptions received by schools, and one of those jurisdictions was sued for those efforts.

One health officer expressed frustration thus: "The law didn't give the health officer any role, and I'll tell you how ridiculous this is. In comparison with the fact that I have to review dog rabies vaccine exemption requests and I get to see medical records of dogs and I have the authority to disapprove requests for exemptions for rabies vaccines…and for people, we don't have that authority." Other health officers said it was unfair for school staff to review exemptions.

Another spotlighted a healthcare provider who was apparently profiting from the law by having patients return for a renewed medical exemption every 3 months, at $300 a pop. One primary care physician granting exemptions was "like a medical marijuana dispensary," according to the interviews. The health officer detailing the lawsuit called it a scare tactic and said it did not deter their efforts.

In the commentary, Richard J. Pan, MD, MPH, and Dorit Rubinstein Reiss, LLB, PhD, said, "Pediatricians can partner with public health advocates and pro-science parents to pass laws that empower public health officers to protect our children and community. Every child needs community immunity."
Oct 29 Pediatrics study
Oct 29 Pediatrics commentary

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