ASP Scan (Weekly) for Apr 09, 2021

News brief

Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans

Australian study links rapid flu tests to reduction in antibiotic prescribing

Originally published by CIDRAP News Apr 8

Antibiotics were initiated less frequently, and antivirals used more frequently, in patients diagnosed as having influenza using rapid polymerase chain reaction (RPCR) tests compared with standard multiplex PCR (MPCR) tests, Australian researchers reported yesterday in BMC Infectious Diseases.

In the retrospective cohort study, the researchers compared outcomes in patients with positive influenza RPCR and MPCR tests at Prince of Wales Hospital in Sydney during the 2017 flu season, examining test turnaround times, antibiotic initiation, oseltamivir initiation, and hospital length of stay (LOS) for both emergency department and inpatient hospital stay.

The RPCR test introduced by the New South Wales public health system in 2017 returns results within 4 hours, while standard MPCR test results are available from 1 to 4 days. Previous research has suggested the potential for reduced antibiotic therapy and increased antiviral use with RPCR tests, but the data are limited.

Of the 484 positive test results identified by the researchers, 362 were from standard MPCR tests and 122 were from RPCR tests. The median turnaround time for the RPCR tests was 2.6 hours, compared with 22.6 hours for the MPCR tests.

Commencement of antibiotics was less frequent in the RPCR than the MPCR cohorts (51% vs 67%; odds ratio [OR], 0.52; 95% confidence interval [CI], 0.34 to 0.79). Patients at high risk of complications from influenza who were tested with RPCR tests were more likely to be treated with oseltamivir than those tested with MPCR tests (76% vs 63%; OR, 1.81; 95% CI, 1.07 to 3.08). No significant difference between the two groups was observed for hospital or emergency department LOS.

"Taken together these data show a very positive impact on appropriate antimicrobial prescribing following introduction of a RPCR influenza test at our institution," the authors wrote.
Apr 7 BMC Infect Dis study

Latin American ICUs show benefit from comprehensive stewardship

Originally published by CIDRAP News Apr 8

A study involving 77 Latin American hospitals found that medical-surgical intensive care units (MS-ICUs) with more comprehensive antimicrobial stewardship programs (ASPs) used fewer antibiotics and had fewer multidrug-resistant infections, researchers reported today in Infection Control & Hospital Epidemiology.

The study, conducted over 2 years, included a network of hospitals from nine Latin American countries. During the 6-month preintervention period, ASP members at each hospital were trained through an online course. In the following 12 months, the hospitals implemented locally salient antimicrobial stewardship strategies, and monthly point-prevalence surveys were conducted to measure the appropriateness of antimicrobial prescribing, antimicrobial consumption, mortality, and incidence of multidrug-resistant organisms in healthcare-associated infections (MDRO-HAIs). Self-assessment surveys of the ASPs (using a 0 to 100 scale) were conducted at the beginning and end of the study.

The hospitals were stratified into three groups according to the global score of the final self-assessment (ie, the 25th percentile or lower, between the 25th and 75th percentile, and the 75th percentile or higher). Overall 76.6% of the ASPs showed significant improvement in their self-assessment scores, but only 26% reached the 75th percentile or higher in the final self-assessment, and 23.4% did not improve their scores.

The point-prevalence surveys showed that the MS-ICUs in the 75th versus 25th percentiles performed better on several indicators: antimicrobial consumption (143.4 vs 159.4 defined daily doses per 100 patient-days), adherence to clinical guidelines (92.5% vs 59.3%), validation of prescriptions by pharmacists (72.0% vs 58.0%), crude mortality (15.9% vs 17.7%), and MDRO-HAIs (9.45 vs 10.96 cases per 1,000 patient-days). Only Clostridioides difficile infection rates were higher in the MS-ICUs above the 75th percentile.

"Our findings confirm that ASPs are often only partially implemented in Latin American hospitals," the study authors wrote. "This issue represents a very important challenge because institutional support, interventions to optimizing antibiotic use, monitoring and reporting processes, as well as physician education, are necessary to implement an ASP effectively."
Apr 8 Infect Control Hosp Epidemiol study

European health groups release antimicrobial resistance declaration

Originally published by CIDRAP News Apr 7

Health First Europe (HFE) and the European Patient Group on Antimicrobial Resistance (AMR Patient Group) today launched their 2021 Declaration on AMR.

The document aims to raise awareness among European citizens about the real-world impact of AMR and HAIs and to encourage patients to speak out. It also lists a range of interventions that European Union (EU) policymakers and national governments should make to address AMR from a One Health perspective.

"Drug-resistant infections know no borders—they can easily cross from humans to animals and spread from one geographic location to another," the declaration states.

The groups call for EU policymakers and member states to increase awareness and understanding of AMR and HAIs among health professionals through communication, education, and training; establish clear governance arrangements at all levels to ensure leadership, accountability, and coordination around the issue; improve infection prevention and control measures in human and animal healthcare settings; create national targets for surveillance of antibiotic use in humans and animals; and implement antibiotic stewardship programs in primary and secondary care settings.

The document also recommends that governments invest in and promote medical technologies that prevent AMR and HAIs, promote equitable access to appropriate treatments, and support activities that raise public awareness of antibiotic resistance.

The groups are inviting other European patient associations to promote the declaration.
Apr 7 HFE-AMR Patient Group declaration on AMR

Antibiotic use is significantly lower on UK organic farms

Originally published by CIDRAP News Apr 7

A survey published yesterday by the UK-based Alliance to Save Our Antibiotics and the Soil Association indicates that antibiotic use on organic livestock farms in the United Kingdom is much lower than the national average for all livestock farming.

The survey, involving data from 248 organic farms certified by the Soil Association, found that overall antibiotic use in animals on those farms (7.46 milligrams per population correction unit [mg/pcu]) was four times lower than the national average of 31 mg/pcu. On organic dairy farms, the average was less than half the level found in a national survey of dairy farms (10.66 mg/pcu vs 22.5 mg/pcu), while organic beef farms used less than a third of the antibiotics found in a national survey of beef farms (7.22 mg/pcu vs 24.5 mg/pcu).

Significantly lower antibiotic use was also found on organic sheep (five times lower), pig (77 times lower), and poultry farms (six times lower in broiler chickens), but the small sample sizes for pig and poultry farms make those figures less reliable, the report notes. Antibiotic use varied widely among the farms in the survey.

Interviews with organic farmers revealed that organic rules on antibiotic use in livestock, good nutrition, a low-stress environment, breeding specifically for health traits, and minimizing the period when animals are kept indoors during the winter were among the factors that kept antibiotic use low on their farms.

"British farmers have voluntarily cut their antibiotic use by nearly 50% in the last five years, which is very welcome, but these findings show that much lower use could still be achieved," Alliance scientific adviser Cóilín Nunan said in a press release from the group. "Organic farming has stricter rules on antibiotics which do not permit routine use or preventative mass medication. If the government is serious about tackling the antibiotic-resistance crisis, it should immediately move to end these practices on all British livestock farms."
Apr 6 Alliance to Save Our Antibiotics survey
Apr 6 Alliance to Save Our Antibiotics press release

Stewardship intervention linked to reduced fluoroquinolone use

Originally published by CIDRAP News Apr 7

Cascade reporting at a Veterans Affairs (VA) medical center in Virginia was associated with a significant decline in ciprofloxacin consumption, researchers reported yesterday in Infection Control & Hospital Epidemiology.

Cascade reporting is a strategy of only reporting antimicrobial susceptibility results for secondary, broad-spectrum agents if an organism is resistant to primary, narrow-spectrum antibiotics. The strategy, which aims to reduce unnecessary use of broad-spectrum antibiotics, was implemented at the Hunter Homes McGuire VA Medical Center in 2018 to reduce inappropriate fluoroquinolone and carbapenem use. To determine the strategy's effectiveness, researchers collected antibiotic consumption data across eight inpatient units for the 12 months before and after implementation (April 2017 through March 2019).

An interrupted time series analysis showed that consumption of ciprofloxacin, a fluoroquinolone, fell by 2.16 days of therapy per 1,000 days present per month after implementation of cascade reporting, but no significant change in levofloxacin consumption was observed. Mean monthly meropenem consumption also declined, but the slope of consumption did not significantly change, a result the study authors suggest could reflect the hospital's restriction on meropenem use during the study period. No significant changes in hospital-onset Clostridioides difficile infection rates were observed.

"Cascade reporting is a valuable tool that ASPs can deploy to encourage prescribers to select more narrow-spectrum antimicrobial agents," the authors wrote. "Further investigation is warranted to determine how cascade reporting strategies affect rates of C. difficile, antimicrobial resistance, and clinical outcomes."
Apr 6 Infect Control Hosp Epidemiol abstract

CARB-X awards funding for rapid sexually transmitted infections test

Originally published by CIDRAP News Apr 6

CARB-X announced today that it is awarding up to $3.6 million in funding to Novel Microdevices, Inc. of Baltimore to develop a rapid, portable molecular diagnostic test for sexually transmitted bacterial infections.

Novel's rapid point-of-care test, which is in the early stages of development, would be able to diagnose Neisseria gonorrhoea or Chlamydia trachomatis infections in 25 minutes from a vaginal swab or urine sample, and detect genetic mutations that indicate resistance to antibiotics. The lightweight, battery-powered device is particularly suited to low-resource healthcare settings.

The device will be eligible for an additional $10.2 million from CARB-X (the Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator) if certain project milestones are met.

"Novel's technology is in the early stages of development and, if successful, could be used world-wide to help health-care providers diagnose gonorrhea, including resistance markers, more rapidly, thus improving treatment decisions, and mitigating the devastating effects of these diseases," CARB-X research and development chief Erin Duffy, PhD, said in a press release.

Drug-resistant gonorrhea has been identified by the World Health Organization (WHO) as a high-priority pathogen.
Apr 6 CARB-X press release

Hospitals worldwide display wide variation in antibiotic consumption

Originally published by CIDRAP News Apr 5

A worldwide analysis of hospital antibiotic prescribing patterns found considerable differences between countries and regions in proportional use of Access, Watch, and Reserve (AWaRe) antibiotics, researchers reported today in the Journal of Antimicrobial Chemotherapy.

Using data collected in 2015, 2017, and 2018 by the Global Point Prevalence Survey on Antimicrobial Consumption and Resistance (Global-PPS), researchers from the University of Antwerp analyzed hospital antibiotic use at 664 hospital in 69 countries. They categorized inpatient antibiotic consumption using the AWaRe classification system, introduced by the WHO in 2017 to provide an indirect indication of the appropriateness of antibiotic use at national and global levels, then calculated proportional Access, Watch, and Reserve use by region and country. The final dataset included 80,671 patients who received at least one systemic antibiotic.

Regional use of Access antibiotics, which are first- and second-line agents that should be widely available and affordable, ranged from 28.4% in West and Central Asia to 57.7% in Oceania. Regional use of Watch antibiotics—broad-spectrum drugs that are not recommended for routine use because of their higher potential for resistance—was lowest in Oceania (41.3%) and highest in West and Central Asia (66.1%). The overall use of Reserve antibiotics, which are last-resort antibiotics, ranged from 0.03% in sub-Saharan Africa to 4.7% in Latin America.

Stratified by World Bank country classification, low-income countries had the highest Access use (62.8%) and the lowest Watch antibiotic use (36%). Beyond that, the proportion of Watch antibiotic use was 63.4% in lower-middle-income countries, 62.2% in upper-middle-income countries, and 53.1% in high-income countries. Reserve antibiotic use was highest in upper-middle-income countries (3.0%).

By country, Access use was highest in Guinea (66.7%) and lowest in Armenia (12.1%), while Watch use was highest in Armenia (87.9%) and lowest in Guinea (32.1%). Reserve antibiotic use was highest in Argentina (12.6%), India (7.8%), and Brazil (7.1%). The median Access-to-Watch ratio was 0.7.

"We observed large heterogeneity in AWaRe prescribing at country, regional and income levels," study authors conclude. "Further research on local levels, integrating contextual information, could usefully explore some of the drivers behind the prescribing patterns reported here."
Apr 5 J Antimicrob Chemother study

Dental antibiotic prescribing significantly higher in US

Originally published by CIDRAP News Apr 5

A comparison of dental antibiotic prescribing rates found that US dentists prescribe antibiotics much more frequently than those in England, Australia, and Canada, researchers reported today in Infection Control & Hospital Epidemiology.

The population-level analysis of dental antibiotic prescribing looked at pharmacy-dispensed systemic antibiotic prescriptions by dentists in the United States, England, Australia, and British Columbia in 2017. The three outcomes analyzed for each country were the rate of antibiotic prescribing per 1,000 population, the relative proportions of each antibiotic class, and the prescribing rate per 1,000 population of each antibiotic type.

Dentists in the United States prescribed 23.6 million antibiotic items in 2017, compared with 3 million in England, 0.8 million in Australia, and 0.3 million in British Columbia. US dentists also had the highest prescribing rate (72.6 antibiotic items per 1,000), more than twice the rate of Australia, which had the lowest (33.2 per 1,000). Penicillins, mainly amoxicillin, were the most prescribed antibiotic class in each country (highest at 80.5% in British Columbia and lowest at 66.8% in England). Lincosamides (eg, clindamycin) comprised the second most frequently prescribed class of antibiotics in the United States (14.3%) and British Columbia (12.4%), while nitroimidazoles (eg, metronidazole) comprised the second most frequently prescribed class of antibiotics in England (28.4%) and Australia (13.2%).

Broad-spectrum agents, such as amoxicillin-clavulanic acid and azithromycin, were most frequently used in Australia and the United States, respectively.

The study authors say the variation in dental antibiotic prescribing rates among the four countries does not seem to be explained by differences in dental health, but may be related to differences in use of prophylactic antibiotics in certain patients to reduce infection risk during invasive procedures—a frequent practice among US dentists. Whatever the reasons, they say the variation, and the frequent, unnecessary use of broad-spectrum antibiotics in all countries, is a concern.

"Dental antibiotic stewardship programs are urgently required as part of national responses to delivering the WHO global action plan on tackling antimicrobial resistance," they write. "Further research to understand locally relevant factors driving unnecessary dental antibiotic prescribing in each country is needed to support the development of context-appropriate stewardship solutions to the global problem of antibiotic resistance."
Apr 5 Infect Control Hosp Epidemiol abstract

COVID-19 Scan for Apr 09, 2021

News brief

Kidney dialysis patients 40 times more likely to be hospitalized with COVID

COVID-19 hospitalization and all-cause death rates for patients with end-stage kidney disease undergoing dialysis, as well as kidney transplant recipients, climbed steeply early in the pandemic, and both exhibited racial disparities, according to a study published yesterday in the Journal of the American Society of Nephrology (JASN).

Researchers at Hennepin Healthcare Research Institute in Minneapolis retrospectively analyzed data from the Centers for Medicare & Medicaid Services Renal Management Information System before and after the emergence of COVID-19.

The investigators found that when the hospitalization rate for COVID-19 patients undergoing dialysis peaked from Mar 22 to Apr 25, 2020, it was 40 times higher than that of the rest of the population. And the risk of death from any cause was 17% higher among those on dialysis and 30% higher among kidney transplant recipients from Mar 22 to Jul 4, 2020, than during corresponding periods in 2017 to 2019.

Black and Hispanic patients had particularly high hospitalization rates, while those undergoing at-home dialysis had lower rates than those receiving their treatments in clinics. Dialysis patients were also hospitalized 17% less often than usual for reasons other than coronavirus during the pandemic.

The authors noted that roughly 800,000 people on dialysis or living with a kidney transplant in the United States are at higher risk for COVID-19 because many visit clinics multiple times each week for dialysis or, in the case of transplant recipients, take drugs to prevent organ rejection that make them susceptible to infection.

First author Eric Weinhandl, PhD, said in an American Society of Nephrology news release that the first phase of the pandemic had "profound" effects on kidney patients. "With markedly higher rates of all-cause mortality in both dialysis and kidney transplant patients during the second quarter of 2020, there is now a clear rationale for prioritization of kidney failure patients in COVID-19 vaccination schedules promulgated by states," he said.
Apr 8 JASN study
Apr 8 American Society of Nephrology news release

Emergency staff report high stress levels during pandemic

A study in Annals of Emergency Medicine shows that emergency staff reported signs of substantial anxiety, burnout, and post-traumatic stress disorder (PTSD) during the summer months of the COVID-19 pandemic.

Researchers from the University of California San Francisco (UCSF) led the study, based on responses from 1,600 emergency department staff, including physicians, nurses, advanced practice providers, social workers, and other personnel at 20 emergency departments across the country. The study was conducted from May through July 2020.

The participants in the study were tested for COVID-19 via nasal swab polymerase chain reaction and serum antibody tests and then completed a survey. Respondents said their biggest concern during the first weeks of the pandemic was exposing their families or others to the virus.

The authors found that 19.2% of emergency staff were at risk for PTSD, and 46% reported symptoms of emotional exhaustion and burnout from their work. Female respondents were more likely than males to screen positive for increased stress, the authors found (odds ratio, 2.03; 95% confidence interval, 1.49 to 2.78).

Providing antibody serology tests and learning their immune status decreased anxiety among 54% of participants.

"As the nation moves into what many believe is a fourth wave of COVID, this study is important to our understanding of the impact of the pandemic on the mental well-being of frontline medical personnel," said lead author Robert M. Rodriguez, MD, a professor of Emergency Medicine at UCSF in a press release.

"Considering the relatively high levels of burnout symptoms, and that more than half of participants reported experiencing at least one symptom of PTSD and as many as 20 percent were at higher risk, employers should encourage workers to take time off, get adequate rest and utilize available well-being resources," said Rodriguez.
Apr 9 UCSF press release
Feb 4 Ann Emerg Med study

News Scan for Apr 09, 2021

News brief

Nigeria reports H5 avian flu infections in poultry workers

Nasal swab testing of poultry workers and handlers in recent highly pathogenic H5N1 avian flu outbreak settings in Nigeria turned up seven positive results in humans, the European Centre for Disease Prevention and Control (ECDC) said in its weekly communicable disease threat report.

So far this year, Nigeria has reported 30 H5N1 outbreaks in poultry, spanning seven states. As part of outbreak investigations, health officials tested 83 people, none of whom were experiencing symptoms.

The group included farmers, bird handlers, and traders in four states: Kano, Bauchi, Kano, and Plateau. Real-time polymerase chain reaction on 64 samples found that 7 that were positive for influenza A. Six were H5, and 1 was unsubtypable. The samples have been shipped to a World Health Organization collaborating lab in the United States for further characterization.

Investigators have also collected blood samples from 13 close contacts of people in three of the affected states.

The ECDC said different H5 viruses are circulating in West African countries, and more epidemiologic and virologic details are needed to assess the situation, but for now, it considers the risk of zoonotic spread in European countries to be very low.

So far, the human cases haven't been confirmed as H5N1, though the ECDC reported a single H5N1 case in Nigeria in 2007.
Apr 9 ECDC weekly communicable disease threat report
Jan 31, 2007, CIDRAP News story

Laos reports first human H5N6 avian flu case

Laos has reported its first human H5N6 avian flu case, the first known infection to occur outside of China.

The patient is a 5-year-old boy from Luang Probang province in the north central part of the country whose symptoms began on Feb 28, according to the weekly communicable disease threat report from the ECDC. He was hospitalized and recovered from his infection.

An investigation found that he had been exposed to poultry, which also tested positive for H5N6. No similar infections were found among his contacts at home or in the hospital.

H5N6 has been detected in poultry in China and a handful of other nations since 2014, but until the Laos case, human cases involving the strain had been detected only in China. The ECDC said the latest case raised the global total to 32, including 17 deaths. All but 5 cases involved poultry exposure, and so far the virus hasn't been linked to case clusters.
Apr 9 ECDC weekly communicable disease threat report

Three countries report more vaccine-derived polio cases

Three countries reported more polio cases this week, all involving circulating vaccine-derived poliovirus type 2 (cVDPV2), according to the latest weekly update from the Global Polio Eradication Initiative (GPEI).

In the Middle East, Afghanistan reported 5 cases, four in Zabul province and one in Badghis province, raising the country's total for the year to 28.

In Africa, Burkina Faso reported 1 cVDPV2 case, in Banfora, a city in the southwest. The case is included in the country's 2020 total, which is now 60. Meanwhile, Sierra Leone reported one more case, in Northern province, putting its total at nine.
Apr 8 GPEI update