ASP Scan (Weekly) for Oct 22, 2021

News brief

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

Data show low antibiotic prescribing, UTI misdiagnosis on mental health units

Originally published by CIDRAP News Oct 21

A review of antibiotic prescribing at Veterans' Health Administration (VHA) mental health units found that only 1 in 10 patients were exposed to antibiotics, but urinary tract infections (UTIs) appeared to be frequently misdiagnosed, researchers reported today in Infection Control & Hospital Epidemiology.

In the study, researchers from the Iowa City VA Health Care System looked at data on inpatient and post-discharge antibiotics at 111 VHA mental health units from 2016 through 2018. They also conducted chart reviews for a subset of patients to assess adherence to standard recommended practices and professional guidelines for UTIs, cystitis, skin and other soft-tissue infections (SSTIs), and acute respiratory infections (ARIs).

During the study period, 27,401 (10.9%) of 252,588 admitted patients had an antibiotic administered while hospitalized on the mental health unit. The median inpatient antibiotics days of therapy across all 111 units was 73.5 per 1,000 days present. The infections most commonly associated with an antibiotic prescription were UTIs (18.3%), SSTIs (10.9%), and ARIs (7.1%).

Chart review found that, among 111 UTI cases, 63 (56.8%) were not supported by patient history or laboratory findings, and in 24.3% of UTI cases, the presence of altered mental status appeared to be the driver of antibiotic therapy, even though antibiotics are not recommended for bacteriuria in the context of cognitive impairment alone.

"Overall, these findings suggest that UTI is commonly misdiagnosed and therefore represent an optimal target for stewardship efforts," the study authors wrote.

The study also found that 25.3% of the antibiotic recommendations were made by emergency department physicians, and 27.8% by internal medicine physicians, a finding the authors say suggests that these specialties should be included in any efforts to improve antibiotic prescribing at VHA mental health units.
Oct 21 Infect Control Hosp Epidemiol abstract

WHO urges greater linkages between AMR, sustainable development

Originally published by CIDRAP News Oct 20

The World Health Organization yesterday released guidance on how the United Nations (UN) can incorporate antimicrobial resistance (AMR) into its Sustainable Development Goals (SDGs).

The document, which was developed by the WHO in collaboration with the World Organisation for Animal Health, the UN Food and Agriculture Organization, and the UN Environment Programme, lays out the case for why AMR and sustainable development are interconnected. It notes that progress in many of the SDGS, such as improved access to clean water and sanitation, sustainable food production, and appropriate use of antimicrobials in humans and animals, will help address AMR. At the same time, rising levels of AMR threaten the ability to achieve the SDGs for health, poverty reduction, food security, and economic growth.

To help stimulate action on AMR and help support the implementation of the UN's 2030 Agenda for Sustainable Development, the document calls on the UN to include AMR as a risk in the Common Country Analysis (CCA), in which countries collect national-level data on development issues, and the Cooperation Framework, which requires countries to identify areas with the greatest potential for transformative and inclusive development.

"Integration of AMR into CCAs and then into the Cooperation Framework should be a priority, given the risk AMR poses to sustainable development in countries, and the capacity of the UN and other organizations to support collaborative and impactful actions to address the issue," the document states. "AMR should be meaningfully linked to broader development issues such as One Health, pandemic preparedness and response, UHC [universal healthcare], sustainable food systems and environmental issues."

The document proposes that concrete AMR outputs for improved data collection, coordination, regulation, and prevention be included in the Cooperation Framework.
Oct 19 WHO guidance

Resistant ICU infections linked to longer hospital stays, excess costs

Originally published by CIDRAP News Oct 18

Antibiotic-resistant infections acquired in the intensive care unit (ICU) were associated with significant increases in excess hospital days and healthcare costs in three southern European countries, according to a study published today in Infection Control & Hospital Epidemiology.

Using data from the European Surveillance System, researchers studied a cohort of adult patients who developed ICU-acquired infections related to an invasive procedure at hospitals in Spain, Portugal, and Italy from 2008 through 2016. They used regression, matching, and time-to-event methods to analyze the association between antibiotic-resistant infections and excessive length of stay (LOS), controlling for several confounding factors and time-dependent biases. They also calculated the associated economic burden of excess resource utilization for each country.

In total, 13,441 patients were included in the analysis. Of these patients, 4,106 (30.5%) were infected with antibiotic-resistant organisms and matched 1:1 to patients with susceptible infections. The median age of all patients was 62 years. In the fully adjusted estimates, the association between resistance status and excess LOS was 2.76 days in the linear model (95% confidence interval [CI], 1.98 to 3.54), 2.60 days in the matched model (95% CI, 1.66 to 3.55), and the hazard ratio was 1.15 in the Cox regression model (95% CI, 1.1 to 1.19).

These estimates, alongside the prevalence of resistance, translated into direct hospitalization attributable costs per ICU-acquired infection of 5,224€ (US $6,066) for Spain, 4,461€ (US $5,180) for Portugal, and 4,320€ (US $5,016) for Italy.

"These results contribute significantly to the antimicrobial resistance literature that explores the consequences of resistance on health and economic outcomes," the study authors write.
Oct 18 Infect Control Hosp Epidemiol abstract

Elbow bumps may transfer MRSA just as much as fist bumps

Originally published by CIDRAP News Oct 18

In another study today in the same journal, researchers from the Cleveland VA Medical Center reported that both a fist bump and an elbow bump are associated with frequent transfer of methicillin-resistant Staphylococcus aureus (MRSA).

Elbow bumps have been increasingly used as greetings over fist bumps and handshakes with the idea that they lessen the potential for pathogenic microorganism transfer. To test this hypothesis, the researchers enrolled 40 patients in isolation for MRSA colonization and paired them with a research staff member wearing sterile gloves and a piece of cotton cloth over their elbows. Each MRSA-colonized patient performed one greeting with a staff member using their right fist or elbow, and one greeting using their left fist or elbow, with the order of the greetings alternating among consecutive participants. The researchers then analyzed the fists and elbows of the MRSA-colonized patients, along with the gloves and elbow cloth from the staff members, for the presence of MRSA.

The results showed no significant difference in the frequency of MRSA transfer for the fist bump compared with the elbow bump (10 of 40 [25%] vs 6 of 40 [15%]). Even so, MRSA was recovered more frequently from the fist versus the elbow of the MRSA-colonized patients (16 of 40 [40%] vs 9 of 40 [22.5%]). Also, significantly more MRSA colonies were recovered from fists compared with elbows, and more MRSA colonies were transferred via fists.

The study authors note that the findings of the study suggest that noncontact greetings should be encouraged instead. "In addition to promoting noncontact greetings, there is a need to improve patient hand hygiene and to identify other strategies to reduce transfer of pathogens by hands and clothing," they write.
Oct 18 Infect Control Hosp Epidemiol abstract

COVID-19 Scan for Oct 22, 2021

News brief

Risk factors linked to severe pediatric COVID-19

Two recent studies in Pediatrics look at risk factors for severe pediatric COVID-19 and COVID deaths in those younger than 21 years of age.

The first study, which was published in the October print issue, involved 2,293 US children hospitalized for COVID-19 across 14 states from March 2020 to May 2021. About 30% had severe COVID-19, and 0.5% died. Increased risk factors for severe COVID-19 were stratified across two-age groups: those less than 2 years (32.5% of the cohort) and those who were 2 to 17 years (67.5%).

The younger group had increased risk associated with chronic lung disease (adjusted risk ratio [aRR], 2.2.), neurologic disorders (aRR, 2.0), cardiovascular disease (aRR, 1.7), prematurity (aRR, 1.6), and airway abnormality (aRR, 1.6), while severe COVID-19 was linked to feeding tube dependence (aRR, 2.0), diabetes (aRR, 1.9), and obesity (aRR, 1.2) in the older group.

Overall, 12.0 children among 100,000 had severe COVID-19, with the highest instances among infants, Hispanic children, and Black children. Children with at least one underlying medical condition had an aRR of 1.5, although severe disease was significantly less likely in those younger than 6 months (aRR, 0.7).
Oct 21 Pediatr study

The second study looked specifically at 112 COVID-19 deaths in those younger than 21 and found that they mostly occurred in older adolescents (median age, 17 years), males (63%), Black people (28%), or Hispanic people (46%). About 86% of the patients had underlying health issues, and the most common were obesity (42%), asthma (29%), and developmental disorders (22%).

Multi-inflammatory syndrome in children received its Centers for Disease Control and Prevention case definition on May 14, 2020, and the researchers found that those with MIS-C were more likely to not have underlying health conditions. However, they add, the MIS-C criteria at the time of the study included severe illness requiring hospitalization, which may have affected the death rate of MIS-C patients.

The researchers created the cohort using reports submitted by 25 of 55 US jurisdictions from Feb 12 to Jul 31, 2020.
Oct 22 Pediatr study

COVID-19 vaccine mandates increase uptake, study says

Vaccine mandates increase uptake, according to a study published in Scientific Reports yesterday. The researchers ran four small experiments looking at vaccine mandate/normalization scenarios, attitudes, and current behavior toward the COVID-19 vaccine in winter and spring 2021.

The first involved 299 people who were asked if they would get the COVID-19 vaccine if it were required for work, travel, or school, and then if they would get it today if it were free. Overall, 86% said they would get it if it were mandated, but only 68% said they would receive the vaccine today. After stratifying the data by race—105 White, 95 Black, and 89 Hispanic people—the gaps between mandate prediction and current behavior ranged from 14 to 24 percentage points, with the mandate resulting in higher uptake in every instance.

The second study involved 359 people who were presented with a hypothetical new employer's attitudes or mandates regarding a vaccine against a new disease, while the third study looked at how 357 people behaved under free choice and mandated scenarios in relation to vaccination norms (eg, population uptake). Results from both suggested that mandates resulted in equal or stronger vaccine uptake, even when people reacted negatively to the mandate.

The last study involved 606 people representative of the US population. Examining vaccination intention, perceived benefits, perceived norms, perceived fairness, and perceived obligation, the researchers found that vaccination mandates resulted in stronger intentions to vaccinate (M = 3.59, SE = 0.07) compared with describing it as a free choice (M = 3.36, SE = 0.07), with similar results observed regardless of any negative psychological reaction to the mandate. Among those who did react negatively to mandates, the researchers note their opinions on the vaccine's benefits did not change, and they felt less moral obligation.

"Our experiments show very clearly that these requirements do not have any negative effects on vaccination intentions," said lead author Dolores Albarracín, PhD, in a University of Pennsylvania press release. "Actually, they have positive effects across various ethnic groups and for people who have a tendency to oppose anything seemingly forced on them."
Oct 21 Scientific Reports study
Oct 21 University of Pennsylvania press release

News Scan for Oct 22, 2021

News brief

CDC finds melioidosis-causing bacteria in aromatherapy room spray

The Centers for Disease Control and Prevention (CDC) said today that lab tests have identified a rare, potentially deadly bacterium in an aromatherapy spray.

The bacterium, Burkholderia pseudomallei, causes melioidosis, and the CDC believes the spray—"Better Homes & Gardens Lavender & Chamomile Essential Oil Infused Aromatherapy Room Spray with Gemstones"—may be linked to four cases of melioidosis reported earlier this year in Georgia, Kansas, Texas, and Minnesota. A bottle of the spray was found in the home of a Georgia resident who became ill with melioidosis in late July, the agency said in a news release.

The CDC says it is testing the genetic fingerprint of the bacteria in the spray to see if it matches the bacteria found in the four patients, two of whom have died. The agency has also reached out to health departments in Minnesota, Kansas, and Texas to determine whether the patients in those states may have used the product.

The first case of melioidosis was identified in March, the second and third in May, and the fourth in July. Based on genomic analysis, the CDC has said in a previous Health Alert Network (HAN) update that it suspected the cases may share a common source of exposure. The CDC says the strain of B pseudomallei that sickened the four patients is genetically similar to strains usually found in South Asia. None of the patients traveled outside the country, but the aromatherapy spray was made in India.

Melioidosis, which causes a range of nonspecific symptoms that can be confused with the flu or a common cold, is rare in the United States. Most cases are typically found in South and Southeast Asia and Northern Australia. The four patients' initial symptoms ranged from cough and shortness of breath to fatigue, nausea, vomiting, intermittent fever, and rash on the trunk, abdomen, and face.

The Consumer Product Safety Commission and Walmart have issued a recall for the lavender and chamomile room spray, along with five other scents in the same product line. Walmart sold the spray at 55 stores, and on its website, until Oct 21.

The CDC recommends that anyone who has the spray in their home stop using it, return the double-bagged and boxed product to a Walmart store, and wipe down and clean any surfaces, sheets, or linens that may have been sprayed.
Oct 22 CDC press release
Jun 30 CDC HAN update

US and Austria report variant flu cases

The CDC reported two variant flu cases in children today, and Austria recently reported a variant case, according to a weekly infectious disease report from the European Centre for Disease Prevention and Control (ECDC).

One of the US cases involves a variant H1N1 (H1N1v) infection in North Dakota, and the other involves a variant H3N2 (H3N2v) infection in Ohio. Both occurred during the 2020-21 flu season. Neither patient was hospitalized, and both are recovered or are recovering from their illnesses.

One patient had close contact with pigs before he or she got sick, and the other had no known contact, which raises the possibility of limited human-to-human transmission. However, no ongoing transmission has been found with either case.

The two infections bring the number of variant flu cases for the past flu season to 11. Six were H1N1v, 3 were H1N2v, and 2 were H3N2v. So far, 1 variant case—which involved H3N2v—has been reported for the new flu season that began earlier this month.

Elsewhere, Austria reported an H1N2v case involving a patient who was sick in September. The patient, who has recovered, is an adult and lives on a farm where pigs are raised. No other human infections were found. So far for 2021, four variant flu cases have been reported from four European Union countries.
Oct 22 CDC FluView report
Oct 22 ECDC weekly communicable disease threat report

Three African nations add to vaccine-derived polio totals

Three African countries reported more polio cases this week, all in Africa and all involving circulating vaccine-derived poliovirus type 2 (cVDPV2), the Global Polio Eradication Initiative (GPEI) said in its latest weekly update.

Nigeria reported the most, with 37 cases reported from 12 different states. Fourteen were from Kebbi. So far this year, the country has reported 224 polio cases.

Elsewhere, Senegal reported one more case, which is from Diourbel, lifting its total for the year to 15. Somalia also reported on more case, marking its first case for 2021 after having reported 14 in 2020. The patient is from Middle Juba region in the south of the country.
Oct 21 GPEI update