The Centers for Disease Control and Prevention (CDC) yesterday issued its second malaria alert of the season, which includes new information about locally acquired infections, including one in Maryland that was caused by the mosquito-borne parasite linked to the most severe form of the disease.

Maryland's case, first reported on August 18 in a resident of the National Capital Region, involved Plasmodium falciparum, which can rapidly result in severe disease and death if not quickly diagnosed and treated. In contrast, the earlier locally acquired malaria cases in Florida and Texas involved Plasmodium vivax.

Florida has reported seven cases this summer, and Texas has reported just one case. No new cases for either state have been reported since the middle of July.

Raising awareness for clinicians

Given the rapid deterioration that can occur in people infected with P falciparum, the CDC urged clinicians to routinely consider malaria as a cause of fever in patients who have a history of international travel and in those with unexplained fever, regardless of travel history. It emphasized that malaria is a medical emergency and should be treated accordingly.

So far all of the US patients who had locally acquired infections were treated, with their conditions improving. Surveillance for additional cases in all three states, along with stepped-up mosquito control efforts, will continue.

For most Americans, the risk for locally malaria cases is low, but the threat is higher in areas where Anopheles mosquitoes survive over most of the year and in areas with larger numbers of people who travel internationally.

A study conducted among women in Seattle found that, despite a nearly threefold drop in ciprofloxacin prescriptions over 6 years, the amount of fluoroquinolone-resistant Escherichia coli (FQREC) circulating in the community increased, researchers reported earlier this month in Communications Medicine.

For the study, a team led by researchers at the University of Washington School of Medicine analyzed E coli–positive fecal samples collected in 2015 and 2021 from women over the age of 50 who were enrolled in the Kaiser Permanente Washington healthcare system and hadn't taken any antibiotics for at least a year. The aim of the study was to see whether a campaign to reduce the use of fluoroquinolones (ciprofloxacin) for uncomplicated urinary tract infections (UTIs) had any impact on incidence of FQREC in the gut, which is a primary reservoir for UTI-causing E coli.

Increase in resistant gut E coli

Among the target study population, the use of fluoroquinolones was significantly higher than in the total population from 2010 through 2015 (9.2%), but it drastically declined to 3.4% from 2016 through 2021. But comparison of E coli–positive fecal samples from women in 2015 and 2021 showed that the rates of gut carriage of FQREC increased from 14.2% to 19.8%.

The increase was primarily driven by an increase in isolates from the pandemic multidrug-resistant clonal group ST1193 (from 1.7% to 4.25). The other most common clonal groups in the samples were ST131-H30 and ST69; the three combined are the major causes of multidrug-resistant UTIs in women.

The researchers also observed a doubling (from 14.1% to 31.5%) of FQREC isolates with co-resistance to third-generation cephalosporins.

"Taken together, the results of our study suggest that, while increased use of antibiotics in patients can lead to the emergence of resistant isolates, the latter can continue to spread in the community even if antibiotic use is decreased," the study authors wrote.

While increased use of antibiotics in patients can lead to the emergence of resistant isolates, the latter can continue to spread in the community even if antibiotic use is decreased.

They say the findings suggest there may be a need to expand antimicrobial stewardship efforts to include screening and decolonization of vulnerable patients who are carrying antibiotic-resistant bacterial strains in their gut.

A new report from the European Centre for Disease Prevention and Control (ECDC) shows tuberculosis (TB) cases fell across the continent in 2021, but progress toward reaching TB reduction goals remains slow.

The report, published yesterday, shows that the 30 countries of the European Union/European Economic Area (EU/EEA) reported a total of 33,527 TB cases in 2021, for a notification rate of 7.4 cases per 100,000 population. That continues a downward trend observed since 2002.

But country-specific TB notification rates ranged widely, from 1.9 per 100,000 population in Iceland and Greece to 41.6 in Romania, which accounted for nearly 25% of all cases in 2021. In addition, the ECDC said the decline could reflect the continuing impact of the COVID-19 pandemic, which affected TB clinical services and surveillance around the world, resulting in fewer diagnoses.

The ECDC noted that rifampicin resistance/multidrug resistance (RR/MDR) was reported in 4.2% of 16,544 TB cases that received drug susceptibility testing, and that extensive drug resistance (XDR) was reported for 54.4% of 742 MDR-TB cases that underwent second-line drug susceptibility testing. That's up from 45.1% in 2020.

Challenges in achieving TB elimination

The ECDC also noted that, despite the decline in TB notifications, the EU/EEA is still not on track to meet the United Nations Sustainable Development Goal of 2.4 cases TB per 100,000 population by 2030, which would be an 80% reduction from the 2015 TB notification rate.

EU/EEA countries also need to improve on the treatment success rate, which was 71.7% in 2021, well below the World Health Organization (WHO) target rate of 85%.

Despite ongoing progress toward reaching the goals set by the United Nations and WHO, countries continue to face several challenges in achieving elimination.

"If the continued decline in TB incidence also observed during 2021 was real and not solely an artefact of the COVID-19 pandemic, this report indicates that despite ongoing progress toward reaching the goals set by the United Nations and WHO, countries continue to face several challenges in achieving elimination," the ECDC wrote. "Additional resources will be required to accelerate progress towards achieving these goals and to counteract any increase in TB cases resulting from the impact of the COVID-19 pandemic on TB services."

A pediatric hospital system wasted 58,607 antibiotic doses worth more than $230,000, including drugs in limited US supply, in 2 years, finds a study today in Infection Control & Hospital Epidemiology.

A team led by Emory University researchers calculated the number of wasted antibiotic doses dispensed at Children's Healthcare of Atlanta from January 1, 2020, to December 31, 2021. The system has three hospitals with more than 600 beds.

Wasted antibiotics were defined as unused doses returned to the pharmacy and unable to be reassigned. Such drugs include those in intravenous (IV) solutions and doses based on patient weight.

8 of 10 wasted drugs in shortage

During the study, 58,607 antibiotic doses ordered for 17,319 patients were wasted, for an average of 80 daily doses and 169 doses per 1,000 patient-days. Nearly all (99.4%) of the doses were either IV or suspension solutions and the syringes needed to deliver them; the remaining doses were tablets.

A total of 23% of doses were ordered on the first or second day of hospitalization, and 36% were ordered on the day of hospital release. Ten antibiotics made up 77% of the wasted doses, led by ampicillin (13%), clindamycin (13%), and cefazolin (9%). Eight of the 10 most-wasted antibiotics were currently in shortage or were in shortage in the past 3 years.

General pediatric prescriptions made up 41% of doses, followed by critical care (9%), hematology/oncology (8%), and surgery (6%). Total weight of the wasted doses, syringes, and carrier fluid was 2,508 kilograms (5,529 pounds).

The amount of waste is high, partially avoidable, with no contribution to improving patient outcomes.

Estimated cost of the waste was $255,503. The syringes and normal saline totaled $14,570 and $7,805, respectively, and the antibiotics cost $233,128. The five most expensive drugs wasted per milligram, totaling $36,541, were tigecycline (5 doses), ceftaroline (84), ceftazidime-avibactam (30), ertapenem (16), and IV sulfamethoxazole-trimethoprim (163).

"The amount of waste is high, partially avoidable, with no contribution to improving patient outcomes," the authors wrote. "High-priority targets to use antibiotic resources wisely include empiric optimization to minimize drug changes within 24 hours of admission and planning around the time of discharge."

China has reported H9 avian flu, likely H9N2, in a 4-year-old girl from Sichuan province, Hong Kong's Centre for Health Protection said in its weekly update.

The girl's symptoms began on August 7, and the report did not say how she was exposed to the virus. Sichuan province is in southwestern China.

If the infection is confirmed as H9N2, it will be China's first since late June. The country has reported four such cases over the past 6 months.

The virus circulates in poultry in some Asian countries. Illnesses in humans are usually mild and are more likely to be reported in children, especially those who have contact with domestic poultry or their environments.