The number of cases in an ongoing Salmonella outbreak tied to whole and cut-up cantaloupe has more than doubled—to 230 cases—and a third death has been reported. In addition, almost 100 people have been hospitalized, the Centers for Disease Control and Prevention (CDC) said yesterday in an update.

Since the CDC's previous update on November 30, 113 more illnesses have been confirmed, and 4 more states are affected, bringing the total to 38 states. At least 96 people have been hospitalized, including 35 new case-patients. The new outbreak-related death was in Oregon; the previous two were in Minnesota.

Illness-onset dates range from October 16 to November 20. Patients range in age from infants to 100 years old, 54% are male, and 85% are White. Minnesota has the most cases (20), followed by Wisconsin (18), and Arizona (15).

"The true number of sick people in this outbreak is likely much higher than the number reported, and the outbreak may not be limited to the states with known illnesses," the CDC said. "This is because many people recover without medical care and are not tested for Salmonella. In addition, recent illnesses may not yet be reported, as it usually takes 3 to 4 weeks to determine if a sick person is part of an outbreak."

Multiple recalls

Officials have detailed multiple recalls related to the outbreak, including Malichita and Rudy brand whole cantaloupes. Brands included in those recalls are Trufresh, Crown Jewels, and Pacific Trellis. Affected whole cantaloupes might have a sticker that says "Malichita" or "Rudy," with the number 4050, and "Product of Mexico/produit du Mexique."

Recalls also include precut fruit products made with recalled whole cantaloupes and sold by Kwik Trip, TGD Cuts, Freshness Guaranteed and RaceTrac, Vinyard, Kroger, Sprouts Farmers Market, Trader Joe's, Cut Fruit Express, Aldi, and Bix Produce.

All cantaloupe recalls are listed on the Food and Drug Administration's cantaloupe recall website.

"Do not eat pre-cut cantaloupes if you don't know whether Malichita or Rudy brand cantaloupes were used," the CDC said. "This includes cantaloupe chunks and fruit mixes with cantaloupes at restaurants and grocery stores."

A mixed-methods study highlights the importance that knowledge, infrastructure, institutional support, and relationships among clinical teams play in effective antibiotic stewardship, researchers reported this week in Clinical Infectious Diseases.

For the study, a team led by researchers from the University of Utah School of Medicine conducted surveys, document and data analysis, and semi-structured interviews with antibiotic stewardship and clinical stakeholders at seven hospitals in Michigan and the Mountain West that were categorized as high-, medium-, or low-performing on antibiotic overuse at discharge. The aim was to identify the organizational characteristics that differentiate hospitals with low versus high antibiotic overuse.

The analysis of surveys, documents, and interviews with 90 stakeholders across the hospitals (31 hospitalists, 33 clinical pharmacists, 14 stewardship leaders, and 12 hospital leaders) identified four contextual factors that varied between hospitals with low versus high antibiotic overuse: robust knowledge of and access to antibiotic stewardship guidance, high-quality clinical pharmacist-physician relationships, tools and infrastructure to support stewardship, and highly engaged infectious diseases physicians who advocated for stewardship principles.

Relationships and institutional support

The study authors say that while many efforts to improve antibiotic prescribing focus on the behavior of individual physicians, these findings suggest that such a strategy is likely insufficient.

"Relationships and the roles that stewardship stakeholders play also matter," they wrote. "Efforts to improve how decisions are made about antibiotics require attention to the knowledge, interactions between stakeholders, and systems in place to support stakeholders."

Based on the findings, the authors say that hospitals can encourage high performance on antibiotic prescribing by maintaining updated and accurate clinical guidelines, finding ways to improve face-to-face interactions between clinical pharmacists and physicians, engaging end-users in the design and implementation of stewardship tools, and providing institutional support for antibiotic stewardship programs.

Efforts to improve how decisions are made about antibiotics require attention to the knowledge, interactions between stakeholders, and systems in place to support stakeholders.

Three countries reported new polio cases this week, including Pakistan, which recorded another wild poliovirus type 1 (WPV1) case, according to the latest update from the Global Polio Eradication Initiative (GPEI).

Pakistan's latest case—its sixth of the year—was reported from Khyber Pakhtunkhwa, the country's hot spot. GPEI said intensified efforts are under way in the province, focusing on its southern region to stop WPV1 transmission.

Elsewhere, two African nations reported more vaccine-derived polio cases. The Democratic Republic of the Congo (DRC) reported 7 more circulating vaccine-derived poliovirus type 1 (cVDPV1) cases from two different provinces, raising that total to 90 for the year. Also, the country reported one more case involving circulating vaccine-derived poliovirus type 2 (cVDPV2), pushing that total to 109.

Nigeria reported 12 more cVDPV2 cases, 5 each from Kebbi and Sokoto and 2 from Kaduna, raising the country's total to 55.