COVID-19 Scan for Aug 28, 2020

News brief

Coinfections with COVID-19, Candida auris confirmed in India

Scientists in New Delhi, India, report infections with worrisome multidrug-resistant Candida auris in 10 of 15 critically ill COVID-19 patients who also had candidemia over a span of several months, according to a report yesterday in Emerging Infectious Diseases.

After the authors predicted in June that C auris would be a problem during this pandemic, they analyzed samples from 596 intensive care unit patients, 420 of whom (70.5%) required mechanical ventilation. They detected Candida in the blood of 15 patients (2.5%), and C auris was the predominant pathogen in 10 of them.

Eight of the patients were 66 or older, and seven were men. The younger patients were 25 and 52. They required hospital stays of 20 to 60 days, but with a median of 21 days. Six patients died, underscoring the danger of both COVID-19 and this deadly fungal infection. The authors say the patients were probably infected during hospitalization.

Three of the C auris isolates were multi-azole resistant and 7 were multidrug resistant, including 3 that were resistant to three classes of antifungal drugs and 4 that were resistant to two classes. All isolates were resistant to fluconazole but susceptible to echinocandins.

The authors conclude, "Critically ill COVID-19 patients with C. auris infection tend to have concurrent conditions (e.g., diabetes mellitus, chronic kidney disease) and risk factors (e.g., need for mechanical ventilation, receipt of steroids). To reduce complications, admission times in overburdened hospitals, and death rates among COVID-19 patients, identifying and treating C. auris infections is vital."
Aug 27 Emerg Infect Dis study

 

COVID-related inflammatory syndrome reported in kids in Iran, Chile

A rare but serious complication from pediatric COVID-19 infection is MIS-C (multisystem inflammatory syndrome in children), and two new studies describe the first cases of the syndrome in Iran and Chile.

MIS-C, which can look like Kawasaki disease, toxic shock syndrome, or sepsis, has been described in Europe and the United States during the current pandemic, but it has been rare in the Middle East and South America.

Today, in Epidemiology & Infection, Iranian investigators outline the first reported MIS-C cases in Iran. The study details 45 cases detected in Iran's three largest pediatric hospitals from Mar 7 to Jun 23. The median age of patients was 7. Ten cases (22%) had positive SARS-CoV-2 polymerase chain reaction tests upon hospital admission, and five of the patients with MIS-C died.

Forty-one patients (91%) presented with fever, 58% with abdominal pain, 51% with nausea or vomiting, and 53% with a rash. Signs of cardiovascular and renal failure were common, with 56% of patients showing cardiac involvement and 29% having dilated coronary arteries.

In Chile, 27 children with MIS-C detected in three Santiago hospitals from May 1 to Jun 24 were included in a study published yesterday in the International Journal of Infectious Diseases. The average age of case-patients was 6. No children died, but 59% required admission into the intensive care unit. Though gastrointestinal complaints were the most common symptom, 12 patients (44%) showed cardiac abnormalities during their hospital stay.

There is no known treatment for MIS-C, but in both countries most patients were treated with  intravenous immunoglobulin and corticosteroids, with generally positive responses.
Aug 28 Epidemiol Infect study
Aug 27 Int J Infect Dis study

News Scan for Aug 28, 2020

News brief

New DRC Ebola case brings outbreak total to 107, including 47 deaths

One more Ebola infection has been confirmed in the Democratic Republic of the Congo (DRC) Equateur province outbreak, raising the overall total to 107, the World Health Organization (WHO) African regional office said on Twitter today.

Also, 1 more death was reported, raising the fatality count to 47. The developments are part of a small but steady rise in cases in an outbreak that spans a wide geographic area, where an outbreak in 2018 sickened 54 people, 33 of them fatally.

The Equateur province outbreak is the DRC's 11th and began in June, just as a large outbreak in the western part of the country was declared over. The two outbreaks aren't thought to be related.
Aug 28 WHO African regional office tweet

 

CDC: 10 more Salmonella cases, 78 total, linked to peaches

The Centers for Disease Control and Prevention (CDC) said yesterday that 10 more people in 3 more states have been sickened with Salmonella in an ongoing outbreak linked to peaches. The outbreak total now stands at 78 cases in 12 states.

Twenty-three people have been hospitalized, and no deaths have been reported. Minnesota has the most cases, with 23, followed by Michigan (17), New York (9), Iowa (8), New Jersey (7), Wisconsin (5), and Virginia (3). Connecticut, Kentucky, Maryland, and Missouri have each recorded a single case.

Illness-onset dates range from Jun 29 to Aug 3, and 84% of 45 patients interviewed said they ate peaches in the week prior to developing symptoms.

"Do not eat, serve, or sell recalled peaches packed or supplied by Prima Wawona or Wawona Packing Company LLC, or food made with these peaches," the CDC said in a statement. Prima Wawona and Wawona Packing Company have now recalled bagged and loose peaches, organic peaches, and serval retailers have recalled items made with the peaches, including peach salsa. Aug 27 CDC update
Aug 27 CDC statement

 

Six countries report more vaccine-derived polio cases

Six countries reported more polio cases, all involving circulating vaccine-derived poliovirus type 2 (cVDPV2), the Global Polio Eradication Initiative (GPEI) reported in its weekly update yesterday.

In the Middle East, Afghanistan reported 2 cVDPV2 cases, both in Nangahar province, raising its total for the year to 54.

The rest of the countries reporting new cases are in Africa. Benin reported one more case, which involves a patient from Zou province and is its second case of 2020. So far all of the country's cases are linked to Nigeria's Jigawa state outbreak. Chad also reported one new cVDPV2 case, which affected a patient from Longone Occidental province, bringing its total for the year to 56 from two separate outbreaks.

The DRC reported 2 more cases, both in Equateur province, which is grappling with an Ebola outbreak. So far, the DRC has reported 25 cases this year. Somalia reported 1 more case, which involves a patient from Banadir province, lifting its total to 2 for 2020.

And finally, Sudan, where the virus recently reemerged for the first time since 2009, reported 11 new cases in eight provinces, raising its total to 13. All are linked to the virus circulating in Chad.
Aug 27 GPEI update

ASP Scan (Weekly) for Aug 28, 2020

News brief

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

Co-infections with COVID-19, Candida auris confirmed in India

Scientists in New Delhi, India, report infections with worrisome multidrug-resistant Candida auris in 10 of 15 critically ill COVID-19 patients who also had candidemia over a span of several months, according to a report yesterday in Emerging Infectious Diseases.

After the authors predicted in June that C auris would be a problem during this pandemic, they analyzed samples from 596 intensive care unit patients, 420 of whom (70.5%) required mechanical ventilation. They detected Candida in the blood of 15 patients (2.5%), and C auris was the predominant pathogen in 10 of them.

Eight of the patients were 66 or older, and seven were men. The younger patients were 25 and 52. They required hospital stays of 20 to 60 days, but with a median of 21 days. Six patients died, underscoring the danger of both COVID-19 and this deadly fungal infection. The authors say the patients were probably infected during hospitalization.

Three of the C auris isolates were multi-azole resistant and 7 were multidrug resistant, including 3 that were resistant to three classes of antifungal drugs and 4 that were resistant to two classes. All isolates were resistant to fluconazole but susceptible to echinocandins.

The authors conclude, "Critically ill COVID-19 patients with C. auris infection tend to have concurrent conditions (e.g., diabetes mellitus, chronic kidney disease) and risk factors (e.g., need for mechanical ventilation, receipt of steroids). To reduce complications, admission times in overburdened hospitals, and death rates among COVID-19 patients, identifying and treating C. auris infections is vital."
Aug 27 Emerg Infect Dis study

 

Study: Feedback, education reduced antibiotic prescribing in telemedicine

Originally published by CIDRAP News Aug 27

Individualized prescribing feedback and education in a telemedicine practice significantly decreased antibiotic prescribing rates for upper respiratory infection (URI) and bronchitis compared with education alone, US researchers reported yesterday in the Journal of General Internal Medicine.

In a randomized controlled trial conducted at Doctor on Demand, a US telemedicine practice, from Jan 1 to Nov 30, 2018, a team lead by researchers from the Antibiotic Resistance Action Center at the George Washington Milken Institute of Public Health examined the effect of two antibiotic stewardship interventions on antibiotic prescribing for upper respiratory infection, bronchitis, sinusitis, and pharyngitis—four conditions for which antibiotics are inappropriately prescribed or overprescribed. One group of clinicians at the practice (the control group) received education (treatment guideline presentation and an online course), and the intervention group received education plus individualized feedback via an online dashboard with monthly rates of personal and practice-wide prescribing rates.

The primary outcome of the trial was the antibiotic prescription rates for each of the four diagnostic categories.

In the pre-intervention period, the control and intervention groups had different baseline antibiotic prescribing rates for URI (18.4% vs 15.0%), bronchitis (46.8% vs 64%), sinusitis (84.1% vs 87.2%), and pharyngitis (81.3% vs 74.9%). Antibiotic prescriptions for all conditions decreased in the post-intervention period compared with those in the pre-intervention period. Compared with the control group, however, the reduction in antibiotic prescriptions for URI and bronchitis was greater in the group that received education plus individual feedback (interaction term ratio, 0.60; 95% confidence interval [CI], 0.47 to 0.77 for URI and 0.42; 95% CI, 0.32 to 0.55 for bronchitis). There was no significant difference between the two groups for sinusitis and pharyngitis.

The authors of the study note that in December 2018 Doctor on Demand expanded the intervention to provide feedback dashboards to all clinicians at the practice.

"These findings should be used to promote antibiotic stewardship across telemedicine and other ambulatory medical practices," the authors wrote. "Future studies should examine the long-term impact of education and feedback interventions, and maintenance of antibiotic prescription reductions."
Aug 26 J Gen Intern Med study

 

Study highlights impact of fluoroquinolone restriction initiative

Originally published by CIDRAP News Aug 26

A quality improvement initiative to restrict fluoroquinolone prescribing in high-risk patients reduced fluoroquinolone use without negative impacts, researchers from the University of Wisconsin School of Medicine and Public Health reported yesterday in PLOS One.

The initiative was implemented in the intensive care unit (ICU) and solid-organ transplant unit at the University of Wisconsin Hospital in July 2016 in an attempt to decrease the rate of hospital-onset Clostridioides difficile infection (HO-CDI), which is associated with fluoroquinolone use. The restriction required antimicrobial stewardship pre-approval for fluoroquinolone prescribing. In the study, the researchers compared rates of HO-CDI in the 24 months before and after the initiative, along with fluoroquinolone and alternative antibiotic days of therapy (DOT), length of hospital stay, readmissions, and mortality.

The results showed that HO-CDI rates did not decrease significantly after the initiative, but fluoroquinolone use fell from 111.6 to 19.8 DOT per 1,000 patient-days without negatively impacting length of stay, readmissions, or mortality.

In contrast, use of third-generation cephalosporins, aminoglycosides, and piperacillin-tazobactam increased post-intervention. Interviews with hospital staff (residents, attending physicians, advanced practice providers, and pharmacists) identified the strength of the hospital's antimicrobial stewardship program (ASP) and pharmacy involvement as key facilitators of the restriction program, and patient complexity and lack of provider education as barriers.

"Lessons from our initiative, particularly those learned from exploring the perspectives of front line providers, can be applied to larger-scale ASP interventions," the authors of the study wrote. "Future studies should confirm safety and efficacy of restriction policies among critically ill and immunocompromised patients with particular attention to the impact on prescribing of alternative agents and explore other opportunities for optimization of antimicrobial prescribing, such as at the time of hospital discharge."
Aug 25 PLOS One study

 

New AVMA report highlights resistant bacteria in animals

Originally published by CIDRAP New Aug 25

The American Veterinary Medical Association (AVMA) yesterday released a new report on the antibiotic-resistant pathogens affecting animal health in the United States.

Like the Centers for Disease Control and Prevention's 2019 report on antibiotic resistance threats, which highlighted the impact of antibiotic-resistant bacteria on human medicine, the AVMA report summarizes the issue for veterinary medicine. It highlights the bacterial pathogens that cause disease in food-producing and companion animals, with a focus on pathogens identified as a concern for elevated antibiotic resistance.

The report provides a host-species–specific breakdown of pathogens of concern, with summary reports for dogs and cats, cattle, chicken and turkeys, horses, fish and shrimp, sheep and goats, and swine, and detailed report cards for each specific bacterial pathogen identified as a potential resistance threat. The information is intended to help veterinarians evaluate the potential for resistance in clinical cases and inform antibiotic therapy and other treatment approaches.

The AVMA report also provides guidance for veterinarians on how they can combat antibiotic resistance, encouraging appropriate antibiotic prescribing, use of diagnostic testing to inform treatment, infection prevention and control strategies, and collaboration with producers to develop comprehensive herd health programs.

"Slowing and limiting the emergence and spread of antimicrobial resistance can only be achieved with widespread engagement, especially among leaders in veterinary medicine, animal agriculture, and public health," the report states. "Only through concerted commitment and action will those caring for the health and welfare of animals be able to succeed in reducing this threat." 
Aug 24 AVMA report

 

Policy at VHA hospitals lowers unnecessary urine cultures

Originally published by CIDRAP News Aug 25

Policies that limit unnecessary urine culturing were associated with a decrease in urine cultures without negative consequences at Veterans Health Administration (VHA) hospitals, US researchers reported today in Infection Control & Hospital Epidemiology.

The retrospective, quasi-experimental study compared rates of urine cultures at six VHA hospitals from August 2013 through January 2018. Three of the hospitals implemented conditional urine reflex testing policies under which urine cultures are performed only if a preceding urinalysis met prespecified criteria, and three of the hospitals served as control sites.

Participants included all adult patients with at least one urinalysis ordered. The primary outcome was the rate of urine cultures performed per 1,000 patient-days, and the secondary outcome was the rate of gram-negative bloodstream infections—the most common severe outcome of untreated urinary tract infections (UTIs)—per 1,000 patient-days.

During the study period, there were 50,901 patient admissions from 24,759 unique patients, and a total of 224,573 urine cultures were performed. At the intervention sites, the overall average number of urine cultures performed did not significantly decrease relative to the pre-intervention period (5.9% decrease, P = 0.8), but the researchers observed a 21% decrease in the rate of urine cultures performed compared to the control hospitals. Analysis of gram-negative bloodstream infection rates found no significant difference between infection and control sites (P = .49)

The findings are noteworthy because asymptomatic bacteriuria—defined as a positive urine culture in the absence of symptoms of a UTI—is a significant driver of inappropriate antibiotic prescribing.

"Conditional urine reflex testing policies in the acute-care setting was associated with reduced unnecessary urine culturing without adverse effects," the authors of the study concluded.
Aug 25 Infect Control Hosp Epidemiol abstract

 

CMS sepsis bundle linked to increased use of broad-spectrum antibiotics

Originally published by CIDRAP News Aug 24

Implementation of a core measure sepsis bundle by the Centers for Medicare and Medicaid Services (CMS) was associated with an immediate and long-term increase in the use of broad-spectrum antibiotics for hospital-onset multidrug-resistant (MDR) organisms, researchers reported late last week in Clinical Infectious Diseases.

In the study, a team led by researchers from Virginia Commonwealth University evaluated monthly antibiotic data for four categories of antibiotics at 111 US hospitals before and after the 2015 implementation of the Sepsis Bundle Core Performance Measure for hospitals participating in Inpatient Quality Reporting (SEP-1). One element of the bundle is initiation of broad-spectrum antibiotics within 3 hours of sepsis diagnosis. The four antibiotic categories evaluated included antibiotics for surgical prophylaxis, broad-spectrum agents for community-acquired infections, broad-spectrum antibiotics for hospital-onset/MDR organisms, and anti–methicillin resistant Staphylococcus aureus agents.

Using interrupted time series and negative binomial regression analyses, the researchers observed an immediate increase in the level of broad-spectrum agents for hospital-onset/MDR organisms (+ 2.3%, P = .0375) and a smaller long-term increase in trend (+ 0.4%, P = .0273) after the SEP-1 bundle was implemented. Overall antibiotic use also increased immediately following SEP-1 implementation (+ 1.4%, P = .0293). There was also an unexpected decrease of 7.3% in Clostridioides difficile infection (CDI) rates immediately following implementation.

When the analyses was limited to sepsis patients, there was a significant increase in the use of all antibiotic categories at the time of SEP-1 implementation.

The authors of the study say the findings are noteworthy because correctly diagnosing sepsis is challenging, and there are concerns that the aggressive timelines for antibiotic therapy in SEP-1 may result in overdiagnosis and inappropriate use of broad-spectrum agents, which could promote development of antibiotic resistance.

"These data suggest that antimicrobial stewardship programs should apply postprescription audit and feedback strategies among sepsis patients to ensure that antibiotic de-escalation is occurring appropriately," the authors wrote. "Further investigations regarding higher use of broad-spectrum antibiotics and impact on CDI and antibiotic resistance development are warranted."
Aug 22 Clin Infect Dis abstract

 

Antibiotic resistance likely not a major driver of gonorrhea spread in NYC

Originally published by CIDRAP News Aug 24

In a study yesterday in the same journal, an analysis of gonococcal isolates collected in New York City in 2012 and 2013 showed that all large transmission clusters were susceptible to current gonorrhea therapies.

In their analysis of genome sequences, antibiotic susceptibility, and patient data from 897 gonococcal isolates cultured by the New York City Public Health Laboratory from January 2012 through June 2014—a convenience sample that represents 1.5% of total gonorrhea infections in New York City during the period—the researchers found that the New York City gonococcal phylogeny reflected global diversity, with isolates from 22 of the 23 global Neisseria gonorrhea lineages.

They also observed that the isolates clustered on the phylogeny by sexual behavior (P < 0.001), with one lineage significantly associated with isolates from men who have sex with men (MSM) and another associated with isolates from heterosexuals. They also clustered based on race and ethnicity (P < 0.001).

Analysis of antibiotic susceptibility showed that 24.3% of isolates were resistant to ciprofloxacin, 0.9% had reduced susceptibility to azithromycin, and 0.3% had reduced susceptibility to ceftriaxione. Minimum inhibitory concentrations were higher across antibiotics in isolates from MSM compared with heterosexuals (P < 0.001) and white heterosexuals compared with black heterosexuals (P < 0.01). The largest transmission clusters were all susceptible to azithromycin, ceftriaxone, and ciprofloxacin and included isolates from across patient demographic groups.

The authors of the study say the findings indicate that antibiotic resistance was not a major driver of gonorrhea transmission in New York City during the study period, but note that, nationally, reduced susceptibility to azithromycin has increased from 0.6% in 2013 to 4.6% in 2018—after the study period.

"While resistance remains a major public health concern, strategies to reduce overall gonorrhea transmission are also needed as pre-existing transmission networks may present opportunities for rapid spread of resistant lineages," they wrote. "Greater understanding of the transmission dynamics of both susceptible and resistant infections can aid the design of effective intervention strategies for controlling gonorrhea, and further investment in sexual health services and interventions are critical."
Aug 23 Clin Infect Dis abstract

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