COVID-19 Scan for Jan 08, 2021

News brief

Studies describe Candida auris outbreaks in COVID-19 patients

Two new studies highlight the threat posed by the multidrug-resistant yeast Candida auris to hospitalized COVID-19 patients.

In a case report today in Morbidity and Mortality Weekly Report (MMWR), investigators with the Centers for Disease Control and Prevention and the Florida Department of Health describe an outbreak of C auris in a COVID-19 specialty care unit of an acute care hospital in Florida.

After the hospital alerted Florida health officials about four C auris infections in the unit in July 2020, staff conducted a unit-wide point-prevalence survey from Aug 4 through Aug 18 to identify additional patients colonized with the pathogen. The results showed that, among 67 patients admitted to the unit, 35 (52%) were positive, and 6 later had clinical cultures that grew C auris.

Eight of the colonized patients died within 30 days of screening, but it's unclear whether C auris contributed to those deaths.

Investigators concluded that use of multiple layers of gloves and gowns by healthcare workers, and repeated doffing and donning of secondary layers, may have led to contamination of base layers, which in turn could have contributed to C auris transmission. They also suggest lapses in cleaning and disinfection of shared medical equipment, along with lapses in adherence to hand hygiene, may have played a role.
Jan 8 MMWR case report

In the other study, published today in Clinical Microbiology and Infection, researchers in Mexico describe the clinical and microbiologic characteristics of 12 patients with severe COVID-19 and C auris co-infection at a Mexican hospital in August.

All patients were under mechanical ventilation and had peripherally inserted central lines and urinary catheters. C auris was isolated from blood in 6 patients, urine in 8, and from both sites in two 2. Five of the six patients with bloodstream infections died.

Antifungal susceptibility testing revealed that 8 of 15 isolates (12 from patients and 3 environmental isolates) were multidrug-resistant.

The authors of the study say use of multiple antibiotics and central venous catheters may have contributed to C auris co-infection in these patients, but they also suggest that factors specifically associated with COVID-19, such as excessive corticosteroid use, which can have an immunosuppressive effect, might have also contributed to the problem.
Jan 8 Clin Microbiol Infect study

 

Cats infected with SARS-CoV-2 show immunity, long-term lesions

Nine domestic cats inoculated with SARS-CoV-2, the virus that causes COVID-19, showed lung lesions and other long-term inflammation in the respiratory tract after the virus had cleared from their system, reports an Emerging Infectious Diseases research letter published yesterday. Despite these lingering effects, however, six cats who were re-infected showed protection against the disease.

Previous studies have proved that domestic cats can transmit COVID-19 among themselves, and the researchers similarly found that the virus efficiently replicated in the upper respiratory organs (nasal passages and trachea), showing up in organ and lung samples on days 3 and 6 post-infection but absent by day 10 (detectable levels were 10 plaque-forming units per gram of tissue).

No animal showed symptoms of respiratory illness during the entire process, but three cats who were euthanized postinfection day 28 showed persistent lung lesions that shared characteristics with chronic peribronchiolar fibrosis (scarring) and vascular proliferation. One cat had severe pneumonia, as well.

Even with these long-term effects, SARS-CoV-2 infection appeared to give cats at least some level of protection against reinfection. When the researchers re-infected the six remaining cats about 4 weeks after the initial infection, they found that those euthanized 3 days after reinfection didn't have any detectable SARS-CoV-2 in their organs or lungs. Cats euthanized 21 days after reinfection had lung lesions comparable to those observed from the first cohort of cats, but the alveolar septa suffered less thickening.

"Because SARS-CoV-2 did not cause acute lethal respiratory disease in the cats in our study, cats are a compelling animal model for studying the long-term effects of nonfatal infections," write the researchers. "These results suggest that virus infection by natural transmission between cats, as well as by experimental inoculation, induces protective immunity against a second SARS-CoV-2 infection."
Jan 7 Emerg Infect Dis
research letter

 

Black populations lack COVID-19 testing, study finds

To have an equitable COVID-19 testing strategy in seven counties around St. Louis, 30.4% of tests would have to be reallocated, according to a research letter published today in JAMA Open Network. The researchers defined equitable testing as "the balance between the number of tests and the actual disease burden," but only 22.9% of COVID-19 tests took place in the 23 zip codes that held 50% of the region's hospitalizations.

Almost three quarters of these zip codes (73.9%) had a population of at least 50% blacks. Even with the same zip code, black residents had consistently lower rates of tests per hospitalization compared with their white neighbors.

The researchers collected data from Mar 14 through Aug 10 and used an adapted Lorenz curve to measure the number of tests, the disease burden, and a color-coded line that varied depending on the racial makeup of a particular zip code. During the study period, 404,904 COVID-19 tests and 4,059 hospitalizations took place in the region, which has a total population of 2,149,222.

"Equitable testing is paramount to a successful COVID-19 response and is essential for early case detection, self-isolation, and overall prevention of onward transmission," the researchers write. "Lorenz curves provide straightforward metrics that can also be easily tracked over time to quantify these disparities."
Jan 8 JAMA Netw Open research letter

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ASP Scan (Weekly) for Jan 08, 2021

News brief

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

Studies describe Candida auris outbreaks in COVID-19 patients

Two new studies highlight the threat posed by the multidrug-resistant yeast Candida auris to hospitalized COVID-19 patients.

In a case report today in Morbidity and Mortality Weekly Report (MMWR), investigators with the Centers for Disease Control and Prevention (CDC) and the Florida Department of Health describe an outbreak of C auris in a COVID-19 specialty care unit of an acute care hospital in Florida.

After the hospital alerted Florida health officials about four C auris infections in the unit in July 2020, staff conducted a unit-wide point-prevalence survey from Aug 4 through Aug 18 to identify additional patients colonized with the pathogen. The results showed that, among 67 patients admitted to the unit, 35 (52%) were positive, and 6 later had clinical cultures that grew C auris.

Eight of the colonized patients died within 30 days of screening, but it's unclear whether C auriscontributed to those deaths.

Investigators concluded that use of multiple layers of gloves and gowns by healthcare workers, and repeated doffing and donning of secondary layers, may have led to contamination of base layers, which in turn could have contributed to C auris transmission. They also suggest lapses in cleaning and disinfection of shared medical equipment, along with lapses in adherence to hand hygiene, may have played a role. 
Jan 8 MMWR case report

In the other study, published today in Clinical Microbiology and Infection, researchers in Mexico describe the clinical and microbiologic characteristics of 12 patients with severe COVID-19 and C auris co-infection at a Mexican hospital in August.

All patients were under mechanical ventilation and had peripherally inserted central lines and urinary catheters. C auris was isolated from blood in 6 patients, urine in 8, and from both sites in two 2. Five of the six patients with bloodstream infections died.

Antifungal susceptibility testing revealed that 8 of 15 isolates (12 from patients and 3 environmental isolates) were multidrug-resistant.

The authors of the study say use of multiple antibiotics and central venous catheters may have contributed to C auris co-infection in these patients, but they also suggest that factors specifically associated with COVID-19, such as excessive corticosteroid use, which can have an immunosuppressive effect, might have also contributed to the problem.
Jan 8 Clin Microbiol Infect study

 

Policy brief shows support for antibiotic development incentives

Originally published by CIDRAP News Jan 6

Interviews with policymakers and antimicrobial resistance (AMR) experts from 13 countries indicate broad support for financial incentives to boost antibiotic development, despite uncertainty over which incentives are appropriate and how much they'll cost, according to a policy brief released yesterday by the European Union Joint Action Antimicrobial Resistance and Healthcare-Associated Infections (EU-JAMRAI) and the Global AMR Research and Development Hub.

In the interviews, which were conducted to better understand perceptions of antibiotic development incentives and barriers to implementing them, 11 of 13 interviewees expressed high-level, general support for incentive programs.  But before selecting a type of incentive, they said they prefer to wait for evidence from the three countries—United Kingdom, Germany, and Sweden—currently testing "pull incentives" models that aim to increase revenues for antibiotics while also ensuring access to them.

Experts from 9 of the 10 European countries said they would prefer a common, European or multinational incentive that's independent of national drug pricing and reimbursement plans.

Policymakers were also clear that incentives should apply only to antibiotics that meet public health needs, and that the public heath value must be demonstrated in clinical trials that test those antibiotics against multidrug-resistant infections.

In addition, 12 of 13 interviewees indicated that shortages of existing antibiotics is a problem in their countries, and 8 of 13 said shortages have resulted in greater use of broad-spectrum antibiotics.

"The results of these interviews point to a clear need for specific, detailed incentives that national policymakers can assess, tailor, and implement," the policy brief said. "These incentives must be designed with the aim of ensuring national access to important antibiotics that meet public health need."
Jan 5 EU-JAMRAI and Global AMR R&D Hub policy brief

 

High antibiotic prescribing rates found in COVID-19 patients

Originally published by CIDRAP News Jan 5

A rapid review and meta-analysis of studies involving more than 35,000 COVID-19 patients has found that three-quarters received antibiotics even though fewer than 10% had a bacterial co-infection, Canadian researchers reported today in Clinical Microbiology and Infection.

A total of 35,263 patients with laboratory-confirmed COVID-19 were included across 154 studies published from Jan 1 through Jun 9, 2020. Random effects meta-analysis of all combined studies estimated an antibiotic prescribing prevalence of 74.6% (95% confidence interval [CI], 68.3% to 80.0%). The prevalence of antibiotic use was highest in east/southeast Asia (87.5%), followed by the Middle East (86%), China (76.2%), North America (64.8%), and Europe (63.1%). Across healthcare provider settings, antibiotic use was highest in the intensive care unit (86.4%).

On univariable meta-regression, antibiotic prescribing was lower in children compared with adults (prescribing prevalence odds ratio [OR], 0.10; 95% CI, 0.03 to 0.33), higher with increasing patient age (OR, 1.45 per 10-year increase; 95% CI, 1.18 to 1.77), and higher with increasing proportion of patients requiring mechanical ventilation (OR, 1.33 per 10% increase; 95% CI, 1.15 to 1.54).

Among the 31 studies that reported on concomitant bacterial infection, pooled data indicated 8.6% prevalence (95% CI, 4.7% to 15.2%).

"As such, antibiotic prescribing is significantly higher than the prevalence of bacterial co-infection suggesting a large number of antibiotic prescriptions are unnecessary, increasing the risk of preventable harm including adverse events, C. difficile infection, and antimicrobial resistance," the authors wrote.

They concluded that antimicrobial stewardship efforts are urgently needed to help mitigate the impact of COVID-19 on antimicrobial resistance.
Jan 5 Clin Microbiol Infect abstract

 

CDC study finds sharp drop in outpatient antibiotics in first half of 2020

Originally published by CIDRAP News Jan 4

A new study by researchers from the CDC shows a substantial decrease in the number of outpatients who received antibiotic prescriptions during the first 5 months of 2020 compared with previous years.

In the study, published last week in Clinical Infectious Diseases, CDC researchers looked at data from the IQVIA Total Patient Tracker to estimate the monthly number of patients dispensed prescriptions for commonly used antibiotics from retail pharmacies from January 2017 through May 2020. They averaged estimates from 2017 through 2019 to create a baseline, and defined the percent change from January through May in each year as the seasonally expected change. They then calculated the percent change in January through May 2020 and compared it to the previous years.

The results of the analysis showed that from January through May 2020, the number of outpatients dispensed antibiotic prescriptions fell from 20.3 million to 9.9 million, exceeding seasonally expected decreases by 6.6 million patients and 33 percentage points. The largest differences were observed in April and May, when the number of patients receiving outpatient prescriptions was 39% and 42% lower, respectively, than the 2017-2019 averages for those months.

The largest beyond-expected decreases were observed in prescriptions for penicillins (2.3 million fewer patients), macrolides (1.5 million fewer patients), and cephalosporins (1.1 million fewer patients). Trends in azithromycin prescribing varied slightly, with the number of patients receiving azithromycin climbing by 5% from January through March 2020 and then declining by 71% from March through May. Beyond-expected decreases in dispensed antibiotics were observed across age groups, with the greatest decline occurring in children 4 and under and adults 65 and over.

The authors of the study say it's unclear at this point whether the decreases were driven by declines in non-COVID-19 disease transmission or changes in care-seeking related to the COVID-19 pandemic.

"Ongoing surveillance of antibiotic prescribing, antibiotic-associated adverse events, antibiotic-resistant infections, and complications of common infections is needed to evaluate the longterm impacts of these changes in outpatient antibiotic trends," they wrote. "Shifts in healthcare delivery, particularly the use of telehealth, are likely to be sustained, and should prompt assessment of effective antibiotic stewardship interventions to optimize antibiotic prescribing practices and ensure patient safety."
Dec 28 Clin Infect Dis abstract

News Scan for Jan 08, 2021

News brief

CWD reported farther east in Mississippi

Two cases of chronic wasting disease (CWD), a fatal disease affecting cervids such as deer, elk, and moose, were found in Mississippi on Dec 29, 2020, says the state's Department of Wildlife, Fisheries, and Parks (MDWFP). Both were hunter-harvested white-tailed deer, bringing the state up to 78 suspected or confirmed white-tailed deer cases since 2018 and expanding the disease range in the state.

One case was found in Tippah County, which was not wholly unexpected, says MDWFP deer program coordinator William McKinley in the Jackson Clarion Ledger. A positive CWD case had previously been reported within a few miles of the county in Tennessee.

The second case, in Alcorn County, was more of a surprise. "The Alcorn positive was 25 miles away from the nearest Mississippi positive," Mckinley said in the article. "So this is quite a stretch. It tells us there's more in between there and it's doubtful it's the farthest east."

Both counties are already a part of the North Mississippi CWD Management Zone, but because of the Alcorn case location, Tishomingo County would normally be added to the zone as well.  Because of an in-process transition of management zone regulations, however, McKinley doesn't know if Tishomingo will face the same hunter regulations as past zones or if it will be added at all.

More than 8,000 deer samples were tested during both 2018 and 2019, but this year, only 3,600 samples have been submitted, writes the Clarion Ledger. The MDWFP continues to urge hunters to submit deer samples so disease spread can be better monitored.
Dec 31, 2020 MDWFP report
Jan 5 Clarion Ledger article

 

Four countries report more polio cases

Four countries reported more polio cases this week, Pakistan in the Middle East and three countries in Africa, according to the latest weekly update from the Global Polio Eradication Initiative (GPEI).

Pakistan reported 1 wild poliovirus type 1 case, which was in Balochistan province and is included in its total for 2020, which is now 84.

The three African countries reported more circulating vaccine-derived poliovirus type 2 (cVDPV2) cases, which reflect 2020 illness onsets and are included in 2020 totals.

Chad reported a case in Mandoul, which makes 94 cases from three different outbreaks. Ivory Coast reported 3 cases, 1 each in Gbeke, Belier, and Agneby-Tiassa, putting its total at 71. And the Democratic Republic of the Congo reported 1 case, in Mainbombe, lifting its total to 75.
Jan 7 GPEI update

 

H5N8 avian flu strikes poultry in Lithuania

Lithuania is the latest country in Europe to report highly pathogenic H5N8 avian flu in poultry, according to a report from the World Organization for Animal Health (OIE).

The outbreak began on Dec 31 in backyard poultry of multiple species in Kaunas, the country's second-largest city, located in the central Lithuania. The virus killed 22 of 27 birds, and the rest were culled to control the spread. The event marks the first appearance of the virus in the country's poultry since 2017.

Lithuania also reported three outbreaks wild birds, all involving mute swans found dead in the central and western parts of the country.

Other European countries also reported more avian flu outbreaks in wild birds, which involved H5N8 in the United Kingdom and Slovakia and H5N5 in Wales.
Jan 8 OIE report on H5N8 in Lithuanian poultry
Jan 8 OIE report on H5N8 in Lithuanian wild birds
OIE avian flu outbreak page

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