COVID-19 Scan for Jul 17, 2020

News brief

Ethnic minorities have more severe COVID-19 chest x-rays findings

Racial and ethnic minorities are more likely to have evidence of severe COVID-19 disease on chest x-rays, according to a study yesterday in Radiology.

The study was based on 326 patients hospitalized with confirmed COVID-19 infection between Mar 27 and Apr 10, seen by radiologists at Massachusetts General Hospital (MGH). Doctors at the hospital noticed non-white patients had significant more lung disease on admitting chest x-rays than white patients and studied the phenomenon.

The study that found non-white patients admitted with confirmed COVID-19 infection were more likely to have signs of more severe disease on admission chest radiographs, as measured by the radiographic assessment of lung (mRALE) score (adjusted average difference, 1.6)

The study authors said the severe disease progression was likely because non-white patient accessed healthcare later in their illnesses.

"Many of these patients delay their care because they're considered essential workers and they don't have a lot of sick leave, but also it's difficult for them to leave because they are living on a weekly paycheck and have other dependents," said study coauthor Efren J. Flores, MD, a radiologist at MGH in a press release. "It wasn't uncommon for us to go into the medical record when we were interpreting their exams and see that many of them worked at grocery stores or warehouses."
Jul 16 Radiology study
Jul 16 Radiological Society of North America
press release


Age remains key risk factor for COVID-19 ICU admission, study shows

A study today in Clinical Infectious Diseases reiterates that advanced age is a main risk factor for intensive care unit admission (ICU) among US patients hospitalized for COVID-19 infections.

The study, based on 2,491 adults hospitalized with laboratory-confirmed COVID-19 from Mar 1 to May 2 through the Coronavirus Disease 2019-Associated Hospitalization Surveillance Network (COVID-NET), showed that risk for severe COVID-19 was raised over the ages of 50 to 64, 65 to 74, 75 to 84 and older than 85 years, versus 18 to 39 years (adjusted risk ratio [aRR] 1.53, 1.65, 1.84 and 1.43, respectively).

Ninety-two percent of all hospitalized patients had one or more underlying condition, and 32% with underlying conditions required ICU admission. Nineteen percent required mechanical ventilation, and 17% died.

Men were more likely than women to suffer severe COVID-19 infections, and the most significant comorbidities were immunosuppression (aRR, 1.39), renal disease (1.33), chronic lung disease (1.31), cardiovascular disease (1.28), neurologic disorders (1.25), and diabetes (1.19).

"In our study, age ≥65 years was the strongest independent predictor of ICU admission and in-hospital mortality," the authors concluded. "Persons aged 75–84 years had the highest the risk of ICU admission compared to 18-49 years old, and those ≥85 years experienced 11 times the risk of death. These findings are similar to other studies from China, Europe, and the United States."
Jul 16 Clin Infect Dis

News Scan for Jul 17, 2020

News brief

Another case added to DRC Equateur Ebola outbreak total

One more Ebola case has been reported in the Democratic Republic of the Congo (DRC) Equateur province outbreak, raising the total to 57, the World Health Organization (WHO) African regional office said on Twitter today.

The added case is a probable infection, involving a patient who apparently died. Of the 57 cases, 53 are lab-confirmed and 4 are now listed as probable. The fatality count is now at 22.

The outbreak, the DRC's 11th involving Ebola, is occurring across six health zone in the northwestern province, which experienced a similar outbreak in 2018. Cases this week exceeded the earlier outbreak, which resulted in 54 cases, 33 of them fatal.
Jul 17 WHO African regional office tweet


More polio cases reported in 4 countries

In the latest global polio developments, Afghanistan, Pakistan, Angola, and Chad reported new polio cases, according to a weekly update from the Global Polio Eradication Initiative (GPEI).

Afghanistan reported 4 more circulating vaccine-derived poliovirus type 2 (cVDPV2) cases, 1 in Badakhshan and 3 in Nangarhar, raising the country's total for the year to 25.

Pakistani health officials reported 2 more wild poliovirus type 1 (WPV1) cases, both in Sindh province, raising the 2020 total to 58.

In Africa, Angola reported a cVDPV2 case involving a patient from Zaire province, its third such case of the year. And Chad reported 2 more cVDPV2 cases in Tandjile province, lifting its total for the year to 52 from two different outbreaks, one linked to Nigeria's Jigawa state outbreak.
Jul 16 GPEI weekly update

ASP Scan (Weekly) for Jul 17, 2020

News brief

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

Vaccination linked to fewer antibiotics for cats and dogs

Originally published by CIDRAP News Jul 15

An analysis of electronic health records from UK veterinary practices found frequent antimicrobial prescribing for cats and dogs but identified vaccination as one of the factors associated with slightly reduced odds of receiving an antibiotic, UK researchers reported today in Emerging Infectious Diseases.

For the study, researchers from the University of Liverpool, University of Bristol, and the UK's Animal and Plant Health Agency analyzed records of unwell dogs and cats treated at 173 veterinary practices from 2014 through 2016, looking for antimicrobial prescriptions and exploring associations between antimicrobial prescribing and a range of veterinary practice, practitioner, client, and animal-related factors. They analyzed data on 281,543 consultations for sick dogs and 111,139 sick cats.

The analysis found that systemic antimicrobial were prescribed in 25.7% of dog consultations, with topical antimicrobials prescribed in 14.2% and highest-priority critically important antimicrobials (HPCIAs) prescribed in 1.4%. For cats, antimicrobials were prescribed in 32.9% of consultations, with topical antimicrobials prescribed in 6.1% of visits and HPCIAs prescribed in 17.3% of visits. Prescription of antimicrobial drugs for dogs and cats was most commonly associated with respiratory symptoms.

Using multivariable mixed effects logistics regression, the researchers found that factors associated with decreased odds of systemic antimicrobial prescription were client decisions focused on preventive health: vaccination (dogs, odds ratio [OR] 0.93; 95% confidence interval [CI], 0.90 to 0.95; cats, OR 0.92; 95% CI, 0.89 to 0.95), insurance (dogs, OR 0.87; 95% CI, 0.84 to 0.90; cats, OR 0.82; 95% CI, 0.79 to 0.86), neutering of dogs (OR 0.90; 95% CI, 0.88 to 0.92), and attending veterinary practices accredited by the Royal College of Veterinary Surgeons (RCVS)(dogs, OR 0.79; 95% CI 0.68–0.92). Mixed practices (companion and large animal) practices were associated with increased odds of systemic antimicrobial prescription for both dogs and cats (dogs, OR, 1.15; 95% CI, 1.01 t0 1.30; cats, OR, 1.20; 95% CI, 1.03 to 1.39).

"Although factors influencing decision-making remain multifactorial and complex, our findings suggest that gathering clinical evidence surrounding respiratory disease might be of value to stewardship," the authors of the study concluded. "Preventive healthcare could also play a role in stewardship and should form the basis of client-targeted health messaging."
Jul 15 Emerg Infect Dis study


Survey highlights antifungal stewardship in pediatric hospitals

Originally published by CIDRAP News Jul 14

The results of a survey sent to pediatric antimicrobial stewardship program (ASP) physicians and pharmacists indicate that most pediatric ASPs conduct antifungal stewardship but many don't feel confident about making antifungal recommendations, US researchers reported today in Infection Control & Hospital Epidemiology.

The electronic survey, which included 17 close-ended questions about institutional antifungal stewardship practices, was sent to 74 hospitals participating in the Sharing Antimicrobial Reports for Pediatric Stewardship collaborative, 68 of which responded.

Overall, 63 of the 68 hospitals (93%) responded that they conduct one or more antifungal stewardship activities, with 43 (63%) performing prospective audit and feedback and 52 (76%) requiring preauthorization for one or more antifungal agents. The most commonly restricted antifungals were isavuconazole (42 of 52 hospitals [80%]) and posaconazole (39 of 52 hospitals [75%]).

Although 33 ASPs (48%) agreed or strongly agreed that antifungals are used inappropriately at their institution, only 25 (37%) felt very confident making recommendations about antifungals. Respondents reported that having clinical guidelines specific to antifungal use in children (31 of 68 [46%]) and better diagnostics (25 of 68 [37%]) would improve their level of confidence in making antifungal recommendations.

"Although implementing antifungal stewardship has challenges, it has the potential to decrease unnecessary and suboptimal antifungal use, to reduce toxicities associated with inappropriate antifungal use, and to prevent the emergence of antifungal resistance," the authors of the study wrote. "Currently, [prospective and adult feedback] and preauthorization are the main strategies used by pediatric ASPs to perform antifungal stewardship. Future studies should evaluate the effectiveness and clinical impact of such interventions."
Jul 14 Infect Control Hosp Epidemiol abstract


Stewardship program tied to less carbapenem resistance in Australian hospitals

Originally published by CIDRAP News Jul 14

Implementation of a computer-assisted stewardship program at healthcare facilities in an Australian local health district and a reduction in carbapenem use were associated with a decline in carbapenem-producing Enterobacteriaceae (CPE) isolates, according to a new study in JAC-Antimicrobial Resistance.

For the study, researchers analyzed CPE isolates collected from hospitals in the Illawarra Shoalhaven Local Health District from 2008 through 2018. In particular, they were looking to see whether the 2012 introduction of a district-wide stewardship program supported by a computerized clinical decision support system had any impact on carbapenem use and detection of CPE isolates.

They also looked at microbiological and demographic data, CPE risk factors and outcomes, and hand hygiene compliance rates among healthcare workers. Bivariate relationships were examined using Pearson's r, and predictors of CPE isolates were assessed using time series linear regression.

In total, 120 CPE isolates from 110 patients were identified. Most isolates (61%) were urinary and primarily categorized as hospital acquired. The numbers of CPE isolates and carbapenem use both showed a strong downward trend during the study period, and the decreases were strongly correlated (r = 0.80; P = 0.006).

Hand hygiene compliance remained at high levels throughout the study period and was negatively correlated with the numbers of CPE isolates (r = –0.70; P < 0.038). The time series regression analysis showed that the positive relationship between CPE isolation and carbapenem use was maintained while adjusting for time (b = 0.05; P < 0.001).

The average yearly consumption of carbapenems fell from 18.4 defined daily doses (DDDs) per 1,000 occupied bed days (OBDs) in the years before implementation of the ASP to 14.7 DDDs/1,000 OBDs in the years after implementation.

"In conclusion, we demonstrated a reduction in CPE isolates in conjunction with reduced carbapenem use in an Australian setting, longitudinally consolidated by a comprehensive district-wide AMS [antimicrobial stewardship] programme," the authors wrote. "Prospective studies are needed to confirm the influence of the AMS-driven carbapenem use reduction on carbapenemase prevalence, as well as the effect in high-prevalence settings."
Jul 13 JAC-Antimicrob Resist study


Canadian report shows worrisome rise in drug-resistant infections

Originally published by CIDRAP News Jul 13

A new report from the Public Health Agency of Canada (PHAC) indicates antimicrobial resistance (AMR) is worsening in the country, highlighted by dramatic increases in drug-resistant bloodstream infections (BSIs).

The 2020 Canadian Antimicrobial Resistance Surveillance System Report, released late last week, shows that from 2014 through 2018, the rate of healthcare-associated vancomycin-resistant Enterococcus (VRE) BSI more than doubled, while the rate of community-associated methicillin-resistant Staphylococcus aureus (MRSA) BSI rose by 140%. Approximately 30% of VRE-BSI and 20% of MRSA-BSI patients died within 30 days of diagnosis.

The report also showed a nine-fold increase in the number of patients testing positive for carbapenem-resistant organisms without signs of infection, detection of carbapenemase genes in Acinetobacter isolated from hospital patients, a 78% increase in the proportion of multidrug-resistant gonorrhea isolates (including the first Canadian reports of ceftriaxone-resistant gonorrhea), and rising ceftriaxone resistance in Salmonella Typhi (typhoid fever) infections.

The frequency of highly drug-resistant Salmonella enterica isolated from animals, humans, and the food chain reached new highs (132 isolates in 2018).

Antimicrobial use in the country increased as well, with rising prescription rates for Canadians over age 65 and a 30% uptick in antimicrobial purchasing by hospitals. In addition, the use of antibiotics that should be reserved for treating multidrug-resistant infections rose by 10%, and the use of carbapenems increased by more than 120% in the community setting. Kilograms of antimicrobials distributed for use in animals dropped overall by 11% but saw a 6% increase from 2017 to 2018.

The reported also highlighted several new surveillance initiatives, including a pilot project to track AMR in the community sector by looking at patterns of resistance in urinary tract infections, and the implementation of whole-genome sequencing to help identify factors associated with food production and AMR.

"No one country, level of government or single sector can slow the growing problem of AMR on its own," the report said. "Preserving the effectiveness of existing antimicrobial drugs will be achieved through collaboration among governments and partners in healthcare, animal health, agri-food, industry, academia, professional associations and the general public."
Jul 9 PHAC report


International study finds low rate of antibiotic prescribing for kids' bronchiolitis

Originally published by CIDRAP News Jul 13

A large international study of infants evaluated in the emergency department (ED) for bronchiolitis found that the overall rate of antibiotic therapy was low, but the use of laboratory testing was substantial, researchers reported today in Pediatrics.

To address the knowledge gap in the understanding of antibiotic use and laboratory testing in infants with bronchiolitis—both of which are discouraged unless bacterial infections are suspected—researchers with the Pediatric Emergency Research Networks conducted a secondary analysis of a retrospective cohort study of previously healthy infants with bronchiolitis treated at 38 EDs in eight countries (United States, Canada, United Kingdom, Ireland, Spain, Portugal, Australia, and New Zealand).

The primary outcome was administration of at least one antibiotic in the ED or a prescription for an antibiotic at discharge, and the secondary outcome was performance of at least one non-recommended laboratory test.

In total, 180 of 2,359 infants (7.6%) received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. Chest x-rays (adjusted odds ratio [aOR], 2.3; 95% CI, 1.6 to 3.2), apnea (aOR, 2.2; 95% CI, 1.1 to 3.5), and fever (aOR, 2.4; 95% confidence interval [CI], 1.7 to 3.4) were associated with antibiotic use.

Antibiotic use did not vary across networks. A total of 768 of 2,359 infants (32.6%) had at least one non-indicated test, with rates of testing ranging from 14.9% in the United Kingdom and Ireland to 50% in Spain and Portugal. Testing was associated with the network, indicators of respiratory distress, fever, and suspected bacterial infection.

The authors said that while the rate of antibiotic use for bronchiolitis is close to the published achievable benchmarks of care, the rate of unnecessary testing observed needs to come down.

"In view of the high global prevalence of bronchiolitis and the cost of bronchiolitis care, our results highlight the need for development of international bronchiolitis benchmarks, guidelines, and quality initiatives to optimize the global management of bronchiolitis," they concluded.
Jul 13 Pediatrics abstract


National stewardship campaign in China tied to fewer primary care antibiotics

Originally published by CIDRAP News Jul 13

A study of community health centers in China found that strict enforcement of a national antimicrobial stewardship campaign had a strong effect on antibiotic prescribing, Chinese researchers reported last week in Clinical Infectious Diseases.

The study used an interrupted time series (ITS) analysis to evaluate the impact of local interventions, based on China's long-term national antimicrobial stewardship campaign, on antibiotic prescribing for primary care in Shenzhen, China, a city of 13 million. Previous studies have shown that the campaign, launched in 2011, has been associated with declines in antibiotic use in Chinese general hospitals, but no studies have assessed the impact on primary care.

The ITS analysis lasted 72 months, including 24 months before the intervention (January 2010 to December 2011) and 48 months after the intervention (January 2012 to December 2015).

Overall, 1,482,223 outpatient prescriptions were obtained from 11 community health centers in Shenzhen. The results of the ITS analysis showed that intervention was associated with an immediate decline of 5.2% and a monthly decline of 3.1% in the percentage of prescriptions with antibiotics, with a cumulative decline of 74% at the end of the study, representing 420,057  antibiotic prescriptions avoided during the 48 post-intervention months.

The percentage of prescriptions for acute upper respiratory infection containing antibiotics fell by 76.2%. In addition, the percentage of prescriptions with broad-spectrum and parenteral antibiotics fell by 36.7% and 77.3%, respectively, immediately after the intervention. But no significant decline in broad-spectrum and parenteral antibiotic use was observed over the course of the study.

The authors of the study said the decline in the percentage of prescriptions with antibiotics was attributed to the multidimensional interventions implemented at the community health centers.

"Additionally, achieving such a good intervention effect was attributed to the strict enforcement of this stewardship campaign," they wrote. "The Chinese government should embed the multidimensional interventions into the routine management of antibiotic prescribing in primary care to optimize antibiotic prescribing and prevent AMR."
Jul 10 Clin Infect Dis abstract

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