News Scan for Sep 04, 2019

News brief

DRC confirms 6 more Ebola cases as schools open

Health officials in the Democratic Republic of the Congo (DRC) confirmed 6 more Ebola infections, raising the overall outbreak total to 3,049, according to the World Health Organization (WHO) online dashboard today. Also, outbreak responders are still investigating 327 suspected cases.

Ten more people died from their infections, raising the fatality count to 2,045.

In an update today the DRC's multisector Ebola response committee (CMRE) said the three cases reported yesterday were in Kalunguta, Mandima, and Mambasa. It also noted the addition of four more probable cases, two each in Butembo and Kalunguta, raising the overall number of probable infections to 109.

Of six deaths reported yesterday, two occurred in the community: one in Kalunguta and one in Mandima.

No new health worker infections were reported, keeping the total at 156, and the number of people who have received the VSV-EBOV vaccine has reached 211,635.
WHO online dashboard
Sep 3 CMRE report

Meanwhile, UNICEF said yesterday that most schools in the Ebola-affected area of the DRC have reopened for the start of the new school year. It said there are 2 million children living in communities affected by Ebola and that, of 6,509 primary and secondary schools, 3,800 of them are in high-risk areas.

Fati Bagna Seyni, UNICEF's education lead, said in a news release yesterday that the Ebola outbreak was still new when school started last year. He said many parents were afraid that students could be infected in class and that teachers lacked information and training on how to educate children about the disease and help vulnerable children.

Over the past year, however, he said UNICEF has worked with the DRC's education ministry to deliver assistance to schools, teachers, parents, and students, including thermometers, hygiene supplies, and handwashing stations. It has also trained school administrators and teachers on topics ranging from prevention steps to basic case management.
Sep 3 UNICEF press release


Pharmacist-led review of outpatient antibiotics linked to better outcomes

A pharmacist-led review of outpatient cultures and antibiotic treatment at a Veterans Administration (VA) hospital was associated with decreased rates of treatment failure and hospital admission, researchers reported yesterday in the American Journal of Infection Control.

In the prospective study, a team of infectious disease (ID) pharmacists from the VA Western New York Healthcare System were alerted when oral antibiotics were prescribed for outpatient use, paying special attention to prescriptions with patient cultures. The cultures were reviewed daily to ensure the appropriate antibiotic choice, dose, and duration, and to evaluate for drug allergies and interactions. Interventions were communicated directly to providers and included changes to antibiotic regimens, diagnostic recommendations, and patient counseling. The primary objective was to compare outcomes in patients with accepted interventions versus those with rejected interventions.

From January 2018 to January 2019, the ID pharmacists reviewed a total of 7,360 antibiotic orders and intervened on 20.1% (n = 194) of encounters with related cultures. Interventions were most frequent in the emergency department (42%), followed by primary care (38.7%). Ciprofloxacin required the most interventions (26%), followed by third-generation cephalosporins (22%). The intervention acceptance rate was 76%, with 73.8% of interventions involving a change to the prescribed antibiotic regimen. Intervention was associated with decreased rates of 30-day treatment failure (5% vs 28%, P < .001) and 30-day admission (0.7% vs 11%, P = .001) when interventions were accepted rather than rejected. There was no difference in 30-day mortality.

The authors of the study conclude, "Culture review services can improve patient care by closing a gap in follow up between various levels of care in the outpatient setting. Implementing a culture review service can decrease rates of re-presentation to the health care system, thereby decreasing health care utilization and saving health care dollars."
Sep 3 Am J Infect Control study


Oral vancomycin for C diff doesn’t raise risk for VRE infection, study finds

A nationwide study of VA patients who had Clostridioides difficile infection (CDI) indicates that a shift to oral vancomycin does not increase the risk of developing vancomycin-resistant enterococci (VRE) infection, researchers from the University of Utah School of Medicine reported yesterday in Clinical Infectious Diseases.

The researchers conducted a retrospective, propensity-matched cohort study of patients within the VA system who were diagnosed as having CDI from January 2006 through December 2016. The goal was to assess how oral vancomycin and metronidazole impact the risk of developing a clinically relevant VRE infection.

While metronidazole has long been the first-line treatment for CDI, the newest clinical practice guidelines from the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America recommend treating all initial CDI episodes with vancomycin. The patients treated with oral vancomycin were compared with those treated with metronidazole, and the primary outcomes of interest were positive VRE clinical cultures within 3 and 6 months after treatment initiation.

Overall, 5,267 patients treated with vancomycin alone were matched to one or more metronidazole-treated patients, for an average total of 10,513 patients included in the analysis. The results from multivariable models within the propensity-matched cohorts showed that patients treated with oral vancomycin were no more likely to develop VRE within 3 months than metronidazole-treated patients (adjusted relative risk [RR], 0.96; 95% confidence interval [CI], 0.77 to 1.20), equating to an absolute risk difference of -0.11% (95% CI, -0.68% to 0.47%). RR estimates were similar for clinical cultures at 6 months.

The authors of the study conclude that in settings of stable CDI incidence, replacement of metronidazole with oral vancomycin is unlikely to be a significant driver of increased VRE risk, and that continued antimicrobial stewardship and infection control efforts will likely have a greater impact on VRE acquisition and transmission.

"Future research efforts should focus on identifying patients with self-limiting CDI who may not need antibiotic therapy and on balancing the tradeoffs of vancomycin and metronidazole with a broader range of important risks and benefits," they write.
Sep 3 Clin Infect Dis abstract


Young doctor survey shows influence of culture, specialty on antibiotic use

A survey of young European physicians in training has found that country of specialization and type of specialty are the most important determinants of attitudes toward antibiotic use and resistance. The findings were detailed yesterday in the Journal of Antimicrobial Chemotherapy.

The cross-sectional survey, designed by an international team of experts for the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), was focused on young doctors after graduation from medical school and the start of specialty training. The idea was to see which factors influence the culture and habits of antibiotic prescribing, and whether socio-cultural environmental influences play a role. Principle component analysis (PCA) and bivariate and multivariate analyses were used to investigate the differences among young doctors according to their country of specialization, specialty, year of training, and gender.

The survey was completed by 2,842 participants from 29 countries and 61 specialties, and further analysis was performed on 2,366 participants from six countries (Spain, France, Italy, Portugal, Greece, and Slovenia) with more than 100 respondents. Young doctors from Italy reported the most frequent prescribing and those from Slovenia the least, and trainees in infectious diseases and related specialties were more frequent prescribers than colleagues from surgery or internal medicine. Very few differences were associated with the year of training or gender. More than half of those surveyed (54.2%) prescribed antibiotics as instructed by their mentor.

PCA revealed five dimensions of antibiotic prescribing culture: self-assessment of knowledge, consideration of side effects, perception of prescription patterns, consideration of patient sickness, and perception of antibiotic resistance. Multivariate analyses indicated that the country of specialization had the strongest influence on all five dimensions, followed by specialty training, with the strongest effect observed on self-assessed knowledge and perception of antibiotic resistance.

The authors say the survey results indicate a need for education in responsible antibiotic prescribing at an international level and in all specialty curricula.
Sep 3 J Antimicrob Chemother study

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