Quick takes: Antifungal-resistant ringworm, avian flu in sea lions, dengue in Italy

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  • In an August 25 clinicians outreach message, the US Centers for Disease Control and Prevention (CDC) urged healthcare providers to consider antifungal-resistant ringworm infections in patients with widespread lesions, especially when the condition doesn't
    CDC / Dr. Lucille K. Georg
    improve with first-line topical antifungal agents or oral terbinafine. The CDC said ringworm caused by Tinea indotineae is often resistant to antifungals and can cause widespread, highly inflamed lesions on the face, trunk, arms, legs, or groin. Outbreaks have been reported on the Indian subcontinent, with cases found throughout Asia and Europe. New York City dermatologists have reported severe infections, including fungal nail infections that are resistant to terbinafine. Though a recent review of resistant isolates found that 19% of samples in the United States and Canada were resistant to terbinafine, more data are needed to understand the extent of the problem, the CDC added.
  • Argentina has reported H5 avian flu in South American sea lions at four locations, according to a notification from the World Organization for Animal Health (WOAH). The outbreaks began from August 8 to August 21 and involved 57 seals found sick or dead. The locations are Santa Cruz province in the south, Tierra del Fuego in the Antarctica gateway area, Buenos Aires province in the southwest, and Rio Negro province's Patagonian region in the south.
  • Italian health officials recently reported four locally acquired dengue cases, including three from the same neighborhood in Lombardy region, according to the most recent weekly communicable disease update from the European Centre for Disease Prevention and Control (ECDC). The fourth case involved a patient from Lazio region, and investigators have found no link between the case there and the ones in Lombardy. The cases are Italy's first local cases since 2020. Earlier this summer, France reported two local cases. The ECDC said Aedes albopictus mosquito populations that harbor dengue viruses are established in most of Europe and that more introductions could be reported from other countries, especially since weather conditions in most areas where the mosquito is found are favorable for vector propagation.

A few more BA.2.86 COVID-19 detections noted in human samples, wastewater

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Omicron variant

In the latest developments on the BA.2.86 Omicron SARS-CoV-2 subvariant, a few more sequences and wastewater findings were detected in the United States in Europe, according to scientists tracking the viruses and uploads to publicly available databases. Two sequences were reported from Portugal, which have August 15 collection dates.

Ohio, which had a preliminary positive from wastewater, now has a BA.2.86-positive human sample, which was collected on July 29. Marc Johnson, PhD, a molecular virologist at the University of Missouri School of Medicine, said the patient sample was collected from the same general area as Ohio's wastewater sample and that the Ohio sample matches a sublineage that includes earlier Danish and UK samples, which differs from an earlier Michigan sample that was related to the lineage that includes Israel's sample. The different lineages hint at three separate introductions into the United States, he said.

In Switzerland, the latest wastewater sequencing data found BA.2.86 detections from more regions, which have collection dates that range from August 8 to August 14. Last week, the country reported its first wastewater detections, in Bern canton.

Global health groups are closely monitoring developments with the BA.2.86 strain due to its many mutations and detections from multiple world regions. Earlier this month, the World Health Organization added it as a variant under monitoring. So far, it's not known if the virus has the ability to easily escape immunity from earlier infection or vaccination. Based on a few cases, there's no evidence that infections involving the virus are more severe.

Omicron variant may be less likely to lead to long COVID

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Tired woman on treadmillInfection with the SARS-CoV-2 Omicron variant is less likely to lead to long COVID than previous variants, and prior infection—but not monovalent (one-strain) vaccination—helps protect against persistent symptoms, suggests a study published late last week in the International Journal of Infectious Diseases.

Researchers at Martin Luther University Halle-Wittenberg in Germany surveyed 17,008 participants who had at least one COVID-19 infection about their vaccination status and symptoms 12 or more weeks after infection from January 2021 to June 2022. The study took place before the availability of the bivalent (two-strain) COVID-19 vaccine, which offers protection against Omicron and the wild-type virus.

About 70% of participants were vaccinated before infection, and roughly half had received three doses. Vaccination rates increased over time, with 0% during wild-type virus predominance, 10% during Alpha, 67% during Delta, and 89% during Omicron. Most infections (68.0%) occurred during the Omicron wave, and about 1% of patients were hospitalized.

Wild-type virus linked to greatest risk

A total of 2,822 participants reported symptoms 12 weeks post-infection, including 5.1% who didn't previously report symptoms. Relative to thrice-vaccinated participants with Omicron infections, unvaccinated respondents with wild-type infections were at higher risk for long COVID (adjusted odds ratio [aOR], 6.44), followed by unvaccinated and vaccinated participants with Alpha (aORs, 5.97 and 5.08, respectively).

The number of previous infections—but not number of vaccine doses—was strongly tied to a lower risk of long COVID (aOR, 0.14), regardless of time since last infection. Long-COVID symptom severity didn't differ by variant or vaccination or previous infection status. Omicron long-COVID participants were less likely to have smell and taste disorders (18.9%) than those infected with previous variants.

The lack of protection by vaccination against long COVID suggests that it could become a serious challenge for the healthcare system, the authors said. "At the same time, the strong protective effect of a preceding infection in individuals who did not have PCC [post-COVID condition] after their initial infection, suggests that in the midterm, the problem might resolve," they concluded.

US spending on mental health services increased 53% in pandemic

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Video call with doctorA new study published in JAMA Health Forum shows that US spending on mental health services rose 53% from March 2020 to August 2022, according to claims of almost 7 million commercially insured adults from January 2019 through August 2022.

To conduct the study, researchers looked at health insurance claims during three study periods: immediately before the pandemic (January 1, 2019, through March 12, 2020), during the acute phase of the pandemic before vaccines were available (March 13, 2020, through December 17, 2020), and after vaccines were widely available (December of 2020 through August of 2022).

The researchers looked at claim and diagnostic codes for anxiety disorders, major depressive disorder, bipolar disorder, schizophrenia, and posttraumatic stress disorder. A total of 1,554,895 mental health service claims were analyzed.

Large transition to telehealth

Unlike physical health concerns, mental health care transitioned to telehealth during the acute and continued phase of the pandemic.

"During the acute phase, in-person visits decreased by 39.5% and telehealth visits increased more than 10-fold (1,019.3%) compared with the year prior," the authors wrote. "Jointly, this represented a 22.3% increase in overall utilization. These trends were generally consistent across conditions."

The changes that occurred during the COVID-19 pandemic have triggered a significant expansion in the use of mental health services.

During the post-acute phase of the pandemic, telehealth visits remained more than 10 times (1,068.3%) that of prepandemic levels, and in-person visits increased 2.2% each month over the period. By August 2022, the authors write, in-person visits had returned to 79.9% of prepandemic levels; overall mental health service use was 38.8% higher than before the pandemic.

"The changes that occurred during the COVID-19 pandemic have triggered a significant expansion in the use of mental health services among adults with employer-based health insurance," said Jonathan Cantor, PhD, lead author of the study and a policy researcher at RAND, in a RAND Corporation press release. "It remains uncertain whether this trend will continue or return to levels similar to those seen before the pandemic."

UK study calls for nurses to be included in antimicrobial stewardship efforts

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Nurse hanging IVA study conducted in England found that nurses are increasingly responsible for antibiotic prescriptions and should be included in antimicrobial stewardship (AMS) efforts, researchers reported late last week in the Journal of Antimicrobial Chemotherapy.

Using National Health Service antibiotic dispensing data from 2014 through October 2021, researchers from Cardiff University and the University of Reading estimated the proportion of antibiotic prescriptions dispensed in the community by nurse independent prescribers (NIPs) and general practitioners (GPs) over time. They also looked at the impact of COVID-19 on the volume, rate, and type of antibiotic prescriptions dispensed.

More than doubling of antibiotics prescribed by nurses

Over the study period, the number of NIPs in England nearly doubled (from 24,457 to 41,649) and the number antibiotic prescriptions dispensed by NIPs rose by 146% (from 14,225 to 34,997). The proportion of dispensed antibiotics prescribed by NIPs rose from 7.5% in 2014 to 9.6% in 2020. But the rate of dispensed antibiotic prescriptions per prescriber per calendar year decreased by 50% for NIPs and by 21% for GPs from 2014 through 2020, a trend that continued across both groups following the onset of the COVID-19 pandemic.

The five most commonly prescribed antibiotic classes were similar for GPs (penicillins, tetracyclines, macrolides, nitrofurantoin, and suplhanomides/trimethoprim) and NIPs (penicillins, nitrofurantoin, tetracyclines, macrolides, and sulphanomides/trimethoprim).

The study authors note that while NIPs are playing an increasing role in primary care and antibiotic prescribing, their contribution to AMS and potential impact on antimicrobial resistance (AMR) are absent from the United Kingdom's national AMR action plan, which aims to reduce antibiotic use in humans by 15% by 2024.

[Nurse independent prescribers] are an increasing contributory influence on total antibiotic prescribing and an important group to include in [stewardship] efforts.

"NIPs are an increasing contributory influence on total antibiotic prescribing and an important group to include in AMS efforts," they concluded. "NIPs prescribe fewer antibiotics than GPs but work under different conditions, e.g. longer consultations and less complex patients, so interventions should be tailored to this group and the population and context in which they are delivered."

Study highlights threat from Klebsiella bloodstream infections

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Klebsiella pneumoniae

A study of patients with bloodstream infections (BSIs) caused by Klebsiella pneumoniae highlights the diversity of the opportunistic pathogen and the high in-hospital mortality risk in certain patients, researchers reported late last week in Clinical Infectious Diseases.

In the study, researchers used clinical and microbiology data to evaluate a cohort of patients with K pneumoniae BSI at Massachusetts General Hospital from 2016 through 2022. Although several studies have analyzed BSI caused by highly resistant or hypervirulent strains of K pneumoniae, few have attempted to understand K pneumoniae BSI in general clinical settings and evaluate risk factors for acquisition and in-hospital mortality.

1 in 6 infections multidrug-resistant

Among 562 patients with K pneumoniae BSIs, intra-abdominal infection (34%) was the most common source of infection, followed by urinary tract, central venous catheter, and respiratory infections. Twenty percent of K pneumoniae isolates were resistant to ceftriaxone, 3% were resistant to carbapenems, and 16% were multidrug-resistant.

A respiratory source of infection was associated with a more than five-times higher mortality rate (adjusted odds ratio [aOR], 5.35; 95% confidence interval [CI], 2.2 to 12.8) compared with other sources, as was resistance to the first antibiotic prescribed (aOR, 5.22; 95% CI, 2.2 to 12.4).  Other independent risk factors of in-hospital mortality were intensive care unit admission (aOR, 5.06; 95% CI, 2.92 to 9.07) and hematologic malignancy (aOR, 4.48; 95% CI, 2.13 to 9.41).

Whole-genome sequencing of 94 K pneumoniae isolates revealed high diversity, with 70 sequence types represented, and no clusters of cases that were epidemiologically or genetically linked. Virulence factors associated with invasiveness were observed at a low prevalence.

"In our large, unselected cohort we found that K. pneumoniae BSI was not driven by a restricted population of bacteria with increased potential for invasion and dissemination, but rather by diverse strains with potential to cause invasive disease in compromised hosts," the study authors wrote, which they say suggests that either community acquisition is the driving factor or that there is a large reservoir of K pneumoniae strains in the healthcare environment.

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