San Francisco officials report measles cluster, plus related case in Nevada

The San Francisco Department of Public Health (SFDPH) yesterday issued a health advisory about six confirmed measles cases, plus another from Nevada linked to the cluster. The Bay-area cases are from Santa Clara (5) and Alameda (1) counties and involve unvaccinated people.

All seven cases are linked to an unvaccinated traveler who was exposed in Europe and began having symptoms after returning to the Bay area.

Local health departments are conducting contact investigations, and the SFDPH is urging clinicians to suspect measles in patients with a rash and fever, regardless of travel history. Also, the department advised clinicians to prepare their facility for the possibility of measles cases and to ask patients to call ahead if they have fever and rash.

The patient in Nevada appears to be a student at the University of Nevada, Reno, according to an Apr 4 statement from the Washoe County Health District (WCHD). It said the patient doesn't pose an ongoing risk to the public, but was at several locations in the area during the infectious period, and health officials are working to notify potential contacts. Many of the locations were at the university, but they also include Squaw Valley Ski Resort, medical clinics, and retail locations.
Apr 5 SFDPH health advisory
Apr 4 WCHD announcement

New polio cases recorded in Afghanistan, Pakistan 

Pakistan confirmed its first case of wild poliovirus type 1 (WPV1) in 2018, according to the most recent update published by the Global Polio Eradication Initiative (GPEI).

The case occurred in Dukki district, Balochistan province, with the patient experiencing an onset of paralysis on Mar 8. In 2017, Pakistan recorded eight polio cases.

Afghanistan also recorded a new case of WPV1, in Ghaziabad district, Kunar province. This is Afghanistan's seventh case this year. The patient experienced onset of paralysis on Mar 3.

On Apr 9, health officials in both Pakistan and Afghanistan will begin a coordinated immunization campaign with bivalent (two-strain) oral polio vaccine to interrupt transmission the virus.
Apr 3 GPEI update

Ebola household study identifies risk factors for transmission

A study to tease out factors associated with the spread of Ebola in households found the deaths of the index case and more days with wet symptoms (vomiting, diarrhea, and bleeding) were among risk factors for transmission. Researchers from Sierra Leone, the US Centers for Disease Control and Prevention, and the World Health Organization (WHO) reported their findings today in an early online edition of the Journal of Infectious Diseases.

For their analysis, the investigators enrolled all confirmed case-patients who were the first to be sick in their households in Freetown, Sierra Leone, from December 2014 to April 2015, about 6 months after the country's outbreak began. The team interviewed patients and followed their contacts through the 21-day incubation period and tested secondary cases.

Among 150 index cases, 83 household contacts (9.9%) got sick with Ebola during the incubation period. Besides index patient death and presence of wet symptoms, risk factors also included Ebola symptoms in the absence of fever, being younger than 20 years old, and caring for infected people. Care providers had a three times higher rate of contracting Ebola, and few reported using any form of barrier protection such as gloves or plastic bags over their hands.

Researchers also found some factors were associated with lower transmission rates, such as avoiding the index patient after illness onset and having a piped-in drinking water source.

The findings are useful for planning public health strategies for future outbreaks, the group wrote. For example, they noted that the risk profile found in the study can be used to identify higher-risk households and ways to modify risk. "Consideration should be given to more intensive monitoring of high risk contacts to promote rapid diagnosis of secondary cases and to minimize further transmission within the household," they wrote.
Apr 6 J Infect Dis abstract

English health officials issue written warning about antibiotic prescribing

England's chief medical officer has sent letters to more than 8,000 general practitioners (GPs) telling them that they're overprescribing antibiotics, according to a report today in Pulse, a UK medical publication.

The letters were targeted to all GPs in the top 20% of antibiotic prescribing, as well as GPs in practices where prescribing rates have increased every year by more than 4%. Public Health England (PHE) has sent letters to practices in the top 20% of prescribing in previous years, as part of a campaign to reduce inappropriate antibiotic prescribing.

"These annual letters are designed to support and encourage practice-based stewardship, as we know antimicrobial resistance is an issue of serious concern," a PHE spokesperson told Pulse. "We hope that the letters will respectfully support GPs to improve their antibiotic stewardship."

Recent PHE research found that at least 20% of all antibiotics prescribed in English primary care could be classified as inappropriate. The British government has called for cutting the amount of inappropriate prescribing by GPs in half by 2020.
Apr 6 Pulse story
Feb 28 CIDRAP News story "UK study deems 20% of primary care antibiotics inappropriate"

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

English health officials issue written warning about antibiotic prescribing

England's chief medical officer has sent letters to more than 8,000 general practitioners (GPs) telling them that they're overprescribing antibiotics, according to a report today in Pulse, a UK medical publication.

The letters were targeted to all GPs in the top 20% of antibiotic prescribing, as well as GPs in practices where prescribing rates have increased every year by more than 4%. Public Health England (PHE) has sent letters to practices in the top 20% of prescribing in previous years, as part of a campaign to reduce inappropriate antibiotic prescribing.

"These annual letters are designed to support and encourage practice-based stewardship, as we know antimicrobial resistance is an issue of serious concern," a PHE spokesperson told Pulse. "We hope that the letters will respectfully support GPs to improve their antibiotic stewardship."

Recent PHE research found that at least 20% of all antibiotics prescribed in English primary care could be classified as inappropriate. The British government has called for cutting the amount of inappropriate prescribing by GPs in half by 2020. 
Apr 6 Pulse story
Feb 28 CIDRAP News story "UK study deems 20% of primary care antibiotics inappropriate" 

Study finds racial disparities in invasive MRSA incidence remain

Originally published by CIDRAP News Apr 5

A study today in Clinical Infectious Diseases shows that while rates of healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) have decreased in the United States, racial disparities in MRSA rates have not changed.

In the study, researchers from the Centers for Disease Control and Prevention (CDC) and elsewhere analyzed 2005-2014 surveillance data from nine states collected by the CDC's Emerging Infections Program to determine whether reductions in invasive MRSA incidence affected racial disparities in rates. Previous research has consistently documented higher rates of MRSA infections among blacks compared to whites across age groups, but the reasons for this disparity remain unclear.

Case classification included hospital-onset (HO), healthcare-associated hospital-onset (HACO), or community-associated MRSA. Negative binomial regression models evaluated the adjusted rate ratio (aRR) of MRSA in black patients (versus white patients), controlling for age, sex, and temporal trends.

The analysis found that despite substantial decreases in HO and HACO (but not CA) MRSA incidence from 2005 through 2014, the racial disparities did not decline. When adjusted for age, sex, and year, blacks had higher rates for HO MRSA (aRR: 3.20), HACO MRSA (aRR: 3.84), and CA MRSA (aRR: 2.78) incidence, with no significant change in the aRR over time.

"In summary, blacks continue to have a 2-3 times higher incidence rate of healthcare-associated invasive MRSA despite significant decreases in overall disease rates from 2005-2014," the authors write. "Eliminating racial disparities will require improved understanding of the determinants underlying these disparities, as well as prevention strategies to address those determinants."
Apr 5 Clin Infect Dis study

ESBL Klebsiella found more harmful than ESBL E coli

Originally published by CIDRAP News Apr 5

A study today in Infection Control & Hospital Epidemiology found that bloodstream infections caused by extended-spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBL-KP) lead to more severe clinical symptoms and higher death rates than bloodstream infections caused by ESBL-producing Escherichia coli (ESBL-EC).

A large international group of researchers analyzed data on 687 patients with ESBL-EC bloodstream infections and 222 with ESBL-KP bloodstream infections. ESBL-KP was associated with intensive care unit stay, cardiovascular and neurologic comorbidities, length of hospital stay greater than14 days, and a nonurinary source, while ESBL-EC was not.

The investigators also discovered a 33.7% 30-day mortality rate in the ESBL-KP patients, compared with 17.4% in ESBL-EC patients. They noted that CTX-M was the most common ESBL subtype—occurring in 76% of isolates tested—but it was not tied to differences in clinical outcome or death.

The authors concluded, "All ESBL-producing Enterobacteriaceae should not be considered a homogeneous group."
Apr 5 Infect Control Hosp Epidemiol abstract

Defensive medicine found common when prescribing antibiotics

Originally published by CIDRAP News Apr 4

A study group with the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) reports that 45% of specialists in infectious diseases and clinical microbiology sometimes worried and 29% often worried about malpractice implications when prescribing or advising on antibiotic prescriptions, and 85% reported defensive behaviors when prescribing, according to a study today in the Journal of Antimicrobial Chemotherapy.

The experts report on their experience with AntibioLegalMap, an international Internet-based survey targeting those two specialties. The survey included 830 professionals in 74 countries.

When asked about the fear of liability, 164 of 774 respondents (21.2%) said they never worried, 349 of 774 (45.1%) sometimes worried, and 221 of 774 (28.6%) frequently worried when prescribing or advising on antibiotic prescriptions. Being female, 35 years or younger, and aware of previous cases of litigation were independently associated with such concerns.

In addition, 525 of 618 respondents (85.0%) reported some defensive behavior in antibiotic prescribing and 505 of 661 (76.4%) reported defensive behaviors in advising. The preferred measures to reduce fear and defensive behaviors were having local guidelines and sharing decisions through teamwork, the scientists reported.
Apr 4 J Antimicrob Chemother abstract

Diagnostic stewardship tied to lower hospital rates of Clostridium difficile

Originally published by CIDRAP News Apr 4

A new study in Infection Control and Hospital Epidemiology describes how University of California-Los Angeles researchers achieved a two-fold reduction of Clostridium difficile rates after implementing diagnostic stewardship and provider education programs.

The study took place over a 12-month period at the Los Angeles County and University of Southern California Medical Center. The stewardship program began with provider education on how to properly collect and include stool samples as diagnostic criteria.

Before the program was implemented, researchers found that more than 50% of admitted patients with positive C difficile tests lacked symptoms of colitis and had at least one confounding factor at the time of stool collection, such as laxative use. The rate of false-positives was estimated to be 70%. This is because a positive C difficile NAAT does not distinguish between infection and colonization, the authors said.

The hospital implemented a two-step C difficile testing program that required a confirmatory test with a toxin-specific enzyme-linked immunosorbent assay (ELISA) assay after a positive C difficilenucleic acid amplification tests (NAAT).

"Starting in January 2017, after implementing the diagnostic and education interventions, the average number of tests ordered fell to 85 per month (a 43% reduction), of which 7 per month were positive (36% reduction)," the authors said.

C difficile infections are the most common healthcare-associated infections in the United States, resulting in 44,500 deaths and $5.4 billion in healthcare expenses.
Apr 3 Infect Control Hosp Epidemiol study

Study finds high antimicrobial resistance levels in Cambodian kids

Originally published by CIDRAP News Apr 4

A 9-year analysis of bacteria samples from hospitalized children in Cambodia found high rates of antibiotic resistance, especially among gram-negative organisms, an international research group reported yesterday in Emerging Infectious Diseases.

The samples were from Angkor Hospital for Children in Siem Reap. From 39,050 bacterial cultures collected from 2007 to 2016, they identified 1,371 target pathogens. Multidrug-resistance rates were 82% each for E coli and K pneumoniae. In addition, 62.1% of K pneumoniae isolates and 47.2% of E coli isolates were resistant to ampicillin and gentamicin. Third-generation cephalosporin resistance was seen in 78.8% of K pneumoniae, 49.5% of E coli, and 93.3% of Acinetobacter baumannii isolates.

For Salmonella, the team found that resistance patterns varied by subtype, with the proportion highest for Salmonella Typhi—85% of them fluoroquinolone and multidrug resistant—and lowest for Salmonella Paratyphi A, of which only 22.7% were resistant to fluoroquinolone or other drugs.

The researchers found that resistant K pneumoniae was more common in infants, which they said might be the result of acquisition of gram-negative organisms from hospital surfaces. And Salmonella Typhi was more often resistant in kids younger than age 5, which the team said could be related to their exposure to more antimicrobial drugs.

In patients who had community-associated gram-negative bacteremia, resistance to third-generation cephalosporins was associated with more deaths, intensive care unit admissions, and a 2.26-fold greater healthcare costs in survivors.

The team concluded that the surveillance findings fill a gap in the understanding of antimicrobial resistance in Cambodian kids and shows that tracking the patterns is feasible in similar low-resource settings.
Apr 3 Emerg Infect Dis study

Surveillance network finds more evidence for global spread of MCR gene

Originally published by CIDRAP News Apr 3

Tests on clinical samples collected from a large global antimicrobial resistance surveillance network confirmed the worldwide spread of the colistin-resistance gene MCR, a research team based at the International Health Management Associates in Schaumberg, Ill., reported yesterday in PLoS One.

The samples are from the International Network for Optimal Resistance Monitoring (INFORM), which monitors antimicrobial resistance to pathogens isolated from a number of anatomic sites. From 2014 to 2016 the system collected 44,407 Enterobacteriaceae isolates from 39 countries in Europe, the Asia-Pacific region, Latin America, the Middle East, Africa, and the United States.

The group screened a subset of 908 colistin-resistant Enterobacteriaceae isolates for MCR-1, MCR-2, MCR-3, MCR-4, and MCR-5 genes, which came from 15 different countries. Of the collection, 3.2% (29) were positive for MCR: 27 E coli, 1 K pneumoniae, and 1 Enterobacter cloacae. Of the group, 24 had the MCR-1 gene, with 1 containing MCR-1.2 and 1 containing MCR-1.5. The researchers found MCR-3 genes in 4 isolates from Thailand, 3 that contained MCR-3.1 and 1 that contained MCR-3.2. And finally, they found the newly identified MCR-5 gene in an E coli sample isolated from a patient in Colombia who had a urinary tract infection, expanding its known host and geographic range.

They didn't find any coexistence of MCR with any carbapenemase genes. Testing of the full group against a set of microbial agents found that ceftazidime-avibactam and tigecycline showed the highest antimicrobial activity.
Apr 2 PLoS One study

CARB-X awards $1.7 million for drug-resistance rapid test for blood

Originally published by CIDRAP News Apr 3

In an effort to change the way drug-resistant infections in the blood are diagnosed and treated, CARB-X today awarded California-based Specific Diagnostics up to $1.7 million to develop its antibiotic susceptibility testing (AST) system, with an option of $1.7 million more if the company meets certain milestones. CARB-X, a public-private collaboration that supports companies to combat antimicrobial resistance, announced the award in a news release.

Specific's system is designed to quickly detect volatile molecules that are the first sign of bacterial growth in blood, then determine which antibiotic to use. According to the statement, the test can determine susceptibility and identify resistant organisms within 4 hours of a positive blood sample.

Kevin Outterson, JD, executive director of CARB-X, said in the statement that Specific Diagnostic's project is an example of cutting-edge technology that could speed up and change the way life-threatening infections are diagnosed.

Paul Rhodes, PhD, chief executive officer of Specific, said his company is honored by the CARB-X award. "Our new instrument determines phenotypic antibiotic susceptibility with[in] hours of blood infection, and CARB-X's support affirms the importance of that capability and helps us bring it to clinics around the globe for evaluation in 2018."

The latest CARB-X award is the fourth targeted to a diagnostic testing product. So far, CARB-X—with funding from Wellcome Trust and the US government—has announced support for 29 projects in seven countries totaling $75.6 million, plus $90.7 million more if companies meet their milestones.
Apr 3 CARB-X news release

Antibiotics, acid suppressors early in life may increase kids' allergies

Originally published by CIDRAP News Apr 3

The use of antibiotics or acid-suppressing drugs in the first 6 months of life was associated with an increased risk of developing allergies later in childhood, according to a large study published yesterday in JAMA Pediatrics.

Researchers with the Uniformed Services University of the Health Sciences in Bethesda, Md., analyzed data on 792,130 children born from October 2001 through September 2013 who were enrolled in the U.S. military health system until at least 1 year old.

The scientists determined that, for infants 6 months old and younger who were prescribed antibiotics, the adjusted hazard ratios (aHRs) later in childhood were 2.09 for asthma, 1.74 for allergic rhinitis, 1.51 for anaphylaxis, and 1.42 for allergic conjunctivitis. This means the risk was raised from 42% for allergic conjunctivitis—and it more than doubled the risk of asthma—compared with children who hadn't been prescribed antibiotics early in life.

For two common acid-suppressing medications, aHRs were 2.18 and 2.59 for food allergy, 1.70 and 1.84 for medication allergy, 1.51 and 1.45 for anaphylaxis, 1.50 and 1.44 for allergic rhinitis, and 1.25 and 1.41 for asthma.

It is possible that antibiotics or acid-suppressing medicines were prescribed to infants for allergic diseases that were misdiagnosed, although the authors said they doubt this can explain all their findings, according to a JAMA Pediatrics news release. The authors conclude in the study, "Acid-suppressive medications and antibiotics should be used during infancy only in situations of clear clinical benefit."
Apr 2 JAMA Pediatr study
Apr 2 JAMA Pediatr news release