News Scan for Feb 28, 2019

News brief

Study presented to ACIP finds no link between flu shots and miscarriage

A larger follow-up on a 2017 study that found an association between repeated doses of flu vaccine containing the 2009 H1N1 strain and miscarriage in pregnant women ruled out the association, researchers reported to federal vaccine advisors yesterday.

The group that presented the findings to the Centers for Disease Control and Prevention's (CDC's) Advisory Committee on Immunization Practices (ACIP) was from the Marshfield Clinic Research Institute — the same team that published the 2017 report on a potential safety signal. At the time they said the findings called for deeper investigation but cautioned that there was no biological basis for the phenomenon and that the data didn't show the vaccine causes miscarriages.

The new findings include data from three more flu seasons—2012-13, 2013-14, and 2014-15—and include 1,236 pairs of women, 627 who had been vaccinated and 609 who had not, CNN reported yesterday.

When the investigators looked at data from each flu season and all of the seasons combined, researchers found no increased miscarriage risk during the 28 days following flu vaccination or any other time period they examined. They said the odds ratio of having a miscarriage were less than or close to one and that minor variations could be explained by chance, concluding that the findings provided a high level of reassurance, according to the report.

In other ACIP developments, the group voted to recommend for anthrax pre-exposure prevention a booster dose of anthrax vaccine adsorbed (AVA), which can be given every 3 years to maintain protection, Healio, a medical news service, reported yesterday. AVA, also known as BioThrax, is the only licensed vaccine against disease caused by Bacillus anthracis, the bacterium that causes anthrax. Also, ACIP members approved a shorter duration between the first and second doses of Japanese encephalitis vaccine for travelers.
Feb 27 CNN story
Sep 13, 2017, CIDRAP News story "
Study signals association between flu vaccine, miscarriage"
Feb 28 Healio report


New MERS case recorded in Saudi Arabia

The Saudi Arabian Ministry of Health (MOH) announced one new MERS-CoV case today, recorded in epidemiologic week 9, in Sajir in the central part of the country. The case does not appear to be part of an ongoing outbreak of the virus in Wadi ad-Dawasir, more than 300 miles to the south.

A 43-year-old man from Sajir is hospitalized for his MERS-CoV (Middle East respiratory syndrome coronavirus) infection. The MOH said the man had camel contact prior to illness.

The new case raises the total number of MERS cases reported in Saudi Arabia so far this year to 82. Fifty-one of those cases have occurred in a hospital-based outbreak in Wadi ad-Dawasir, which has featured both human and zoonotic transmission.

The MOH confirmed two MERS cases in Sajir in December 2018, both involving camel contact.
Feb 28 MOH


2018 measles cluster shows stricter vaccine exemptions can be dodged

Today in the CDC's Morbidity and Mortality Weekly Report (MMWR), California public health officials describe a cluster of seven measles cases in 2018 involving minors who were able to evade the state's stricter vaccine exemption requirements.

Five of the seven cases, including the index case, were teenage boys who were unvaccinated because of parental beliefs, despite that fact that in 2016 California passed Senate Bill 277, which stated children entering school in California may no longer receive exemptions from immunization requirements based on parental personal beliefs.

"Medical exemptions for reasons determined by individual physicians, including family medical history, rather than a uniform standard (i.e., a medical contraindication to vaccination), remain permitted," the authors wrote. "Interviews with local health authorities suggest that some students without contraindications to vaccination have received medical exemptions."

The index case, a 15-year-old boy, contracted measles while traveling to England and Wales in early 2018. He spread the disease to other unvaccinated contacts during scouting events.

The MMR (measles, mumps, rubella) vaccine, is recommended for all Americans born after 1957 who do not have a medical contraindication.
Mar 1 MMWR


Study: Common malaria drug on bed nets kills parasite in mosquitoes

In an effort to combat growing insecticide resistance, researchers writing in Nature yesterday said exposing mosquitoes to the malaria drug atovaquone (ATQ) killed the parasite in the mosquitoes.

ATQ, in combination with proguanil, is used extensively under the name Malarone for prophylaxis in travelers. Insecticides effectively kill mosquitoes and have helped combat malaria, but resistance to these chemicals is increasing.

The authors said atovaquone could be paired with insecticides to treat mosquito bed nets, and demonstrated that after just 6 minutes of contact with the medicine, Plasmodium falciparum was eliminated in a sample of Anopheles misquotes, the most common vectors of malaria in Africa.

"Parasite development was also completely aborted when mosquitoes were exposed to ATQ 24 h before or 12 h after infection," the authors said.

"These findings indicate that ATQ-like antimalarials could be incorporated into control interventions other than treated nets, such as attractive toxic sugar baits, in which female mosquitoes become exposed to chemicals while feeding on sugar, or indoor residual-insecticide spraying, in which contact occurs while female mosquitoes are resting before or after blood feeding."
Feb 27 Nature study

Stewardship / Resistance Scan for Feb 28, 2019

News brief

Surveillance data show gonorrhea resistance levels stable in Europe

The latest data from the European Gonococcal Antimicrobial Surveillance Programme (Euro-GASP) reveal stable levels of resistance to the currently recommended antibiotics for Neisseria gonorrhoeae, according to a report today from the European Centre for Disease Prevention and Control (ECDC). But high resistance to azithromycin threatens the effectiveness of the treatment regimen, ECDC officials warn.

Testing of 3,248 N gonorrhoeae isolates collected from 27 European Union/European Economic Area countries in 2017 shows that resistance to cefixime and azithromycin (1.9% and 7.5%, respectively) remained stable compared with 2016 (2.1% and 7.5%). In addition, no isolates with resistance to ceftriaxone were detected for the second year in a row. But the number of countries reporting resistant isolates for both antibiotics increased, with the number of countries reporting cefixime-resistant isolates climbing to 15 (from 14 in 2016 and 9 in 2015) and the number of countries reporting azithromycin-resistant isolates rising to 23 (from 21 in 2016 and 18 in 2015).

"The fact that we have not seen ceftriaxone resistance among the tested isolates for two consecutive years is promising," ECDC expert Gianfranco Spinaldi, MD, MPH, said in a press release. "But at the same time, the persistent level of resistance to azithromycin across Europe is a major concern for us because it compromises the recommended dual therapy with ceftriaxone and azithromycin."

The ECDC also notes that the recent reports of extensively drug-resistant gonorrhea strains, particularly the cases with ceftriaxone resistance and high-level azithromycin resistance identified in the United Kingdom and Australia in 2018, highlight the need to understand what is driving changes in resistance prevalence.

The ECDC will publish a revised version of its multidrug-resistant gonorrhea response plan later this year.
Feb 28 ECDC Euro-GASP report
Feb 28 ECDC press release


UTI study ties risks of infection, death to no or delayed antibiotics in seniors

A study yesterday in the British Medical Journal (BMJ) found that, in elderly patients with a diagnosed urinary tract infection (UTI), receiving no antibiotics or delayed antibiotics was associated with an increased risk of bloodstream infection or death within 60 days

The retrospective study looked at primary care records from 157,264 adults aged 65 years and older in England who presented to a general practitioner with at least one UTI symptom from November 2007 to June 2015. The main outcome measures were bloodstream infection, hospital admission, and all-cause mortality within 60 days after the index UTI diagnosis.

Among the 312,896 UTI episodes recorded, 7.2% did not have a record of antibiotics being prescribed, and 6.2% showed a delay in prescribing. Overall, 1,539 episodes of bloodstream infection were recorded after the initial UTI. The rate of bloodstream infection significantly increased when patients were not prescribed an antibiotic (2.9% vs 0.2% for immediate antibiotics) and when antibiotics were deferred (2.2% vs 0.2%). After adjusting for covariates, patients were significantly more likely to experience a bloodstream infection in the no antibiotics group (adjusted odds ratio [aOR], 8.08; 95% confidence interval [CI], 7.12 to 9.16) and the deferred antibiotics group (aOR, 7.12; 95% CI, 6.22 to 8.14).

In addition, the results showed that the proportion of patients admitted to the hospital was nearly two times higher for those in the no antibiotics group (27%) and the deferred antibiotics group (26.8%) compared with the immediate antibiotics group (14.8%), and the risk of all-cause mortality within 60 days was significantly higher with no antibiotics (aOR, 2.18; 95% CI, 2.04 to 2.33) and deferred antibiotics (aOR, 1.16; 95% CI, 1.06 to 1.27). Men older than 85 were particularly at risk for both bloodstream infection and 60-day all-cause mortality.

The authors of the study say the findings are particularly noteworthy given the rising incidence of gram-negative bloodstream infections in England.

"Our study suggests the early initiation of antibiotics for UTI in older high risk adult populations (especially men over aged >85 years) should be recommended to prevent serious complications," they conclude.
Feb 27 BMJ study


Study examines deaths from XDR gram-negative infections

A study from a large healthcare database estimated that deaths from extensively drug-resistant (XDR) gram-negative infections was 12.6% and that hospitalization for an XDR infection costs more than $35,000. A team led by the National Institutes of Health (NIH) reported their findings yesterday in the American Journal of Infection Control.

The database they used from Vizent, Inc., contained clinical information, including claim codes and specific medication charges, from 120 academic medical centers and 300 affiliated hospitals. For the study, researchers looked at inpatient encounters between January of 2010 and December of 2013. And they used a tracer antibiotic algorithm as a surrogate marker to investigate and estimate mortality related to XDR gram-negative infections.

Over the study period, 232,834 gram-negative infections were reported from 79 hospitals, of which 1,023 per 3,350 (30.5%) who were prescribed colistin died and 9,188 per 105,641 (8.7%) who were on beta lactams died. Patients who received 4 or more consecutive days of intravenous colistin or died within 4 days of starting the treatment had an excess mortality of 12.6% compared to those who received noncarbapenem beta-lactams that targeted gram-negative bacteria.

The team also found that mortality for the XDR gram-negative infections varied by infection site, onset, and severity. For example, infections coded for sepsis had 3-fold higher mortality and severe sepsis or septic shock had 9-fold higher mortality, which the authors said could suggest that a higher baseline risk of death could amplify the impact of XDR on clinical outcome.

They noted that the healthcare cost of the infections falls within earlier estimates for multi-drug resistant infections, but may be a conservative estimate, because discharge factors such as rehabilitation costs and productivity loss weren't factored in.

Though the prevalence of XDR phenotypes among gram-negative infections is relatively now, documenting their high mortality, role in outbreaks, and global spread are important for raising awareness, the group wrote, adding that new tools for analyzing information from large databases and electronic medical record repositories will help guide antibiotic use and development, as well as other control measures, such as new rapid diagnostics.
Feb 27 Am J Infect Control abstract


Joint Commission, Pfizer fund grants to boost stewardship in Asia-Pacific

The Joint Commission and drug company Pfizer this week announced the selection of six quality improvement projects to receive funding as part of a 2-year grant to improve antimicrobial stewardship in the Asia-Pacific region, according to a Joint Commission news release.

Grant recipients range from establishing a unit-based safety program in India to developing a primary care stewardship model in China to building an international network in India, Micronesia, Nepal, and the Philippines. The projects are anticipated to be completed by early 2022.

Scott Williams, PsyD, director of research with the Joint Commission, said, "We believe the projects can help accelerate the development and adoption of evidence-based approaches that have the capacity to prevent or contain antimicrobial resistance and support the appropriate use of antimicrobial agents."

The Joint Commission did not specify a dollar amount for the grants.
Feb 26 Joint Commission news release

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