News Scan for Mar 07, 2019

News brief

Two more MERS cases recorded in Saudi Arabia

Saudi Arabia's Ministry of Health (MOH) recorded two cases of MERS-CoV in young women from Khamis Mushait in an update to its epidemiologic week 10 report.

The first patient is a 33-year-old woman who is listed as a secondary case, meaning she likely contracted MERS-CoV (Middle East respiratory syndrome coronavirus) from another sick person. She did not report recent camel contact, the MOH said.

A 42-year-old woman is also a secondary case with no camel contact. The cases may represent a healthcare-associated outbreak or could have contracted the disease from another patient at home. Khamis Mushait is in far southwestern Saudi Arabia and hasn't seen a MERS case in more than a year.

The newly reported illnesses raise Saudi Arabia's MERS-CoV total this year to 94, including 53 in Wadi ad-Dawasir, which has reported cases linked to healthcare and camel exposure.
Mar 7 MOH report

PAHO: Brazil, in midseason, reporting only 50 yellow fever cases

In the its latest update on yellow fever in the Americas, the Pan American Health Organization (PAHO) said three South American countries have reported cases since December 2018: Bolivia, Brazil, and Peru.

Brazil, which is in the middle of yellow fever season, has recorded 50 cases in humans, including 12 deaths. That number is dwarfed by the previous two yellow fever seasons; in 2016-17, officials confirmed 778 confirmed human cases, including 262 deaths, and 2017-18 saw 1,376 confirmed human cases, including 483 deaths.

The large outbreaks—or waves — were caused by the virus spreading to parts of Brazil with unvaccinated populations, and PAHO said the cases in the current season still represent a geographic shift.

"The occurrence of cases and epizootics in the southern part of the state of Sao Paulo and in the state of Parana indicates the progression of transmission towards the Southeast and South regions of the country, with the possibility of reaching bordering countries such as Argentina and Paraguay," PAHO said.

Bolivia has recorded one yellow fever case so far this year, and Peru has recorded nine, with eight probable cases under investigation.
Mar 6 PAHO update

Gastrointestinal, respiratory illness more common in low-income US families

A study today in Morbidity and Mortality Weekly Report (MMWR) involving national data from 2000 through 2016 found gaps among household incomes, illness, and school absenteeism in American families.

Using data collected from the National Health Interview Survey (NHIS), the researchers found that low-income families (households that made $35,000 annually or less) were more likely to report children having gastrointestinal or respiratory illnesses in the 2 weeks prior to the survey, but those children had a lower likelihood of missing school during the previous year.

"Adjusting for age, sex, and year of survey, children in the lowest income bracket were 4%–12% less likely to miss school (95% confidence interval [CI] = 1%–16%), but 12%–28% more likely to have had a recent gastrointestinal illness (95% CI = 2%–35%)," the study found. "Children in the lowest income bracket were also 6%–11% more likely to have had a respiratory illness, although comparisons with each of the next two highest income brackets ($35,000–$49,999 and $50,000–$74,999) were not statistically different."

The authors suggest that low-income families may send sick children to school more frequently because parents lack jobs with paid sick leave, among other factors.
Mar 8 MMWR study

Study suggests flu shots in hospitalized patients may cut heart attack risk

A large study based on hospital records found an association between getting vaccinated against flu during hospitalization and a 10% lower risk of heart attack in the following year. Researchers are slated to present the findings on Mar 16 at the American College of Cardiology (ACC) annual meeting in New Orleans, according to an ACC news release today.

For the study, the scientists analyzed data from the National Inpatient Sample, which includes records for nearly 30 million adults who were hospitalized in the United States in 2014. First they divided patients into two groups: those who had been immunized against flu during their hospital stay and those who had not. Then they looked at the proportion who were hospitalized for a heart attack or unstable chest pain at any time during 2014.

About 2% of patients had received a flu shot during their hospital stay. Of those who didn't, 4% had a heart attack or unstable angina, compared with 3% of those who had been immunized. The researchers found that the difference was statistically significant, given the large size of the data set, amounting to about 5,000 fewer heart attacks than expected without the vaccine. After adjusting for confounders, the team found that flu vaccination was associated with a 10% reduction in heart attack risk.

Mariam Khandaker, MD, study coauthor and internal medicine resident at Icahn School of Medicine at Mount Sinai St. Luke's in New York City, said in the press release that, as a very low-cost intervention, the flu vaccine is still underused. "It is important for physicians to educate patients about the benefits of vaccination in order to help them make informed decisions. Hospitals are a good venue to do this, in addition to other places such as the primary care clinic," she said.
Mar 7 ACC press release

Stewardship / Resistance Scan for Mar 07, 2019

News brief

VA study finds 5% rate of prolonged antibiotics after outpatient surgery

A 2-year multicenter Veterans Administration (VA) retrospective cohort study published yesterday discovered that 5% of patients having outpatient surgeries received antimicrobial prophylaxis longer than 24 hours after surgery, with rates varying by procedure, facility type, and surgical specialty.

Writing in Antimicrobial Resistance & Infection Control, VA researchers said they analyzed data from Oct 1, 2015, through Sep 30, 2017, on any veteran undergoing an outpatient surgical procedure in any of five specialties: general surgery; urology; ophthalmology; ears, nose, and throat (ENT); or orthopedics. Guidelines recommend postoperative preventive antimicrobials for no longer than 24 hours after incision closure.

Among 153,097 outpatient surgeries, 7,712 patients (5.0%) received antimicrobial prophylaxis lasting longer than 24 hours. Rates ranged from 0.4% for eye surgeries to 13.7% for genitourinary procedures. Cystoscopies (16%) and cystoureteroscopy with lithotripsy (20%) had the highest rates, while hernia repair, cataract surgeries, and laparoscopic cholecystectomies had the lowest rates, at 0.2% to 0.3.

The investigators also found that lower-complexity ambulatory surgical centers and hospital outpatient departments had about a 30% higher incidence of prolonged antimicrobial prophylaxis compared with complex hospitals.

The authors conclude, "Increasing pharmacy, antimicrobial stewardship and/or infection prevention resources to promote more evidence-based care may support surgical providers in lower complexity ambulatory surgery centers and hospital outpatient departments in their efforts to improve this facet of patient safety." They add that genitourinary and ENT specialists may especially benefit from stewardship interventions.
Mar 6 Antimicrob Resist Infect Control study

Study links antibiotic resistance prevalence to sepsis-related outcomes

A paper published yesterday in the International Journal of Antimicrobial Agents suggests an association between the prevalence of antibiotic resistance and rates of hospitalization and mortality for sepsis in the United States, with a particularly strong association observed for fluoroquinolone-resistant Escherichia coli.

While antibiotic resistance is known to contribute to rates of septicemia and associated mortality, which have risen significantly over the past 2 decades, less is known about the relationship between the prevalence of resistance to various antibiotics and rates of sepsis-related outcomes.

Using data from the Centers for Disease Control and Prevention's Antibiotic Resistance Patient Safety Atlas, researchers from Harvard, the US Department of Health and Human Services, and the National Institutes of Health explored the issue by looking at the relationship between state-specific percentage of resistant bacteria samples in patients with catheter-associated urinary tract infections and rates of hospitalization and mortality for sepsis. They evaluated the associations for different age-roups and different combinations of antibiotics and bacteria.

Many positive correlations between prevalence of antibiotic resistance and rates of septicemia hospitalization and mortality were found in the study, particularly for older adults. But among the different combinations of antibiotics and bacteria, resistance to fluoroquinolones in E coli had the strongest association with septicemia hospitalization rates for patients over 50, and with sepsis mortality rates for patients between 18 and 84 years old. The authors note that E coli is a major source of gram-negative septicemia in the United States, and that the prevalence of fluoroquinolone-resistant E coli isolates in urinary tract and bloodstream infections is high.

The authors say the results support the need to enhance antibiotic stewardship, step up efforts to prevent infection with antibiotic-resistant bacteria, and examine whether replacing certain antibiotics with other agents in the treatment of different syndromes could reduce the rate of severe outcomes associated with bacterial infections.
Mar 6 Int J Antimicrob Agents abstract

Resistant gonorrhea clone identified in two UK women

A team of British scientists reported today that a Neisseria gonorrhoeae clone with ceftriaxone resistance and intermediate resistance to azithromycin has been detected in the United Kingdom.

Writing in Eurosurveillance, the investigators describe a cluster of cases involving the N gonorrhoeae FC428 clone, which was first reported in Japan in 2015 and has since been detected in Australia, Canada, Denmark, Ireland, and France. The clone was detected in two women (Case 1 and Case 2) from the United Kingdom who tested positive for gonorrhea in October and November 2018 after having unprotected sex with men from the UK while in Ibiza, Spain.

The two sexual contacts of Case 1 could not be contacted for testing but are suspected of also being infected. The contact of Case 2, who was also linked to the sexual network of Case 1, was asymptomatic when tested in November 2018, but the investigators believe he may have been the source of Case 2's infection.

Case 1 was treated empirically with ceftriaxone and azithromycin and was cured; Case 2 failed the first two treatments but cleared the infection after treatment with intravenous ertapenem.

Whole-genome sequencing revealed that the genomes of the isolates from the two cases were indistinguishable, and comparison with previously sequenced ceftriaxone-resistant isolates demonstrated that the isolates belonged to the FC428 clone. Except for one other case, all previous FC428 cases had been linked to sexual contact in Southeast Asia, which is believed to be the reservoir for the clone.

"There is growing evidence that the FC428 clone has the potential to spread globally, which is of concern given it is resistant and intermediate resistant to the only two remaining empirical treatment options for N. gonorrhoeae, ceftriaxone and azithromycin," the authors of the report write. "As the transmission between our cases is likely to have occurred between UK residents visiting Ibiza, a well-known European party destination, there is a risk that further undetected transmission has occurred."
Mar 7 Eurosurveill rapid communication