ASP Scan (Weekly) for Dec 23, 2016

Hospital penalties for resistant bugs
Bacterial vs viral infections
Antibiotics in food animals
Fungal disease tests
MDR-TB in migrants
Bacteriophage study

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


Hospitals penalized for high rates of MRSA and C difficile

Originally published by CIDRAP News Dec 22.

The federal government is for the first time cutting Medicare payments to hospitals that have high rates of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile, according to Kaiser Health News.

The Medicare penalties, a provision of the Affordable Care Act, are for the hospitals that rank in the worst 25% with respect to rates of hospital-acquired conditions (HACs), which include central-line bloodstream infections, surgical site infections, and urinary tract infections. This is the third year that the penalties have been enforced by the Centers for Medicare and Medicaid Services, but the first time that the government has taken MRSA and C difficile rates into consideration.

Overall, 769 hospitals will lose 1% of their Medicare payments under the government's HAC Reduction Program. In total, Kaiser reports, the hospitals will lose about $430 million—18% more than the amount lost by penalized hospitals last year.

MRSA and C difficile have long been problematic pathogens in healthcare settings because of their ability to spread among patients via contaminated surfaces and healthcare workers, and excessive use of antibiotics exacerbates the problem. But progress is being made. According to the latest report on healthcare-associated infections from the US Centers for Disease Control and Prevention, national acute care hospitals saw an 8% decrease in C difficile infections and a 13% decrease in MRSA bacteremia between 2011 and 2014.

Lisa McGiffert, director of Consumer Union's Safe Patient Project, tells Kaiser that because of Medicare's penalty program and other efforts, "more hospitals are thinking about appropriate use of antibiotics."
Dec 21 Kaiser Health News story


New test shows promise in distinguishing bacterial from viral infections

Originally published by CIDRAP News Dec 22.

A test combining three blood biomarkers for distinguishing bacterial from viral infections has the potential to improve diagnosis, according to a double-blind study involving young children seen at the hospital for lower respiratory infections in the Netherlands and Israel.

Researchers from both countries reported their findings today in The Lancet Infectious Diseases.

The new test, called ImmunoXpert, combines three proteins that have been used as markers to pinpoint infection sources: tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), interferon gamma induced protein-10 (IP-10), and C-reactive protein (CRP). Researchers compared its performance with commonly used CRP and procalcitonin tests. Clinicians are eager for new testing tools that can quickly distinguish between bacterial and viral infections to help curb antibiotic use and reduce hospitalizations.

In an effort to externally validate ImmunoXpert, the researchers assessed 577 children aged 2 to 60 months. A panel of three pediatricians assessed the children's clinical information but were masked to the test results. They diagnosed 71 bacterial infections and 435 viral infections, with inconclusive assessments for 71.

Sensitivity for distinguishing between the two infections was 86.7% (95% confidence interval [CI], 75.8% to 93.1%). Specificity was 91.1% (95% CI, 87.9% to 93.6%), with a positive predictive value of 60.5% (49.9% to 70.1%). The percentages were a little higher in 354 cases in which the panel's assessment was unanimous.

The team concluded that the trial showed the added value of the test, compared with CRP and procalcitonin, which they say has the potential to reduce antibiotic misuse in young children. They added that more studies are needed to explore the test's usefulness in clinical care.

In a commentary in the same issue, two experts from Italy wrote that, when compared with procalcitonin, the new test improved the identification of bacterial infections by 6.3% and viral infections by 5.4%. When compared with CRP, ImmunoXpert was as effective at identifying bacterial infections, but it improved the identification of viral infections by 8.6%.

They said the test has some limitations that are obstacles to routine clinical use, including that the test requires lab techniques that aren't available outside of hospitals and that the data came from a relatively small number of children.
Dec 22 Lancet Infect Dis abstract
Dec 22 Lancet Infect Dis 


Pew releases recommendations for reduced antibiotic use in food animals

Originally published by CIDRAP News Dec 21.

The Pew Charitable Trusts has released a set of recommendations for how to ensure more appropriate use of antibiotics in animal agriculture.

In 2017, two new policies from the Food and Drug Administration (FDA) that are intended to reduce the inappropriate use of antibiotics in food animals will go into effect. One is Guidance for Industry #213, which prohibits the use of medically important antibiotics to promote growth. The other is the Veterinary Feed Directive, which outlines the conditions under which veterinarians can authorize antibiotic use in animal feed.

While full implementation of both these new policies will help reduce antibiotic use in animal agriculture, Pew has laid out four other recommendations that it believes could enhance those policies and lead to further reductions. These recommendations include collecting and reporting better data to create a more comprehensive picture of antibiotic use in food animals and how it is linked to resistance; refining antibiotic labels to fully meet judicious use guidelines; minimizing the need for antibiotics through the increased use of alternative practices and interventions, such as vaccines and probiotics, that promote animal health; and buying meat that is raised according to responsible antibiotic use guidelines.

According to Pew, antibiotic sales data reported to the FDA showed that pharmaceutical companies sold more than 20 million pounds of medically important antibiotics for use in farm animals in 2014. That's 23% more than was sold in 2009, the first year that such data was made available. Overall, available data show that roughly 70% of the total volume of all medically important antibiotics sold in the United States is for use in food production.
Dec 19 Pew Charitable Trusts report 


Experts: Antimicrobial stewardship must include better fungal testing

Originally published by CIDRAP News Dec 21.

The underuse of nonculture fungal diagnostic tests is exacerbating the problem of antimicrobial resistance (AMR) and overprescribing, and addressing the issue is critical to mounting an effective broad-based stewardship program, experts from the Geneva-based Global Action Fund for Fungal Infections said yesterday in Emerging Infectious Diseases.

To underscore the problem, the authors detail four common clinical situations:

  • Inaccurate diagnosis of fungal sepsis in hospitals, resulting in inappropriate use of broad-spectrum antibacterial drugs in patients who have invasive candidiasis
  • Failure to diagnose chronic pulmonary aspergillosis in patients who have smear-negative pulmonary tuberculosis
  • Misdiagnosis of fungal asthma, resulting in unnecessary treatment with antibacterial drugs instead of antifungal drugs and missed diagnoses of life-threatening invasive aspergillosis in patients who have chronic obstructive pulmonary disease
  • Overtreatment and undertreatment of Pneumocystis pneumonia in HIV-positive patients

The authors conclude, "This lack and underuse of proper diagnostics squanders resources. The large scale of the problem, even in many of the world’s most advanced medical centers, compromises AMR control.

"In many countries, the government and private healthcare providers should be actively promoting diagnosis of fungal infections to minimize deaths and illness from fungal disease; such efforts will probably also have a positive benefit on inappropriate antibacterial drug usage and support stewardship programs."
Dec 20 Emerg Infect Dis commentary

In a related development, the European Centre for Disease Prevention and Control (ECDC) in a Rapid Risk Assessment yesterday warned about the threat that Candida auris poses to patients in healthcare facilities because of its propensity to cause outbreaks and its antifungal resistance. The agency said that difficulties with lab identification and a lack of awareness raise the risk of the pathogen, which has spread in recent years to hospitals on five continents.

The ECDC assessment outlines options to prevent C auris spread, including improved detection, infection control measures, and improved preparedness among European countries. Infection control measures include targeting high-risk patients, preventing transmission from carriers, recommendations for outbreaks settings, and antifungal stewardship.
Dec 20 ECDC risk assessment
Dec 20 ECDC
 news release


ECDC investigating small cluster of multidrug-resistant tuberculosis cases

Originally published by CIDRAP News Dec 20.

European health officials yesterday reported a 16-case cluster of multidrug-resistant tuberculosis (MDR-TB) involving asylum seekers from the Horn of Africa.

According to a Rapid Risk Assessment from the European Centre for Disease Prevention and Control (ECDC), the first 7 cases were identified in Switzerland between February and August 2016. Somalia is the country of origin for 5 of those patients, with 1 person coming from Ethiopia and 1 from Eritrea. All patients were males aged 15 to 19 years.

Based on the results of whole-genome sequencing (WGS), the strains are highly genetically similar and likely belong to a single molecular cluster. WGS showed no difference among isolates in four cases and differences of one allele in three others. Investigators say the strain of MDR-TB is resistant to rifampicin, isoniazid, ethambutol, pyrazinamide, and capreomycin but is fully sensitive to amikacin and fluoroquinolones.

Since the initial 7 cases were identified, 9 additional cases have been identified among Somali asylum seekers in Germany (6), Austria (2), and Sweden (1). All of these cases involve the same WGS profile, and several have similar drug susceptibility patterns.

Migrants seeking refuge from conflict or economic deprivation are considered at increased risk for TB or MDR-TB because of poor health services infrastructure in their countries of origin. That risk can be exacerbated by exposure to destitution and overcrowded living conditions along the migration route and after entry in a host country. The ECDC says the multi-country outbreak investigation is focusing on identifying risk factors.

The agency says the limited number of cases detected so far suggests the outbreak is not likely to become a widespread event, but it has asked all European Union and European Economic Area countries whether they have identified MDR-TB cases with a similar genetic profile. While several countries say no such pattern has been identified, other countries have yet to respond. 
Dec 19 ECDC Rapid Risk Assessment 


Aerosolized bacteriophages help reduce drug-resistant Acinetobacter

Originally published by CIDRAP News Dec 19.

A new study by researchers in Taiwan has found that bacteriophages show promise as an environmental biocontrol agent against drug-resistant infections.

In a paper published Dec 16 in PLoS One, the researchers describe a two-phase prospective intervention study in which they added aerosol with active bacteriophage to the standard cleaning procedures in the intensive care units at a public teaching hospital in Taiwan. Bacteriophages, also known as phages, are viruses that infect bacteria and have been shown to have some activity against drug-resistant bacteria. The purpose of the study was to investigate whether aerosolized phages could affect nosocomial incidence of carbapenem-resistant Acinetobacter baumannii (CRAB), a problematic pathogen in ICUs that can survive for long periods of time on inanimate surfaces.

In the study, the researchers measured the incidence density of CRAB, along with carbapenem resistance rates and antimicrobial drug consumption amounts, in the ICUs over two periods: January 2012 to February 2013 (the baseline period), and March 2013 to December 2013 (the intervention period). During the baseline period, routine environmental decontamination procedures were followed. In the intervention period, a phage aerosol was used after routine cleaning.

During the study, a total of 264 new acquisitions of CRAB were identified in the ICUs—191 in the baseline period and 73 in the intervention period. The rates of new acquisitions of CRAB decreased from 8.57 per 1,000 patient-days in the baseline period to 5.11 per 1,000 patient-days in the intervention period. In addition, the percentage of carbapenem-resistant isolates with A baumannii decreased from 87.76% to 46.07%. There was also a significant reduction in the consumption of three antimicrobials used against CRAB (tigecycline, meropenem, and colistin methanosulfonate). Consumption of imipenem decreased as well, but less dramatically.

"In conclusion, this is the first study to use a phage as an environmental biocontrol agent to decontaminate CRAB colonization in ICUs," the authors write. "Phage can significantly reduce the incidence of CRAB and provides adjuvant activity for the control of CRAB infection in healthcare settings."
Dec 16 PLoS One study

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