ASP Scan (Weekly) for Jun 30, 2017

Students' antibiotic knowledge
MCR-1 in Portugal
Opposition to AMR budget cuts
Antibiotics for skin wounds
Antibiotic resistance at the Hajj
C diff in cancer patients
Contact precautions for MRSA
Antibiotic-resistant acne

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

Early education boosts students' antibiotic savvy, study finds

A hands-on educational program dramatically increased primary school students' knowledge of antibiotic action and use, according to a study yesterday in the International Journal of Antimicrobial Agents.

The program involved scientific workshops at 26 primary schools in Turin, Italy, led by public health experts for more than 1,200 children aged 9 to 11 years. The project involved hands-on experiments, microscope observation, quizzes, interactive games, and team competitions. Course topics were: (1) introduction to microbes, (2) infection spread, (3) the immune system, (4) infection treatment, and (5) infection prevention. It was implemented for three school years from 2011 to 2015.

Students' responses on both antibiotic action and use improved significantly pre- and post-education. Before the program, only 5.0% of 956 students correctly agreed that antibiotics are effective against bacteria, while afterward the number rose to 77.2%. And before the program 75.8% incorrectly thought the drugs were effective against bacteria and viruses, and 19.1% incorrectly thought they were effective against all microorganisms. After the program those rates dropped to 12.8% and 10.0%, respectively.

Regarding antibiotic use, the percentage of students who correctly agreed with, "The unnecessary use of antibiotics can increase the resistance of bacteria to them" rose from 12.1% to 73.6% pre- and post-program, respectively. And those who incorrectly agreed with, "The use of antibiotics can speed up the recovery of cold, cough, and flu" dropped from 87.9% to 26.4%.

The authors conclude, "Although it is difficult to determine the true success of this project, due to the lack of data on long-term retention of knowledge and real behavior changes of students after being taught, data gathered support the idea that early childhood microbial literacy through a hands-on approach should contribute to engage students with scientific subjects and health-related issues."
Jun 29 Int J Antimicrob Agents study


Portuguese researchers report MCR-1 in ICU patient

Researchers in Portugal describe the detection of the colistin-resistance MCR-1 gene in Escherichia coli isolates from a patient who had been treated with meropenem and colistin, according to a report today in Emerging Infectious Diseases.

The patient, a 70-year-old woman, was admitted to intensive care last July for abdominal pain and received meropenem, fluconazole, and linezolid after emergency surgery for an abdominal occlusion. After 50 days of antibiotics, a urine specimen tested positive for Klebsiella pneumoniae, and further testing showed resistance to carbapenems but susceptibility to colistin and tigecycline, so she was prescribed colistin and tigecycline for 6 days, after which urine cultures were negative for K pneumoniae.

Six weeks later, however, E coli were isolated that showed a resistance profile identical to that of the previous K pneumoniae isolate but also expressing colistin resistance. In addition to the MCR-1 gene, the investigators confirmed the presence of the blaKPC-3 gene and other resistance genes.

The authors conclude, "Colistin-resistant [E coli] may have been part of the patient’s gut microbiome, acquiring the blaKPC-3-encoding plasmid from the [K pneumoniae] strain. Although neutropenic, the patient's samples showed an asymptomatic bacteriuria. Thus, prophylactic administration of antibacterial drugs was likely avoidable."
Jun 30 Emerg Infect Dis report


Letter urges Congress to oppose Trump administration's AMR cuts

Originally published by CIDRAP News Jun 28

The Infectious Diseases Society of America (IDSA) today sent a letter to members of congressional appropriations committees urging them to reject President Trump's proposed cuts to antimicrobial resistance (AMR) initiatives.

The letter, signed by more than 60 organizations representing the human and animal health sectors, expresses concern that the "gravity and importance" of AMR is not reflected in the president's budget request, which was released in May. The president's FY18 budget seeks reductions to AMR programs administered by several different agencies, including the Centers for Disease Control and Prevention (CDC), the National Institute of Allergy and Infectious Diseases (NIAID), the US Department of Agriculture (USDA), the Food and Drug Administration (FDA), and the US Agency for International Development (USAID).

The budget cuts $22.7 million from the CDC's Antibiotic Resistance Solutions Initiative (ARSI), which funds statewide efforts to detect and track resistance threats, and seeks to move ARSI's funding source to the Prevention and Public Health Fund, which would disappear if Congress is successful in repealing the Affordable Care Act. "A cut of this magnitude would impact every aspect of CDC's work to protect us from AMR, including its support for state public health labs and research collaborations with academic institutions," the letter says.

In addition, the budget proposes a $76 million cut from the CDC's Center for Global Health, which studies global resistance patterns, a $1.1 billion cut to the NIAID, a significant funder of research into new antimicrobials, and a $50 million cut to the FDA's Center for Veterinary Medicine, which promotes antimicrobial stewardship in agriculture. A $62.6 million cut to USAID's global tuberculosis program would diminish efforts to screen, diagnose, and treat patients who have multidrug-resistant tuberculosis.

The letter asks the chairs and ranking members of the Labor-HHS-Education, Agriculture, and State-Foreign Ops Appropriations subcommittees to not only reject the cuts detailed in the budget but "continue Congress's bipartisan support for AMR that reflects the US commitment to infection prevention, antimicrobial stewardship, surveillance, and innovation."
Jun 28 IDSA letter


Study finds benefit for antibiotic treatment of simple skin wounds

Originally published by CIDRAP News Jun 28

A study today in the New England Journal of Medicine reports that the use of clindamycin or trimethoprim-sulfamethoxazole (TMP-SMX) in conjunction with incision and drainage, when compared with incision and drainage alone, improves short-term outcomes in patients who have uncomplicated skin abscesses.

The multicenter, prospective, double-blind trial involved 786 participants who had a skin abscess of 5 centimeters or smaller. Staphylococcus aureus was isolated from 527 participants, and methicillin-resistant S aureus (MRSA) was isolated from 388. After abscess incision and drainage, participants were randomly assigned to receive clindamycin, TMP-SMX, or placebo for 10 days. The primary outcome was clinical cure 7 to days after treatment.

The results showed that the cure rates for participants in the clindamycin group (83.1%) and the TMP-SMX group (81.7%) were significantly higher than in the placebo group (68.9%). The beneficial effects were limited to patients with S aureus infection. Among participants who were initially cured, new infections at 1 month follow-up were less common in the clindamycin group (6.8%) than in the TMP-SMX (13.5%) or the placebo group (12.4%), while adverse events were more frequent with clindamycin (21.9%) than with TMP-SMX (11.1%) or placebo (12.5%).

The authors say the benefits of adding treatment with clindamycin or TMP-SMX after incision and drainage of simple skin abscesses should be weighed against the known side-effect profiles of these antibiotics
Jun 29 N Engl J Med study


Meta-analysis documents rise in drug-resistant bacteria at the Hajj

Originally published by CIDRAP News Jun 27

A review and meta-analysis of studies on bacterial transmission and antibiotic resistance during the annual pilgrimage to Mecca has found rising rates of resistance among certain gram-positive and gram-negative bacteria, researchers report in Travel Medicine and Infectious Disease.

The review of drug-resistant bacteria at the Hajj included 31 studies involving pilgrims, food workers, and local patients at hospitals in Mecca, Mina, and Medina. The studies were conducted during the Hajj seasons from 2000 to 2015 and most of them provided antibiotic susceptibility results, with 11 identifying antibiotic-resistance genes. While many of the pilgrims came from different continents and countries, most were from Saudi Arabia and France; the majority of patients with infections were from Saudi Arabia.

While resistance rates varied between studies, the review indicates rising rates of antibiotic-resistant bacteria in the Hajj area. MRSA isolated from food handlers rose from 0 in a 2001-02 study to 20% in a 2014 study, while MRSA isolated from pilgrims rose from 1% in 2000 to 63.2% in 2015. Studies of patients with bacterial infections reported rising rates of third-generation cephalosporin-resistant E coliK pneumoniae, and Acinetobacter baumannii from 2005 to 2015, ranging from 18.8% to 94%.

Carbapenem-resistant bacteria were detected in fewer than 10% of E coli isolates but up to 100% of K pneumoniae and A baumannii isolates. An increase in colistin-resistant bacteria, including MCR-1–producing E coli and K pneumoniae, was also noted. Rates of vancomycin-resistant gram-positive bacteria remained low.

The rising rates of antibiotic resistant bacteria are a concern because the mass gathering, which involves more than 2 million participants from over 184 countries each year, can facilitate the acquisition and spread of bacterial pathogens. "Hajj pilgrims therefore have the potential to disseminate or acquire [antibiotic resistant] bacteria during their stay in Saudi Arabia and to spread these bacteria when returning to their home country," the authors write.
Jun 24 Travel Med Infect Dis abstract


Study finds increase in C difficile in cancer patients

Originally published by CIDRAP News Jun 26

Researchers with the University of Texas at Austin report that the incidence of Clostridium difficileinfection (CDI) is increasing among cancer patients, according to a new study in BMC Infectious Diseases.

Using data from the US National Hospital Discharge Surveys, the researchers identified more than 30 million cancer discharges from US hospitals from 2001 to 2010. CDI was present in 260,219 (0.9%) of cancer patients. The overall CDI incidence for the study period was 8.6 per 1,000 adult discharges, with incidence increasing from 6.8 per 1,000 cancer discharges in 2001 to 12.8 in 2010. Incidence peaked in 2008 at 17.2 per 1,000 discharges. Increases were seen in both principal CDI and secondary CDI.

Patients with CDI were more likely to be older, male, residents of the Northeast, and Medicare users, and CDI was found to be over 2.5 times more common among patients with blood cancers than those with solid-organ cancers.

Death occurred in 7.4% of cancer patients during the study period. The mortality rate was significantly higher for cancer patients with CDI compared with those without (9.3% vs 7.4%). In addition, the median length of hospital stay was significantly longer for CDI patients compared with those without (9 days vs 4 days).

The authors of the study say that knowing the burden of CDI among cancer patients is important because cancer patients can now be identified as a high-risk population and a target for antimicrobial stewardship and infection control efforts. 
Jun 23 BMC Infect Dis study


Editorial urges narrower use of contact precautions with MRSA, VRE

Originally published by CIDRAP News Jun 26

An editorial today in JAMA is calling for a rethinking of the use of contact precautions for MRSA and vancomycin-resistant Enterococcus.

Under 2007 guidance from the CDC, which recommends the use of gloves and gowns for patients with target multidrug-resistant organisms (MDROs) and those who have previously been identified as colonized with target MDROs, patients infected or colonized with MRSA and VRE have become the most common focus of contact precautions. In addition, many states have passed laws mandating active culturing and contact precautions for MRSA patients.

But the authors of the editorial argue that no strong clinical trial evidence supports this policy. Observational data suggesting that contact precautions prevent MRSA or VRE infections, they say, come from reports of bundled approaches to outbreaks and not endemic MRSA or VRE, which are the more significant concern for hospitals. In addition, they cite higher-quality studies that have found no reduction in MRSA or VRE transmission rates associated with glove and gown use.

Furthermore, the authors argue that contact precautions can be burdensome when applied to an entire hospital, slowing the time it takes to move patients from the emergency room to hospital inpatient services and prolonging discharge time for patients being transferred to long-term care facilities, and result in less-satisfied patients. They also suggest that having to wear gloves and gowns for every patient visit could divert attention from other infection control activities, such as hand hygiene and chlorhexidine bathing.

One potential solution they offer is more selective use of contact precautions, given that MRSA or VRE contamination are more common when healthcare workers are performing high-risk patient care activities, such as bathing patients or dressing wounds, and caring for patients with clinical infections. Hospitals that have used such an approach, they say, have found no adverse effects on infection rates.

"Contact precautions are of unproven benefit and, at best, are low-value interventions that require significant personnel engagement," the authors write. "Reports of successful, alternative uses of gloves and gowns to prevent all infections while decreasing the health care worker, institutional, and environmental burden of personal protective equipment use are encouraging."
Jun 26 JAMA viewpoint


Antibiotic resistance in acne

Originally published by CIDRAP News Jun 26

A synopsis of clinical evidence suggests that the use of topical and systemic antibiotics for acne is associated with the formation of resistance in Propionibacterium acnes and other bacteria, with clinical consequences.

The synopsis, published in JAMA Dermatology, encompasses five trials conducted from 1987 to 2002 and 2007 to 2008 and including more than 120,000 patients in the United States, United Kingdom, Greece, Hungary, Italy, Spain, and Sweden. The primary outcomes were prevalence of antibiotic-resistant P acnes among patients and untreated contacts, nasal/pharyngeal colonization with S aureus, diagnosis of upper respiratory or urinary tract infection, and self-reported pharyngitis.

A summary of the findings showed that multiple countries have reported resistance in more than half of P acnes isolates, predominantly to topical erythromycin and clindamycin, and that resistant P acnes is found on the skin of untreated contacts of acne patients prescribed antibiotics. In addition, the reviewers found that use of topical antibiotics is associated with resistance in S aureus, that acne patients treated with topical and/or oral antibiotics for at least 6 weeks were more likely to develop upper respiratory infections during 1 year of follow-up than those who had not received antibiotics, and that university students receiving oral antibiotics for acne were four times more likely to report pharyngitis during 1 year of follow-up.

To reduce resistance, current guidelines from the American Academy of Dermatology recommend benzoyl peroxide, a topical bactericidal agent not reported to cause resistance, alongside topical and oral antibiotics. Benzoyl peroxide is thought to impede the formation of resistance, but evidence of its ability to limit resistance is stronger with topical antibiotics than with oral antibiotics.

The authors say additional studies are needed to address multiple evidence gaps. 
Jun 21 JAMA Dermatol clinical evidence synopsis

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