ASP Scan (Weekly) for Sep 29, 2017

Money for HAI prevention
Drug resistance in supply chains
Restaurant antibiotic grades
Antibiotics for kids' diarrhea
MDR pathogens and gangrene
XDR Acinetobacter in Turkey

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

CDC awards $10 million for healthcare-associated infection research

The US Centers for Disease Control and Prevention (CDC) has awarded $10 million to five organizations for research into the spread and prevention of healthcare-associated infections (HAIs), especially those that are antibiotic resistant.

The five recipients are the University of Utah, RTI International, the University of Iowa, Washington State University, and the Center for Disease Dynamics, Economics & Policy. Their projects include developing tools and methods to understand the transmission of HAIs and antibiotic-resistant infections in healthcare facilities, assessing hospital-based strategies to prevent HAI transmission, and evaluating outbreak alert algorithms.

The investments are part of the CDC's Antibiotic Resistance Solutions Initiative, which supports activities to detect, prevent, and respond to resistant infections in healthcare, food, and the community.

In its most recent survey of HAI prevalence, the CDC estimated that nearly 722,000 HAIs occurred in US acute care hospitals in 2011, and 75,000 patients with HAIs died during their hospitalization. The leading HAIs included surgical-site infections, pneumonia, and gastrointestinal illness.
Sep 27 CDC information page 


UN, FAO join forces to combat antimicrobial resistance in supply chains

European Union (EU) Commissioner of Health and Food Safety Vytenis Andriukaitis, MD, and United Nations Food and Agriculture Organization (FAO) Director-General Jose Graziano da Silva, PhD, today agreed to bolster collaboration between the two organizations to address food waste, food safety, and antimicrobial resistance (AMR) in supply chains, according an FAO news story today.

In a letter of intent signed today, the FAO and the EU pledge to bolster cooperation on tackling the spread of AMR on farms and in food systems.

Calling AMR a growing global concern, Graziano da Silva said: "Unfortunately, the use of antibiotics, including their use to promote growth, is already widespread." He said the FAO believes that antibiotics and other antimicrobials should be used only to cure diseases and, in certain circumstances, to prevent epidemics, but not to promote animal growth.

Areas of cooperation include the following, according to the story: (1) increasing the exchange of information and evidence related to antimicrobial use in food production, as well as best AMR management practices; (2) joint advocacy and education efforts to promote the responsible use of antimicrobials and improve farm-level hygiene; (3) supporting nations in drafting legislation surrounding antimicrobial usage; and (4) conducting joint training and capacity building aimed to improve tracking the use antibiotic in food systems and mapping the presence of AMR.
Sep 29 FAO 
news story


New report grades US restaurant chains on antibiotic use in meat supply

Originally published by CIDRAP News Sep 27

More than half of the nation's top 25 chain restaurants are taking steps to reduce the use of medically important antibiotics in their meat and poultry supply, according to a report today from a collection of consumer, environmental, and public health organizations.

The third annual Chain Reaction report, which assesses and grades fast food and fast casual restaurant chains on the progress they've made in eliminating the routine use of antibiotics in the meat they purchase, found that 14 of the 25 largest chains received passing grades on their efforts, up from 9 in 2016. Chipotle and Panera received "A" grades for their efforts. Eleven chains received an "F" for not taking any discernable action to reduce the use of antibiotics in their food supply.

The chains that received passing grades have adopted a range of antibiotic use policies. Some have pledged to buy only meat raised without any antibiotics ever, while other policies are limited to antibiotics that are also used in human medicine. Some chains will purchase meat only from suppliers that don't routinely use medically important antibiotics in their animals. And while Chipotle and Panera have fully implemented these policies, other chains have set timelines for full compliance with their commitments. The report grades the chains on the content of their policies, implementation, and transparency.

But most restaurant policies target antibiotic use only in chicken, the report notes, with few companies establishing similar policies for beef, pork, and turkey. Only Chipotle, Panera, and Subway (which received a "B+" grade) have taken steps to prohibit or reduce antibiotic use across nearly all of their supply chains.

“When it comes to chicken nuggets, we've seen incredible change in a few short years—but burgers and bacon are another story," Lena Brook, food policy advocate at the Natural Resources Defense Council (NRDC), said in a press release issued by Consumers Union. The two groups co-produced the report with the Food Animal Concerns Trust, Friends of the Earth, U.S. PIRG Education Fund, and the Center for Food Safety.

And while the report lauds the role that restaurant chains are playing in pushing the poultry industry away from routine antibiotic use, it also argues that the federal government needs to take more action to combat antibiotic misuse in the livestock industry. In particular, it argues that efforts by the Food and Drug Administration to end the use of antibiotics for growth promotion, and to collect data on the impact of those efforts, have not gone far enough.

Based on data from 2011, an estimated 70% of medically important antibiotics sold in the United States are for use in livestock and poultry production.
Sep 27 Chain Reaction III report
Sep 27 Consumers Union press release


Vietnamese study finds antibiotics don't benefit pediatric diarrhea patients

Originally published by CIDRAP News Sep 27

Empirical antimicrobial therapy for pediatric diarrhea in a high-usage, high-resistance setting provided no clinical benefit, and it even prolonged hospital stays in some groups, researchers reported yesterday in Clinical Infectious Diseases.

The prospective, observational, multi-center cross-sectional study of pediatric patients hospitalized with diarrhea was conducted in Vietnam, where all-cause diarrhea affects 7% to 11% of all children under the age of 5 and accounts for as much as 12% of all-cause deaths in this age-group. Although CampylobacterSalmonella, and Shigella have been identified as the main diarrhea-causing bacteria, less is known about the epidemiology, resistance profiles, treatment, and associated outcomes of these bacteria in pediatric diarrhea patients. But empirical antibiotic treatment for diarrhea is common in Vietnam.

From May 2014 through April 2016, researchers recruited 3,166 children hospitalized at three hospitals in Ho Chi Minh City. More than one third of the children (34.6%) had acute bloody diarrhea, 56.1% had acute non-bloody diarrhea, and 25% were culture-positive for ShigellaSalmonella, or Campylobacter.

The use of antimicrobials among all patients was high, with 85.2% receiving empirical treatment following admission to hospital and before obtaining a bacterial culture result. Fluoroquinolones, which are recommended by the World Health Organization for treatment of pediatric diarrhea, were the most commonly used class of antimicrobial, accounting for 66.7% of all antimicrobials. Antimicrobial resistance (AMR) was highly prevalent on the isolated bacteria, mainly to fluoroquinolones and third-generation cephalosporins. 

The effect of antimicrobial treatment was assessed using two proxy disease outcome measures—clinical outcome at 3 days post-enrollment and duration of hospital stay. While more than 80% of patients improved or recovered at 3 days post-enrollment regardless of antimicrobial treatment, those given fluoroquinolones had a longer hospital stay compared with those not receiving an antimicrobial. In addition, antimicrobial treatment in those with non-bloody diarrhea was also associated with a longer hospital stay.

The authors say the findings highlight the need for adequately powered randomized controlled trials to be conducted to better assess the potential benefits and drawbacks of antimicrobial therapy for treatment of diarrhea. "These data will become essential for controlling antimicrobial usage during the present AMR crisis," they write. 
Sep 26 Clin Infect Dis study


Study finds a 21% incidence of MDR pathogens in Fournier's gangrene

Originally published by CIDRAP News Sep 27

More than one in five patients with Fournier's gangrene were found to be infected with multidrug-resistant organisms (MDROs), according to a small study yesterday in the Journal of Infection.

San Diego researchers analyzed data from 59 patients who had Fournier's gangrene in their large academic hospital from 2006 through 2015. Patients had an average age of 56 years (range, 18 to 91), with risk factors that included obesity, diabetes, and having a compromised immune system. Fournier's gangrene involves dead or dying tissue (necrosis) of the scrotum, penis, or perineum.

The scientists were able to identify a causative organism in all but 2 cases, and 12 of those (21%) had an MDRO. The most common MDROs were methicillin-resistant Staphylococcus aureus (MRSA), in 8, followed by extended-spectrum beta-lactamase–producing Escherichia coli, in 3. Among aerobic gram-negative rod (GNR) bacilli isolated in the study, 32% were fluoroquinolone-resistant.

Among all the patients with gangrene, 15% lost an organ or other body part, and another 15% died.

The authors conclude, "This report highlights the emergence of MDROs as an important cause of these infections including MRSA and drug-resistant GNRs. Antibiotics should be chosen with broad-spectrum, anti-MDRO activity given the high morbidity and mortality associated with these infections."
Sep 26 J Infect study


Study describes XDR Acinetobacter baumannii outbreak in neonates

Originally published by CIDRAP News Sep 26

An outbreak of bacteremia caused by extensively drug-resistant Acinetobacter baumannii (XDR-AB) affected 41 infants at a neonatal intensive care unit (NICU) in central Turkey, with 58% mortality, researchers reported yesterday in the American Journal of Infection Control.

The clustering of bloodstream infections (BSIs) due to XDR-AB in the NICU at Erciyes University Hospital was first noticed in mid-2014. Once the outbreak was identified, patients with A baumannii infection were cohorted in isolation rooms or separate areas within the NICU, and contact isolation was performed for all case patients. It took 2 years to get the outbreak under control.

In a retrospective case-control study conducted from July 2014 to July 2015 that included 41 case patients and 108 control patients, investigators found that the risk factors (by univariate analysis) associated with BSI due to XDR-AB were mechanical ventilation, 14-day mortality, use of peritoneal dialysis, and use of umbilical catheter. Multivariate analysis identified umbilical catheter use as an independent risk factor (odds ratio 2.44). All 41 strains isolated from the case patients were found to be XDR and fully susceptible only to colistin, and pulsed-field gel electrophoresis indicated they belonged to a distinct clone (common pulsotype 2).

Because XDR-AB is endemic in the adult wing of the hospital, the investigators initially hypothesized inter-hospital transmission of the bacterium because of lapses in environmental cleaning and disinfection. But the major epidemic clone of A baumannii was not related to the strain circulating in the adult section. Investigators were also unable to identify an index case or an environmental source. They suggest the source of the outbreak could have been a neonate who was transferred to the NICU from an outpatient clinic.

Control of the outbreak was achieved by implementing long-term infection control measures in the unit, including maximal barrier precautions during insertion of catheters, compliance to hand washing protocols, and full adherence of healthcare workers to periodic education programs. A baumannii infection rates gradually decreased over the following 2 years, in parallel with the decline in umbilical catheter-related infection rates.
Sep 25 Am J Infect Control abstract

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