ASP Scan (Weekly) for Nov 17, 2017

Primary care stewardship
No-touch superbug disinfection
Surgical antimicrobial prescribing
Ceftriaxone-resistant gonorrhea
E coli ST131
Single-room ICU design
ECDC CRE guidance
European research funding
Optimal MDR-TB treatment
Real-time resistance tracker
Salmonella in calves
Drug-resistant malaria controversy
US AMR progress
Antimicrobial use in Northern Ireland
Resistance in space

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

Hong Kong launches antibiotic stewardship efforts

Hong Kong's Centre for Health Protection (CHP) this week launched an Antibiotic Stewardship Program (ASP) in Primary Care and hospital guidelines on multidisciplinary prescribing as two key steps in rolling out the Hong Kong Strategy and Action Plan on Antimicrobial Resistance (AMR).

In a seminar on ASP in primary care and hospital settings to commemorate World Antibiotic Awareness Week, Dr Wong Ka-hing, CHP controller, said, "Optimising the use of antimicrobials is one key in controlling the emergence of AMR," according to a CHP press release. He added that primary care providers "play a pivotal role in tackling the AMR problem, not only by practising rational antibiotics prescription, but also educating and empowering patients on the safe use of antibiotics during clinical encounters." Ka-hing said the launch of the ASP and prescribing guidelines "provides comprehensive and updated clinical guidelines of infections for healthcare professionals in both the community and hospitals."

For the primary care ASP, an advisory group of experts has produced evidence-based guidance for acute pharyngitis (throat inflammation), acute uncomplicated cystitis (bladder inflammation) in women, and simple skin and other soft-tissue infections, with a goal of reducing unnecessary prescriptions. The advisors plan to formulate additional guidelines for other common infections.

The CHP has provided guidance notes on antibiotic use, educational materials for physicians, and other material on its ASP in Primary Care website.

The CHP, in collaboration with hospitals, two universities, and the Hong Kong Medical Association, has updated its hospital prescribing guidelines to make them more useful in reinforcing appropriate antimicrobial use and has added a new section on tuberculosis. The guidelines, interactive medical calculators, and easy-to-read antibiograms are available on a separate website.
Nov 13 Hong Kong CHP news release


Studies show positive effect of no-touch disinfection on C difficile

No-touch disinfection methods may be effective against Clostridium difficile and other AMR bacteria, according to two studies yesterday in Infection Control & Hospital Epidemiology.

In the first paper, Iowa researchers conducted a meta-analysis involving 20 studies that involved either ultraviolet light (UVL; 13 studies) or aerosolized hydrogen peroxide (AHP; 7 studies) to decontaminate hospital rooms.

Their pooled analysis of the UVL studies showed statistically significant reductions in C difficile and vancomycin-resistant enterococci infections but not for methicillin-resistant Staphylococcus aureus (MRSA) or gram-negative multidrug-resistant pathogens. Analysis of AHP data revealed only a statistically nonsignificant drop in C difficile infections.
Nov 16 Infect Control Hosp Epidemiol meta-analysis

In the second study, investigators at University College London Hospitals compared the effects of manual disinfection and of AHP on C difficile contamination at various hospital locations.

Over the course of a year, the team sampled 2,529 sites in 146 rooms and 44 bays. They found C difficile on 131 of 572 surfaces (22.9%) before cleaning, on 105 of 959 surfaces (10.6%) after manual cleaning, and on 43 of 967 surfaces (4.4%) after AHP disinfection. The bacterium persisted most frequently on floor corners (97 of 334; 29.0%) after disinfection.

The researchers also noted that feedback of results did not lead to lower C difficile rates after manual cleaning.
Nov 16 Infect Control Hosp Epidemiol study


Australia survey cites frequent poor surgical antimicrobial prescribing

In another report during World Antibiotic Awareness Week, the Australian Commission on Safety and Quality in Health Care (ACSQHS) released updated data on surgical use of antimicrobials that highlighted up to a 60% rate of inappropriate prescribing, depending on the situation.

Citing 2016 data, the ACSQHS said 50.5% of antimicrobials administered preventively before or during surgery (prophylactic use) were deemed appropriate, while 43.4% had at least one inappropriate prescribing element. When procedural antimicrobials were prescribed, 46.1% were compliant with national guidelines, 8.3% were compliant with local guidelines, and 38.3% were not compliant with any guidelines. The most common reason for inappropriate procedural antimicrobial prescribing (45.7% of the instances) was incorrect timing.

Post-operative antimicrobials, in contrast, were prescribed appropriately 38.7% of the time, whereas 59.9% had at least one inappropriate prescribing element.

The report cites four areas of potential improvement:

  • Documentation of incision time and administration time for antimicrobials
  • Compliance with guidelines for surgical antimicrobial prophylaxis
  • Timing of procedural antimicrobial administration
  • Duration of therapy for post-procedural antimicrobials, when required

The authors of the report conclude, "As the use of antimicrobials for surgical prophylaxis has been demonstrated to be suboptimal, and antimicrobials are used for longer than necessary in this setting, the Commission will continue to work with the Royal Australasian College of Surgeons to develop guidance in this area."
Nov 16 ACSQHS report


Canadian patient identified with rare ceftriaxone-resistant gonorrhea

Originally published by CIDRAP News Nov 16

Canadian researchers have identified a ceftriaxone-resistant Neisseria gonorrhea isolate in a Canadian patient, according to a new report in Emerging Infectious Diseases. It's one of only a handful of ceftriaxone-resistant N gonorrhea isolates reported worldwide.

The isolate was identified in a 23-year-old woman who tested positive for gonorrhea in January 2017. Antimicrobial susceptibility testing indicated that the isolate was non-susceptible to ceftriaxone and cefixime but susceptible to azithromycin. Tests of cure 14 days after initial treatment with azithromycin and cefixime came back negative, suggesting the azithromycin was effective in treating the infection.

Testing of two previous sexual partners for gonorrhea also came back negative, but one of the men reported unprotected sexual activity during a trip to China and Thailand in November 2016.

Whole genome sequencing showed that the isolate belonged to multilocus sequence type ST1903 and contained a mosaic penA allele (penA-60); these elements are identical to those found in a ceftriaxone- and multidrug-resistant N gonorrhea isolate reported in Japan in 2015. The authors of the study say the epidemiologic information suggests the international spread of a penA allele associated with high-level ceftriaxone resistance.

Rising resistance to the combination therapy of azithromycin and ceftriaxone or cefixime—the last remaining effective treatment for gonorrhea—has raised concerns about the global emergence of untreatable gonorrhea. 
Nov 13 Emerg Infect Dis study


Chinese study shows prevalence, characteristics of E coli clone

Originally published by CIDRAP News Nov 16

More than 11% of Escherichia coli isolated from patients at a Chinese hospital belong to the extensively drug-resistant sequence type (ST) 131 clonal group, researchers reported yesterday in Antimicrobial Resistance and Infection Control.

For the study, researchers at a Chinese university hospital collected a total of 700 non-duplicate E coli isolates obtained from urine, blood, miscellaneous sources from August 2014 to August 2015. Isolates belonging to ST131 were identified by polymerase chain reaction testing and multilocus sequence typing and were also characterized for antibiotic resistance levels, resistance genes, and virulence factors.

Overall, 83 isolates (11.6%) were identified as belonging to the ST131 clonal group, which is similar to rates reported previously. The H30 lineage, an important ST131 subclone that has become the most dominant and extensively distributed multidrug-resistant lineage of E coli worldwide, accounted for 63.9% of the isolates. Results of O typing revealed that the ST131 isolates belonged to two types—O25b-B2-ST131 (66.3%) and O16-B2-ST131 (33.7%).

The researchers say that although O25b-B2-ST131 remains the predominant ST131 clone type in China, the high percentage of O16-B2-ST131 identified in the study indicates the subclone may be an important type of E coli ST131 in China and should be further investigated. 
Nov 15 Antimicrob Resist Infect Control study


Dutch researchers find single-room ICU design reduced MDR pathogens

Originally published by CIDRAP News Nov 16

A study in the Netherlands indicates that transforming an intensive care unit (ICU) into single-occupancy rooms helped reduce transmission of multidrug-resistant (MDR) pathogens, Dutch researchers reported yesterday in Antimicrobial Resistance and Infection Control.

The single-center retrospective study looked at two periods at a Dutch ICU: A first period from January 2002 to April 2009 and second period from May 2009 to March 2013. In the first period, the patients were treated in an ICU with 21 beds located in five single rooms, two double rooms, and an open bay. This unit was closed on two occasions because of outbreaks of extended-spectrum beta lactamase-producing Klebsiella pneumoniae (ESBL-Kp) and MDR Acinetobacter baumannii. In May 2009, the patients were transferred to a newly built ICU with 9 single-occupancy rooms.

The two periods were compared with respect to the occurrence of representative MDR gram-negative (MDR-GN) bacteria. Routine microbiological screening was performed on all patients on admission to the ICU and then twice a week. To assure comparability, the two periods were approximately identical with respect to number of admissions, number of beds, and bed occupancy rate, per year and per month.

The results showed that despite infection prevention efforts—including improved hand hygiene, use of contact precautions, isolation of ESBL-Kp patients, and temporary ward closure on two occasions—high prevalence of MDR-GN bacteria continued to occur during the first period. After the move to the single-room ICU, a clear and sustained decrease in MDR-GN bacteria was observed.

"Our results provided strong evidence that the single room policy as an infection control strategy has contributed significantly to the control of cross transmission of resistant pathogens in the ICU," the authors write.
Nov 15 Antimicrob Resist Infect Control study


ECDC publishes guidance on reducing CRE infections

Originally published by CIDRAP News Nov 15

The European Centre for Disease Prevention and Control (ECDC) today published guidelines on screening for and prevention of carbapenem-resistant Enterobacteriaceae (CRE) that include hospital stay, chemotherapy treatment, and link to a CRE carrier as risk factors.

CRE—predominantly drug-resistant E coli and K pneumoniae—are responsible for many deaths and high healthcare costs. The ECDC noted in a surveillance report today that E coli resistance is on the rise in Europe (see related CIDRAP News story).

The ECDC published its CRE guidance in Antimicrobial Resistance and Infection Control "to raise awareness and identify the 'at-risk' patient when admitted to a healthcare setting and to outline effective infection prevention and control measures to halt the entry and spread of CRE." A team of experts met twice to formulate the guidance after analyzing the current data and expert opinion.

The guidelines place any patient with one of these factors in the "at-risk" category: (1) overnight stay in a healthcare setting in the previous year, (2) dialysis-dependent or cancer chemotherapy in the past year, (3) known carriage of CRE in the past year, and (4) epidemiologic linkage to a known CRE carrier. The experts define "carrier" as anyone infected with a CRE or harboring one without showing symptoms.

Healthcare professionals should implement the following steps for prevention control for any at-risk patient: (1) pre-emptive isolation, (2) active screening for CRE, and (3) contact precautions. "Patients who are confirmed positive for CRE will need additional supplemental measures," the authors wrote.

The experts conclude, "This guidance document offers suggestions for best practices, but is in no way prescriptive for all healthcare settings and all countries. Successful implementation will result if there is local commitment and accountability. The options for intervention can be adopted or adapted to local needs, depending on the availability of financial and structural resources."
Nov 15 ECDC guidance


Europe's Joint Programming Initiative funds 10 AMR projects

Originally published by CIDRAP News Nov 15

In other European news, the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR) today announced funding of €11.5 million ($13.6 million) for 10 transnational research projects involving multidisciplinary studies on antimicrobial resistance (AMR), including One Health approaches.

Awardees include 47 funded research groups from 11 countries (Canada, Germany, Ireland, Israel, Latvia, the Netherlands, Norway, Poland, Romania, Sweden and Switzerland), and an additional 6 international partners in the Czech Republic, Israel, Romania, and United States.

Funded projects include preventing the spread of methicillin-resistant Staphylococcus aureus from livestock to people, improving prescribing for urinary tract infections in the elderly, AMR manure intervention, online stewardship efforts, and AMR transmission in the food chain.

The final funding decision will depend on national regulations and inspection of the formal proposals by the national funding organizations, the JPIAMR said in a news release.
Nov 15 JPIAMR news release


Brazil study finds standardized MDR-TB therapy effective

Originally published by CIDRAP News Nov 15

Patients with multidrug-resistant tuberculosis (MDR-TB) in Brazil who received standardized regimens had almost a third the rate of failure or relapse compared with those receiving individualized treatment, according to a study yesterday in BMC Infectious Diseases.

Brazilian scientists analyzed data on 1,972 MDR-TB patients from 2007 through 2013, of whom 60% were successfully treated. Success was more likely in patients who didn't have HIV, those were sputum-negative at baseline, had unilateral disease, and had no prior DR-TB.

After the researchers adjusted for these variables, they determined that MDR-TB patients receiving standardized regimens had a 2.7-fold odds of success compared with those receiving individualized treatments when failure/relapse were considered, and a 1.4-fold odds of success when death was included as an unsuccessful outcome. Patients who used levofloxacin instead of ofloxacin had 1.5-fold odds of success.

The authors concluded, "Our findings support the Brazilian recommendation for the use of standardized instead of individualized regimens for MDR-TB, preferably containing levofloxacin."
Nov 14 BMC Infect Dis study


FDA launches Resistome Tracker to monitor antibiotic resistance

Originally published by CIDRAP News Nov 14

The US Food and Drug Administration (FDA) today launched an interactive research tool called Resistome Tracker to track antibiotic-resistance genes.

"Resistome Tracker is one of the first publicly available tools to provide visually informative displays of antibiotic resistance genes in bacteria," the FDA said in a news release. Designed mainly for public health officials, academics, and researchers who are using new genomics technologies, the tool allows users to identify new resistance genes, customize visualizations by antibiotic drug class, compare resistance genes across different sources, and map resistance genes to geographic region.

By using whole-genome sequencing (WGS), Resistome Tracker represents a major advancement in resistance monitoring that will enhance the evaluation of the impact of antibiotic use on the evolution and spread of antibiotic resistance, the agency said.

Resistome Tracker has launched with a focus on Salmonella. Scientists upload Salmonella genome sequences from the National Center for Biotechnology Information (NCBI) public databases Resistome Tracker each week, allowing near real-time monitoring of antibiotic resistance. Resistome Tracker includes WGS data on 97,390 genomes from NCBI, 27,512 of which are US isolates and 8,900 are isolates from the National Antimicrobial Resistance Monitoring System (NARMS).

Later the tool will include data on pathogens like Escherichia coli and Campylobacter as well as additional gene categories such as serotype, sequence type, and virulence genes.
Nov 14 FDA news release
Resistome Tracker


CDC reports more cases of drug-resistant Salmonella tied to dairy calves

Originally published by CIDRAP News Nov 14

A multistate outbreak of Salmonella Heidelberg infections linked to contact with dairy calves has grown by 8 cases, to 54 cases, the Centers for Disease Control and Prevention (CDC) said today in an update.

Of the 54 cases, 17 have required hospitalization, the CDC said, but no deaths have been reported. The latest cases were in six states, including Virginia, which had its first case and increase the number of infected states to 15, 1 more than the agency reported in its previous outbreak update on Aug 2. Wisconsin has had the most cases (19), followed by Missouri (7), Minnesota (6), and South Dakota (5).

Officials have interviewed every patient, and 34 of them (63%) reported contact with dairy calves or other cattle in the week before they fell ill.

The CDC said, "Ongoing surveillance in veterinary diagnostic laboratories showed that calves in several states continue to get sick with the outbreak strains of multidrug resistant SalmonellaHeidelberg. Information collected earlier in the outbreak indicated that most of the calves came from Wisconsin. Regulatory officials in several states are now tracing the origin of the calves that are linked to the newer illnesses."

The update said WGS has identified multiple resistance genes in 43 outbreak-related isolates from patients, 87 from cattle, and 11 from animal environments. All 8 isolates from people that were tested were resistant to amoxicillin-clavulanic acid, ampicillin, cefoxitin, ceftriaxone, streptomycin, sulfisoxazole, and tetracycline, and had reduced susceptibility to ciprofloxacin. Seven isolates were also resistant to trimethoprim-sulfamethoxazole, 5 to nalidixic acid, and 3 to chloramphenicol. All eight isolates, however, were susceptible to azithromycin and meropenem.
Nov 14 CDC update


Controversy simmers over drug-resistant malaria threat

Originally published by CIDRAP News Nov 14

Researchers concerned about alarming levels of treatment failures of preferred malaria drugs in the Greater Mekong region are at odds over whether stronger actions should be taken to head off the threat, such as declaring a public health emergency of international concern (PHEIC), according to a Nov 10 report from BMJ.

On Sep 21, researchers writing in a letter to The Lancet Infectious Diseases described a multidrug-resistant parasite lineage that has now been detected in southern Vietnam, following spread in Cambodia, Thailand, and Laos. They said that, over 8 years, the lineage, resistant to the piperaquine component of combination therapy, has now been found in all four Greater Mekong countries.

The report from Mahidol Oxford Tropical Medicine Research Unit (MORU) triggered calls for greater action, including from its top funder, the Wellcome Trust. One of the concerns is the impact that drug-resistant malaria would have if it spread to Africa, which carries 90% of the world's malaria death burden. And some experts said they worried that the development might undo steady progress in battling the disease.

In a response to the letter and calls for action in late September, the World Health Organization (WHO) said the research is sound, though it questioned the group's interpretation. It said resistance to malarial drugs is a big concern, but warned against creating unnecessary alarm. The WHO also said current malaria elimination efforts have had a big impact.

Nicholas White, MD, DSc, one of the researchers at MORU, told BMJ that the group doesn't see any new strategies taking shape that address heightened concerns over the spread of drug-resistant malaria and that the WHO may be overly optimistic about current combination treatments and new ones to be developed.

Other global health experts, however, discounted the need for a PHEIC, noting continued progress against the disease and the need to focus efforts on access to treatment for populations who need it. Yet others said the uncertainty over whether to declare an emergency shows weakness in the current system for responding to infectious disease threats.

Ed Whiting, policy director at Wellcome Trust, told BMJ, "A new, graded system that triggers a concerted international response at scale, before reaching crisis status, would enable serious threats like artemisinin resistance to be tackled sooner, and may prevent them from becoming a global health emergency."
Nov 10 BMJ extract
Sep 21 Lancet Infect Dis letter
Sep 29 WHO Q and A on Lancet Infect Dis letter


HHS report notes stewardship, resistance progress in the US

Originally published by CIDRAP News Nov 13

Almost two thirds of US hospitals now have full-scale antibiotic stewardship programs and the incidence of several antimicrobial-resistant (AMR) infections are declining in the country, according to a progress report on 2 years of US efforts to combat AMR, the Department of Health and Human Services (HHS) said today.

The report, published by the HHS Office of the Assistant Secretary for Planning and Evaluation, also highlights the US government response to the emerging threat of MCR-1, the gene that confers resistance to colistin, an antibiotic of last resort. In its case study on MCR-1 risk, HHS describes a targeted response across federal agencies.

The report highlights progress made and steps needed for the five goals established in the National Action Plan for Combating Antibiotic-Resistant Bacteria (CARB) in 2015: (1) slow AMR bacteria; (2) strengthen national One Health efforts; (3) advance the development of rapid tests; (4) accelerate basic and applied science for developing new antibiotics, other drugs, and vaccines; and (5) improve international collaboration. Officials plan to implement these goals by 2020.

As part of its assessment of goal 1, the report notes that methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in US hospitals declined 13% from 2011 to 2014 and a further 5% by 2016. And C difficile infections dropped in US hospitals 8% from 2011 to 2014 and an additional 7% by 2016.

In addition, the percentage of US hospitals having programs that meet all seven of the Centers for Disease Control and Prevention's Core Elements of Antibiotic Stewardship rose to 46% in 2015 and to 64% in 2016. The report also noted that Veterans Health Administration centers saw a 10% decline in inpatient antimicrobial use.

As part of goal 2 efforts, HHS noted that the Food and Drug Administration doubled annual retail meat testing from 6,700 food samples in 2015 to about 17,280 in 2017. And testing of chicken parts by US Department of Agriculture inspectors increased from 3,850 facilities in 2015 to 8,000 in 2016.
Nov 13 HHS progress report
March 2015 CARB 
Action Plan


Northern Ireland report rise in bacteremia, drug-resistant infections

Originally published by CIDRAP News Nov 13

Northern Ireland's first report on antimicrobial use and resistance, also published today, notes that resistance levels in several common pathogens have risen in recent years, but the country has seen no change in antibiotic use since 2014.

The report, published by the country's Public Health Agency (PHA), notes that the percentage of E coli resistant to piperacillin-tazobactam increased from 8.8% in 2009 to 15.6% in 2016. And K pneumoniae resistant to the combination therapy increased from 8.6% to 19.0% in the same period. The PHA report also notes that the number of reported bloodstream infections caused by E coli increased from 980 to 1,487 and by K pneumonia from 143 to 208 from 2009 to 2016.

Total consumption of antibiotics in primary and secondary care remained at 32 doses per 1,000 inhabitants per day from 2014 through 2015, the report found. Of the doses prescribed, 85% were in primary care. The most frequently used antibiotics in both primary and secondary care in Northern Ireland were penicillins (37.7% and 31.1%, respectively), tetracyclines and related drugs (25.8% and 9.9%), and macrolides (14.3% and 8.5%).

The authors of the report concluded, "While the proportion of isolates that are resistant to key antibiotics has not changed very much over time, the absolute number of resistant infections has increased because of the overall rising number of infections."
Nov 13 PHA annual report


Experiments slated to test E coli resistance in space

Originally published by CIDRAP News Nov 13

Yesterday the National Aeronautics and Space Administration (NASA) launched E coli samples to the International Space Station (ISS) for experiments on antibiotic resistance, reported.

The bacterial specimens were launched to the ISS on Orbital ATK's Cygnus cargo spacecraft along with many other science experiments and supplies for the Expedition 53 crew. Experiments will examine how microgravity affects the ability of E coli to thrive while exposed to antibiotics. The project was developed through a partnership between NASA's Ames Research Center and the Stanford University School of Medicine.

"Bacterial antibiotic resistance may pose a danger to astronauts in microgravity, where the immune response is weakened," NASA said in a news release. "Scientists believe that the results of this experiment could help design effective countermeasures to protect astronauts' health during long-duration human space missions."

The experiment will determine the lowest concentration of antibiotic that inhibits E coli growth. The resulting data may be useful for prescribing correct antibiotic doses for future astronauts, NASA said.
Nov 12 story
Nov 3 NASA 
news release

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