ASP Scan (Weekly) for Jan 12, 2018

Online stewardship course
OIE report on animal antibiotics
MCR-4 in humans
Antibiotics in early pregnancy
Nasal screen for MRSA pneumonia
C difficile decline
Antibiotics in nursing homes
Environmental health risks
Migrant MDR-TB
Cost of VRE infections
Drug-resistant Acinetobacter

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

Online antimicrobial stewardship course reaches 33,000 people

An "interactive massive open online course" (MOOC) on antimicrobial stewardship was taken by 32,944 people in 163 countries and was rated highly by its participants, most of whom were healthcare professionals, according to a report this week in the Journal of Antimicrobial Chemotherapy.

The course, "Antimicrobial Stewardship: Managing Antibiotic Resistance," was developed by scientists at the University of Dundee and the British Society for Antimicrobial Chemotherapy, which publishes the journal. It ran over four 6-week periods in 2015 and 2016 supported by educators and was evaluated via data on uptake and feedback from participants on the impact on their clinical practices.

Of the 32 944 learners, 70% were healthcare professionals, with regional breakdown as follows: Europe (49%), Asia (16%), Africa (13%), North America (9%), Australia (8%), and South America (5%). From 33% to 37% of participants in each session completed at least one step in any week of the course, and 219 participants responded to a post-course survey.

Of those, 208 (95%) rated the course as good or excellent, and 83 (38%) said they intended to implement stewardship interventions in their own workplace. A follow-up survey 6 months later suggested that 49% of the 83 had implemented those interventions.

The authors of the report conclude, "The MOOC has addressed a global learning need by providing education free at the point of access, and learning from its development will help others embarking upon similar educational solutions."
Jan 10 J Antimicrob Chemother report


OIE: Fewer nations saying no to any animal antimicrobials for growth

The percentage of countries worldwide that do not authorize the use of any antimicrobial agents for growth promotion in food animals fell from 2015 to 2016, according to the second annual report on the use of such drugs in animals from the World Organization for Animal Health (OIE), published last month.

In 2015, 96 of 130 OIE member countries, or 74%, reported no authorization for the use of antimicrobial agents like antibiotics for growth promotion. But in 2016, according to the new report, that percentage fell to 59% (86 of 146). The numbers are based on surveys sent to all 180 OIE member nations.

In the 2017 report, 107 of 146 countries (73%) reported quantitative data for 1 or more years from 2013 to 2016, an increase from 89 countries in the 2016 report. Sources of these data varied among OIE regions but were most commonly sales and import records.

The new report is the first from the OIE to include drug use per animal weight. Based on data from 60 nations, the OIE estimates animal antimicrobial consumption of 98.97 milligrams per kilogram (mg/kg), with an upper-level estimate of 134.31 mg/kg.

The executive summary of the report concludes, "The OIE remains strongly committed to supporting our Members in developing robust measurement and transparent reporting mechanisms for antimicrobial use, but the challenges for many of our Members must not be under-estimated. . . . While data collection systems further develop, this annual report will provide an essential global and regional analysis of antibiotic use in animals, and changes over time."
December 2017 OIE report


Italian scientists report first MCR-4 isolates from human samples

Originally published by CIDRAP News Jan 11

Scientists from Italy today reported detecting the worrisome colistin-resistance gene MCR-4 in two isolates of Salmonella from people, only the second time the gene has been reported and the first time in humans, according to their report in Eurosurveillance.

Chinese researchers first reported the MCR-1 gene in Escherichia coli from pigs, pork products, and humans in 2015. Since then, the gene has been detected in bacteria from animals and humans in more than 30 countries, and MCR-2 and MCR-3 have been identified, as well. The MCR-4 gene was first identified last August in the same journal by a mostly different group of Italian researchers.

The genes are of particular concern because they are located on plasmids, which are small, highly mobile pieces of DNA that can spread resistance within and between different species of bacteria. They confer resistance to colistin, a last-resort antibiotic used to treat multidrug-resistant infections.

In today's report, the investigators said the MCR-4 genes were identified in two SalmonellaTyphimurium isolates collected in October and November 2016 from separate Italian patients.

They conclude, "To our knowledge, this is the first report of mcr-4-positive bacterial isolates of human origin. The two Salmonella species belonged to the same serovar as the first mcr-4-positive Salmonella strain reported in a pig slaughtered in Italy."
Jan 11 Eurosurveill report
Aug 3, 2017, 
CIDRAP News story on first identification


CDC notes inappropriate UTI antibiotic prescribing in early pregnancy

Originally published by CIDRAP News Jan 11

Because of concern over birth defects, sulfonamides and nitrofurantoin are not recommended for treating urinary tract infections (UTIs) in the first trimester of pregnancy unless other options are deemed inappropriate. But more than 40% of pregnant women with UTIs receive those antibiotics early in pregnancy, experts with the Centers for Disease Control and Prevention reported today in Morbidity and Mortality Weekly Report (MMWR).

The researchers analyzed insurance data for pregnant women in 2014. Of 14,286 women diagnosed as having a UTI in the first trimester, 9,846 (68.9%) received antibiotics. The most-prescribed antibiotics were nitrofurantoin (34.7%), ciprofloxacin (10.5%), cephalexin (10.3%), and trimethoprim-sulfamethoxazole (7.6%).

Which means that, in spite of American College of Obstetricians and Gynecologists guidelines recommending against sulfonamides and nitrofurantoin unless absolutely necessary, 42.3% of women in their first trimester of pregnancy received them to treat UTIs.

The authors conclude, "Given the recommendations to avoid nitrofurantoin and trimethoprim-sulfamethoxazole in early pregnancy if possible, it is important that health care providers of various specialties be familiar with these recommendations and that they consider that they might be 'treating for two' when prescribing antibiotic treatments for urinary tract infections to pregnant women and women who might become pregnant in the near future."
Jan 12 MMWR study


Review highlights utility of nasal screening for MRSA pneumonia

Originally published by CIDRAP News Jan 11

A meta-analysis of 22 studies has found that nasal screening for methicillin-resistant Staphylococcus aureus (MRSA) had a high specificity and negative predictive value (NPV) for ruling out MRSA pneumonia and may be an important antibiotic stewardship tool, according to a study today in Clinical Infectious Diseases.

US researchers pooled the data from the studies, which covered 5,163 patients. Overall sensitivity and specificity for nasal screening for all MRSA pneumonia types was 70.9% and 90.3%, respectively. Positive predictive value (PPV) was 44.8%, while NPV was 96.5%. Sensitivity and specificity for community-acquired and healthcare-associated MRSA pneumonia was 85.0% and 92.1%, respectively, while PPV and NPV increased to 56.8% and 98.1%, respectively.

The authors conclude, "Utilization of MRSA nares screening is a valuable tool for [stewardship programs] to streamline empiric antibiotic therapy."
Jan 11 Clin Infect Dis study


CDC says C diff cases in long-term care facilities have dropped sharply

Originally published by CIDRAP News Jan 10

A study yesterday by experts from the US Centers for Disease Control and Prevention (CDC) found that the incidence of Clostridium difficile in long-term care facilities decreased 17.5% annually from 2011 to 2015 at 10 US sites, along with a concomitant decline in inpatient fluoroquinolone use.

C difficile infection, a largely healthcare-related disease, can cause severe symptoms and death, the CDC says, with states reporting increased cases in US hospitals in recent years.

Writing in the American Journal of Infection Control, the CDC researchers said they analyzed data from 10 labs serving the agency's Emerging Infections Program (EIP) in 10 states during the 5-year period. The number of C difficile infections in long-term care facilities dropped from 3,151 in 2011 to 1,909 in 2015, for an overall decrease of 49%. The decline ranged from 6% to 65% by EIP site. The adjusted annual decrease across the country was 17.5%.

The researchers reported that the rate of the NAP1/027 epidemic strain likewise dropped, from constituting 29% of all C difficile strains in 2011 to accounting for only 18% in 2015. Fluoroquinolone use dropped a full 25 days of therapy per 1,000 patient-days.

The authors concluded, "A concomitant decline in inpatient fluoroquinolone use and the C difficile epidemic strain NAP1/027 among persons aged ≥65 years may have contributed to the decrease in long-term-care facility-onset C difficile infection incidence rate."
Jan 9 Am J Infect Control study


Study notes high antibiotic use in nursing homes linked to confusion

Originally published by CIDRAP News Jan 10

A study today in the Journal of the American Geriatrics Society reports high antibiotic use in nursing homes, especially for urinary tract infections (UTIs), with patient confusion tied to antibiotic treatment for suspected UTI.

Researchers reviewed the charts of 450 residents of five nursing homes in northern Queensland, Australia, from Aug 28, 2015, through Jun 21, 2016, to determine the prevalence of documented UTI, nonspecific and specific UTI symptoms, antibiotic use, and other factors.

They found that UTI accounted for 33% of all infections treated with antibiotics and 40% of all infections treated with antibiotics in the past 30 days. They also found that 20% of residents had received antibiotics in the past 30 days, 45% of which were for UTI. At the time of review, 40 residents (9%) were currently on antibiotics, of which 16 (40%) were for a UTI.

The investigators also found that new or worsening confusion was found to be strongly associated with urinary frequency (odds ratio [OR], 33), current UTI antibiotic prescription (OR, 15), and having a full blood count measured (OR, 8.6).

Lead author Sean Mayne, MD, of James Cook University, in Cairns, Australia, said in a Wiley news release, "Suspected UTI is the most common reason for antibiotic prescription in nursing home residents, often a presumptive diagnosis based on non-specific symptoms, which makes it a key target for reducing inappropriate antibiotic prescriptions."
Jan 10 J Am Geriatr Soc study
Jan 10 Wiley 
news release


UN Environment-WHO collaboration to tackle environmental health issues

Originally published by CIDRAP News Jan 10

United Nations (UN) Environment and the World Health Organization (WHO) have established a new collaboration to accelerate steps to curb environmental health risks—including antimicrobial resistance—that cause an estimated 12.6 million deaths a year, the two agencies said in a press release today.

Today in Nairobi, Erik Solheim, head of UN Environment, and WHO Director-General Tedros Adhanom Ghebreyesus, MD, signed an agreement to ramp up joint efforts to combat air pollution, climate change, and antimicrobial resistance, as well as to improve coordination on waste and chemicals management, water quality, and food and nutrition issues.

Although the two agencies cooperate on a range of concerns, today's measure represents their most significant formal agreement across the spectrum of environment and health issues in more than 15 years, according to the release. "There is an urgent need for our two agencies to work more closely together to address the critical threats to environmental sustainability and climate—which are the foundations for life on this planet," said Solheim.

The two agencies will develop a joint work program and hold annual meetings to evaluate progress and make recommendations. The collaboration creates a more systematic framework for joint research, development of tools and guidance, capacity building, global and regional partnerships, and other approaches.
Jan 10 UN Environment news release


Genetic study finds transmission clues in migrant MDR-TB cluster

Originally published by CIDRAP News Jan 9

An investigation into a cluster of multidrug-resistant tuberculosis (MDR-TB) infections in refugees entering European countries found that all originated in the Horn of Africa or Sudan and were linked to a Mycobacterium tuberculosis clone that came from Somalia or Djibouti. Researchers form the MDR-TB Cluster Consortium reported their findings yesterday in The Lancet Infectious Diseases.

In the spring of 2016, findings from Swiss and German labs regarding four MDR-TB cases triggered an outbreak investigation that led to the identification of 29 cases diagnosed in seven European countries. All patients had come from the Horn of Africa or Sudan. Travel routes were known for 22 patients, and analysis showed a clear spatiotemporal overlap. Genetic analysis of samples collected in the Horn of Africa before the outbreak showed they were related to the outbreak strain.

The team said MDR-TB transmission probably occurred en route before arrival in Europe and that a shared mutation they found is likely a drug resistance mutation (linked to capreomycin resistance) and phylogenetic marker, the first of its kind in M tuberculosis.

In a related commentary, two WHO experts wrote that the study sheds light on the importance of early TB detection and the usefulness of molecular epidemiology. They noted that Somalia is known to have one of the highest prevalences of MDR-TB, a result of poor TB management because of decades of war and political conflict.

Screening arriving migrants from high-incidence countries requires specific actions and follow-up, they said, but challenges include language barriers and fear of deportation—factors that call for a humane approach to migrants. "Although screening of migrant populations on arrival is vital, we believe it is equally important to ensure a continuum of care for those who are moving across borders," they wrote.

Also, they said whole-genome sequencing—coupled with research into a new vaccine and better point-of-care diagnostics—could play an important role in mapping transmission chains and conducting outbreak investigations, not only in migrants, but also in settings such as prisons and healthcare facilities.
Jan 8 Lancet Infect Dis abstract
Jan 8 Lancet Infect Dis commentary


VRE infections associated with significant costs, study finds

Originally published by CIDRAP News Jan 8

A case-control study by German investigators has found that nosocomial infections caused by vancomycin-resistant enterococci (VRE) are costlier than those caused by vancomycin-susceptible enterococci (VSE), according to a new study in Antimicrobial Resistance & Infection Control.

VRE infections are known to result in more invasive procedures, additional antibiotic therapy, and extended time in the hospital, and studies conducted in the United States have found a considerable impact on hospital costs. But to date, no such studies have been conducted in Europe. This study, performed at a tertiary care hospital in Hanover, Germany, set out to determine the costs that are directly attributed to vancomycin resistance by comparing hospital costs of VRE and VSE infections. The investigators also determined factors that may be associated with increased costs of VRE patients.

In the study, 42 cases with VRE infections and 42 controls with VSE infections admitted from January 2005 to December 2008 were matched for type of infection, age, gender, admission and discharge within the same year, Charlson Comorbidity Index (± 1), and time at risk for infection. Median overall costs per case were significantly higher for VRE patients compared with controls (€57,675 vs. €38,344, or $69,001 vs. $45,874), with no significant difference in costs between the two groups before onset of infection (€17,893 vs. €16,600, or $21,407 vs. $19,860) but much higher per-patient costs for VRE patients after onset of infection (€37,971 vs. €23,025, or $45,431 vs. $27,546). The median attributable costs per case for vancomycin resistance were €13,157 ($15,742).

Detailed analysis of the costs after onset of infection showed that the major drivers of cost differences were pharmaceuticals, nursing staff, medical products, and assistant medical technicians. Multivariate analysis revealed that VRE infection was independently associated with a 1.4-fold increase in total costs per patient.

"These results emphasize the importance of strategies for the prevention of VRE spread in the hospital," the authors write.
Jan 5 Antimicrob Resist Infect Control study


ICU risk factors for multidrug-resistant Acinetobacter baumannii identified

Originally published by CIDRAP News Jan 8

In another case-control study in Antimicrobial Resistance and Infection Control, researchers in China identified risk factors associated with multidrug-resistant Acinetobacter baumannii (MDR-AB) infection.

In the study, the researchers identified 489 intensive care unit (ICU) patients at three tertiary general hospitals in Xiamen, China, who had A baumannii isolated from January 2015 to December 2015. MDR-AB was detected in 39.9% of all cases (195 patients). In both MDR-AB and non-MDR-AB patients, the pathogen was commonly isolated in the respiratory tract (72.3% vs. 66.3%). Multivariate regression analysis revealed that mechanical ventilation (odds ratio [OR], 3.93), combined use of antibacterial drugs before infection (OR, 4.11), and indwelling catheters (OR, 4.15) were independent risk factors associated with MDR-AB infection.

The researchers also found that the risk of MDR-AB infections increased with higher age and longer time of mechanical ventilation.

The authors of the study say their findings could help inform future management of MDR-AB patients in ICU clinical practice.
Jan 5 Antimicrob Resist Infect Control study

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