Stewardship / Resistance Scan for Apr 12, 2018

Overreporting C difficile
MCR-1 in travelers
Drivers of irrational antibiotic use

Study finds overreporting of healthcare-associated C diff in urban hospital

A study yesterday in the American Journal of Infection Control has found that only 62% of reported cases of healthcare facility–onset Clostridium difficile (HO-CDI) at a New York hospital met clinical criteria.

In the study, investigators at New York-Presbyterian Weill Cornell Medical Center performed a retrospective chart review on 212 cases of HO-CDI reported by the hospital to the Centers for Disease Control and Prevention in 2015. The cases had been identified using the polymerase chain reaction (PCR) test for the C difficile toxin B gene on unformed stool specimens collected more than 3 days after admission. They categorized the cases into six clinical surveillance groups: community-acquired infection, recurrence/relapse, asymptomatic colonization, colonization with self-limited symptoms, possible HO-CDI, and probable HO-CDI.

The investigators found that, of the 212 cases, 51 (24%) met the clinical surveillance definition of probable HO-CDI, and 81 (38.2%) could be considered possible HO-CDI cases. Thirty-nine cases (18.4%) were classified as colonization with self-limiting symptoms, 31 cases (14.6%) were classified as community-acquired, four cases (1.9%) were considered asymptomatic colonization, and six cases (2.8%) were classified as recurrence/relapse. All but two of the patients were treated with antibiotics.

The authors of the study suggest that the misclassification of HO-CDI may in part result from the use of stool softeners and laxatives, which were given to 73 patients (34.3%) within 24 hours of testing. But they also cite the inability of widely used PCR testing to distinguish active CDI infection from symptomatic colonization with diarrhea due to other causes.

They conclude, "Ongoing review of reported HO-CDI cases is critical for guiding efforts to improve the diagnosis, treatment, and control of C difficile to ensure the reliability of HO-CDI surveillance as a meaningful quality metric."
Apr 11 Am J Infect Control abstract


Small Japanese study finds MCR-1 gene in men who traveled to Vietnam

A small study by Japanese researchers in the journal Infection and Drug Resistance illustrates the role that international travel could play in the spread of dangerous antibiotic resistance genes.

The researchers from Osaka University followed 19 Japanese men who made 34 trips to Vietnam between June 2015 and August 2016. Recent reports have indicated the presence of Escherichia coli harboring the mobile colistin resistance gene MCR-1 in food animals, farmers, and urban residents in Vietnam. Because of the concerns about widespread dissemination of MCR-1, the researchers wanted to investigate whether travelers could bring MCR-1–harboring E coli back to Japan after a short-term stay in the country.

Fecal specimens were collected from travelers before and after their trips to Vietnam and analyzed for bacterial identification, antibiotic susceptibility, and production of genetic resistance elements. Overall, 175 isolates of extended-spectrum beta-lactamase (ESBL)-producing E coli were identified; in 30 of 34 travel events, the travelers brought the ESBL-producing E coli back to Japan. This is noteworthy because the dissemination of ESBL-producing E coli is low in Japan. The ESBL-producing isolates exhibited 100% resistance to ampicillin and cefotaxime.

In addition, the researchers found that three of the travelers brought back ESBL-producing E coli that also harbored the MCR-1 gene. None of the men were treated with antibiotics, and MCR-1 was not detected in samples collected 3 weeks later.

"Our study supports the notion that even short-term travel can bring colistin-resistant strains back to the country of origin," senior author Yoshimasa Yamamoto, PhD, said in a university press release. "In a globalized community in which travel to developing countries is common, the spread of colistin-resistant bacteria is a significant concern to worldwide health. We need to ensure that proper surveillance and public hygiene measures are in place, so that we can minimize the dissemination of highly resistant strains to the greatest extent possible."
Mar 12 Infect Drug Resist study
Mar 30 Osaka University press release


New report lists drivers of irrational antibiotic use in Europe

The European nonprofit organization Health Action International has released a new report outlining the major drivers of irrational antibiotic use in Europe, along with potential remedies.

The report, written by researchers from Sweden's Karolinska Institutet, suggests that among the general public, the lack of knowledge and awareness about antibiotics and antibiotic resistance, access to antibiotics without a prescription, and leftover antibiotics from earlier prescriptions are the most significant drivers of inappropriate antibiotic use. For healthcare providers, they cite attitudes toward antibiotic use and resistance, lack of adequate education on antibiotic prescribing, pharmaceutical promotion, lack of rapid diagnostic tests, and patient pressure.

To counter irrational antibiotic use, the authors recommend more education for healthcare providers and the public, strategies to optimize antibiotic use (including infection prevention and control measures and take-back programs for unused antibiotics), stronger data on antibiotic use and resistance, tougher regulations on pharmaceutical promotion, and the development, implementation, and coordination of national action plans on antibiotic resistance. They also call for more support for research into new antibiotics and diagnostics.

Research by the European Surveillance of Antimicrobial Consumption Network has shown that large variations in antibiotic use exist across Europe, with higher use in southern Europe and lower use in northern Europe.
Apr 5 Health Action International report

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