ASP Scan (Weekly) for Jan 11, 2019

US XDR typhoid cases
ICU Klebsiella stewardship
Antimicrobials in European chickens
MCR-1 in Wyoming
CDC alert over Mexico infections
Highly resistant gonorrhea in the UK
Penicillin allergy testing
Antibiotics and joint replacement
MDR Shigella in Australia
Resistant-infection alert in RI

CDC reports 5 US cases of XDR typhoid infections

Enhanced surveillance has identified five US cases of extensively drug-resistant (XDR) typhoid infections associated with travel to Pakistan, according to a report today from the Centers for Disease Control and Prevention (CDC).

In Morbidity and Mortality Weekly Report (MMWR), the researchers report that, from 2016 through 2018, 29 patients with typhoid fever—a highly infectious illness caused by Salmonella enterica serotype Typhi—reported travel to or from Pakistan and had isolates tested for antimicrobial susceptibility. Five of those patients had XDR Salmonella Typhi, which is resistant to five classes of antibiotics (chloramphenicol, ampicillin, trimethoprim-sulfamethoxazole, fluoroquinolones, and third-generation cephalosporins). All patients were children aged 4 to 12 years and had traveled to or from Pakistan from late 2017 through mid-2018.

The World Health Organization recently reported that an XDR Salmonella Typhi outbreak that began in Pakistan's Sindh province in 2016 has now affected 5,372 people in Pakistan. It's the first widespread outbreak of an XDR Salmonella Typhi strain to be reported. The WHO has warned that the risk of acquiring XDR typhoid in Pakistan is high because of poor sanitation and hygiene and insufficient access to clean water.  

In March 2018, the CDC enhanced surveillance for typhoid fever in the United States by asking state and local health departments to interview every patient with typhoid fever about travel to or from Pakistan and to expedite submission of Salmonella Typhi isolates from these patients to CDC.

The report says clinicians should be aware that the XDR Salmonella Typhi outbreak strain associated with travel to and from Pakistan is only susceptible to azithromycin and carbapenems. Providers caring for patients with suspected typhoid fever should obtain a travel history and report confirmed cases to their local health departments. Travelers to Pakistan are advised to get vaccinated against typhoid fever and to follow safe food and water practices. 
Jan 11 MMWR report
Dec 28, 2018, CIDRAP News story "WHO: XDR typhoid outbreak in Pakistan tops 5,200 cases"


Multipronged steps helped curb ICU Klebsiella, Chinese researchers say

Infection prevention and control (IPC) enhancements, plus modified treatment de-escalation and targeted bundle interventions, appeared to have played a key role in controlling an outbreak of carbapenem-resistant Klebsiella pneumoniae (CRKP) in an intensive care unit (ICU) at a teaching hospital in Shanghai.

Researchers from the hospital described their findings yesterday in Antimicrobial Resistance and Infection Control. The hospital's CRKP incidence had increased markedly, from 7.3% in 2011 to 25% in 2015. Their study included clinical data from 629 patients admitted to the ICU consecutively from January 2013 through June 2016. A total of 87 patients had CRKP, of whom 69 acquired their infections in the ICU and 18 were infected before admission.

The study had four stages: baseline, IPC interventions that included de-escalation of treatment based on culture results and targeted bundle interventions, modified IPC interventions for the next year, and a follow-up period.

Incidence of ICU-acquired CRPK was 10.08 (range, 4.43 to 16.43) per 1,000 ICU patient-days during baseline, but it significantly decreased during the early stages of IPC interventions. Colonization testing showed that the infections reappeared in April 2014, suggesting that other factors were involved. When the team modified the interventions during the third stage, colonizations dropped to 5.62 (0.69 to 6.34), then to 2.84 (2.80 to 2.89), during follow-up, even though colonized patients continued to be admitted to the hospital.

The authors wrote that the decrease they saw when modified steps were taken in the third study phase were done according to monitoring and analysis of screening results, with promptly applied measures including, for example, non-ICU medical staff education, contact precautions for shared equipment, and multiple rigorous cleaning and disinfection interventions.

"The integration of epidemiological and microbiological data and the strict application of infection-control measures played a decisive role in preventing against the spread of CRKP in our hospital," they wrote.
Jan 10 Antimicrob Resist Infect Control study


Survey profiles antimicrobial use at European broiler chicken farms

A study designed to gauge antimicrobial usage in broiler farms and flocks in nine European countries found that raising the chickens without the drugs is feasible, but there was wide variation in amount, administration, and antimicrobial classes, signs that more work is needed to reduce the practice. A team from Belgium and the Netherlands reported its finding yesterday in the Journal of Antimicrobial Chemotherapy.

The team notes that European efforts have harmonized the collection and reporting of European veterinary antimicrobial sales data, which is useful, but results don't show what's happening at the farm or flock level.

The cross-sectional survey, done as part of the European Union Ecology from Farm to Fork Of microbial drug Resistance and Transmission (EFFORT) project, was conducted at about 20 conventional, comparable farms in each of the nine countries: Belgium, Bulgaria, Denmark, France, Germany, Italy, Poland, Spain and the Netherlands. The study included 181 broiler farm tota.

The researchers visited the farms from May 2014 to June 2016, and poultry producers completed a questionnaire that asked about farm technical and antimicrobial use data. The investigators focused on substance administered or bought and assessed three parameters: defined daily dose, defined course dose, and used daily dose.

Polymyxins (colistin), extended-spectrum penicillins (amoxicillin and ampicillin), and fluoroquinolones were the most often-used classes, but drugs and their usage varied among countries. Intestinal disorders were the most common treatment indication (45%), followed by colibacillosis (16%), and omphalitis (12%).

Overall, broilers were treated with antimicrobials during 9% of their rearing period, though that percentage varied from 3.3% to 36.7% between countries. Each country, however, had at least one untreated flock. Timingwise, 26% of farms started treatment on day 1 of production, and 49% of them began treatment within the first week.

The authors said the wide variation calls for more research into what drives the differences, which would be useful for devising additional steps to curb antimicrobial use on broiler farms.
Jan 10 J Antimicrob Chemother abstract


Wyoming reports colistin-resistant MCR-1 infection

Originally published by CIDRAP News Jan 10

A patient in a Laramie County, Wyo., hospital has been confirmed to have an infection caused by an Enterobacteriaceae containing the MCR-1 resistance gene, which confers resistance to the critical antibiotic colistin, the Wyoming Department of Health (WDH) said yesterday in a news release.

The patient is receiving care at Cheyenne Regional Medical Center (CRMC), but officials say the infection was likely acquired outside the hospital. Hoo Feng Choo, MD, an infectious disease specialist at CRMC, said "Thankfully, the patient continues to receive care, has responded to treatment, and is in good condition."

Tests by a US Centers for Disease Control and Prevention (CDC) lab confirmed the findings.

Alexia Harrist, MD, PhD, state health officer, said, "When bacteria become antibiotic-resistant, then certain categories of antibiotic medicines will not work to kill the bacteria to treat an infection. In this case, the organism found is resistant to a category of antibiotics sometimes described as 'last resort' medications used to fight infections. The gene found with this patient has been identified in only a handful of states over the past few years."

She added, "We believe the contact precautions already in place at the hospital have likely limited the potential spread of the bacteria." WDH epidemiologist are working with CRMC staff to help with infection control.

MCR-1 was first identified in China in 2015 and has since been reported in more than 30 nations.
Jan 9 WDH news release


CDC issues advisory over antibiotic-resistant infections in Tijuana, Mexico

Originally published by CIDRAP News Jan 10

The CDC yesterday warned the public and healthcare professionals about potential infections with an antibiotic-resistant form of Pseudomonas aeruginosa bacteria after US residents contracted the serious infections following medical procedures in Tijuana, Mexico.

The agency issued a level 2 (out of 3) alert and recommended visitors to practice enhanced precautions. "All of the travelers with this particular infection had an invasive medical procedure performed in Tijuana," the CDC said. "Most (but not all) of them had weight-loss surgery. About half of those infected had their surgery done at the Grand View Hospital."

Mexican officials have closed the hospital until further notice, the CDC said. It did not specify the number of cases but said, "Infections caused by this particular drug-resistant Pseudomonas are rare in the United States and difficult to treat."

The advisory includes several steps travelers should take, including seeing a travel medicine specialist at least a month before their trip, as well as recommendations for clinicians. Pseudomonas is found widely in the environment, and P aeruginosa is the most common type that infects people.
Jan 9 CDC alert


Two cases of extensively drug-resistant gonorrhea reported in the UK

Originally published by CIDRAP News Jan 9

Public Health England (PHE) is investigating two cases of extensively drug-resistant Neisseria gonorrhoeae.

The cases, which were resistant to the first-line antibiotics ceftriaxone and azithromycin, involved heterosexual women. PHE said one of the women appeared to have acquired the infection in Europe, while the other has links to Europe but acquired the infection in the United Kingdom. Both infections were successfully treated, and PHE is following up with sexual contacts to see if there are any links between the two women and to stem any onward transmission.

PHE officials say the cases are a good reminder of the need to practice safe sex to lower their risk of sexually transmitted infections (STIs).

"Everyone can substantially reduce their risk by using condoms consistently and correctly with all new and casual partners," Nick Phin, deputy director of PHE's National Infection Service, said in a statement. "Anyone who thinks they may have been at risk of getting an STI should seek an STI screen at a sexual health clinic."

In March 2018, UK officials reported a case of gonorrhea with combined high-level resistance to ceftriaxone and azithromycin in a heterosexual man. It was the first known case of high-level resistance to the dual therapy, which is the last remaining recommended treatment for gonorrhea. PHE says the type of resistance seen in these two cases is different and therefore unrelated.

England has also been seeing a rise in cases of azithromycin-resistant gonorrhea, highlighted by an outbreak of a highly azithromycin-resistant strain that originated in Leeds in 2015 and has spread to other parts of the country.

The agency says it has introduced enhanced surveillance to identify and manage resistant gonorrhea strains promptly and help reduce further spread.
Jan 9 PHE news release


Study shows penicillin skin testing cost effective for Staph bacteremia

Originally published by CIDRAP News Jan 9

An economic analysis in PLOS One by University of Maryland experts estimates that inpatient penicillin skin testing (PST) services that confirm penicillin allergy as part of an antimicrobial stewardship program are cost-effective for patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia.

In the single-center study, the investigators used a decision analytic model to compare an acute care PST intervention to a scenario with no confirmatory allergy testing. They used quality-adjusted life years (QALYs) to measure for effectiveness.

Over a 1-year time study period, PST services applied to all MSSA bacteremia patients reporting a PCN-positive allergy would result in a cost per patient of $12,559 and 0.73 QALYs, while no PST services would cost $13,219 and 0.66 QALYs per patient. This resulted in a cost-effectiveness estimate of -$9,429 per QALY gained, demonstrating the cost-effectiveness of the intervention.
Jan 7 PLOS One study


Study indicates pre-op antibiotics may ward off joint replacement infection

Originally published by CIDRAP News Jan 7

Researchers in Finland report in a study yesterday in Clinical Microbiology and Infection that the use of oral antibiotics before joint replacement surgery is common and may lower the risk for periprosthetic joint infection (PJI), but indiscriminate use of antibiotics before such surgeries cannot be recommended.

The investigators analyzed data on 23,171 hip or knee replacements that took place at a tertiary care hospital at the University of Tampere from September 2002 through December 2013. They noted that 4,106 patients (17.7%) received at least one course of antibiotics before surgery, and 158 patients (0.68%) developed a PJI.

The incidence of PJI for those with preoperative antibiotics was 0.29%, compared with 0.77% for those who did not take antibiotics. Depending on the method used, the risk of PJI was reduced 34% to 40% in those receiving antibiotics.

The authors conclude, "The use of oral antibiotics before elective joint replacement surgery is common and has a potential effect on the subsequent risk for PJI. Nevertheless, indiscriminate use of antibiotics before elective joint replacement surgery cannot be recommended, even though treatment of active infections remains an important way to prevent surgical site infections."
Jan 6 Clin Microbiol Infect study


Australian researchers note high rates of MDR Shigella in MSM in Victoria

Originally published by CIDRAP News Jan 7

Australian scientists are reporting high rates of multidrug-resistant (MDR) Shigella infections among men who have sex with men (MSM) in the state of Victoria, according to a study today in Clinical Infectious Diseases.

The burden of shigellosis in urban Australia is typically either in travelers returning from Shigella-endemic regions or in MSM, the authors note. They explored genomic data on 545 clinical isolates and comprehensive epidemiologic data collected from Jan 1, 2016, through Mar 31, 2018, to determine the spread of MDR Shigella lineages.

They discovered high rates of antimicrobial resistance—17.6% of isolates were resistant to ciprofloxacin and 50.6% were resistant to azithromycin. They also identified two major MSM-associated Shigella lineages, one affecting 159 men and the other 105. Among the first lineage, 92.4% of isolates harbored mutations associated with reduced susceptibility to azithromycin, trimethoprim-sulfamethoxazole, and ciprofloxacin. MDR plasmids were predominantly associated with MSM isolates.

The authors conclude, "Our contemporary data highlight the ongoing public health threat posed by resistant Shigella, both in Australia and globally. Urgent multidisciplinary public health measures are required to interrupt transmission and prevent infection."
Jan 7 Clin Infect Dis abstract


Rhode Island warns of antibiotic-resistant infected picked up overseas

Originally published by CIDRAP News Jan 7

The Rhode Island Department of Health (RIDOH) late last week warned residents about the potential risk of traveling abroad for medical treatment, highlighting an increase in cases of serious antibiotic-resistant infections, especially in residents who traveled to the Dominican Republic.

Although the RIDOH did not list case numbers, it said in a news release, "Rhode Island hospitals have seen an increase in the number of Rhode Islanders who have traveled to other countries for medical procedures and returned with serious, antibiotic-resistant infections that require months to years of treatment. These infections have been associated with wounds that are painful, slow to heal, and often require draining. Such infections can also lead to permanent disfigurement."

The department specifically mentioned "several patients" who had procedures done in the Dominican Republic, including breast augmentation, tummy tucks, liposuction, eyelid surgery, nose jobs, oral surgery, and heart procedures.

"Various factors can sometimes make traveling for a procedure risky," said Nicole Alexander-Scott, MD, MPH, RIDOH director. "When it comes to procedures that are done for the sake of appearance, instead of to treat health needs, it's often not worth the risk."

Rhode Island officials also posted several tips for those planning to travel for medical procedures, such as consulting with the healthcare provider well in advance of the trip.
Jan 3 RIDOH news release

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