ASP Scan (Weekly) for Mar 15, 2019

Penicillin allergy de-labeling
Antibiotic misuse in Irish long-term care
Resistant bacteria in imported shrimp
MRSA in hospital roaches
Test for resistant gonorrhea
German funding for CARB-X
Antibiotics for citrus trees
Origins of MCR-1 in France
VA outpatient prescribing
FDA to review new TB drug

Penicillin allergy intervention cuts down on restricted antibiotic use

Australian researchers reported yesterday in the Journal of Antimicrobial Chemotherapy that a novel, pharmacist-led penicillin allergy de-labeling intervention at a tertiary hospital led to a significant decrease in the prescribing of restricted antibiotics.

The single-center study evaluated the impact of a weekly ward round that was implemented at the hospital in March 2018 and was led by an infectious disease physician, an allergy nurse, and an antimicrobial stewardship (AMS) pharmacist. Using electronic health records, the team identified patients with a documented penicillin allergy who were receiving an antibiotic, then reviewed their allergy history and phenotype to determine whether the allergy label was a type A (non-immune-mediated) reaction or the patient required a direct oral rechallenge or skin test, and whether he or she could be transitioned from a restricted antibiotic. The 5-month audit looked at how many penicillin allergies were de-labeled, and the resulting impact on restricted antibiotics.

Over the 5-month period, 309 patients were identified during 19 ward rounds, and 106 met the inclusion criteria for the study. Of those 106 patients, 40 (37.7%) had their penicillin allergy de-labeled. The highest rate of penicillin allergy de-labeling was among patients who were referred for a direct oral rechallenge, with 95.2% (20 of 21) having their allergy label removed. Of the 22 patients with a type A reaction, 14 (63.6%) were de-labeled, and 4 of 4 patients who underwent a skin test were found to tolerate penicillin. Prescribing of restricted antibiotics in the 106 patients fell from 42.5% pre–ward round to 17.9% post–ward round.

The authors of the study conclude, "We have illustrated a successful model for a pharmacist-led AMS, a penicillin allergy de-labelling ward round, targeting non-immune-mediated and low-risk allergy phenotypes. Similar models should be encouraged in other hospitals with established AMS programmes."
Mar 14 J Antimicrob Chemother study


Survey finds significant prophylactic antibiotic use in Irish long-term care

Point-prevalence surveys conducted in Irish long-term care facilities (LTCFs) have a found a high rate of prophylactic antibiotic prescribing, according to a paper yesterday in Eurosurveillance.

The Healthcare-Associated Infections in Long-Term Care Facilities (HALT) surveys were conducted in 2013 and 2016. Researchers collected and analyzed data on the type of facility, resident characteristics, and systemic antimicrobial prescriptions for healthcare-associated infections, including whether the antimicrobial was for prophylactic or therapeutic purposes.

A total of 190 LTCFs participated in the 2013 HALT survey, and 224 participated in the 2016 survey; 119 participated in both surveys. Most were nursing homes and mixed care, intellectual disability, and psychiatric LTCFs. The overall prevalence of antimicrobial prescribing was similar in both surveys (9% to 10%). The proportion of prophylactic prescribing was higher in 2016 (42.5%) than it was in 2013 (38.3%), but among the 119 LTCFs that took both surveys, prophylactic prescribing was the same (40%). In both surveys, urinary tract infections (UTIs) accounted for most of the prophylactic antibiotics prescribed, followed by respiratory tract infections (RTIs), skin or wound infections, and infections at other sites.

The analysis of all the LTCFs in both surveys found that the main prophylactic agents were nitrofurantoin (39%) and trimethoprim (41%) for UTIs; macrolides (47%) for RTIs, and macrolides and tetracycline (56%) for skin or wounds. More than 50% of the prophylactic antibiotics were prescribed in intellectual disability facilities and around 40% in nursing homes. Prophylaxis was recorded more often for female patients, residents living in LTCFs for more than 1 year, and residents with a urinary catheter.

The authors of the study note that while antimicrobial prophylaxis is appropriate for selected indications—such as surgery—much of the prophylactic prescribing they identified does not appear to follow guidelines or be evidence-based.

"The high prevalence of antimicrobial use in Irish LTCFs, particularly antimicrobial prophylaxis, indicates an urgent need to develop and implement education and stewardship programmes specifically targeted towards residential care settings," the authors write. "While participation in repeated HALT surveys is a valuable surveillance method, it must be supplemented by local quality improvement initiatives, based on each LTCF's survey results."
Mar 14 Eurosurveill study


Canadian investigation finds resistant bacteria in imported shrimp

An investigation by CBC News has found troubling levels of antibiotic-resistant bacteria in imported shrimp bought at Canadian grocery chains.

In a report today, CBC News Marketplace found that 9 of 51 frozen shrimp products (17%) bought from major grocery stores in Calgary, Toronto, Saskatoon, and Montreal were carrying bacteria—including Escherichia coli and Staphylococcus aureus—that were resistant to at least one antibiotic, and bacteria in three of the shrimp products were harboring extended-spectrum beta-lactamase (ESBL) genes. Two of the shrimp products were carrying methicillin-resistant Staphylococcus aureus.

According to the report, Canada imports about $700 million worth of shrimp each year, mainly from India, Vietnam, China, and Thailand, and much of it from shrimp farms that commonly use antibiotics. Five of the contaminated products were from India. Marketplace notes that while the Canadian Food Inspection Agency inspects 5% of imported shrimp for antibiotic residues, it does not test for antibiotic-resistant bacteria.

Gerry Wright, PhD, an infectious disease expert at McMaster University, told Marketplace that the lack of testing for resistant bacteria in imported food is a gap that needs to be addressed.

"Once these organisms are here, once these genes are in Canada, then there's no good way to keep them from spreading around. So what would be a really good idea is to prevent them from getting in in the first place," he said.
Mar 15 CBC News story


Iranian researchers report high MRSA rates in hospital cockroaches

Originally published by CIDRAP News Mar 14

Iranian investigators have discovered a high rate of methicillin-resistant Staphylococcus aureus (MRSA), a common superbug, in two types of cockroaches found in hospitals, according to a study yesterday in Antimicrobial Resistance & Infection Control.

The group collected 533 Periplanets americana and Blattella germanica cockroaches and isolated bacteria from their gut content and exoskeleton.

They found that 52.8% of P americana and 43.3% of B germanica cockroaches harbored MRSA. The prevalence was highest (59.6%) among body-surface samples of P americana. MRSA isolates from the P americana surface samples harbored 100% resistance to penicillin, ceftaroline, and tetracycline, as well as 83.3% resistance to gentamicin and 80.6% resistance to trimethoprim-sulfamethoxazole.

The authors conclude, "The present investigation is the first report of the phenotypic and genotypic evaluation of antibiotic resistance in the MRSA strains isolated from P. americana and B. germanicahospital cockroaches. Hospital cockroaches are considered as a potential mechanical vector for MRSA strains."
Mar 13 Antimicrob Resist Infect Control study


US company launches rapid test for antibiotic-resistant gonorrhea

Originally published by CIDRAP News Mar 14

Shield Diagnostics of San Jose, California, yesterday announced it has launched a rapid molecular test, called Target-NG, for diagnosing antibiotic susceptibility in Neisseria gonorrhoeae, the bacterium that causes gonorrhea.

The company said in a press release that the British Association for Sexual Health and HIV recently recommended treating N gonorrhoeae with ciprofloxacin if susceptibility results are available prior to treatment. The US Centers for Disease Control and Prevention recommends ceftriaxone in combination with azithromycin to treat uncomplicated gonorrhea.

"Rapid molecular testing for ciprofloxacin resistance allows for smarter medicine," Jeffrey D. Klausner, MD, MPH, a professor of infectious diseases at the University of California, Los Angeles, said in the news release. "Right now we're treating gonorrhea with a sledgehammer; we're treating everything with the same exact regime. And it's not a surprise that the organism will become resistant to what we're currently using."

Ciprofloxacin can be used to treat 80% of gonorrhea and is 99.8% effective when susceptibility has been determined, Shield Diagnostics said. It is administered as a single oral dose.

"Target-NG can determine if a given gonorrhea infection is susceptible to ciprofloxacin with the same turnaround time as regular gonorrhea screening tests," said Fred Turner, MS, the company's CEO.
Mar 13 Shield Diagnostics news release


CARB-X announces partnership with German government

Originally published by CIDRAP News Mar 14

CARB-X announced today that the German government has committed more than $45 million to the effort to fight drug-resistant superbugs.

Under a partnership agreement, Germany's Federal Ministry of Education and Research (BMBF) will invest €39 million over 4 years in CARB-X (the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator), a private-public partnership that funds pre-clinical development of new antibiotics, vaccines, and diagnostics for multidrug-resistant infections. BMBF will also commit an additional €1 million to a consortium of the German Center for Infection Research, the Federal Institute for Vaccines and Biomedicines, and the Federal Institute for Drugs and Medical Devices (BfArm).

"The growing number of pathogens being no longer responsive to lifesaving therapies puts the life of millions of people worldwide at risk," German Federal Research Minister Anja Karliczek said in a CARB-X news release. "Resistant pathogens spread globally. Thus, combatting them takes joint international collaborative actions, such as CARB-X." 

Under the agreement, which went into effect on Jan 1, 2019, BfArM will also join CARB-X's Global Accelerator Network. 
Mar 14 CARB-X news release


EPA urged to deny proposal for more antibiotic spraying on citrus fields

Originally published by CIDRAP News Mar 13

Representatives from the Center for Biological Diversity, Public Interest Network, and US PIRG (Public Interest Research Group) today delivered 45,000 petition signatures to the Environmental Protection Agency (EPA), calling on the agency to deny a proposal that would allow for expanded antibiotic spraying on citrus fields.

Under the proposal, citrus growers would be allowed to spray more than 650,000 pounds of streptomycin on citrus fields to treat the bacteria that causes citrus greening disease. The groups say spraying streptomycin on citrus fields does not cure the disease and would be an irresponsible use of an antibiotic that's considered critically important for human health by the World Health Organization (WHO).

"The more you use antibiotics, the greater the risk that bacteria resistant to the drugs will flourish and spread," Matt Wellington, director of US PIRG's antibiotics program, said in a press release. "The bottom line is that the potential problems created by spraying massive amounts of streptomycin on citrus fields could outweigh the original problem the EPA wants to solve."

The groups say that, if the proposal is allowed, it would be the largest-ever use of a medically important antibiotic in plant agriculture in the United States.

In December, the EPA approved a proposal for wider use of oxytetracycline on citrus trees to combat citrus canker and citrus greening disease.
Mar 13 Center for Biological Diversity press release


MCR-1 in France the result of divergent evolutionary paths, study says

Originally published by CIDRAP News Mar 13

French and Swiss scientists isolated 153 colistin-resistant E coli strains from fecal samples obtained from 152 patients in Paris and discovered the MCR-1 gene in about 5% of the samples and note that colistin resistance is the result of two distinct evolutionary pathways, according to a study yesterday in the Journal of Antimicrobial Chemotherapy.

The researchers conducted the analysis because they say large epidemiological studies to estimate the human burden of colistin-resistant E coli gut carriage are lacking. They screened 1,217 patients in six Parisian hospitals during a 3-month stretch in 2017. Colistin is considered an antibiotic of last resort for multidrug-resistant infections.

They identified the MCR-1 colistin-resistance gene in 7 (4.6%) of the 153 colistin-resistant E coli samples, and the gene was located on various plasmids, which are mobile units of DNA. Genetic analysis indicated an animal origin for the genes, compared with a human origin for the 146 non-MCR-1 isolates.

The team summarized the findings thus: "We showed that the occurrence at a high rate of colistin resistance in human faecal E. coli is the result of two distinct evolutionary pathways, i.e. the occurrence of chromosomal mutations in an endogenous E. coli population and the rare acquisition of exogenous mcr-1-bearing strains probably of animal origin."
Mar 12 J Antimicrob Chemother study


VA study finds significant antibiotic over-prescribing in outpatients

Originally published by CIDRAP News Mar 11

A new study by pharmacists with a Veterans Affairs (VA) hospital in upstate New York has found that 40% of the antibiotics prescribed for outpatients were inappropriate. The findings appeared in the American Journal of Infection Control.

The prospective observational cohort study, conducted at the VA Western New York Healthcare System, analyzed outpatient antibiotic prescriptions for 1,063 veterans over a 4-month period (June 2017 through September 2017). The researchers evaluated whether the antibiotic was appropriate for the indication, whether the selected antibiotic was first-line therapy or based on culture data, and whether the dose and duration of the antibiotic were appropriate. The primary objective was to identify the most commonly overused antibiotics and their associated syndromes.

The study found that 40% of the antibiotic prescriptions were unnecessary, the selected drug was inappropriate in 48% of cases, and the duration and dose were inappropriate in 25% and 19% of patients, respectively. The most common indications resulting in unnecessary antibiotics, based on the targeted included antibiotics, were urinary tract infections (21%), bronchitis (20%), skin and skin structure infections (17%), and sinusitis (10%). Azithromycin was the most commonly prescribed unnecessary antibiotic (37%) of the targeted agents, followed by ciprofloxacin (16%), amoxicillin/clavulanate (13%), and cephalexin (12%). Altogether, these drugs accounted for nearly 80% of unnecessary drug use.

The authors of the study suggest an outpatient stewardship program that focuses on these four drugs, including the use of alerts whenever the drugs are prescribed, could provide the most opportunities for intervention.
Mar 9 Am J Infect Control study


FDA grants priority review for new TB drug

Originally published by CIDRAP News Mar 11

The US Food and Drug Administration (FDA) has granted priority review to the new drug application for pretomanid, a novel tuberculosis (TB) drug candidate.

TB Alliance, which developed pretomanid, is seeking approval of the drug as part of a regimen for the treatment of multidrug-resistant (MDR), extensively drug-resistant (XDR), and treatment non-responsive MDR-TB. The regimen will also include bedaquiline and linezolid. In a phase 3 clinical trial of patients with XDR-TB and treatment non-responsive MDR-TB, interim results on the first 75 patients indicated 89% had a favorable outcome, with their clinical infection resolved and sputum cultures negative for TB after 6 months of treatment and 6 months of follow-up.

The World Health Organization estimates that roughly 558,000 cases of drug-resistant TB were diagnosed in 2017; 82% and 8.5% of these cases were MDR-TB and XDR-TB, respectively. The current success-rate for MDR-TB treatment is only 54%, compared with 82% for non-resistant TB.

TB Alliance says the FDA's decision is expected in third quarter 2019.
Mar 8 TB Alliance news release

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