Stewardship / Resistance Scan for Jun 14, 2019

Nebraska superbug warning
Urine culture stewardship
Candida auris spread

Nebraska issues alert about highly resistant Enterobacteriaceae

The Nebraska Department of Health and Human Services (NDHHS) yesterday issued a health alert about an increase in carbapenemase-producing carbapenem-resistant Enterobacteriaceae (CP-CRE) cases this year. After detecting 7 each year in 2017 and 2018, officials have already confirmed 12 CP-CRE infections so far this year.

"Some of these are due to a particular type of carbapenemase referred to as NDM or New Delhi Metallo-beta-lactamase that have rarely been seen in Nebraska," the NDHHS said in the advisory. "Infections with this organism have a higher rate of morbidity and mortality than with less resistant organisms."

The carbapenem class of antibiotics includes the common drugs meropenem, imipenem, and ertapenem.

The increase in CP-CRE cases has been especially evident in southeast Nebraska, and long hospital stays, high antibiotic use, and being immunocompromised seem to increase the risk.

The NDHHS said, "At this time we are alerting hospitals, rehabilitation centers and long term care facilities of the recent increase so that facilities can expand their surveillance efforts, detect these organisms early and forward organisms suspected of this type of resistance to the NPHL [Nebraska Public Health Laboratory]."

Officials added, "Although all multidrug resistant organisms (MDROs) are difficult to treat and need to be contained, there are some especially concerning patterns of resistance."
Jun 13 NDHHS advisory


High urine culture rates in nursing homes tied to more antibiotics, C diff

A Public Health Ontario study today in Clinical Infectious Diseases found that nursing homes in the province have highly divergent urine culturing rates, and this variability is associated with higher antibiotic use and higher rates of Clostridioides difficile infection.

The investigators analyzed data from quarterly nursing home assessments from April 2014 through January 2017 at 591 Ontario nursing homes—representing 91% of the nursing homes in the province. They tracked urine culturing as the proportion of nursing home residents who had a urine culture taken in the preceding 14 days, and the study included data on 131,218 residents.

Overall, 7.9% of resident assessments had a urine culture (to test for pathogens) in the prior 14 days, but the rates varied widely, with 3.4% in the 10th percentile and 14.3% in the 90th percentile. The mean culturing rate was 6.5 per 1,000 resident-days, varying from 2.1 in the 10th percentile to 9.2 in the 90th percentile.

The researchers also determined that obtaining a doubling of the rate of urine culture was associated with a 21% increase in antibiotic use for urinary tract infection and an 18% higher rate of C difficile infection. The most common antibiotics prescribed were ciprofloxacin (2.7%), cephalexin (2.6%), trimethoprim and/or sulfonamides (2.5%), nitrofurantoin (2.2%), and amoxicillin (2.1%).
Jun 14 Clin Infect Dis abstract


Colombia Candida auris outbreak in 2015-16 tied to high death rates

An investigation into 40 cases of Candida auris illness in Colombia primarily in 2016 revealed a 43% 30-day mortality rate and evidence of person-to-person spread, according to a study yesterday in Emerging Infectious Diseases. C auris is a worrisome resistant fungus that is spreading worldwide.

The investigation, led by US Centers for Disease Control and Prevention scientists, involved four hospitals in three Colombian cities. Median patient age was 23 years, but 12 patients (30%) were less than 1 year old. Twenty-four (60%) were male. Cases were clustered in May through July 2016 in three hospitals but ranged from January 2015 through September in the fourth.

Seventeen patients (43%) died within 30 days. Five of the babies (42%) died within 30 days, but a sixth died later in the hospital, for a 50% death rate. Isolates showed resistance to multiple antimicrobial drugs.

Spatial and temporal analysis of samples taken from outbreak patients "showed a high degree of relatedness on whole-genome sequencing within hospitals and regional clustering, supporting in-hospital and person-to-person transmission," the scientists wrote. C auris skin colonization was common, especially in armpit and groin regions, which the authors said likely increases the risk of disease spread.

They conclude, "The findings of our investigation highlight the necessity of adherence to infection control recommendations, especially aspects of careful central line care and maintenance, hand hygiene, proper disinfection of medical equipment, and use of standard and contact precautions. C. auris remains an emerging pathogen with the potential for high levels of resistance to a limited body of antifungal drugs."
Jun 13 Emerg Infect Dis study

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