News Scan for May 22, 2020

C diff in COVID-19 patients
Pharmacist review for Staph bacteremia
Romaine E coli and cattle proximity
Polio in Afghanistan, Pakistan

Clinicians detail coinfections with C difficile, COVID-19 virus

A study by researchers from Detroit Medical Center and Wayne State University highlights the risk of Clostridiodes difficile infection (CDI) among COVID-19 patients linked to antibiotic use. The findings appeared in Emerging Infectious Diseases.

The researchers identified nine cases of co-infection with SARS-CoV-2 (the virus that causes COVID-19) and CDI during screening surveillance conducted from Mar 11 through Apr 22 at Detroit Medical Center. The patients were mainly elderly, predominantly female, and severely ill. Two of the patients were found to be positive for C difficile on admission, and the remaining seven had onset of diarrhea and were diagnosed with CDI after COVID-19 diagnosis. Three patients received antibiotics in the month before admission and eight received them on admission. The most commonly administered antibiotics were cefepime, ceftriaxone, meropenem, and azithromycin. Four of the patients died in the hospital.

The authors of the study said that symptoms of CDI can complicate diagnosis of COVID-19 because both conditions can have similar manifestations, and that the cases highlight the importance of judicious use of antibiotics for potential secondary infections in certain COVID-19 patients.

"All patients in our cohort were elderly, an age group at higher risk for complications from overuse of antibiotics, such as adverse events, antibiotic resistance, and concomitant infections like CDI," the authors wrote. "To prevent CDI co-infections during the COVID-19 pandemic, integrated use of antimicrobial stewardship is needed to monitor appropriate antibiotic use."
May 20 Emerg Infect Dis study


Antibiotic stewardship pharmacist review tied to better care for Staph bacteremia

Adding real-time antimicrobial stewardship (AMS) pharmacist review to infectious diseases consultation (IDC) for management of patients who have Staphylococcus aureus bacteremia (SAB) was associated with more optimal antibiotic use and better care at hospitals in Illinois, researchers reported yesterday in Open Forum Infectious Diseases.

The retrospective study included all patients with SAB treated at seven Aurora Advocate Health hospitals in Chicago from January 2016 through December 2018. The researchers compared outcomes between three time periods: pre-mandatory IDC and AMS review (period 1), post-mandatory IDC and pre-AMS review (period 2), and post-mandatory IDC and AMS review (period 3). The primary outcome was adherence to a quality care bundle, defined as appropriate intravenous antimicrobial therapy, appropriate duration of therapy, appropriate surveillance cultures, echocardiography, and removal of indwelling intravenous catheters, if applicable. Secondary endpoints included individual bundle components, source control, length of stay (LOS), 30-day bacteremia-related admission, and in-hospital all-cause mortality.

A total of 579 patients met inclusion criteria for analysis. Complete bundle adherence was 65% in period 1 (n=241/371), 54% in period 2 (n=47/87), and 76% in period 3 (n=92/121). Relative to period 3, bundle adherence was significantly lower in period 1 (odds ratio [OR], 0.58; 95% CI, 0.37 to 0.93; P = 0.02), and period 2 (OR, 0.37; 95% CI, 0.20 to 0.67; P = 0.0009). No difference in bundle adherence was noted between periods 1 and 2. Significant differences were seen in obtaining echocardiography (91% vs 83% vs 100%; P < 0.001), source control (34% vs 45% vs 45%; P = 0.04), and hospital LOS (10.5 vs 8.9 vs 12.0 days; P = 0.01). No differences were noted for readmission or mortality.

"This study describes an effective real-time, pharmacist-driven AMS review that was associated with improved management of SAB in the setting of pre-existing mandatory IDC," the authors of the study wrote. "Our study is unique in that it demonstrates the benefit of AMS review in addition to IDC for optimizing SAB care."
May 21 Open Forum Infect Dis study


FDA: Nearby cattle farms possible source of E coli in romaine outbreaks

The US Food and Drug Administration (FDA) yesterday released its investigation findings into three Escherichia coli O157:H7 outbreaks in 2019 that were linked to romaine lettuce, which revealed that cattle proximity may be a contributing factor and a persistent source of E coli O157:H7 and other Shiga toxin-producing E coli (STEC).

According to the full report, the outbreaks were reported in November and December and sickened 188 people. Illnesses were reported in Canada, as well. Each of the three outbreaks was caused by a different strain, but trace-back investigation of illness clusters and supply chain information identified a common grower in the Salinas, California, area that had multiple ranches and fields that supplied romaine during the outbreak timeframe to busineses associated with all three events.

The same E coli strain tied to one of the outbreak was linked to two different fresh-cut salad brands that contained romaine, and the strain in that outbreak matched a fecal-soil composite sample taken from a cattle grate on public land 2 miles upslope from a produce farm with multiple fields tied to the outbreak. Other STEC strains, though not linked to the outbreaks, were found closer to where the lettuce crops were grown, including two samples from a border area where cattle were grazing and two samples from on-farm water drainage basins.

Taken together, the findings, along with those from investigations as far back as 2013, suggest cattle proximity as a possible contributing factor. Based on recurring problems, the FDA said it recently released a 2020 Leafy Greens STEC Action Plan that included a three-part approach for addressing the contamination and lays out how the FDA will work with industry and other groups to address leafy greens safety.
May 21 FDA outbreak investigation notice
FDA investigation report


Afghanistan, Pakistan report vaccine-related polio cases

Afghanistan and Pakistan this week both reported circulating vaccine-derived poliovirus type 2 (cVDPV2) cases, according to the latest update from the Global Polio Eradication Initiative (GPEI).

Afghanistan confirmed 5 new cVDPV2 cases, 1 in Kunar and 4 in Nangarhar province. The country has had 7 cVDPV2 cases so far this year, compared with none in all of 2019.

Pakistani officials reported 1 new cVDPV2 case, in Khyber Pakhtoon province, pushing its 2020 total to 67. Last year the country reported 22 cVDPV2 cases.

Neither country reported a case of wild poliovirus type 1 (WPV1) infection, the first time without one in many weeks. Afghanistan so far this year has confirmed 12 WPV1 cases—keeping it even with last year's pace—while Pakistan has recorded 47, compared with 25 at this point last year.
May 21 GPEI update

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