Stewardship / Resistance Scan for Nov 19, 2020

News brief

Report says COVID-19 holds lessons for response to AMR

The COVID-19 pandemic, and the global response, contain important lessons that can be used to avert a future pandemic caused by antimicrobial resistance (AMR), according to a new report from the Global Antibiotic Research and Development Partnership (GARDP).

The report notes that while there are differences between fast-moving viral pandemics and the slower-moving "silent pandemic" of AMR, the COVID-19 pandemic has underscored what happens when governments are unprepared, international cooperation is low, and treatments, diagnostics, and vaccines are not available. As a result, the pandemic is reinforcing the importance of research, development, and equitable supply of medical countermeasures to treat and prevent pandemic diseases and presenting an opportunity to improve the response to future pandemics, including those caused by drug-resistant infections, the authors say.

Among the lessons highlighted in the report are that investments in preparedness are necessary, collaboration and international cooperation are critical, and that equitable and affordable access to medical countermeasures is an essential element of effective pandemic response. But inequitable access to medical countermeasures can undermine the trust that many nations have in the international system.

To prepare for a pandemic of drug-resistant infections, the report recommends five concrete steps that the global community can take. These include recognizing and addressing antibiotic resistance; investing in development of medical countermeasures; ensuring that access to treatments, diagnostics, and vaccines for all is a cornerstone of pandemic preparedness and response; expanding global cooperation within a One Health framework; and making low- and middle-income countries equal partners in a comprehensive response.

"AMR requires a long-term investment and is an opportunity for governments to find a collective approach to global health that is fair to all; that prioritises coordination, partnership and solidarity; that takes a multisectoral and multilateral approach; and that satisfies public health needs and human life over economic and political considerations," the report concludes. "Achieving this would cascade into lasting and life-saving benefits for people and countries across the world."
Nov 17 GARDP report

UK farmers, veterinarians set new targets for antibiotic use in animals

A task force of veterinarians and farmers in the United Kingdom yesterday released new targets for responsible use of antibiotics in farm animals.

The goals for 2021 through 2024, laid out in a report from the Responsible Use of Medicines in Agriculture Alliance (RUMA), include a 30% decrease in antibiotic use in pigs, reductions of 15% in dairy herds and 25% in calf rearing units, and a 40% reduction in game birds.

"We look forward to working with the sectors as we continue on this endeavour, which will ultimately be of benefit to the reputation of the UK livestock sectors as well as helping to protect human and animal health," Peter Borriello, PhD, chief executive of the UK's Veterinary Medicines Directorate, said in a RUMA press release.

The new goals were released the same day as the UK Veterinary Antibiotic Resistance and Sales Surveillance Report (UK-VARSS 2019), which showed a 45% decline in sales of antibiotics for food-producing animals from 2015 through 2019 (despite a 5% increase between 2018 and 2019), and 74% decline in the sales of highest-priority critically important antibiotics. The report also showed lower levels of antibiotic resistance in Escherichia coli in healthy pigs at slaughter compared with 5 years ago.

RUMA says its initial targets, released in 2017, have helped UK farmers achieve the antibiotic sales reductions documented in the UK-VARSS report. Over 75% of the 2017 targets have already been achieved or are on track to be achieved by December.

"The UK farming industry has responded extremely well to the targets. Our original aim of lowering overall antibiotic use, and in particular highest-priority critically important antibiotics (HP-CIAs), has been categorically achieved in the face of some challenging external conditions," said RUMA chair Catherine McLaughlin.
Nov 18 RUMA press release
Nov 18 RUMA 2020 targets task force report
Nov 18 UK-VARSS 2019 report

UK reports show rise in resistant infections, drop in gonorrhea resistance

Two reports released yesterday by Public Health England (PHE) highlight good and bad news on antibiotic-resistant infections in humans.

The English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) report shows a 17% increase in incidence of bloodstream infections caused by key bacterial species (E coli, Klebsiella pneumoniae, Enterococcus spp) between 2015 and 2019 and a 32% increase in antibiotic-resistant bloodstream infections caused by those species, with an estimated 18,110 antibiotic-resistant bloodstream infections diagnosed in England in 2019 (up from 13,671 in 2015). Overall, the report estimates there were 65,162 severe antibiotic-resistant infections diagnosed in 2019, up from 61,946 in 2018.

But the report also shows that antibiotic consumption in England has fallen since peaking in 2014, with total use declining from 19.4 defined daily doses per 1,000 inhabitants per day in 2015 to 17.4 in 2019, driven largely by a 12.2% decline in antibiotic prescribing in general practices and a 19.5% decline in dental practices. Antibiotic consumption rose, however, in other community settings and in hospital inpatients and outpatients.

The report from the Gonococcal Resistance to Antimicrobial Surveillance Programme (GRASP), meanwhile, found that the proportion of Neisseria gonorrhoeae isolates in England and Wales with reduced susceptibility to ceftriaxone—the current first-line therapy for gonorrhea in England—fell from 7.1% in 2018 to 2.9% in 2019, following a steady increase from 2013 through 2018. Outside of the sentinel surveillance system, three cases of ceftriaxone-resistant gonorrhea were confirmed by PHE in 2019.

The surveillance report also showed a slight decline in azithromycin resistance (9.8% to 9.3%) and a decline in cefixime resistance (2.2% to 0.8%).

"The effectiveness of first-line treatment for gonorrhoea continues to be threatened by the development of antimicrobial resistance," the report said. "However, the decline in reduced ceftriaxone susceptibility, together with decreasing cefixime resistance and stable rates of azithromycin resistance, are encouraging developments."
Nov 18 PHE ESPAUR report
Nov 18 PHE GRASP report

News Scan for Nov 19, 2020

News brief

Public transit use drops 73% in pandemic, with vulnerable most affected

Public transportation usage dropped 72.7% across the United States from Feb 15 to May 17, but vulnerable populations and essential or physical workers were most likely to continue using it, according to a study published yesterday in PLOS One.

The study used data from the Transit app across 63 metro areas, as well as applicable surveys and studies to measure demand timeline and changing demographics.

Hourly traffic data revealed that weekday and weekend demand came to resemble each other more during the pandemic, highlighting that those without orthodox 9-to-5 schedules—typically, essential workers—were most affected, according to the researchers. The biggest indicator of continued transit usage, however, was race.

The larger the black population in a city, the less decline in demand for public transit. Women made up 70% of black passengers. Many others who needed to commute via public transport for physical jobs were Hispanic, which corresponds with 2018 statistics that show that Hispanics have the lowest percentage (22%) of management, professional, and related occupations compared with white, black, and Asians.

COVID-19 awareness, indicated by "coronavirus" searches on Google, also had a significant association with less public transit use, but it was not as influential as ethnicity, occupation, and even age. The relative ratio of bus passengers aged 45 to 64 doubled when comparing April 2020 with September 2019, whereas use by children and those aged 25 to 44 dropped.

"It is a dramatic social equity story about who has to move during the pandemic," said study co-author Harvey Miller, PhD, in an Ohio State University (OSU) press release.

Coastal cities saw a decline in demand sooner compared with Midwest and Southern cities. College towns were among those that saw the steepest falls, most likely in relation to school ordinances. Ridership in other cities, like Austin, Texas, likely reflected political action, as declines in transit use happened on the same day a local state of emergency was declared.
Nov 18 PLOS One study
Nov 18 OSU press release

Mink a possible animal reservoir for COVID-19

A Danish study today in Emerging Infectious Diseases demonstrates the rapid spread of COVID-19 in farmed mink, the emergence of novel virus variants, and viral transmission to people.

SARS-CoV-2 infection has been documented in a variety of animal hosts, including ferrets, costs, dogs, hamsters, and nonhuman primates, but not in pigs or chickens. Previous studies have identified COVID-19 in farmed mink in the Netherlands and in Denmark.

Researchers identified three mink farms—of 1,200 total in Denmark—for investigation because of COVID-19 in people linked to the farms. Mink blood, throat, nasal, and fecal swab samples were tested via reverse-transcriptase polymerase chain reaction, along with feed and air samples from each farm. Viral genomes were sequenced to analyze relationships between virus variants, and animal serum samples were tested for SARS-CoV-2 antibodies.

The researchers found high initial seroprevalence (97% and 67%) for sampled animals on two farms, but only 3% seroprevalence for a third farm, suggesting a more recent introduction. Significantly, when animals on the farm with low prevalence were retested 12 days later, the seroprevalence had risen to 97%, indicating rapid transmission among farmed animals and the possibility of major virus exposure to persons working with mink.

Air samples within cage houses tested positive for the virus at two farms, but not feed or other air samples.

Viral sequences from mink on the first farm closely matched those of a human case, diagnosed in mid-May, leading researchers to suspect human introduction of the virus. A viral variant present at one farm appears to have spread to the other two farms and may indicate adaptation to mink and increased transmission ability. The same variant was detected in subsequent linked human cases.

"There appears to be some risk of virus transmission to persons working with infected mink as well as for their contacts and thus, indirectly, for the public," the authors wrote.

The mink infections occurred with little apparent clinical disease or animal mortality, making viral spread difficult to detect. "Mink farms could represent a serious, unrecognized animal reservoir for SARS-CoV-2," they added.
Nov 19 Emerg Infect Dis study

COVID-19 infection not linked to poor pregnancy outcomes

A large Texas hospital study today in JAMA Network Open found that SARS-CoV-2 infection during pregnancy was not associated with adverse pregnancy outcomes. Neonatal infection occurred in 3% of infants—primarily among asymptomatic or mildly symptomatic women—and hospitalization rates for infected mothers were similar to those of nonpregnant women.

Researchers evaluated 3,374 pregnant women who delivered infants from Mar 18 to Aug 22 at Parkland Health and Hospital System in Dallas—252 of whom tested positive for SARS-CoV-2, the virus that causes COVID-19.

There were no differences in age, parity (number of live births), body mass index, or diabetes among infected and noninfected women, but SARS-CoV-2 positivity was more common among Hispanic women. Women of Hispanic ethnicity accounted for 75% of the cohort, but they represented 91% of the SARS-CoV-2–positive women. Thirteen infected women (5%) had severe or critical illness.

Infected women did not have a significantly higher frequency of preterm birth, severe preeclampsia, or cesarean delivery for abnormal fetal heart rate compared with SARS-CoV-2–negative women (52 women [21%] vs 684 women [23%]; relative risk, 0.94; 95% CI, 0.73 to 1.21; P = .64), and there were no stillbirths among women with COVID-19 during pregnancy.

No difference between groups was observed for secondary outcomes such as placental abruption, infection of any type, and excessive blood loss, and placental abnormalities were not associated with disease severity.

Among 188 tested neonates, 6 (3%) were positive for COVID-19, and all were born to women whose infections were diagnosed during the third trimester. The researchers caution that they were unable to determine whether diagnosis of early neonatal SARS-CoV-2 infection was the result of vertical transmission—from mother to child—or via another route.

In contrast with previous studies showing high rates of hospitalization in pregnant women, the hospitalization rate for infected women in this study was similar to rates among nonpregnant women (6% hospitalized vs 5.8% among nonpregnant women).

"Our findings that 5% of all delivered women with SARS-CoV-2 infection present with or develop severe or critical illness are novel and lower than rates in previous reports," the authors note.
Nov 19 JAMA Netw Open study