ASP Scan (Weekly) for Dec 11, 2020

News brief

Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans

First US case of gonorrhea with resistance-conferring mutation identified

Originally published by CIDRAP News Dec 10

A paper today in Morbidity and Mortality Weekly Reports (MMWR) describes the first US case of Neisseria gonorrhoeae harboring a genetic element that confers resistance to a first-line antibiotic.

The N gonorrhoeae isolate, collected from an HIV-negative heterosexual man in Nevada, was identified by investigators from the Southern Nevada Health District (SNHD) in November 2019, when testing revealed reduced susceptibility to ceftriaxone and cefixime, but not to azithromycin. An intramuscular shot of ceftriaxone and an oral dose of azithromycin is the current recommended regimen for gonorrhea.

Molecular testing of the isolate by the Centers for Disease Control and Prevention (CDC) revealed the emerging mosaic penA60 allele, which was first identified in Japan in 2016 and confers resistance to cephalosporins and increases the risk of treatment failure. Despite the reduced susceptibility to ceftriaxone, the patient reported at the end of November 2019 that his symptoms had resolved, and further testing returned negative results.

The CDC subsequently tested 257 N gonorrhoeae isolates collected from the Southern Nevada area by SNHD from September 2019 through November 2019 to look for the presence of the penA60 allele but found no additional isolates carrying it. Additional testing of 5,500 gonococcal isolates from the Gonococcal Isolate Surveillance Project (GISP) found none with reduced susceptibility to ceftriaxone or cefixime. The investigation was stopped in February.

The origin of the isolate remains unclear, the investigators said.

"This case highlights the utility and importance of surveillance programs like GISP as effective tools in identifying emerging antimicrobial-resistant pathogens that can negatively impact patient outcomes and threaten public health," they wrote.
Dec 10 MMWR Notes from the Field

Primary care stewardship cuts antibiotics, costs for respiratory infections

Originally published by CIDRAP News Dec 8

A cluster-randomized controlled trial conducted in Spanish primary care settings suggests a multifaceted stewardship intervention helped reduce antibiotic prescribing for acute respiratory infections (ARIs) and was cost-effective, Spanish researchers reported yesterday in Antimicrobial Resistance and Infection Control.

The intervention was introduced among primary care providers in Galicia, a region of northwest Spain where at least one third of all antibiotic prescriptions are for ARIs but only half are thought to be appropriate. It included a one-hour educational outreach visit tailored to physician knowledge gaps identified in a previous study, an online course integrated in practiced accreditation, and a clinical decision support system.

To evaluate the intervention, after a median of 19 months, researchers looked at antibiotic prescribing among 1,217 physicians recruited from seven intervention clusters and 1,393 from control clusters. The main outcomes measured were overall antibiotic prescribing for ARIs, antibiotic use by class, the ratio of consumption of broad- to narrow-spectrum antibiotics, and the savings attributed to the intervention.

The results showed a 4.23% decline in overall antibiotic prescribing in the intervention group compared with the control group, highlighted by a 6.51% reduction in penicillin use. The ratio of consumption of broad- to narrow-spectrum penicillins, cephalosporins, and macrolides fell by 8.97%. Because of the reduction in antibiotic prescriptions, Spain's National Health Service directly saved €311 (USD $377) per physician and patients directly saved €573 ($694).

"The results of this study indicate that low-cost interventions based on the previously identified gaps can be effective and, in addition, have a positive cost-benefit relationship over a short time horizon, something that could be highly relevant for their application by healthcare systems," the authors wrote.
Dec 7 Antimicrob Resist Infect Control study

VA stewardship interventions linked to reduced antibiotic use for ARIs

Originally published by CIDRAP News Dec 8

Implementation of the Centers for Disease Control and Prevention's Core Elements of Outpatient Antibiotic Stewardship at Veterans Affairs (VA) emergency departments and primary care clinics was associated with reduced antibiotic prescribing for uncomplicated ARIs and a drop in hospitalizations, US researchers reported today in Clinical Infectious Diseases.

Key elements of the intervention included physician education and diagnosis-based audit and feedback reports.

The quasi-experimental, controlled study compared the effects of Core Elements implementation at 10 VA sites—four emergency departments and six primary care clinics—with prescribing data from 40 control sites over a 5-year period.

There were 16,712 and 51,275 uncomplicated ARI visits at the intervention and control sites, respectively, from 2014 through 2019. Antibiotic prescribing rates fell from 59.7% pre-intervention to 41.5% post-intervention, compared with 73.5% to 67.2% at the control sites. The proportion of visits with appropriate therapy increased from 53.8% to 69.1% at the intervention sites (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.31 to 2.14), but was unchanged at the control sites (OR, 1.04; 95% CI, 0.91 to 1.19).

There was no statistical difference in ARI-related return visits post-implementation (-1.3% vs -2.0%), but all-cause hospitalization was lower within the intervention sites (-0.5% vs -0.2%). The OR to diagnose upper respiratory tract infection not otherwise specified compared to other non-ARI diagnosis increased post-implementation for intervention sites (1.27) but not control sites (0.97).

The authors conclude that healthcare systems interested in improving antibiotic prescribing should embrace the Core Elements framework and consider implementation of similar interventions.
Dec 8 Clin Infect Dis abstract

More improper antibiotics noted for ARIs in rural vs city Tennessee kids

Originally published by CIDRAP News Dec 8

In another study on antibiotic prescribing for respiratory infections, researchers in Tennessee reported today in Open Forum Infectious Diseases that inappropriate antibiotic use for ARIs was significantly higher in children from rural counties compared with urban counties.

The study cohort consisted of children aged 2 months to 5 years who were enrolled in Tennessee Medicaid from 2007 through 2012 and diagnosed with an ARI in the outpatient setting during that period. Using electronic medical record and pharmacy data, researchers from Vanderbilt University Medical Center and Atrium Health compared rates of ARI and related antibiotic use among children in completely rural, mostly rural, and mostly urban counties. Multivariable regression models were used to measure associations between rurality of residence and the rate of study outcomes.

Compared with children from mostly urban areas, children from mostly rural and completely rural counties had higher rates of ARIs (adjusted incidence rate ratio [aIRR], 1.07 1.07, respectively), ARI-related antibiotic use (aIRR, 1.15 and 1.17), and ARI-related inappropriate antibiotic use (aIRR, 1.34 and 1.33).

Although the proportion of ARIs associated with overall and inappropriate antibiotic use decreased over time, they remained higher in children living in rural counties compared to urban counties throughout the study period. The strength of the association between rurality and rate of antibiotic use was higher among black children and those from households with lower median incomes.

"These findings should inform targeted outpatient stewardship efforts to reduce inappropriate antibiotic use and its consequences," the authors concluded.
Dec 8 Open Forum Infect Dis abstract

CDC report shows declines in healthcare-associated infections

Originally published by CIDRAP News Dec 7

A new report from the CDC shows some encouraging declines in healthcare-associated infections (HAIs) across four US healthcare settings, including one linked to antibiotic use.

The 2019 National and State HAI Progress Report, which covers data from acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, and long-term acute care hospitals, shows a 7% decrease in central line-associated bloodstreams infections from 2018 to 2019 and an 8% reduction in catheter-associated urinary tract infections. Compared with the 2015 baseline standardized infection ratio, 51 states performed better on at least two infection types in 2019, 40 states performed better on three infection types, and 30 states improved on at least four infection types.

The report also showed an 18% decline in Clostridioides difficile infections from 2018 to 2019. C difficile is the leading cause of hospital- and antibiotic-associated diarrhea in the United States.

But there remains room for improvement. The data showed a 2% increase in ventilator-associated events, no significant change in surgical-site infections related to 10 select procedures, and no significant change in methicillin-resistant Staphylococcus aureus bacteremia.

The CDC estimates that, on any given day, 1 in 31 US hospital patients has an HAI, a growing number of which are caused by antibiotic-resistant bacteria. The agency has placed an increased focus on reducing HAIs in US hospitals recent years, but it says more work on HAI surveillance and prevention is needed.

"While much progress has been made, more needs to be done to prevent healthcare-associated infections in a variety of settings," the report stated.
Dec 2 CDC HAI Progress Report

COVID-19 Scan for Dec 11, 2020

News brief

Biogen conference linked to hundreds of thousands of COVID cases

A study published yesterday in Science by researchers in Massachusetts suggests that a coronavirus outbreak linked to an international biotech conference in Boston in February is linked to more than 300,000 national and international infections with SARS-CoV-2, the virus that causes COVID-19.

The findings stem from an analysis of 772 genomes from SARS-CoV-2 nasopharyngeal samples led by scientists with Harvard, the Massachusetts Institute of Technology, and Massachusetts General Hospital (MGH). The samples were collected by the Massachusetts Department of Health and MGH from Mar 4 through May 9 and included samples from two putative superspreading events—one at a skilled nursing facility and the other at the Biogen conference, held in Boston on Feb 26 and 27.

Initial public health investigation and contact tracing identified approximately 100 cases associated with the conference. Viral sequencing of 28 conference-associated genomes revealed the presence of a single mutation (C2416T) not previously found in Massachusetts and likely introduced by a European conference attendee. C2416T and another conference-associated variant, C2416T/G26233T, accounted for more than half of the 772 SARS-CoV-2 genomes from Massachusetts.

Using the C2416T variant as a marker for tracking the spread of SARS-CoV-2 from the conference and comparing the conference-associated genomes with a dataset of 4,011 SARS-CoV-2 genomes from the United States and other countries, the researchers found that the conference-associated lineage began to appear in multiple states in early March and increased rapidly in frequency. By Nov 1, viruses containing C2416T could be found in 29 states.

The researchers estimate that a total of 245,000 cases (205,000 to 300,000) marked by C2416T occurred through Nov 1, with Florida accounting for the greatest proportion of those cases (29.2%). In addition, they estimate that 88,000 cases (56,000 to 139,000) were caused by C2416T/G26233T, which spread to 18 states and other countries.

"Because SARS-CoV-2 viruses circulating at the conference happened to be marked by distinct genomic signatures, we were able to track its downstream effects far beyond the superspreading event itself, tracing the descendants of the virus as they made a large contribution to the local outbreak in the Boston area and as they spread throughout the US and the world, likely causing hundreds of thousands of cases," the authors of the study wrote.
Dec 10 Science study

CDC: Emergency visits for child abuse down during pandemic

Data published today in the Centers for Disease Control and Prevention's (CDC's) Morbidity and Mortality Weekly Report (MMWR) show fewer emergency department (ED) visits for child abuse and neglect during the first 6 months of the pandemic, but the proportion of these visits increased.

Pandemics are linked to an increased risk of child abuse and neglect because of stress and less contact with mandated reporters. Preliminary reports from some facilities during COVID-19 have shown increased severity of abuse and neglect, but official reports to child protection agencies have declined by 20% to 70%, the authors note.

CDC researchers analyzed national data representing approximately 73% of all US ED visits from Jan 6 to Sep 6 and stratified them by age-group (0 to 4, 5 to 11, and 12 to 17 years old).

Beginning Mar 15—and coinciding with the president's declaration of a national emergency—the total number of ED visits meeting the definition for child abuse and neglect decreased below 2019 levels for all age-groups. At the same time, the proportion of ED visits related to child abuse and neglect (per 100,000 ED visits) began increasing above 2019 levels—likely related to a decrease in the overall number of ED visits and a pandemic-related shift in healthcare use, the authors suggest.

The researchers found 53% fewer overall ED visits for child abuse and neglect from Mar 29 to Apr 4 compared with the same period in 2019, with the largest proportional declines in children aged 5 to 11 years (61%). But the number of ED visits for child abuse and neglect resulting in hospitalization did not decline in 2020, suggesting that injury severity did not decrease.

Although weekly visits resulting in hospitalization for children of all ages remained stable for 2020, the overall percentage of such visits increased from 2.1% in 2019 to 3.2% in 2020 (P < 0.001), with the largest increase in children aged 0 to 4 years (5.3% in 2020 vs 3.5% in 2019; P < 0.001).

The authors conclude, "Implementation of strategies to prevent child abuse and neglect is important, particularly during public health emergencies."
Dec 11 MMWR study

News Scan for Dec 11, 2020

News brief

CDC reports first pediatric flu death of the new flu season

Though flu activity in the United States remains well below expected levels for this time of year, the Centers for Disease Control and Prevention (CDC) today reported the first pediatric flu death of the 2020-21 season, a child who died from influenza B.

The percentage of respiratory specimens that were positive for flu last week was 0.2%, and the percentage of clinic visits for flulike illness stayed at 1.6% for the third week in a row. Deaths from flu, pneumonia, and COVID-19 were at 14.3%, well above the 6.5% epidemic threshold, but with the vast majority deaths due to COVID-19. The CDC cautioned that flu patterns should be interpreted with caution, due to impacts from COVID-19.

Of respiratory samples tested at clinical labs last week, 40 were positive for flu: 19 were influenza A and 21 were influenza B. Of 16 flu specimens detected last week at public health labs, 5 were influenza A and 11 were influenza B. Only one influenza A virus was subtyped, which revealed 2009 H1N1.
Dec 11 CDC FluView

Four countries report vaccine-derived polio cases

Four countries reported more polio cases over the past week, all involving vaccine-derived polio, according to the latest report from the Global Polio Eradication Initiative (GPEI).

Pakistan reported 6 cases of circulating vaccine-derived poliovirus type 2 (cVDPD2), including 3 in Sindh province, 2 in Balochistan, and 1 in Punjab, bringing the number of cVDPD2 cases reported in the country in 2020 to 110. There were also eight cVDPD2 environmental samples reported, along with five wild poliovirus type 1 (WPV1) environmental samples.

The other reported cVDPD2 cases were in Africa. Central African Republic (Region Sanitaire province) and Somalia (Baidoa province) each reported 1 cVDPD2 case, and Chad reported 9—1 each in N'Djamena, Logone Occidental, and Kanem provinces and 6 in Logone Oriental province. The GPEI report says further cVDPD2 spread across the Lake Chad subregion remains high.
Dec 9 GPEI weekly update

H5N8 avian flu hits more poultry and wild birds in Europe

More highly pathogenic avian flu outbreaks were reported across Europe, mainly in wild birds but with France reporting another H5N8 outbreak in poultry, according to the latest notifications from the World Organization for Animal Health (OIE).

In France, surveillance avian flu at a duck farm in Landes department turned up H5N8 on Dec 7, though no illnesses or deaths were reported. Authorities culled 12,043 birds at the facility as a precaution.

Meanwhile, three countries—Belgium, Ireland, and Poland—reported more H5N8 detections in wild birds.
Dec 10 OIE report on H5N8 in French poultry
Dec 11 OIE report on H5N8 in Belgian wild birds
Dec 10 OIE report on H5N8 in Irish wild birds
Dec 10 OIE report on H5N8 in Polish wild birds

In a related development, the European Centre for Disease Prevention and Control (ECDC) today posted a snapshot of avian flu on the continent since Aug 15, noting that 561 highly pathogenic detections have been reported in 15 countries, mostly in wild birds but also affecting poultry and captive birds.

The hardest-hit countries are Germany, Denmark, and the Netherlands. Subtypes include mainly H5N8, but also H5N5 and a reassortant H5N1 that isn't related to the type that has been deadly in humans.

The risk of further spread to poultry is high to birds in other European countries, as autumn migration continues southward and westward. Though the risk of spread to humans is still very low, virus evolution and reassortment needs to be closely monitored for emerging threats, the ECDC said.
Dec 11 ECDC avian flu overview