Turkish hospital study shows benefits of antifungal stewardship

Implementing daily, pharmacist-driven antifungal stewardship activities at a tertiary care hospital in Turkey was associated with significant improvements in the appropriateness of antifungal therapy, Turkish researchers reported yesterday in Antimicrobial Agents and Chemotherapy.

The researchers evaluated and compared antifungal therapy at the hospital during three different periods. In the observation period, they evaluated the use of systemic antifungals for baseline measurement of appropriateness. In the second period, pharmacists organized monthly meetings to provide feedback and education on antifungal therapy to physicians. In the third period, pharmacists participated in daily ward rounds to evaluate appropriateness of antifungal therapy and make recommendations.

During the three periods, 105, 109, and 204 episodes of antifungal therapy, respectively, were assessed. During the third period, 157 recommendations were made and 151 (96.2%) were accepted.

The overall appropriateness of antifungal use increased significantly in the third period compared with the first two, with improvements observed in antifungal drug choice, dosage, and duration of therapy. Statistically significant increases were detected for antifungal prophylaxis (30.8%, 17.9%, and 46.3% in the three periods, respectively) and treatment of fungal disease (27.8%, 32.4%, 71.9%). Thirty-day mortality was not significantly changed between the three periods (19%, 15.6%, and 27.5%), but the authors note that was likely the result of the COVID-19 outbreak, which occurred during the third period and was accompanied by a high rate of patients with severe comorbidities.

"Considering the workload and variety of patients encountered in ward rounds, a team-based evaluation of fungal infections, including feedback and support from a clinical pharmacist, may help to increase the quality of antifungal therapies," the study authors wrote.
Jun 21 Antimicrob Agents Chemother abstract


Manitoba reports H3N2v flu case

Public health officials in Manitoba, Canada, yesterday reported a swine-related variant H3N2 (H3N2v) flu case involving a patient in the southern part of the province, according to a government statement.

The illnesses was detected in early June when the patient sought testing after experiencing a flulike illness. They had mild symptoms and recovered. Tests were negative for COVID-19, but the virus was later identified as H3N2v as part of routine flu surveillance.

Health officials said the case appears to be isolated and is different than earlier H1N1v and H1N2v cases reported in late April. An investigation is under way to determine how the patient contracted the virus.

Health officials said the risk of human-to-human transmission is low and that the detection of the recent variant flu cases could reflect increased surveillance for respiratory viruses against the backdrop of COVID-19 or could reflect a true increase in variant cases, either from infected pigs or subsequent human-to-human transmission.
Jun 21 Manitoba press release


H9N2 avian flu infects 2 more people in China

China reported two more human H9N2 avian flu infections in different provinces, Hong Kong's Centre for Health Protection (CHP) said in its latest weekly avian influenza update.

One of the patients is a 78-year-old woman from Jiangsu province whose symptoms began on Apr 20, and the other is a 2-year-old boy from Sichuan province who started having symptoms on Apr 27.

The report did not say how the patients were exposed. H9N2 avian influenza is known to circulate in poultry in the region, and sporadic infections occur, typically in people who had direct or indirect contact with poultry. Sustained transmission hasn't been reported, and the infections are usually mild and more commonly reported in children. China has reported 13 H9N2 cases so far this year.
Jun 22 CHP avian influenza update

COVID-19 Scan for Jun 22, 2021

News brief

Racial disparities noted in children with COVID-19

Non-White children may receive less COVID-19 testing and experience higher COVID-19 infections, COVID-19 severity, and hospitalization duration, according to a study yesterday in JAMA Pediatrics.

The researchers looked at data from 2,576,353 English children from Jan 24 to Nov 30, 2020, via the QResearch Database, which covers about 20% of the UK population. The mean age was 9.23 years, and 48.8% were female. Of the cohort, 15.9% were tested, 6.4% tested positive, 0.01% (343) were admitted to a hospital, and 0.002% (73) needed intensive care unit (ICU) treatment. About 30% of children did not have listed racial or ethnicity information, but overall, 18.8% were not White.

White children received the most COVID tests (17.1%), followed by Asians (13.6%), those of mixed or other races (12.9%), and Black children (8.3%). Minority children had significantly higher COVID-19 infections, ranging from 6.3% (mixed/other races) to 10.8% (Asian) versus the 5.8% identified in White children. Compared with White children, Asian children were more likely to be admitted to the hospital (odds ratio [OR], 1.62) or ICU (OR, 2.11), and the researchers found that Black and children of mixed or other races were at higher risk for hospitalizations lasting 3 or more days (ORs, 2.31 and 2.14, respectively).

"In the UK, Black and Asian communities are overrepresented in the poorest regions that have the highest COVID-19 mortality rates; thus, socioeconomic status in the UK is also likely to be associated with the higher rates of positive test results in Black and Asian children," write Evida A. Dennis-Heyward, MD, PhD, and Snehal N. Shah, MD, MPH, in an editorial.

"If future initiatives do not prioritize equity over equality by distributing resources based on relative need and ensuring that children from communities most severely impacted by COVID-19 are given preference, we run the risk of perpetuating existing disparities for generations to come."
Jun 21 JAMA Pediatr study and editorial


Rare cases of Guillain-Barre syndrome detailed after COVID vaccine

Two studies this month in the Annals of Neurology describe Guillain-Barre syndrome in seven Indian patients and four English patients, both within 22 days of receiving the AstraZeneca-Oxford vaccine, which has already been linked to rare but severe clotting.

The researchers described the seven cases in Kerala, India, where symptom onset occurred within 2 weeks after receiving the first dose of the vaccine, noting that the frequency was 1.4- to 10-fold higher than expected from mid-March to mid-April in the 1.2 million vaccinees. In all cases, the patients progressed to areflexic quadriparesis, and while only about 20% of GBS patients have bilateral facial paralysis, all seven patients did. Six needed mechanical ventilation for respiratory failure, and four patients also developed other neuropathies such as abducens palsy and trigeminal sensory impairment.

Six patients were female and one was male; all were in their 40s to 60s. At the time of writing, only one patient had fully recovered while the rest were bed-ridden and undergoing rehabilitation.

"While the benefits of vaccination substantially outweigh the risk of this relatively rare outcome (5.8 per million), clinicians should be alert to this possible adverse event, as six out of seven patients progressed to areflexic quadriplegia and required mechanical ventilatory support," the researchers write.
Jun 22 Ann Neurol study

Of the four GBS patients in Nottingham, England, all were male (one British Iranian, three White), ranging from 20 to 57 years of age. Symptoms started presenting between 11 to 22 days post-vaccination with the AstraZeneca-Oxford COVID-19 vaccine. The researchers say that in a population pool consisting not only of both AstraZeneca and Pfizer COVID vaccine recipients but all local residents (including about 870,000 unvaccinated people), they would expect less than four GBS cases per month.

"Although these patients had neurological symptoms temporally associated with vaccination, causality cannot be assumed," the researchers write. "It certainly warrants robust post-vaccination surveillance, which requires both accurate clinical diagnosis and robust national reporting mechanisms."
Jun 10 Ann Neurol study


Delta and Gamma variants make up larger share of US COVID cases

The Delta and Gamma variants (B1617.2 and P.1, respectively) are on track to surpass the Alpha variant (B117) in the United States, according to a study on the non–peer-reviewed medRxiv preprint server yesterday.

The researchers looked at 243,769 positive COVID-19 samples collected from Jan 1 to Jun 15 and viral sequence data from 19,987. Distribution is not representative of the US population, they note; for instance, Florida had 25.7% of the samples.

The Alpha variant began plateauing in April, peaking at 71.1% on Apr 25, before declining down to 42% 6 weeks later, by Jun 11 to 15. Other variants appeared to be displacing it: Sequences of 353 S-positive samples from Jun 2 to 8 showed that Gamma represented 28% and Delta represented 24.6% at the time, with both projected to continue growing. By Jun 9 to 15, 57.1% of 1,401 samples were non-Alpha variants, and the researchers believe 14% of total cases were Delta and 16% were Gamma.

The researchers created a logistic growth curve and estimated that Delta's and Gamma's growth rates are 0.61 and 0.22, respectively, which they say are comparable to a UK estimation of 0.93 and 0.34. "While the numbers obtained in Florida confirm this analysis, it was also evident that the number of B.1.617.2 in Florida was still too low to make accurate predictions," they write.

"Overall, these results showed that the main variants replacing B.1.1.7 in the United States are the two variants of concern P.1 and B.1.617.2," the researchers conclude. Delta seemed to be spreading faster in counties with lower vaccination rates, and while Gamma appeared less transmissible, it had a higher prevalence than Delta in counties with higher vaccination rates. "As of early June 2021, our data showed that the proportion of S-positives that are P.1 vs. B.1.617.2 differed between states."
Jun 21 medRxiv study

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