News Scan for Oct 05, 2021

News brief

US stewardship effort tied to lower antibiotics in ambulatory care during COVID

A national ambulatory antibiotic stewardship program was associated with declines in overall and acute respiratory infection (ARI)-related prescribing during the COVID-19 pandemic, US researchers reported last week at ID Week 2021.

Out of 467 ambulatory practices enrolled, 389 completed the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use, a program that aims to incorporate antibiotic stewardship into practice culture, communication, and decision-making through education and technical support. The program uses webinars, audio presentations, educational tools, and office hours to address attitudes and culture that pose challenges to judicious antibiotic prescribing and to incorporate best practices for managing common infections into clinician workflow.

To evaluate the program's effectiveness, researchers compared total visits to the practices, visits for ARI, and antibiotic prescribing in the pre-intervention (September to November 2019) and intervention (December 2019 to November 2020) periods.

The 389 practices included 162 primary care practices, 160 urgent care clinics, and 49 federally supported practices. Visits per practice-month declined from March to May 2020 but gradually returned to baseline by program end.

Total antibiotic prescribing declined by 9 prescriptions per 100 visits (95% confidence interval [CI], -10 to -8). ARI visits/practice-month declined significantly from March to May 2020, then increased but remained below baseline by program end. ARI-related antibiotic prescriptions decreased by 15/100 ARI visits by program end (95% CI, -17 to -12). The greatest reduction was in penicillin class prescriptions, with a reduction of 7/100 ARI visits by program end (95% CI, -9 to -6).

"We have demonstrated that it is possible to implement stewardship on a large scale in different practices and settings across the country,” Sara Keller, MD, MPH, associate professor at Johns Hopkins University School of Medicine and the study's presenting author, said in an ID Week press release. "To improve antibiotic use is to improve patient safety. There is immense hope in that."
Sep 30 IDWeek press release

Leafy greens outbreaks part of this season's Cyclospora cases

In an annual final update on domestically acquired Cyclospora cases, which typically increase in warm weather months, the US Centers for Disease Control and Prevention (CDC) said 1,020 cases from 36 states were reported, with 170 linked to two large multistate outbreaks associated with restaurants or events.

One multistate outbreak involved 40 illnesses and the other resulted in 130 infections. For both, traceback investigations suggested leafy greens, but no specific grower or type of greens were identified. In the past, Cyclospora outbreaks were tied to various produce items, including basil, cilantro, mesclun lettuce, and snow peas. In 2020, multiple outbreaks were reported and involved various produce items, including bagged salad mix.

The CDC's tally of this year's cases shows that 70 people were hospitalized, with no deaths reported. The latest illness onset was Aug 31.

Cases this year were below the 1,241 cases reported over the same time period in 2020. Infections are caused by the parasite Cyclospora cayetanensis, which can be found in food or drinking water contaminated with feces. Symptoms of cyclosporiasis include profuse diarrhea that can last weeks to months.
Sep 30 CDC final outbreak update

COVID-19 Scan for Oct 05, 2021

News brief

COVID variants of concern more virulent, study says

COVID-19 variants of concern (VOCs), especially the Delta (B1617.2) variant, are more virulent than the wild type, according to an Ontario-based study published in CMAJ yesterday. The cohort included 212,326 cases of non-VOCs (22.4%) and VOCs with the N501Y mutation (76.7%), such as Alpha (B117), Beta (B1351), Gamma (P1), and Delta.

The researchers found that the VOCs had a 52% increased risk of hospitalization (95% confidence interval [CI], 42% to 63%), 89% increased risk of intensive care unit (ICU) admission (95% CI, 67% to 117%), and a 51% increased risk of death (95% CI, 30% to 78%).

The Delta variant, although only 2.8% of the sample size, was associated with a 108% increased risk of infection (95% CI, 78% to 140%), a 235% increased risk of ICU admission (95% CI, 160% to 331%), and a 133% higher risk of death (95% CI, 54% to 231%).

Data also indicated that those infected by VOCs were significantly younger and less likely to have comorbidities compared with those infected with the wild-type virus.

"Canada is battling a different pandemic from the one it faced in early 2020," writes Kirsten Patrick, MBBCh, MSc, in a related editorial. "The virus has become smarter and more dangerous, which means that we need to be smarter too. Canada’s governments can keep people safe by enacting policies that wisely combine all the measures that have been shown to be effective."

Both Patrick and the researchers highlight the usefulness of the COVID-19 vaccines, with the researchers adding, "The effects reported here represent a substantial degree of protection against death conferred by vaccines (about 80%–90%), even when they fail to prevent infection. Such direct protective effects may help reduce the health impacts of ongoing SARS-CoV-2 transmission in Ontario, even if herd immunity proves elusive, given the high reproduction numbers of VOCs."

The study included COVID-19 tests that took place Feb 7 to June 26. During that time, Delta was first detected in Canada in April, and by July, it was the predominant strain.
Oct 4 CMAJ study and editorial

Convalescent plasma didn't help critical COVID-19 patients

Convalescent plasma didn't help adults with critical COVID-19 have better outcomes, according to a randomized trial published yesterday in JAMA.

The 2,011-person study was rolled out at sites in the United Kingdom (115), Canada (9), Australia (4), and the United States (1, the only location that offered delayed convalescent plasma to 11 patients). The median age was 61 years, and 32.3% were women.

Almost 1,050 people received two units of high-titer, ABO-compatible convalescent plasma an average of 42.7 hours after hospital admission and 17.7 hours after ICU admission; 916 didn't receive anything beyond the standard of care.

The median number of organ support-free days within the first 21 days was zero in the treatment group and 3 in the control group (odds ratio, 0.97). Overall mortality was lower in the treatment group (37.3% vs 38.4%), but serious adverse events were more common (3.0% vs 1.3%). The posterior probability of futility was 99.4% across the primary outcome of being organ support-free within 21 days.

"We speculate that [the futility] could be a combination of too few high-quality antibodies in the plasma and these patients being too far along in their illness with a run-away inflammatory immune response for those antibodies to turn the tide," said co-senior author Derek Angus, MD, MPH, in a University of Pittsburgh press release. "It is still possible that convalescent plasma helps people in earlier stages of illness, though it is likely not efficient to use given that monoclonal antibodies … are such an effective treatment for early COVID-19."

While the study was stopped Jan 15 for futility, the researchers noted that convalescent plasma appeared to help the 126 immunocompromised patients (posterior probability of superiority, 89.8%), unless it was given more than 7 days into their hospitalization (posterior probability of harm, 90.3%). However, the sample size was too small to draw any conclusions.
Oct 4 JAMA study
Oct 4 University of Pittsburgh press release

Excess pandemic deaths hit minorities harder, study says

Excess pandemic deaths in the United States were disproportionately higher in Black, American Indian/Alaska Native, and Latino people than in White and Asian people, according to a study today in the Annals of Internal Medicine.

The researchers used Centers for Disease Control and Prevention and US Census Bureau data to compare mortality per 100,000 people from March to December 2020 with the corresponding months in 2019. Excess deaths by racial population size were calculated under the assumption that the 2019 population sizes still held true.

During the 2020 study period, about 2.88 million people died, for an excess of 477,200 excess deaths compared with the 2019 period. About 74% of them were attributed to COVID-19, but Black, American Indian/Alaska Native, and Latino people had more than double the COVID-19 deaths per 100,000 people compared with White and Asian people.

Among non–COVID-19 deaths, Black and American Indian/Alaska Native people had three- to four-fold higher deaths per 100,000 people compared with White people, while Latinos had almost two-fold higher deaths.

Broken down by race, non–COVID-19 deaths were 22.6% of excess 2020 deaths among White people, 29.7% among Black people, 22.8% among Latino people, 25.8% among Asian people, and 30.9% among American Indian/Alaska Native people.

Data also showed that non–COVID-19 deaths were more prominent in those younger than 45 (75% of deaths vs 22% in those older), and racial disparities were more prevalent in those 75 years and older (eg, deaths per 100,000 people were nine times higher among Black men than among White men).

"It is possible that fear of seeking out health care during the pandemic or misattribution of causes of death from COVID-19 are responsible for a majority of the excess non–COVID-19 deaths," said lead author Meredith S. Shiels, PhD, MHS, in a National Cancer Institute (NCI) press release.

The researchers note that American Indian/Alaska Native deaths may be underestimated, as this race is misclassified 40% of the time on death certificates.
Oct 5 Ann Intern Med study
Oct 4 NCI press release