Study finds no transmission of COVID-19 from moms to newborns

A study yesterday in The Lancet Child & Adolescent Health found no evidence of COVID-19 transmission between 120 babies born to mothers with COVID-19, even after 2 weeks of breastfeeding with appropriate hygiene precautions.

The findings led the American Academy of Pediatrics (AAP) to change its guidance on infants and COVID-19–positive mothers. The guidelines now recommend that newborns "room-in" with infected others after delivery if proper hygiene precautions are taken, including wearing a mask when appropriate and practicing hand hygiene.

The small observational study was based on 120 babies born to 116 mothers at three hospitals in New York City, between Mar 22 and May 17. The babies were kept in enclosed cribs in their mothers' hospital rooms, and mothers wore surgical masks while handling their babies and followed frequent hand and breast washing procedures.

None of the babies tested positive for COVID-19 24 hours after birth. Follow-up at 5 to 7 days post-birth and through the first month of life showed no infections.

In a commentary on the study, Melissa Medvedev, MD, of the University of California San Francisco, said the authors of the study "provide valuable data indicating that perinatal SARS-CoV-2 transmission is unlikely, and allowing newborns to room-in and breastfeed is safe, with appropriate precautions." But Medvedev cautioned more studies are needed to quantify the incidence of complications among pregnant women and newborns.
Jul 23 Lancet Child Adolesc Health study
Jul 22 AAP guidance
Jul 23 Lancet Child Adolesc Health commentary

Study finds higher COVID-19 diagnoses, deaths in counties with more Latinos

COVID-19 diagnosis rates are greater in disproportionally Latino counties, but risks and deaths among Latino populations differ by region, US researchers reported yesterday in the Annals of Epidemiology.

For the study, researchers compared predictors of COVID-19 cases and deaths between counties where Latinos made up more than 17.8% of the population and all other US counties through May 11. They also looked at the heterogeneity of the US Latino population and explored whether differences in a set of core demographic variables play a role in COVID-19 diagnoses and deaths.

Their analysis showed that COVID-19 diagnosis rates were greater in disproportionately Latino counties nationally (90.9 vs 82.0 per 100,000 population), and that COVID-19 diagnoses and deaths increased with the proportion of Latinos living within a given county, particularly in the Midwest and Northeast. In a multivariable analysis that adjusted for other predictors of COVID-19, the adjusted rate ratio [aRR] for Latino counties in the Northeast was 1.42 (95% confidence interval [CI], 1.11 to 1.84) and 1.70 (95% CI, 1.57 to 1.85) for Latino counties in the Midwest. COVID-19 deaths were higher in Midwestern Latino communities (aRR, 1.17; 95% CI, 1.04 to 1.34).

The analysis also found that higher rates of COVID-19 cases were associated with a greater proportion of monolingual Spanish speakers (aRR, 1.28; 95% CI, 1.16 to 1.42), higher heart disease death rates (aRR, 1.o7; 95% CI, 1.o1 to 1.14), less physical distancing (aRR, 0.72; 95% CI, 0.64 to 0.81), and more days since the first case was diagnosed (aRR, 1.90; 95% CI, 1.80 to 2.01). COVID-19 deaths were associated with crowded living conditions (aRR, 1.13; 95% CI, 1.04 to 1.22) and elevated air pollution (aRR, 1.23; 95% CI, 1.03 to 1.47).

The authors suggested the higher death rate in Latino Midwest counties could be linked to Midwestern meat and poultry processing facilities, which employ many Latino migrants. They say the findings call for "focused and energetic" policy responses.

"Our analyses provide a timely proxy for assessing the impact of COVID-19 on Latino communities and affirm the importance of Latino tailored prevention, care, and focused efforts to meet the needs of Latino individuals and communities," they wrote.
Jul 23 Ann Intern Med study

Pilot study evaluates use of dogs for SARS-CoV-2 detection

A small pilot study suggests trained scent-detection dogs have the potential to be used for mass detection of people infected with SARS-CoV-2, the virus that causes COVID-19, German researchers reported yesterday in BMC Infectious Diseases.

In the study, eight dogs were trained for 1 week to detect SARS-CoV-2 from saliva or tracheobronchial secretions of patients infected with the virus. During the training, dogs were presented with positive and negative samples (confirmed by RT-PCR tests) using a device with seven scent holes with tubes leading to metal containers that held the samples. Only one hole had a container with a positive sample, and the other six had containers with control samples. After a week, the researchers conducted a double-blind, randomized controlled trial.

During the presentation of 1,012 randomized samples, the dogs achieved an overall detection rate of 94% (plus or minus 3.4%), with 157 correct indications of a positive sample, 792 correct rejections of a negative sample, and 33 false-positive and 30 false-negative indications. The dogs discriminated between infected and non-infected people with an overall diagnostic sensitivity of 82.63% (95% CI, 82.02% to 83.24%) and specificity of 96.35% (95% CI, 96.31% to 96.39%). There was no noticeable difference in detection ability between saliva and tracheobronchial secretions.

The authors of the study note several limitations, including the fact that the positive samples were from patients with severe COVID-19. They say future research should focus on samples from mild, pre-symptomatic, and asymptomatic patients. In addition, the samples were inactivated, and because it's still unclear whether dogs can spread the virus to humans, using them for testing in the field could be problematic. The authors say they are developing strategies for secure presentation of non-inactivated samples.

"Further work is necessary to better understand the potential and limitation of using scent dogs for the detection of viral respiratory diseases," they wrote.
Jul 23 BMC Infect Dis study

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

New biobank to study bacteria resistant to last-resort antibiotics

Scientists in Luxembourg this week announced the creation of a new biobank that will collect and analyze strains of bacteria from Europe that are resistant to last-resort antibiotics.

Mirabank, a joint project of the Integrated Biobank of Luxembourg (IBBL) and the Laboratoire National de Santé (LNS) launched on behalf of the European Centre for Disease Prevention and Control, will receive roughly 4,000 strains of carbapenem- and colistin-resistant bacteria from 37 European countries in the coming months, starting with strains from Luxembourg's four hospitals. The strains will be stored at IBBL, and LNS will then conduct genomic analysis for a better understanding of the genetic and epidemiologic mechanisms of the strains.

"This project is of great importance in the fight against resistance to antibiotics of last resort, as carbapenem resistance is a problem that has particularly increased in Europe in recent years and needs to be studied for the health of patients in Europe," Kristin Kornerup, PhD, of IBBL said in a press release. "We are very pleased to provide our expertise for this project, and to do so with the LNS." 
Jul 22 LNS press release

UK study identifies sepsis risks, antibiotic benefits, in primary care

Research by a team of UK scientists indicates that the risks of sepsis and the benefits of antibiotics following common infections in primary care are greater among older adults, in severely frail patients, or following urinary tract infections (UTIs), according to a study yesterday in PLOS Medicine.

The cohort study analyzed electronic health records of all registered patients at 706 general practices identified in a large UK clinical database from 2002 to 2017. The researchers identified 35,244 first episodes of sepsis following consultations for respiratory tract infection (RTI), skin infections, or UTIs.

Using a Bayesian decision tree to estimate the probability of sepsis following an infection consultation, they found a lower probability if an antibiotic was prescribed, but that the number of antibiotic prescriptions required to prevent one episode of sepsis (number needed to treat, NNT) decreased with age. At 0 to 4 years old, the NNT was 29,773 (95% uncertainty interval [UI], 18,458 to 71,091) in boys and 27,014 (95% UI, 16,739 to 65,709) in girls; over 85 years old, NNT was 262 (95% UI, 236 to 293) in men and 385 (95% UI, 352 to 421) in women.

The analysis also revealed that frailty was associated with a greater risk of sepsis and lower NNT. For severely frail patients aged 55 to 64 years, the NNT was 247 (95% UI, 156 to 459) in men and 343 (95% UI, 234 to 556) in women. At all ages, the probability of sepsis was greatest, and the NNT lowest, for UTI, followed by skin infection and RTI.

The authors of the study say the findings could be used by antimicrobial stewardship programs to identify groups of consultations in which the reduction of antibiotic prescribing can be pursued more safely.

"The potential risk of antimicrobial resistance has a significance that extends beyond the context of an individual consultation," they wrote. "Prescribing decisions must therefore be informed by the balance of all of the benefits and harms of either prescribing or not prescribing antibiotics. Quantification of the possible risks of sepsis contributes to informing these decisions."
Jul 23 PLOS Med study

Survey shows increase in stewardship programs in English primary care

Originally published by CIDRAP News Jul 23

A 2019 survey of clinical commissioning groups in England showed an increase in antimicrobial stewardship (AMS) programs compared with the previous survey, according to a report yesterday from UK nonprofit The Patients Association.

The group sent freedom-of-information requests with a range of questions about AMS programs to all clinical commissioning groups, which are groups of primary care practices in an area that come together to commission the best services for their population, in England. A previous survey had been conducted in 2016, and progress was judged by comparing the results. Out of 191 clinical commissioning groups that received the survey, a total of 107 responded.

About 79% reported having an AMS program for more than a year, an increase of 19% from the 2016 survey, and only 17% said they did not have a named individual responsible for implementation of their program, down from 33% in 2016. In addition, 64% of respondents said they were currently achieving their antibiotics reduction target, and the number of respondents who reported implementing the full TARGET (Treating Antibiotics Responsibly, Guidance, Education, Tools) toolkit more than doubled compared with 2016.

But only 5% said they had a protected budget for AMS programs, only 15% reported using point-of-care diagnostic tests to determine whether antibiotics were necessary, and 73% said that they could do more to achieve the aims of their AMS programs.

"While good progress has been made, more needs to be done," the report said.

Recommendations include improved metrics and targets, more research into geographic disparities in antibiotic prescribing rates, establishment of dedicated funding, and a better understanding of barriers to point-of-care testing.
Jul 22 Patients Association report

Australian study shows low rate of appropriateness for pre-surgery antibiotics

Originally published by CIDRAP News Jul 20

Analysis of data from a survey of surgical antimicrobial prophylaxis (SAP) conducted in Australian hospitals found a low rate of appropriateness and identified several factors that influence appropriateness, Australian researchers reported in JAC-Antimicrobial Resistance.

The researchers analyzed all procedures audited from April 2016 through April 2019 in the Surgical National Antimicrobial Prescribing Survey (NAPS), which collects data on all antimicrobial prescriptions for surgical procedures, along with clinical information, procedure-related factors, and patient and hospital demographics. The aim of the study was to describe the patient, hospital, and surgical factors associated with appropriateness of antimicrobial choice for procedural SAP, with a focus on the top five antimicrobials and antimicrobial classes prescribed. SAP is the most common indication for antimicrobial use in Australian hospitals.

A total of 12,419 procedures with 14,150 prescribed initial procedural SAP doses were included for analysis. Appropriateness varied across the choice of antimicrobial agent but was low overall (57.7%).

The most common reason for inappropriate antimicrobial choice was that the spectrum of the selected antimicrobial was too broad (55.7%), which is associated with patient harms and is a potential driver of antimicrobial resistance. Allergy status, surgical procedure group, and the presence of prosthetic material were positively associated with cefazolin and aminoglycoside appropriateness (P < 0.05). There were no significant positive associations with glycopeptides and third- and fourth-generation cephalosporins.

"Identification of these prescribing trends supports an ongoing examination of SAP prescribing practices in Australia and identification of potential targets for interventions across multiple health sectors such as AMS, guideline development, and hospital policy," the authors wrote.
Jul 18 JAC-Antimicrob Resist study

Focus groups reveal primary care docs less concerned about antibiotic resistance

Originally published by CIDRAP News Jul 20

In a series of focus groups conducted with primary care providers in four US cities, most participants consistently identified antibiotic resistance as a lower priority compared with other health concerns, and suggested that urgent care, retail clinics, and patient demand were the key drivers of inappropriate prescribing, researchers reported last week in BMJ Open.

The eight focus groups, which were conducted by the Pew Charitable Trusts and the American Medical Association in Chicago, Los Angeles, Philadelphia, and Birmingham, included family medicine and internal medicine physicians and pediatricians. In each focus group, an independent moderator asked the participants to rank a number of public health issues in terms of importance, then asked questions aimed at understanding physicians' attitudes and perceptions around antibiotic use and stewardship. A total 52 primary care providers participated in the recorded discussions.

Two of the main themes that emerged from the conversations were that antibiotic resistance is seen as less of a problem than issues such as obesity, diabetes, and opioid use, and that it does not affect the participants' patients or their daily practice.

Many felt resistance was a more pressing issue for sicker, hospitalized patients. When it came to inappropriate prescribing, participants suggested that urgent care and retail medicine clinics were to blame for prescribing antibiotics too frequently, and often returned to the theme of patient demand and fear of receiving poor patient satisfaction scores.

"We're under pressure all day," one pediatrician in Birmingham said. "You don't want to get written up, potentially, for being insensitive, or not taking care of them, or physician ratings."

Participants reacted positively to stewardship efforts aimed at patient and clinician education but were more skeptical of activities focused on measuring inappropriate prescribing and expressed distrust of tracking and reporting systems.

The authors of the study say it will be important to address these perceptions when designing stewardship interventions for outpatient settings.
Jul 14 BMJ Open study