Stewardship / Resistance Scan for Aug 10, 2022

News brief

Hospital data from India show high rate of healthcare infections, antibiotic resistance

Data from a healthcare-associated infection (HAI) surveillance network in India shows high rates of bloodstream and urinary tract infections (UTIs) and very high levels of antibiotic resistance, researchers reported in The Lancet Global Health.

The data come from a network of 26 public and private tertiary-level hospitals in India created to implement HAI surveillance using standardized HAI surveillance methods that more accurately reflect resources available in Indian hospitals. Each hospital enrolled at least one intensive care unit (ICU) treating adult patients, one ICU treating adult surgical patients, and one pediatric ICU, and collected surveillance data on bloodstreams infections and UTIs, along with pathogen and antibiotic susceptibility test results. Neonatal ICUs reported only bloodstream infections.

From May 2017 through October 2018, the hospitals reported 2,622 bloodstream infections and 737 UTIs from 89 ICUs. Central line-associated bloodstream infection rates were highest in neonatal ICUs (more than 20 per 1,000 central line days), and catheter-associated UTI rates were highest in pediatric medical ICUs (4.5 per 1,000 urinary catheter days). Hospitals identified 2,828 pathogens in the 2,622 bloodstream infections reported and 809 in the 737 UTIs reported. Klebsiella spp (24.8%) were the most frequent pathogens reported in bloodstream infections, followed by Acinetobacter spp (21.3%), and Candida spp (29.4%) were the most frequently reported pathogens in UTIs.

Carbapenem resistance was common in Gram-negative infections, occurring in 72.4% of bloodstream infections and 76.3% of UTIs caused by Klebsiella spp, 77.2% of bloodstream infections and 75.7% of UTIs caused by Acinetobacter spp, 63.7% of bloodstream infections and 71.9% of UTIs caused by Pseudomonas spp, and 58% of bloodstream infections and 62% of UTIs caused by Escherichia coli.

"Healthcare-associated bloodstream infections and UTIs, particularly antibiotic-resistant infections, are major problems across network hospitals, and focused efforts targeting prevention of priority HAIs are underway," the study authors wrote. "Data produced by this network can be used as a foundation for developing a better understanding of the burden of HAIs across India."
Sep 2022 Lancet Glob Health study


Report describes pan-resistant, environmentally-acquired fungal infection

A case report published today in Emerging Infectious Diseases describes a fatal, pan-resistant fungal infection in an immunocompromised patient in the United States.

The infection was caused by Aspergillus fumigatus, the most common cause of invasive aspergillosis, a life-threating fungal infection that occurs when A fumigatus spores in the environment are inhaled. The patient was a 65-year-old man undergoing treatment for acute myeloid leukemia who was hospitalized for progressive graft-versus-host disease following an allogeneic stem cell transplant.

After 23 days of hospitalization and onset of hypoxemic respiratory failure, the patient was diagnosed with multifocal pneumonia, and bronchial cultures were positive for A fumigatus. The patient died on hospital day 28 from sepsis. Subsequent antifungal susceptibility testing and DNA sequence analysis showed resistance to the triazole antifungals itraconazole and voriconazole, with an environmentally-acquired gene mutation that can cause pan-triazole resistance.

The authors of the report say that while triazole resistance can occur through exposure to long-term triazole therapy, it's also been linked to agricultural use of triazole fungicides, which are chemically similar to triazole antifungals. They note that reports of environmentally acquired triazole-resistant A fumigatus infections are increasing, and say systematic clinical and environmental surveillance for triazole resistance is needed in the United States to determine the spread of the fungus and guide clinical treatment. Use of triazole fungicides by US farmers increased fourfold from 2006 to 2016.

"This report underscores the potential severity of triazole-resistant A. fumigatus infections in immunocompromised persons," they wrote. "Furthermore, clinicians should consider the possible presence of drug-resistant A. fumigatus in patients with invasive aspergillosis who do not improve with first-line therapy."
Aug 10 Emerg Infect Dis research letter

News Scan for Aug 10, 2022

News brief

WHO calls for trials of fractional dosing of monkeypox vaccine

One day after the United States said it would allow intradermal, fractional dosing of Bavarian Nordic's monkeypox vaccine, Jynneos, the World Health Organization (WHO) called for more trials on the practice.

The European Medicines Agency (EMA) told Reuters it will discuss the intradermal approach. For now, some European countries, including the United Kingdom, are extending the interval between the two doses of vaccine to allow more people to get their initial shot.

The WHO said trials will give countries critical information about how intradermal administration and fractional dosing could work for this outbreak.

Yesterday, the Centers for Disease Control and Prevention reported 558 more monkeypox cases, raising the total to 9,492.

Globally, the outbreak stands at almost 32,000 cases.

Finally today, Gilead, a major maker of HIV drugs, is partnering with LGBTQ+ organizations to contribute up to $5 million in grants to help with monkeypox education efforts. In part, the money will go towards education programs, with the goal of correcting misinformation.

"As we saw with HIV, COVID-19, and now MPV [monkeypox virus], disinformation continues to challenge the LGBTQ+ community," said Sarah Kate Ellis, president and CEO of GLAAD, in a press release. "This new collaboration will enable creating and distributing content and resources to help our community know the facts and to understand prevention and treatment for MPV."
Aug 10 Reuters story
Aug 10 CDC update
Aug 10 Global Health document
Aug 9 Gilead press release


UK to offer polio vaccine for London children amid more wastewater detections

Following a recommendation from its vaccine advisory group, the United Kingdom Health Security Agency (HSA) today announced that all children ages 1 to 9 in London boroughs will be offered a booster dose of inactivated polio vaccine (IPV). The step is part of the response to the detection of type 2 vaccine-derived poliovirus in sewage.

After the initial detection, wastewater sampling has now detected the virus in seven more boroughs. So far, 116 isolates have been identified in 19 sewage samples collected between Feb 5 and Jul 5, but only a few have enough mutations to be classified as vaccine-derived poliovirus type 2, which is known to result in rare cases of paralysis in unvaccinated people. High genetic diversity among the samples suggests that transmission extends beyond a close network of a few people.

The HSA said it is working with health officials in New York and Israel to investigate links between the viruses detected in London and those in the other two countries. It also it is extending sewage sampling to more sites and London and outside of London to assess whether the virus is spreading beyond the metro area.

Vanessa Saliba, MD, an epidemiologist with the HSA, said no cases have been reported, and for fully vaccinated people, the risk is low. She noted that the transmission area has some of the lowest vaccination rates and that the booster dose will provide extra protection and help people catch up with routine vaccination.
Aug 10 UK HSA press release


Vaccine hesitancy may not be root of US COVID vaccine uptake disparities

Vaccine hesitancy may only partly explain disparities in COVID-19 vaccine uptake in the United States, according to a study published early this week in Vaccine.

A team led by University of Maryland researchers modeled 1-year county-level COVID-19 vaccine hesitancy and uptake data from the Household Pulse Survey and the Centers for Disease Control and Prevention's (CDC's) COVID Data Tracker.

The relationship between vaccine hesitancy and COVID-19 vaccine uptake was not significant initially, but became significantly negative and fell rapidly from March to June 2021 before plateauing. By Jan 31, 2022, a 1% rise in vaccine hesitancy was tied to a 1.94% decline in fully vaccinated adults.

Counties with higher socioeconomic status, more Asian and Hispanic residents, more older residents, broader health insurance coverage, and a higher proportion of Democrats than Republicans had lower vaccine hesitancy and higher COVID-19 vaccine uptake. Some counties, however, showed high vaccine willingness but lower vaccination rates, and vice versa.

Vaccine hesitancy was not the strongest tie to vaccine coverage. For example, political party affiliation had the strongest link to vaccination rate, but was not even in the top 10 in its correlation with vaccine hesitancy. And median household income had the greatest tie to vaccine hesitancy, but ranked seventh in its link to vaccination rate.

The researchers said that their findings challenge the widespread belief that vaccine hesitancy is the only reason for disparities in vaccine coverage.

"Mediation analysis further demonstrated that indirect effects from exogenous variables to vaccination coverage via vaccine hesitancy only partially explained corresponding total effects, challenging the popular narrative that portrays vaccine hesitancy as a root cause of disparities in vaccination," the researchers wrote. "Our study highlights the need of well-funded, targeted, and ongoing initiatives to reduce persisting vaccination inequities."
Aug 8 Vaccine study


Flu levels decline in Southern Hemisphere, other regions

Flu activity in the Southern Hemisphere's temperate countries seems to be decreasing, part of a global decline in cases, the World Health Organization (WHO) said in its latest update, which roughly covers the middle two weeks in July.

Australia has experienced an earlier-than-usual flu season, at high levels that exceeded some prepandemic seasons. Flu detections are now declining across the country, with a similar downward trend reported from New Zealand. Some Pacific island countries are still reporting elevated levels.

Southeast Asia's flu levels are decreasing, with activity appearing to have peaked in southern China.

Globally, among respiratory samples that tested positive in the middle of July, 97.7% were influenza A, and 97.3% of subtyped influenza A samples were H3N2. The WHO urged caution in interpreting flu trends, due to COVID-19 response measures and changes in surveillance practices. It urged countries to watch for cocirculation of COVID-19 and flu and to step up their flu vaccination campaigns.
Aug 8 WHO global flu update


CDC finds treatment gap in hepatitis C patients

Too few people who are diagnosed with hepatitis C infections receive treatment known to cure the disease, the Centers for Disease Control and Prevention (CDC) said yesterday in a Vital Signs report.

Less than one in three people with health insurance got direct-acting antiviral (DAA) treatment within a year of their hepatitis C diagnosis. Fewer than one in four people in state-administered Medicare plans got treatment, and people in states that restrict treatment access for Medicaid recipients were 23% less likely to be treated.

The CDC said its new data show that adults younger than 40 had the lowest treatment rates, which is the same group known to have the highest rates of new infections. Of that group, hepatitis C is most commonly spread though injectable drug use.

The CDC said it's critical to stop preventable deaths and prevent new infections, especially since the oral treatment is well tolerated. The virus can cause liver disease, cancer, and death. In 2019, the virus was linked to 14,000 deaths in the United States.

Officials from the CDC urged states to remove barriers to screening and treatment.
Aug 9 CDC statement

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