Stewardship / Resistance Scan for Feb 25, 2021

News brief

Danish study finds link between community C diff, proton pump inhibitors

A nationwide study in Denmark found an association between the use of proton pump inhibitors (PPIs) and increased risk of community-associated Clostridioides difficile infections (CA-CDI), Danish researcher reported today in Clinical Infectious Diseases.

For the study, researchers from Denmark's Statens Serum Institute used the Danish National Microbiological Database to identify all incident episodes of CA-CDI in Danish adults from February 2010 through December 2013. They obtained data on filled prescriptions for PPIs, which neutralize or reduce the production of gastric acid, from the Danish National Prescription Registry.

The researchers conducted self-controlled case-series analyses to estimate incidence-rate ratios (IRRs) for CA-CDI, comparing periods with and without exposure to PPIs, and adjusted their models to account for confounders such as chronic disease, genetics, hospital stays, and antibiotic and corticosteroid use.

Of the 3,583 CA-CDI episodes identified, 964 occurred during current use of PPIs, 324 occurred 0 to 6 months after treatment cessation, 123 occurred 6 to 12 months after treatment cessation, and 2,172 occurred during periods with no use of PPIs. When the investigators compared the incidence of CA-CDI during current use of PPIs with periods of non-use, the unadjusted IRR was 2.78 (95% confidence interval [CI], 2.40 to 3.22). When adjusted for hospitalization, antibiotic use, and corticosteroid use, the IRR was 2.03 (95% CI, 1.74 to 2.36). The increased risk remained elevated for extended periods: 1.54 (95% CI, 1.31 to 1.80) for 0 to 6 months and 1.24 (95% CI, 1.00 to 1.53) for 6 to 12 months.

The study authors note that while previous observational studies have found varying levels of association between PPI use and CDI, the association has been questioned because of the absence of data from randomized controlled trials and insufficient adjustment for confounding factors.

"This large study with thorough control for confounding significantly adds to the body of evidence that increased risk of CDI, even in the community setting, should be considered when prescribing CDIs, although the underlying biological mechanisms need to be explored," they write.
Feb 25 Clin Infect Dis study


Report examines social science insights on antibiotic use

The London School of Hygiene and Tropical Medicine (LSHTM) yesterday released a new report on antibiotic use in low- and middle-income countries (LMICs) that focuses on social science research and the emerging insights on novel ways to address antimicrobial resistance (AMR).

The report from LHSTM's Fresh Approaches to the Study of Antimicrobials in Society project examines antibiotic use in LMICs through three different lenses: practices, structures, and networks. The idea behind the report, which combines insights gleaned from a growing body of published social science research into AMR and from a series of panel discussions held in 2020, is to formulate ideas of how these insights can be used to develop local interventions for addressing human and animal antibiotic use in a diverse range of settings.

Among the key themes identified in the report is that antibiotic use in many LMICs does not primarily result from a lack of knowledge about AMR but is related to a web of social, economic, political, and historic conditions, and that modifying how people in these countries use antibiotics requires addressing these issues. Another theme is that fractured healthcare systems and lack of access to clean water and sanitation infrastructure have become structural drivers of antibiotic use in many countries, and fixing these structures, rather than focusing on individual antibiotic use, could lead to longer-term solutions.

"In the last few years, there has been a growing acknowledgement of the vital role of social science in understanding and intervening on antibiotic use, a key driver of AMR," author Clare Chandler, PhD, MSc, director of the LSHTM Antimicrobial Resistance Centre, writes in the report. "The growing concern that our off-the-shelf toolkit for addressing antibiotic use is insufficient in the face of rising use across humans, animals and plants, requires that we take a fresh look at the ways we are understanding this problem and possibilities for solutions."
Feb 24 LSHTM report

Dental hygienist survey suggests 3% contracted COVID-19

A survey of US registered dental hygienists reported that 3.1% had been diagnosed as having COVID-19 as of October 2020, according to a Journal of Dental Hygiene study published yesterday. At the time, the study says an estimated 2.3% of the general US population had been infected.

The researchers asked for survey responses from the American Dental Hygienists' Association database between Sep 29 and Oct 8, 2020. Of the 4,776 who answered, 35.4% had been tested for COVID-19 at least once, and 23 had been diagnosed by a physician, resulting in a 3.1% rate of infection. Only 55 of those who had COVID reported that contact tracing was performed, of which 14 (25.5%) said that workplace transmission was the most likely cause.

Most dental practices disinfected between patients (97.9%), asked staff to use masks (97.8%), and screened patients prior to treatment (96.7%), and 96.8% of dental hygienists reported at least five infection-control measures at their primary practice.

However, 28.2% of respondents who provided oral healthcare that month said they didn't follow Centers for Disease Control and Prevention interim guidelines for use of personal protective equipment. Adherence was associated with years of dental hygienist experience, increasing from those with 10 or less years of experience (54.6% adherence), those who had 11 to 20 years (55.4%), and those who had 21 or more years (60.7%).

Personal concern about COVID-19 also affected adherence, but the state's rate of COVID-19 did not. The researchers also found that N95 respirator usage was positively associated with more supply, as was the willingness to change masks and respirators between each patient.

The survey also looked at mental health, finding comparable rates of anxiety and lower levels of depression when compared with the general US population. Dental hygienists reported more distress than dentists, however, and the researchers say further studies could look at how age, perceived control, and time of contact with patients may affect outcomes.
Feb 24 J Dent Hyg study


Low COVID-19 transmission occurred in Air Force trainees

A 7-week Air Force camp for more than 10,000 trainees had 143 cases (1.3%) after a 2-week quarantine, reports a JAMA Network Open study published today. The researchers write that cohorts, systematic testing, restricted access to public spaces, universal masking, physical distancing, and rapid isolation of COVID-19 cases helped contribute to this low prevalence.

Within 48 hours of arrival at Joint Base San Antonio-Lackland, trainees were tested for COVID-19, and all were quarantined for 2 weeks, after which they had another test. If a trainee developed any COVID-19 symptom during the camp, they received a diagnostic test at the clinician's discretion. Anyone with a positive test, regardless of symptoms, was quarantined for 10 days and had to be free of fever for 24 hours without the use of anti-fever medications before rejoining the camp.

Overall, the camp had 403 COVID-19 cases among 10,613 trainees (3.8%), and 64.5% were identified during the initial quarantine period. A little over half of all infections (50.6%) were symptomatic, and the researchers note that 85 asymptomatic cases  were identified at the 2-week quarantine's final testing (32.6% of all initial quarantine cases). Four cases were omitted from the study due to lack of data.

Almost half the cohort (49.0%) experienced at least one COVID-19 infection, but only 5.3% had a cluster, which was defined as 5 or more infected people. Cohorts consisted of 30 to 50 trainees, and the median number of cases per cluster was 12.

If 30% of the cohort had COVID-19, they all underwent diagnostic testing. The researchers found that those with a high number of symptoms and low cycle threshold (Ct)  values, two inversely related factors, were most likely to start a COVID-19 cluster. (Cts are the number of threshold cycles a polymerase chain reaction assay test needs to detect viral genetic material.)

Cohorts without clusters had a median case value of 1.

"Although intensive and likely expensive in both medical services and costs, the Joint Base San Antonio-Lackland COVID-19 control plan could be used as a model for other high-risk, largely confined populations," writes Gregory Gray, MD, MPH, of Duke Global Health Institute in North Carolina, in a related commentary.
Feb 25 JAMA Netw Open study
Feb 25 JAMA Netw Open commentary


More US Listeria cases associated with queso fresco

The Centers for Disease Control and Prevention (CDC) said yesterday that officials have confirmed three more cases of Listeria monocytogenes in an outbreak associated with queso fresco made by El Abuelito Cheese Inc, raising the total number of cases to 10.

Nine of the 10 people sickened have required hospitalization, but so far no deaths have been reported. Cases have occurred in four East Coast states: New York, Connecticut, Virginia, and Maryland. Case-patients range in age from under 1 to 75, and two pregnant women have been sickened. Symptoms began on dates ranging from Oct 20, 2020, to Feb 9, 2021.

On Feb 19, El Abuelito Cheese Inc., of Paterson, New Jersey, recalled all queso fresco—a Hispanic soft cheese—products made at the same facility with a sell-by date of Mar 28, the CDC said.

"Other El Abuelito brand cheeses made or handled in the same facility as the queso fresco have not yet been recalled, but CDC is concerned they may be contaminated and could make people sick," the CDC said. "Do not eat any recalled queso fresco cheeses (sold under brand names of El Abuelito, Rio Grande, or Rio Lindo) or any other El Abuelito brand cheeses."
Feb 24 CDC


More Ebola in Guinea, DRC as vaccination drives gain traction

Both Guinea and the Democratic Republic of the Congo (DRC) have reported one new Ebola case compared with earlier in the week, as vaccination efforts scale up in Guinea and neighboring countries in West Africa boost their preparedness efforts.

In a briefing today, officials from the World Health Organization (WHO) African regional office said Guinea has now had 9 cases, 5 of them fatal. The outbreak epicenter is in N'Zerekore prefecture, the same area where West Africa's massive 2014-16 outbreak began. The WHO said the location poses a threat to neighboring countries because of its proximity to porous borders with Liberia, Sierra Leone, and Ivory Coast. Twenty suspected cases have been reported in three countries, but all were negative.

Vaccination began in Guinea earlier this week, and so far, 225 have been immunized, including 66-high risk contacts.

In the DRC, 8 cases have been confirmed, 4 of them fatal. The WHO said persistent insecurity in the region is hampering outbreak response efforts. Earlier this week, armed insurgents attacked a convoy near Goma, killing Italy's ambassador, his bodyguard, and a World Food Program driver. So far, 650 have been vaccinated. About 8,000 doses are still in the DRC, and 4,320 more are expected to arrive next week.
Feb 25 WHO statement


H5N8 avian flu hits more poultry in Afghanistan, Europe

Afghanistan became the latest country to report highly pathogenic H5N8 avian flu in poultry this winter, as European countries reported more detections, according to the latest notifications from the World Organization for Animal Health (OIE).

Afghanistan's outbreak began at a broiler farm in Herat province in the west on Feb 7, killing 794 of 22,000 susceptible birds. The country's last H5N8 outbreak occurred in June 2019.

In Europe, Estonia reported an H5N8 outbreak at a poultry farm in Laane-Viru County in the north, which began on Feb 17, killing 7 of 78 birds. And Sweden reported another outbreak, which began on Feb 23 at a broiler farm in the city of Linkoping in the south. The virus killed 350 of 14,300 birds.
Feb 24 OIE report on H5N8 in Afghanistan
Feb 19 OIE report on H5N8 in Estonia
Feb 25 OIE report on H5N8 in Sweden

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