Stewardship / Resistance Scan for Jun 20, 2022

News brief

Cascade reporting linked to drop in fluoroquinolone prescribing

A study conducted in a network of urgent care and express care clinics in Iowa found that implementation of cascade reporting was associated with a significant decline in fluoroquinolone prescribing, researchers reported today in Antimicrobial Stewardship & Healthcare Epidemiology.

The analysis by researchers with UnityPoint Health and the University of Iowa-Des Moines looked at antibiotic prescriptions per 1,000 patient encounters (PE) at seven urgent care and two express care clinics in the period before (June 2018 through June 2019) and after (August 2019 through December 2020) implementation of cascade susceptibility reporting, which is a type of selective reporting in which antimicrobial susceptibility results of secondary antibiotics are reported only if an organism is resistant to primary antibiotics.

At the clinics, susceptibility results for Enterobacterales isolates in urine cultures were reported for fluoroquinolones only if the isolates were resistant to trimethoprim-sulfamethoxazole, nitrofurantoin, and cefazolin.

In the 12 months prior to the intervention, the median fluoroquinolone prescribing rate was 24.6 prescriptions per 1,000 PE, compared with a median of 8.23/1,000 PE in the post-intervention period. Estimates from an interrupted time series analysis showed a 38% reduction following implementation of the intervention, and no change in slope was detected. Of the three primary antibiotics, only nitrofurantoin saw an increase in median prescribing rates post-intervention.

The study authors say the findings are noteworthy because, while antibiotic prescribing varies widely in the urgent care setting, urgent care clinics have seldom been the target of antimicrobial stewardship interventions.

"In conclusion, cascade reporting of antimicrobial susceptibility of Enterobacterales in urine cultures is a feasible and sustainable antimicrobial stewardship that can be applied in urgent care and express care clinics in an integrated health system," they wrote.
Jun 20 Antimicrob Steward Healthc Epidemiol study


Study: Sporicidal disinfectant, thorough cleaning cuts hospital-onset C diff

A sporicidal cleaning intervention implemented at eight acute care hospitals resulted in more thorough cleaning of hospital rooms and was associated with a reduction in hospital-onset Clostridioides difficile (HO-CDI) infections, researcher reported today in Infection Control & Hospital Epidemiology.

In the quasi-experimental study, researchers compared the eight hospitals that implemented the hospital-wide sporicidal cleaning intervention with nine control hospitals from the same healthcare system that didn't implement the cleaning program. The intervention began with environmental services technicians and managers from the hospitals participating in education and training sessions, then adding daily hospital-wide, patient-zone, surface-disinfection cleaning with a sporicidal disinfectant cleaner to their traditional disinfection regimen for rooms occupied by CDI patients.

A structured performance monitoring and feedback program using the fluorescent marker system was added to measure thoroughness of disinfection cleaning (TDC)—a measurement of the percentage of patient zone surfaces that have been disinfected—and optimize cleaning practice. The researchers then compared pre- and post-intervention monthly HO-CDI rates at the intervention and control hospitals.

Following a 3-month wash-in period to evaluate the 18-month pre-intervention cleaning performance, the TDC improved steadily from 59% to 86% at all eight sites post-intervention, and by 18 months was 93.6% for the group. The mean standardized infection ratio (SIR) of HO-CDI decreased from 1.03 in the pre-intervention period to 0.6 (95% confidence interval [CI], 0.13 to 0.75) post-intervention. In the adjusted difference-in-differences analysis in comparison to control hospitals, there was a 0.55 reduction (95% CI, −0.77 to −0.32) in HO-CDI, or a 50% relative decrease from baseline.

"This study provides support for the clinical benefit of an integrated 4-component intervention, not bundled with other transmission mitigating activities, focusing solely on environmental hygiene practice that includes daily, hospital-wide sporicidal disinfectant cleaning with objectively optimized thoroughness of cleaning to reduce endemic HO-CDI," the study authors wrote.
Jun 20 Infect Control Hosp Epidemiol abstract 

News Scan for Jun 20, 2022

News brief

Kawasaki disease drop during pandemic leaves hints at possible triggers

Rates of Kawasaki disease, a rare acquired cardiac condition in kids, fell nationally during peak COVID-19 transmission when control measures were in place, potentially providing a clue that multiple triggers and upper airway inhalation might be involved.

Researchers based at the University of California San Diego (UCSD) published the findings of their disease tracking study late last week in JAMA Network Open.

When the pandemic began, the team was already tracking national Kawasaki disease cases from 2018 to 2020 using a multicenter cohort approach. They were also conducting a detailed analysis of patients who were diagnosed at Rady Children's Hospital in San Diego from Jan 1, 2002, to Nov 15, 2021.

The disease is puzzling, and triggers haven't yet been identified. Jane Burns, MD, senior study author who directs the Kawasakai Disease Research Center at UCSD, said the pandemic provided an incredible natural experiment that the group took advantage of.

When they compared rates before and during the pandemic, they found that cases dropped by 28% during the peak pandemic period, then rebounded in the spring of 2021 when mask mandates were lifted and in-person school resumed. The findings hint at a role for social contact in exposure and an inhaled respiratory trigger

First author Jennifer Burney, PhD, part of the study team who is with the environmental science department at UCSD, said though numbers dropped dramatically during the shelter-in-place period, they didn't disappear entirely, as did other respiratory diseases. Also, they found differences among age-groups, especially in kids ages 1 through 5 years, who experienced the steepest drops in cases.

Burns added that the disease may be caused by a virus, pollutant, microbial aerosol, or all of the above. Once verified, the findings could have a major impact on research and prevention of Kawasaki disease, a condition that affects as many as 6,000 children each year.
Jun 17 JAMA Netw Open abstract
Jun 17 UCSD press release


US fungal deaths rose in the first 2 years of the COVID-19 pandemic

US deaths from fungal infections rose in the first 2 years of the COVID-19 pandemic compared with previous years, with the increase driven mainly by COVID-19–associated fungal deaths, researchers reported yesterday in Clinical Infectious Diseases.

Using data from the US National Vital Statistics System covering 2018 through 2021, researchers with the Centers for Disease Control and Prevention and the National Center for Health Statistics identified and examined numbers and age-adjusted rates (per 100,000 population) of fungal deaths by pathogen, COVID-19 association, demographics, and year. A total of 22,700 fungal deaths occurred over the study period.

The number and age-adjusted rates of fungal deaths was similar in 2018 (4,746) and 2019 (4,833) (rate during both years, 1.2 per 100,000 population) but increased to 5,922 in 2020 (rate, 1.5) and to 7,199 in 2021 (1.8).

Of the 13,121 fungal deaths that occurred during 2020-21, 2,868 (21.9%) were COVID-19–associated, and, of those deaths, COVID-19 was the most frequent underlying cause in 2,596 (90.5%). Compared with non-COVID-19–associated fungal deaths, COVID-19–associated fungal deaths more frequently involved Candida (27.1% vs 23.7%) and Aspergillus (23.3% vs 14.5%) and less frequently involved other fungal pathogens.

For COVID-19–associated fungal deaths, age-adjusted death rates per 100,000 population were higher for people who were American Indian/Alaska Native (1.3), Hispanic (0.7), and Black (0.6) compared with White (0.2) and Asian (0.3) persons. Observed death rates from Aspergillus infections were approximately twice as high in the Pacific census division (0.4) compared with most other divisions.

"Our analysis demonstrates the substantial burden of fungal infections in the United States and highlights an increase in fungal deaths during the first two years of COVID-19 pandemic," the study authors wrote. "These data might help increase clinician awareness and support public health planning."

They concluded, "Detailed public health surveillance for fungal infections, involving geographically and demographically diverse patient populations, might help better characterize disease epidemiology and guide ongoing efforts to prevent fungal infections among disproportionately affected populations."
Jun 19 Clin Infect Dis abstract

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