Stewardship / Resistance Scan for May 31, 2022

News brief

World Health Assembly underscores infection prevention and control

The World Health Assembly (WHA) last week passed a resolution that aims to make infection prevention and control (IPC) a critical element of addressing healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) and of preparing for infectious disease health emergencies.

The resolution, which provides 13 recommendations to member states, comes on the heels of a World Health Organization (WHO) report that highlighted the global threat of HAIs and the role that IPC can play in reducing that threat. The report found that 7 of every 100 patients at acute care hospitals in high-income countries, and 15 of 100 in low- and middle-income countries, will acquire at least one HAI during their stay. Mortality was at least two to three times higher among patients with HAIs caused by resistant pathogens.

The recommendations for member states include taking steps to ensure that IPC is a key component of global health preparedness, prevention, and response; acknowledging that clean, high-quality, safe, and affordable medical care should be universally available; taking steps to ensure that science-based IPC programs are implemented, monitored, and updated; ensuring that water, sanitation, and hygiene infrastructures are in place in healthcare facilities; ensuring that IPC programs are integrated and aligned with AMR programs; and encouraging continued investment in IPC research.

The resolution also calls on the WHO director-general to develop a draft global strategy for IPC and to translate the strategy into an action plan.
May 25 WHA draft resolution on IPC

7 of 10 clinicians would prescribe antibiotics for asymptomatic bacteriuria

A survey of US primary care physicians found that more than 70% would prescribe inappropriate antibiotic treatment for asymptomatic bacteriuria, researchers reported late last week in JAMA Network Open.

The survey, conducted from June 2018 through November 2019, presented four clinical scenarios to primary care clinicians from 30 clinics in Texas, the Mid-Atlantic, and the Pacific Northwest. One of the scenarios was the hypothetical case of a 65-year-old man with asymptomatic bacteriuria. The respondents were asked to indicate whether they would prescribe antibiotics and to estimate the probability that the patient in the scenario had a urinary tract infection (UTI). Study authors also analyzed factors associated with reported increased willingness to prescribe an antibiotic for asymptomatic bacteriuria.

The 551 respondents who answered all the questions included 288 resident physicians, 202 attending physicians, and 61 advanced-practice clinicians. Overall, 392 of 551 (71%) indicated they would prescribe an antibiotic for the patient described in the scenario. On average, respondents who said they would prescribe antibiotics estimated a 90% probability of a UTI.

In multivariable analyses, clinicians with a background in family medicine (odds ratio [OR], 2.93; 95% confidence interval [CI], 1.53 to 5.62) or a high score on the Medical Maximizer-Minimizer Scale (indicating stronger medical maximizing orientation; OR, 2.06; 95% CI, 1.38 to 3.09) were more likely to prescribe antibiotic treatment for asymptomatic bacteriuria. Resident physicians (OR, 0.57; 95% CI, 0.38 to 0.85) and clinicians in the Pacific Northwest (OR, 0.49; 95% CI, 0.33 to 0.72) were less likely to prescribe antibiotics for asymptomatic bacteriuria.

The study authors say the survey results likely reflect knowledge gaps, regional differences in healthcare culture that may influence prescribing of inappropriate antibiotics, and clinician attitudes.

"These findings suggest that the Choosing Wisely campaign recommending against antibiotic treatment for asymptomatic bacteriuria has failed to make an impact in the US and that certain types of clinicians are more likely than others to ignore the guidelines and prescribe antibiotics," they wrote, adding that future interventions to reduce unnecessary treatment for asymptomatic bacteriuria should take clinician culture, attitudes, and cognitive characteristics into consideration.
May 27 JAMA Netw Open study

News Scan for May 31, 2022

News brief

Study: Vaccine could have averted 75% of COVID deaths in some Chicago areas

About 75% of COVID-19 deaths in the least-vaccinated Chicago areas could have been prevented if their uptake would have equaled that of the highest-coverage areas during the Alpha and Delta variant surges, suggests a study late last week in JAMA Network Open.

University of Chicago researchers studied vaccine uptake and outcomes of 2,686,355 Chicago residents of 52 ZIP codes using data from the Chicago Department of Public Health and the Cook County Medical Examiner from Mar 1, 2020, to Nov 6, 2021.

Median age was 34 years, 51% were women, 29% were Hispanic, 29% were Black, and 33% were White. Of residents of areas with the lowest vaccination rates, 80% were Black, compared with 8% of those in the most-vaccinated quartile.

After the researchers controlled for age distribution and recovery from infection, they found that a 10-percentage-point increase in ZIP code–level vaccination 6 weeks before the Alpha peak was tied to a 39% lower relative risk of death (incidence rate ratio [IRR], 0.61; 95% confidence interval [CI], 0.52 to 0.72).

Similarly, a 10-percentage-point increase in vaccination 6 weeks before Delta peaked was linked to a 24% lower risk of COVID-19 death (IRR, 0.76; 95% CI, 0.66 to 0.87). A difference-in-difference analysis showed that 119 Alpha deaths (72%; 95% CI, 63% to 81%]) and 108 Delta deaths (75%; 95% CI, 66% to 84%]) could have been prevented in the least-vaccinated quartile if uptake has been that of the most-vaccinated quartile.

"Prior to the vaccination campaign, there existed consistent parallel trends in pandemic mortality between the different parts of the city," the study authors wrote. "During the Alpha wave, a large gap in COVID-19 death rate opened between the most and least vaccinated zip codes and continued to widen throughout the Delta wave."

The researchers said that the vaccine disparity "likely reflects structural inequity in access to testing and surveillance practices."
May 27 JAMA Netw Open study

Excess deaths varied greatly across Canada during COVID-19

An analysis of excess deaths in Canada in 2020 and 2021 published today in CMAJ showed great variation in COVID-19 deaths by province, leading authors to call for more consistent reporting.

Though the United States has reported a 22% increase in excess deaths due to the pandemic, a previous analysis of public data from Canada showed only a 5% increase during the pandemic. Using province-level data from March 2020 through October 2021, the authors measured excess deaths in the pre-Omicron period in each province.

Overall, Quebec had the highest COVID-19 mortality rate. British Columbia, Alberta, and Saskatchewan had double or more overall excess mortality than the other provinces, excluding Quebec, but the authors note that a summer 2021 heat wave contributed to the rise in excess deaths in British Colombia. Excess deaths were lowest in Prince Edward Island and Nova Scotia.

The authors said the wide differences in provinces require a more comprehensive method of counting COVID-19 deaths in the future.

"Some people with COVID-19 were never tested, particularly at the beginning of the pandemic when criteria for testing were limited," the authors wrote. "Furthermore, in subsequent waves, some jurisdictions may have had limited testing capacity. Deaths from COVID-19 that occurred in the community rather than in hospital may not have been reported as COVID-19 deaths."

The pandemic also reduced some common causes of excess deaths, including motor vehicle accidents and influenza-related deaths. Conversely, the pandemic increased opioid use in Canada, leading to more drug overdoses.

"Having confidence in the accuracy of data on COVID-19 deaths is key to understanding different provincial experiences of the pandemic and to distinguish whether provinces had a 'COVID-19 problem,' a broader mortality problem, or both," said study author Kim McGrail, PhD of the University of British Columbia in a CMAJ press release.
May 30 CMAJ study
May 30 CMAJ press release

Strawberries suspected in multistate hepatitis A outbreak

The US Food and Drug Administration (FDA) announced over the weekend that health officials in the United States and Canada are investigating a hepatitis A outbreak that appears to be linked to fresh organic strawberries that carry FreshKampo and HEB branding.

In its announcement, the FDA said 17 illnesses have been reported in three states: California (15), Minnesota (1), and North Dakota (1). The Public Health Agency of Canada (PHAC) reported 10 lab-confirmed cases in two provinces: Alberta (4) and Saskatchewan (6).

The FDA said trace-back investigations found that strawberries from the two brands were bought between Mar 5 and Apr 25 before patients got sick. The brands were sold nationwide at several major grocery chains. The latest illness onset for US cases is Apr 30, and 12 patients were hospitalized. No deaths were reported.

Though the strawberries are past their shelf life, the FDA said people may have frozen them for later consumption. They urged people to throw the frozen strawberries away if they aren't sure if they were from the two brands. The FDA also urged consumers who bought and ate the berries in the past 2 weeks to talk to their doctors about postexposure prophylaxis if not vaccinated against hepatitis A.

Some hepatitis A infections, which cause liver disease, are caused by eating or drinking contaminated food or water, which can occur when an infected food handler prepares food without proper handwashing technique. Symptoms occur within 15 to 50 days of exposure. Infections range from mild to severe, and people with underlying health conditions or compromised immune systems are most at risk.
May 28 FDA outbreak announcement
May 27 PHAC notice