Stewardship / Resistance Scan for Nov 04, 2022

News brief

Procalcitonin trends linked to antibiotic use, duration in COVID-19 patients

A study of hospitalized COVID-19 patients in Michigan found that procalcitonin (PCT) trends were associated with the decision to initiate antibiotics and duration of treatment, independent of bacterial pneumonia (bPNA) status, researchers reported today in Infection Control & Hospital Epidemiology.

The observational study, conducted by researchers with the University of Michigan Medical School, analyzed data on SARS-CoV-2–positive patients hospitalized at Michigan Medicine from March 2020 through October 2021 who had one or more PCT measurement. While PCT levels can be a useful marker for bacterial infections like pneumonia, COVID-19 can raise PCT levels in the absence of bacterial infections, which has raised questions about whether PCT measurements can aid antibiotic stewardship efforts in COVID-19 patients. The primary outcome of the study was the associations of PCT level and bPNA with antibiotic use.

Of 793 patients included in the analysis, 224 (28.2%) were initiated on antibiotics: 33 (14.7%) had proven or probable bPNA, 125 (55.8%) had possible bPNA, and 66 (29.5%) had no bPNA. Patients had a mean of 4.1 (standard deviation [SD], ±5.2) PCT measurements if receiving antibiotics versus a mean of 2.0 (SD, ±2.6) if not.

The odds of receiving antibiotics increased by a factor of 1.27 for every 50% increase in initial PCT level. Initial PCT level was highest for those with proven/probable bPNA and was associated with antibiotic initiation (odds ratio, 1.23; 95% confidence interval [CI], 1.17 to 1.30). Initial PCT (rate ratio [RR], 1.04; 95% CI, 1.01 to 1.08), change in PCT over time (RR, 1.03; 95% CI, 1.01 to 1.05), and bPNA group (RR, 1.51; 95% CI, 1.23 to 1.84) were associated with antibiotic duration.

"Although we identified an association between serum PCT trends and antibiotic initiation and duration, we were unable to determine whether PCT causally drove treatment decisions," the study authors wrote. "Future prospective studies are needed to determine whether PCT data can be used to safely make decisions around antibiotic treatment for bacterial infection in COVID-19 patients, including when to start or stop antimicrobial therapy in patients with an elevated PCT level but no other signs or symptoms of bacterial coinfection."
Nov 4 Infect Control Hosp Epidemiol study

 

Survey evaluates antibiotic attitudes, practices in Egypt

A survey of Egyptian physicians found high levels of knowledge about antibiotic use and resistance, and a good attitude toward appropriate antibiotic use, but assessment of clinical vignettes suggests that it may not translate into more appropriate prescribing, researchers reported yesterday in PLOS One.

The survey was given to 153 physicians dealing with acute upper respiratory tract infections (URTIs) in different healthcare settings in Egypt's Assiut district from September 2021 through February 2022. The four-part survey asked respondents about sociodemographic and professional characteristics, education, factors influencing antibiotic prescribing, knowledge of antibiotic use and resistance, and attitudes toward appropriate prescribing. In the fourth part, respondents were asked to evaluate four different clinical vignettes, provide a diagnosis, and determine whether an antibiotic would be needed.

The mean age of respondents was 32.2 years, 57.5% were women, and 64.1% were pediatric residents. Nearly 89% reported that they rely on their clinical assessment for prescribing antibiotics in cases of URTIs, followed by reported symptoms by patients or their parents (60%).

Out of the 17 knowledge questions, the mean number of correct answers was 12.4. Mean attitude scores for inappropriate prescribing were low, which was consistent with respondents' reports about the factors affecting their prescribing and cases of acute URTI's in which the patients' expectations were listed as the most negligible factor.

But of the 612 clinical vignettes evaluated, which involved two scenarios with viral URTIs and two with bacterial URTIs, antibiotics were prescribed in 326 (53.3%), and those prescriptions were appropriate in only 8.3% of cases. The percentage of inappropriate prescriptions was high because of the wrong choice of antibiotic, the wrong duration of antibiotic, and the use of injectable or combined antibiotics.

"More research is required to determine the causes of improper antibiotic prescribing and non-compliance with guidelines," the study authors wrote. "Also, it is crucial to set up a national antibiotic stewardship program to improve antibiotic prescribing and contain antimicrobial resistance problems."

The authors note that the study aims to help Egypt achieve the first and second goals of its National Action Plan for antimicrobial resistance (AMR), which focus on improving awareness of AMR and promoting rational antibiotic use.
Nov 3 PLOS One study

ASP Scan (Weekly) for Nov 04, 2022

News brief

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

Procalcitonin trends linked to antibiotic use, duration in COVID-19 patients

A study of hospitalized COVID-19 patients in Michigan found that procalcitonin (PCT) trends were associated with the decision to initiate antibiotics and duration of treatment, independent of bacterial pneumonia (bPNA) status, researchers reported today in Infection Control & Hospital Epidemiology.

The observational study, conducted by researchers with the University of Michigan Medical School, analyzed data on SARS-CoV-2–positive patients hospitalized at Michigan Medicine from March 2020 through October 2021 who had one or more PCT measurement. While PCT levels can be a useful marker for bacterial infections like pneumonia, COVID-19 can raise PCT levels in the absence of bacterial infections, which has raised questions about whether PCT measurements can aid antibiotic stewardship efforts in COVID-19 patients. The primary outcome of the study was the associations of PCT level and bPNA with antibiotic use.

Of 793 patients included in the analysis, 224 (28.2%) were initiated on antibiotics: 33 (14.7%) had proven or probable bPNA, 125 (55.8%) had possible bPNA, and 66 (29.5%) had no bPNA. Patients had a mean of 4.1 (standard deviation [SD], ±5.2) PCT measurements if receiving antibiotics versus a mean of 2.0 (SD, ±2.6) if not.

The odds of receiving antibiotics increased by a factor of 1.27 for every 50% increase in initial PCT level. Initial PCT level was highest for those with proven/probable bPNA and was associated with antibiotic initiation (odds ratio, 1.23; 95% confidence interval [CI], 1.17 to 1.30). Initial PCT (rate ratio [RR], 1.04; 95% CI, 1.01 to 1.08), change in PCT over time (RR, 1.03; 95% CI, 1.01 to 1.05), and bPNA group (RR, 1.51; 95% CI, 1.23 to 1.84) were associated with antibiotic duration.

"Although we identified an association between serum PCT trends and antibiotic initiation and duration, we were unable to determine whether PCT causally drove treatment decisions," the study authors wrote. "Future prospective studies are needed to determine whether PCT data can be used to safely make decisions around antibiotic treatment for bacterial infection in COVID-19 patients, including when to start or stop antimicrobial therapy in patients with an elevated PCT level but no other signs or symptoms of bacterial coinfection."
Nov 4 Infect Control Hosp Epidemiol study

 

Survey evaluates antibiotic attitudes, practices in Egypt

A survey of Egyptian physicians found high levels of knowledge about antibiotic use and resistance, and a good attitude toward appropriate antibiotic use, but assessment of clinical vignettes suggests that it may not translate into more appropriate prescribing, researchers reported yesterday in PLOS One.

The survey was given to 153 physicians dealing with acute upper respiratory tract infections (URTIs) in different healthcare settings in Egypt's Assiut district from September 2021 through February 2022. The four-part survey asked respondents about sociodemographic and professional characteristics, education, factors influencing antibiotic prescribing, knowledge of antibiotic use and resistance, and attitudes toward appropriate prescribing. In the fourth part, respondents were asked to evaluate four different clinical vignettes, provide a diagnosis, and determine whether an antibiotic would be needed.

The mean age of respondents was 32.2 years, 57.5% were women, and 64.1% were pediatric residents. Nearly 89% reported that they rely on their clinical assessment for prescribing antibiotics in cases of URTIs, followed by reported symptoms by patients or their parents (60%).

Out of the 17 knowledge questions, the mean number of correct answers was 12.4. Mean attitude scores for inappropriate prescribing were low, which was consistent with respondents' reports about the factors affecting their prescribing and cases of acute URTI's in which the patients' expectations were listed as the most negligible factor.

But of the 612 clinical vignettes evaluated, which involved two scenarios with viral URTIs and two with bacterial URTIs, antibiotics were prescribed in 326 (53.3%), and those prescriptions were appropriate in only 8.3% of cases. The percentage of inappropriate prescriptions was high because of the wrong choice of antibiotic, the wrong duration of antibiotic, and the use of injectable or combined antibiotics.

"More research is required to determine the causes of improper antibiotic prescribing and non-compliance with guidelines," the study authors wrote. "Also, it is crucial to set up a national antibiotic stewardship program to improve antibiotic prescribing and contain antimicrobial resistance problems."

The authors note that the study aims to help Egypt achieve the first and second goals of its National Action Plan for antimicrobial resistance (AMR), which focus on improving awareness of AMR and promoting rational antibiotic use.
Nov 3 PLOS One study

 

Study finds suboptimal adherence to short-term antibiotics

Originally published by CIDRAP News Nov 1

A study of Israeli children with acute bacterial infections found that fewer than two-thirds adhered to antibiotic treatment, researchers reported today in Pediatrics.

In the prospective, blinded, observational study, researchers at a tertiary medical center in Israel electronically monitored patients ages 2 months to 5 years who had been discharged with short-term oral antibiotics (5 to 10 days) after being diagnosed with an acute bacterial infection from January 2018 through December 2021. Diagnoses included acute otitis media (AOM, or ear infection), pneumonia, cellulitis, pharyngitis, urinary tract infection, and bacteremia.

The primary outcomes were overall treatment adherence (defined as administration of more than 75% of doses relative to the number of doses prescribed) and timing adherence (administration of more than 75% of doses at the recommended time interval). Monitoring was conducted via medication bottles that recorded time and date every time they were opened.

Among the 100 infants included in the final analysis (49 boys; mean age, 1.87 years), AOM was the most common diagnosis (18 children), followed by cellulitis and UTI (16 and 14 children, respectively). Overall treatment adherence was 62%, while timing adherence was 21%. Logistic regression analysis found that the only factor associated with nonadherence was parental status, with single parents having a five-fold increase in odds for nonadherence (odds ratio, 5.7; 95% confidence interval [CI], 1.07 to 30.3).

The study also found that prescribers overestimated adherence to treatment, defining 49 of 62 participants (77.7%) as likely adherent, and were unable to differentiate between adherents and nonadherents.

The study authors say that while treatment adherence studies have largely focused on chronic conditions that require prolonged adherence to medication, it's become increasingly recognized that nonadherence to short-term interventions can result in serious consequences. With antibiotics, it can also potentially increase the development of drug-resistant microorganisms.

"These data are important when considering recommended treatment durations and developing interventional programs to increase adherence," they wrote.
Nov 1 Pediatrics study

 

Report highlights animal transport as risk for spread of resistant bacteria

Originally published by CIDRAP News Oct 31

A report last week from the European Food Safety Authority (EFSA) suggests steps could be taken to limit the spread of AMR in food-producing animals during transportation.

Using information from international reports, scientific literature, European legislation, and expert knowledge, scientists with EFSA's Panel on Biological Hazards set out to assess the most significant risk factors associated with the spread of antimicrobial-resistant bacteria and antimicrobial-resistance genes (ARB/ARGs) among poultry, pigs, and cattle when transported from the farm to the slaughterhouse. The panel was also asked to identify preventive measures and control options that could be implemented to reduce the spread of ARB/ARGs between food-producing animals during short and long journeys, and to identify data gaps.

The assessment identified the status that resistance (the presence of ARB/ARGs) of animals pre-transport as one of the main risk factors that almost certainly contributes to the probability of ARB/ARG transmission during transport, followed by increased fecal shedding, insufficient hygiene of vehicles and equipment, exposure to other animals carrying ARB/ARGs, and duration of transport. Among the factors that likely contribute to ARB/ARG spread were airborne transmission within the vehicle, health status of the animal, and high temperature and humidity.

To reduce the probability of ARB/ARG transmission in animals during transport, the report recommended minimizing the duration of transport, properly cleaning and disinfecting vehicles, organizing transport in relation to AMR criteria, improving biosecurity and animal husbandry and handling practices prior to and during transport, and segregating animals.

While a range of data gaps were identified, the panel said that quantifying the impact of transport on AMR transmission, compared with other stages of the food-production chain, was among the most urgent research needs.

"By identifying the main risk factors, mitigation measures and research needs in relation to the transport of animals, EFSA's assessment marks another step forward in the fight against antimicrobial resistance, based on the principle of 'One Health,' which integrates animal and human risk assessment," Frank Verdonck, Head of EFSA's Biological Hazards & Animal Health and Welfare Unit, said in an EFSA press release.
Oct 25 EFSA report
Oct 25 EFSA press release

Study shows moderate, severe COVID diminishes quality of life 1 year later

In a new study in BMC Medicine, Dutch researchers report that, 12 months after illness onset, people with initially moderate to severe COVID-19 still had impaired health-related quality of life (HRQL), but the same was not true for mild COVID-19.

The study is part of the RECoVERED trial, a prospective cohort study in Amsterdam that looks at adult health following a confirmed COVID-19 diagnosis. HRQL was assessed with the Medical Outcomes Study Short Form 36-item health survey (SF-36), which was completed by 269 adults by December of 2021.

The 36 items assessed the respondent's HRQL: ability to perform usual and vigorous activities (physical functioning), ability to participate in social and occupational activities (social functioning, physical role functioning, and emotional role functioning), mood (mental health dimension), amount of energy and pain (vitality/fatigue and pain dimensions) and perceived current health (general health perceptions). Scores were 0 to 100, with higher scores showing higher quality of life.

One month after diagnosis, all adult participants with COVID scored lower on HRQL when compare to population controls, but by 12 months, only those who had moderate or severe/critical COVID-19 had HRQL below population norms on more than half of the SF-36 domains.

People with three or more COVID-19 high-risk comorbidities had significantly worse HRQL at both the 1- and 12-month mark. At 12 months, those with worse initial infection still had significantly lower HRQL on five out of eight categories.

"At month 12, participants with initial moderate or severe COVID-12 still had impaired HRQL on the dimensions physical, social and role emotional functioning, vitality and general health with moderate to large deviations from general population norms," the authors concluded.
Nov 2 BMC Med
study

 

Oral zinc cuts risk of death, ICU stay nearly 40% in COVID-19 patients

Tunisian COVID-19 patients given oral zinc twice daily had a nearly 40% lower rate of death and intensive care unit (ICU) admission, as well as shorter hospital stays and time to symptom resolution, concludes a randomized controlled trial published today in Clinical Infectious Diseases.

The double-blind, multicenter trial involved 190 adult COVID-19 outpatients and 280 hospitalized patients randomly assigned to receive oral zinc (231 patients) or a placebo (239) for 15 days, from Feb 15 to May 4, 2022.

Average duration of symptoms before enrollment was 4.6 days, and average age was 54.2 years. Roughly 20% had received two doses of COVID-19 vaccine, and 23% had at least one dose. Thirty-seven patients died, 81.1% of them in the ICU.

The 30-day death rate was 6.5% among zinc recipients and 9.2% in the placebo group (odds ratio [OR], 0.70; 95% confidence interval [CI], 0.37 to 1.32), and 5.2% and 11.3%, respectively, were admitted to an ICU (OR, 0.46; 95% CI, 0.23 to 0.88). The need for hospitalization was similar in the two groups (1.2% vs 3.8%, respectively; OR, 0.30; 95% CI, 0.03 to 2.8).

The zinc group was also less likely to experience the combined outcome of death or ICU admission (OR, 0.62; 95% CI, 0.38 to 0.99). Hospital stays were shorter among zinc recipients than among those given placebo (difference, 3.5 days; 95% CI, 2.76 to 4.23), as was duration of symptoms among outpatients (difference, 1.9 days; 95% CI, 0.62 to 2.6).

The results were similar in patients older than 65 years and those with underlying medical conditions or the need for supplemental oxygen at baseline. No severe adverse events were reported; minor events occurred in 3.9% of the zinc group and 7.1% of placebo recipients (OR, 0.52; 95% CI, 0.23 to 1.12).

Zinc has a key role in regulating the immune system, the authors noted. "Zinc should be considered for the treatment of patients with COVID-19," they wrote.
Nov 4 Clin Infect Dis study

 

Ebola sickens 1 more in Uganda, kills 5 more

Over the past 2 days, Uganda reported one more Ebola case and five deaths, according to updates from the World Health Organization (WHO) Uganda office.

The new infection was reported from Kampala in a patient who is a known contact of an earlier patient. Of the five deaths, four were in Mubende, the outbreak's main hot spot, and one was in the Ebola treatment center in Entebbe. The developments lift the overall outbreak to 131 confirmed cases, 48 of them fatal. In addition, the country has reported 21 suspected cases, all fatal. The case-fatality rate among confirmed cases is 37%.

The number of districts reporting cases stands at seven, and outbreak responders are monitoring 1,604 contacts across eight districts, with a follow-up rate of 93%.

The outbreak, which involves the less common Sudan Ebola strain, began in September, marking Uganda's first outbreak involving the strain since 2012.
Nov 3 WHO Uganda office situation report
Nov 4 WHO Uganda office situation report

 

Spain reports H5N1 avian flu in 2 poultry workers

Spanish public health officials have identified H5N1 avian influenza in two male poultry workers who underwent nasopharyngeal swabbing in the wake of an avian flu outbreak in September at a poultry farm on which they both worked.

The WHO said the detections were probably due to their exposure to infected poultry and that no evidence of human-to-human transmission has been found. Neither man had symptoms.

In a statement that detailed the findings, the WHO said nasopharyngeal samples were collected from all 12 of workers on the farm in Guadalajara province on Sep 23, which was 3 days after the poultry outbreak began. H5N1 was detected in a sample from a 19-year-old man. Samples from his contacts were negative.

The workers were tested again on Oct 12 after response measures were taken at the farm. A 27-year-old man who had been involved in cleaning and disinfection while wearing personal protective equipment tested positive. Two of his close contacts tested negative.

The WHO said it has now received reports of four such cases. The other was reported from the United Kingdom in 2021 in a man who had prolonged close contact with poultry. In the United States, Colorado officials in April reported an H5 infection in a 40-year-old man who, as a prison inmate, was exposed to poultry outbreak response as part of a prerelease employment program. His only symptoms were mild fatigue.
Nov 3 WHO statement
Apr 29 CIDRAP News story

 

New Mexico reports H3N2v flu case

New Mexico's health department has reported a variant H3N2 (H3N2v) case, the nation's tenth variant flu infection of the year, the US Centers for Disease Control and Prevention (CDC) said its regular weekly flu update today.

The patient is a child who is recovering. An investigation revealed that he or she had been exposed to pigs before symptoms began. No other related H3N2v infections have been found, but the investigation is still under way.

Of the 10 variant flu infections reported so far this year, 5 were H3N2v and 5 were H1N2v.

The CDC said variant flu cases commonly involve exposure to swine, but human-to-human illnesses have been reported. It added that although the viruses don't spread easily among people, early identification is essential to gauge the risk and guide public health measures.
Nov 4 CDC FluView update

 

Four African nations report more polio cases

Four countries reported more polio cases this week, including Mozambique, which reported another wild poliovirus type 1 (WPV1) case, the Global Polio Eradication Initiative (GPEI) said in its latest weekly update.

Mozambique has now reported eight WPV1 cases. Its latest infection was in Tete province. GPEI said reporting of multiple cases in such a short time span shows that intensified surveillance efforts are working. Also, the country reported 5 more circulating vaccine-derived poliovirus type 1 (cVDPV1) cases, all in Zambezia, raising the total for the year to 13.

The Democratic Republic of the Congo (DRC) reported 7 more cVDPV1 cases as well as 3 more involving circulating vaccine-derived poliovirus type 2 (cVDPV2). All of the cVDPV1 cases were in Haut Lomami province and raise the country's 2022 total to 36. The cVDPV2 cases were in three provinces, putting the total for the year at 163, up sharply from the 28 cases the DRC reported in 2021.

Elsewhere, Madagascar reported 2 more cVDPV1 cases, 1 each in Androy and Sava, bringing the total for 2022 to 10. And Nigeria reported 1 more cVDPV2 case, which was in Oyo, lifting the nation's number for the year to 38, compared with 415 in 2021.
Nov 3 GPEI update

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