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

European data show big drop in antibiotic use during the pandemic

New data from the European Centre for Diseases Prevention and Control (ECDC) show a dramatic drop in community antibiotic use across Europe during the first year of the COVID-19 pandemic.

In a report published yesterday in Eurosurveillance, ECDC researchers looked at data reported to the European Surveillance of Antimicrobial Consumption Network (ESAC-Net) by 27 European Union/European Economic Activity (EU/EEA) countries and found that overall community antibiotic consumption fell by 18.3% from 2019 to 2020—the largest annual decline in ESAC-Net's two-decade history. By comparison, community antibiotic use fell by only 1.8% per year from 2016 to 2019.

The largest decreases were observed for penicillins, followed by other beta-lactam antibiotics, including macrolides, cephalosporins, lincosamides, and streptogramins. Only 1 of the 27 countries—Bulgaria—reported an increase in community antibiotic use from 2019 to 2020.

Although the reasons for the dramatic decline are unclear, the authors suggest it's likely related to the low-incidence of non-COVID respiratory infections in 2020, which in turn is linked to COVID-19 mitigation measures, including physical distancing, masking, and hand hygiene. In addition, reduced access to primary care may have resulted in fewer antibiotic prescriptions.

Another ECDC surveillance report, also based on ESAC-Net data, found a significant, though not as dramatic, decline in hospital antibiotic consumption, which fell by 4.5% from 2019 to 2020. Combined hospital and community antibiotic use fell by 17.6%.

EU officials cautioned, however, that resistance rates for pathogens like Escherichia coli and Klebsiella pneumoniae continue to rise, and that countries will need to remain focused on antibiotic stewardship once the pandemic ends.

"Antimicrobial resistance remains a serious challenge globally," Stella Kyriakides, EU Commissioner for Health and Food Safety, said in an ECDC press release. "Antimicrobial resistance is a silent pandemic that is happening here and now. Although antibiotic consumption generally decreased during the pandemic in the EU/EEA, we must increase our public health response."
Nov 18 Eurosurveill rapid communication
Nov 18 ECDC surveillance report
Nov 18 ECDC press release

Staphylococcus bloodstream infections rising in Europe, study finds

In another surveillance study published yesterday in Eurosurveillance, European researchers reported a significant increase across the continent in Staphylococcus aureus bloodstream infections (BSIs), despite a decline in BSIs caused by methicillin-resistant S aureus (MRSA).

The analysis of data from the European Antimicrobial Resistance Surveillance Network (EARS-Net) for 2005 through 2018 found that, in the 25 EU/EEA countries that consistently reported data on S aureus BSIs, the proportion of BSIs caused by MRSA declined from 30.2% in 2005 to 16.3% in 2018. The percentage of MRSA BSIs declined across all age-groups.

During the same period, however, the total number of S aureus BSIs increased by 57%, driven by an 84% increase in BSIs caused by methicillin-susceptible S aureus (MSSA). The number of MRSA BSIs fell by 31%.

The study authors suggest the increase in S aureus BSIs could by linked to an aging population and the increased risk of infection among elderly patients, although they note that aging cannot alone explain the dramatic increase. They say the findings also indicate the possible increasing role of MSSA as a healthcare-associated pathogen.

"This increasing trend in the number of MSSA BSI in the EU/EEA needs further attention since MSSA BSI have high case fatality rates and there are still issues regarding their optimal treatment," they wrote. "Further studies at local, national, or supranational level, based on different data sources, are necessary to answer the questions raised by our results, in particular to identify all the factors associated with the described trends in MSSA and MRSA BSI."
Nov 18 Eurosurveill study

G7 governments urged to do more to boost antibiotic development

Originally published by CIDRAP News Nov 17

A coalition of organizations from academia, healthcare, and the pharmaceutical industry sent a letter today to G7 governments calling for greater engagement in tackling antimicrobial resistance (AMR) and boosting the pipeline for new antibiotics.

The joint statement, issued ahead of World Antimicrobial Awareness Week, calls on G7 governments to explore a range of options, in collaboration with the private sector, to strengthen the antibiotic research and development pipeline from beginning to end. That includes support for basic research, funding to help companies transition from early-stage trials to late-stage clinical development, and development of financial pull incentives to ensure investment into innovative new antibiotics is rewarded.

The signatories, including the AMR Action Fund and the Global Antibiotic Research & Development Partnership, also call on G7 governments to develop new reimbursement models for novel antibiotics for drug-resistant infections to help ensure that patients in all countries have fast access to them, and to capitalize on the potential of vaccines to protect against infections and reduce the need for antibiotics.

"Only if we set these recommendations into immediate action, we will be able to build an innovative and sustainable ecosystem to effectively fight AMR," the groups said in the statement.
Nov 17 joint statement

UK report shows drop in antibiotic-resistant bloodstream infections

Originally published by CIDRAP News Nov 17

A new surveillance report released today by UK health officials shows that the number of antibiotic-resistant BSIs fell in England from 2019 to 2020, a decline that likely reflects the impact of the COVID-19 pandemic and masks the rising burden of resistance.

Data from the eighth annual English Surveillance Programme for Antimicrobial Use and Resistance (ESPAUR) report indicates that the number of antibiotic-resistant BSIs fell from 65,583 in 2019 to 55,384 in 2020, a 15% decline. But that's mainly because the overall incidence of BSIs caused by key bacterial pathogens declined in 2020, led by a 59% decline in Streptococcus pneumoniae BSIs and a 14% reduction in E coli BSIs. The report suggests that decline was due in part to reduced contact between individuals, improved hand hygiene, reduced antibiotic prescribing, and fewer interactions with healthcare during the pandemic.

But the report also shows that among the bacteria that commonly causes BSIs (including E coli and Klebsiella pneumoniae), resistance to several key antibiotics rose from 2016 to 2019 before falling in 2020. And the number of BSIs caused by resistant pathogens rose annually over that period. Even with the 2020 declines, roughly 1 in 5 people with a BSI in 2020 had an antibiotic-resistant infection.

The UK's Health Security Agency says these findings suggest drug-resistant infections will likely climb once the pandemic is over.

"Antimicrobial resistance has been described as a hidden pandemic and it's important that we do not come out of COVID-19 and enter into another crisis," UKHSA chief medical advisor Susan Hopkins, MB BCh, said in a press release.

The ESPAUR report highlighted continuing declines in antibiotic prescribing in English healthcare. From 2016 to 2019, total antibiotic consumption fell by 6.6%, with an additional 10.9% reduction from 2019 to 2020. The greatest decline was observed within the General Practice (GP) setting, where prescribing fell by 10.4% from 2016 to 2019, with a further 9.4% reduction from 2019 to 2020.

Antibiotic use in hospitals, however, increased by 1.9% from 2016 to 2019, with an additional 4.8% increase from 2019 to 2020.
Nov 17 ESPAUR report
Nov 17 UKHSA press release

Scottish report shows 5-year decline in human antibiotic use

Originally published by CIDRAP News Nov 16

A report today from Scotland highlights reduced antibiotic use in the country since it adopted a One Health approach to combatting antimicrobial resistance (AMR).

The report, from Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) Scotland, shows that total antibiotic use in people was 19.2 defined daily doses per 1,000 population per day in 2020, a 17.1% reduction since 2016. The report notes that the 11.8% reduction from 2019 to 2020 likely reflects the impact of the COVID-19 pandemic, which affected antibiotic use in all healthcare settings.

The vast majority of antibiotic use (84.2%) in Scotland in 2020 occurred in primary care settings, while acute care hospitals accounted for 13.2% and non-acute hospitals for 2.6%. Antibiotic use in primary care fell by 20.9% from 2016 to 2020, but rose by 2.3% in acute care settings, despite a decline in use during the pandemic.

"Access" antibiotics—the antibiotics classified by the World Health Organization (WHO) as first-line treatments for common infections—accounted for 61.2% of all antibiotics used in people in 2020, and 76.8% of all antibiotics dispensed in primary care. Use of Watch and Reserve antibiotics, which are broad-spectrum drugs that the WHO recommends should be restricted to more severe, drug-resistant infections, fell by 10.4% in acute care settings since 2016.

Surveillance data show that gram-negative bacteria continue to be a common cause of serious infections in both healthcare and community settings in Scotland, with Escherichia coli accounting for most drug-resistant infections. Nearly a quarter of E coli bacteremia cases in Scotland in 2020 were resistant to one or more key antibiotics.

On the animal side, the report shows that the percentage of companion animal veterinary consultations that resulted in an antibiotic prescription was 16.2% in 2020, down from 19.2% in 2016. Scotland is still in the process of developing systems to collect data on antibiotic use in livestock.

"Tackling AMR, which has been described as a slow burning pandemic, remains vitally important," the report states. "Sustained action to preserve antibiotics and reduce drug resistant infections is crucial to secure the future delivery of healthcare through and beyond the COVID-19 pandemic."
Nov 16 ARHAI Scotland report

Africa CDC issues antibiotic treatment guidelines for common infections

Originally published by CIDRAP News Nov 16

The Africa Centres for Disease Control and Prevention (Africa CDC) and the Center for Disease Dynamics, Economics & Policy (CDDEP), based in Washington, D.C., last week published the first edition of Africa-specific guidelines for antibiotic treatment of common bacterial infections.

Developed by an interdisciplinary panel of infectious disease clinicians, pharmacists, and public health experts, the guidelines aim to provide African healthcare workers with expert recommendations on antimicrobial selection, dosage, and duration of treatment for common bacterial infections and syndromes in African adults and children. They are designed to promote appropriate use of antimicrobials to limit the spread of drug-resistant pathogens.

They're based on a systematic review of existing national treatment guidelines, available AMR data, and expert opinion, and are intended to complement existing national and international clinical guidelines.

Africa CDC notes that the guidelines fill a long-existing gap. With the exception of infectious diseases like HIV, tuberculosis, and malaria, many countries in Africa lack guidelines that define appropriate treatment for common infections, and healthcare providers often have to rely on their own judgment or guidelines developed outside of Africa.

The agency says it hopes the guidelines serve as a standardized model for other jurisdictions or healthcare facilities in Africa to develop their own guidelines.
Nov 12 African Antibiotic Treatment Guidelines
Nov 12 CDDEP blog post

English study finds less antibiotic prescribing amid pandemic

Originally published by CIDRAP News Nov 15

Antibiotic prescribing in general practice in England fell significantly during the first 12 months of the COVID-19 pandemic compared with the previous year, according to data released last week by Antibiotic Research UK (ANTRUK).

Analysis of prescription data from the England's National Health Service showed that from March 2020 through February 2021, antibiotic prescribing by general practitioners (GPs) declined by 17% compared with the previous 12 months, and the decline occurred in almost all areas of the country. The analysis also found that the rise in antibiotic prescribing that typically occurs in the winter in England was considerably lower for the winter of 2020 to 2021.

While antibiotic prescribing has risen by 21% on average from the summer (June to August) to the winter (December to February) in previous years, antibiotic prescribing from December 2020 to February 2021 only rose by 4%.

"The dramatic fall in antibiotic prescribing during the COVID pandemic could be due to many factors including less infection transmission during lockdowns and fewer visits to GPs," ANTRUK Chief Executive Colin Garner, PhD, said in a press release.

"More work is needed to understand the extent to which each of these factors has resulted in this drop in antibiotic prescribing, but the data does tell us that antibiotic prescribing can be reduced to help protect us all from the danger of the growing threat of antibiotic resistance."
Nov 11 ANTRUK press release

Michigan hospital project tied to shorter antibiotic course for pneumonia

Originally published by CIDRAP News Nov 15

Participation in a prospective collaborative quality initiative (CQI) was associated with more appropriate use of short-course antibiotic therapy for pneumonia, according to a study published last week in Clinical Infectious Diseases.

The study looked at data from a 3-year project undertaken by 41 hospitals participating in the Michigan Hospital Medicine Safety Consortium, a statewide collaborative quality initiative. The project targeted appropriate 5-day antibiotic treatment for uncomplicated community-acquired pneumonia (CAP), using benchmarking, sharing of best practices, and pay-for-performance metrics.

To evaluate the impact of the program, researchers assessed appropriate receipt of a 5-day antibiotic duration and 30-day post-discharge composite adverse events (mortality, readmission, urgent visit, antibiotic-associated adverse events) for patients with uncomplicated CAP.

Overall, 6,553 patients with uncomplicated CAP were eligible for 5-day treatment at the 41 hospitals from February 2017 through February 2021. Over the study period, the percentage of patients treated with a 5-day course of antibiotics rose from 22.1% to 45.9%. Each quarter was associated with higher odds of receiving an appropriate 5-day course of antibiotics (adjusted odds ratio, [aOR], 1.10; 95% confidence interval [CI], 1.07 to 1.14), for an annual aOR of 1.49 per year.

Thirty-day composite adverse events occurred in 18.5% of patients over the entire study period and decreased over time (aOR, 0.98 per quarter; 95% CI, 0.96 to 0.99) due mainly to a decrease in antibiotic-associated adverse events (aOR, 0.91; 95% CI, 0.87 to 0.95). Mortality, readmission, urgent visits, and Clostridioides difficile infections did not change over time.

The study authors suggest other states and healthcare systems should consider adopting this three-pronged method for improving antibiotic treatment.

"Participation in a stewardship CQI may not only improve antibiotic use, but also patient outcomes," the study authors wrote. "The observation that all hospitals, including small hospitals, benefited from CQI participation suggests that the CQI model could be one way to advance antibiotic stewardship even in small, rural hospitals with fewer resources."
Nov 13 Clin Infect Dis abstract

1.6 million US COVID survivors may still have impaired sense of smell

Upwards of 700,000—perhaps as many as 1.6 million—US COVID-19 survivors haven't recovered their sense of smell after more than 6 months, according to a research letter yesterday in JAMA Otolaryngology-Head & Neck Surgery.

In the first study of its kind, a researcher from Washington University and two editors from the journal estimated the number of new daily COVID-19 cases from Jan 13, 2020, to Mar 7, 2021, using data from the COVID Tracking Project. They also analyzed data from two studies estimating the incidence of olfactory dysfunction (OD) as 52.7% (95% confidence interval [CI], 29.6% to 75.2%) and the OD recovery rate of 95.3% (95% CI, 92.6% to 98.0%).

Six months after the emergence of SARS-CoV-2, the first cases of chronic OD (COD) were identified and increased steadily through April 2021. In May 2021, the analysis predicted a near-exponential rise in the slope of cumulative COD cases through August, to 712,268. The estimated number of Americans expected to develop COD is 170,238 to 1,600,241.

For reference, the authors said that before the pandemic, the National Institute on Deafness and Other Communication Disorders estimated that as many as 13.3 million Americans 40 years and older had measurable OD. The prevalence of OD is 4.2% for Americans 40 to 49 years and 39.4% for those 80 and older.

"The addition of 0.7 to 1.6 million new cases of COD represents a 5.3% to 12% relative increase," the researchers wrote. "COVID-19 affects a younger demographic group than other causes of OD. Thus, the lifelong burden of OD will be much greater for the COVID-19 cohort than for patients in the older age groups."

The authors said that the true prevalence of COD may be much higher than estimated because the number of COVID-19 cases is likely greater than reported by states, and the estimated incidence of OD was derived from relatively healthier outpatients. "The incidence of OD may be higher among patients who were hospitalized with SARS-CoV-2," they added. "These data suggest an emerging public health concern of OD and the urgent need for research that focuses on treating COVID-19 COD."
Nov 18 JAMA Otolaryngol Head Neck Surg research letter

Poorer nations got fewer doses of the COVID vaccines they helped test

High-income countries have received disproportionately more COVID-19 vaccine doses than low- and middle-income countries, allowing them to vaccinate much more of their populations, finds a study yesterday in JAMA Network Open.

Yale University researchers identified COVID-19 vaccines listed by the World Health Organization for emergency use and all vaccine trials completed by Sep 7, 2021.

Six COVID-19 vaccines were listed for emergency use and tested in 25 countries. Of 11 high-income countries hosting completed clinical trials, 10 (90.9%) authorized the tested vaccine and received enough doses to vaccinate a median of 51.7% of residents 15 years and older.

In contrast, low-middle- and upper-middle-income countries had 100% and 90.9% rates of vaccine authorization, respectively, but median vaccination rates were only 31% and 14.9%, respectively. Rates of ongoing and completed vaccine trials were higher in high-income countries than in their lower-income counterparts.

Moderna completed clinical trials in two countries, while AstraZeneca and Janssen (Johnson & Johnson) completed trials in 14 and 10 countries, receiving authorization for their vaccines in 85.7% and 80.0% of them, respectively.

High-income countries received more vaccine doses and thus were able to vaccinate larger median shares of their residents 15 years and older, regardless of manufacturer. Through the COVAX initiative, a median of 15.4%, 48.8%, and 78.8% of doses of vaccines were sent to low-, lower-middle-, and upper-middle-income countries that hosted completed trials.

"Including low- and middle-income countries in research can be an important goal; however, inclusion should correspond with fair access to research benefits, to help avoid exploitation," the authors wrote. "These wealth-based access inequities among countries hosting trials parallel general disparities in COVID-19 vaccine access, as high-income countries have successfully procured and administered doses ahead of low- and middle-income countries."

In a related commentary, Gavin Yamey, MD, of Duke University, and Richard Gordon, PhD, and Glenda Gray, MBBCH, both of the South African Medical Research Council, said that low- and middle-income countries would do well to conduct their own vaccine trials to "ensure that they test product candidates in their own populations, use locally generated data, and ensure local access to the products."
Nov 18 JAMA Netw Open research letter and commentary

CDC says no smallpox detected in vials found in Pennsylvania lab freezer

After conducting tests on vials marked "smallpox" found in a commercial Pennsylvania lab, the Centers for Disease Control and Prevention (CDC) said they do not contain the virus that causes smallpox, the agency said late yesterday in a news release.

Testing showed the vials contain vaccinia, a related poxvirus used in smallpox vaccine, not variola, the virus that causes smallpox. "CDC is in close contact with state and local health officials, law enforcement, and the World Health Organization about these findings," the agency said.

The lab had notified federal authorities on Nov 15 that a lab worker discovered the vials while cleaning out a freezer in a lab that conducts vaccine research. The facility was immediately secured and staff followed standard protocols for notifying the CDC of the discovery. The vials were sent securely to CDC for testing yesterday, and no one was exposed to the contents of the vials, the CDC said.

In 2014, National Institutes of Health employees found decades-old vials that appeared to contain smallpox in an unused lab storage area on its Bethesda, Maryland, campus. Two vials contained viable virus, but no human infections were related to the discovery.

Smallpox was eradicated in the 1970s, but health officials remain concerned that remaining samples could pose a bioterror threat if terrorists obtain them. The last known remaining stockpiles are kept in approved labs in the United States and Russia.
Nov 18 CDC news release
Nov 17 CIDRAP news scan on the vial discovery

CDC closes Salmonella backyard poultry outbreak probe after 1,135 cases

The CDC yesterday added 272 cases to an ongoing Salmonella outbreak tied to backyard poultry, with 1,135 now confirmed sick in 48 states, the District of Columbia, and Puerto Rico. The CDC also said it has closed its investigation into the outbreak.

Two people died from Salmonella infections during this outbreak, and 273 required hospitalization. Illnesses started on dates ranging from Dec 15, 2020, to Oct 10, 2021. Twenty-four percent of those sick were under 5 years, and 12% were under 1 year. Of 1,107 people with sex information available, 646 (58%) were female.

Of 293 people who reported contact with backyard poultry and provided more information, 212 (72%) reported that they bought backyard poultry this year, the CDC said.

In related news, earlier this week the CDC said the Salmonella outbreak linked to onions has grown by 84 cases, to 894, and 1 more state is affected, bringing the total to 38 states plus Puerto Rico. Texas continues to have the most cases, with 207, followed by Oklahoma, with 114 cases.

Twenty-six more people have required hospitalization, bringing that total to 183. No deaths have been reported. Illness onset dates range from May 31 to Oct 25.

"Multiple companies have recalled onions," the CDC said. "All recalled onions were supplied by ProSource Produce LLC and Keeler Family Farms and imported from the State of Chihuahua, Mexico, between July 1, 2021, and August 31, 2021."
Nov 18 CDC backyard poultry report
Nov 18 CDC onion report

US flu levels show another slight rise; biggest burden in younger people

Though flu levels remained below their seasonal baselines, the number of positive respiratory samples and doctor's visits for flulike illness continued to rise in the past week, mainly due to H3N2 in children and young adults, the CDC said today in its latest weekly flu season update.

Both public health and clinical labs reported increasing numbers of flu viruses, mostly H3N2, with 90% of the detections in people ages 5 to 24 years old. Earlier this week, the CDC said it was assisting with an investigation into a large outbreak at the University of Michigan and had received anecdotal reports of outbreaks on other college campuses.

Nationally, clinic visits for flu were at 2.1%, a number that's rising but is still below the baseline of 2.5%.

New Mexico was the only state that reported high or very high activity, based on clinic visits for flulike illness, and Georgia reported moderate activity.

No pediatric flu deaths have been reported this season.
Nov 19 CDC FluView report
Nov 16 CIDRAP News scan

China reports fatal H9N2 avian flu case

China recently reported another H9N2 avian influenza case, which involved a 39-year-old man who died from his infection, according to the latest weekly communicable disease threat report from the European Centre for Disease Prevention and Control (ECDC).

The man from Guizhou prefecture, located in southwest China, became sick on Oct 29 and was hospitalized the same day with a severe illness. He died on Nov 1. The ECDC said no other related cases were detected.

Before the man's illness, China had reported five other H9N2 cases over the past 6 months, including another from Guizhou, according to an avian flu update from Hong Kong's Centre for Health Protection (CHP). The ECDC notes that 94 cases from 8 countries have been reported since 1998, most of them from China.

H9N2 is common in Asian poultry, and sporadic infections are known to occur in people who have contact with poultry or their environments. Infections are usually mild and typically reported in children.
Nov 19 ECDC weekly communicable disease threat report
Nov 16 CHP avian flu update

Nigeria reports another spurt of vaccine-derived polio cases

Only one country—Nigeria—reported new polio cases this week, with more circulating vaccine-derived poliovirus type 2 (cVDPV2) infections, according to the latest weekly update from the Global Polio Eradication Initiative (GPEI).

Nigeria has six new cases, three from Bauchi state, plus one each from Gombe, Katsina, and Yobe states. So far, the country has reported 280 cases this year, up sharply from 8 reported in 2020.

Also, Nigeria reported 26 more environmental cVDPV2 positive, which were from the same three states reporting cases this week, as well as Borno, Kano, Katsina, and Taraba states.
Nov 18 GPEI update