Stewardship / Resistance Scan for Oct 12, 2022

News brief

Report: Carbapenemase-producing Enterobacterales rose in Latin America

A report today in Emerging Infectious Diseases highlights increased detection of carbapenemase-producing Enterobacterales (CPE) in Latin America and the Caribbean during the COVID-19 pandemic.

The report, by researchers with the Pan American Health Organization and several national laboratories in the region, notes that while several countries had reported detection of CPE prior to the pandemic, detection of Enterobacterales harboring multiple carbapenemase genes was limited.

But during the pandemic, national laboratories in Argentina, Brazil, Colombia, Guatemala, Paraguay, Peru, Uruguay, Venezuela, Ecuador, and Costa Rica reported the emergence or increased detection of carbapenemase combinations—mainly the carbapenemase genes bla_KPC and bla_NDM—while Belize, Dominica, and Chile reported the emergence of carbapenemase genes that had not previously been detected.

Among the countries reporting increased CPE detection, Colombia reported more than twice the number of CPE strains from January 2020 through December 2021 compared with 2018-2019, while data from hospitals in five Brazilian states showed a 42.8% increase in CPE isolates during the pandemic (March 2020 to October 2021) compared with 20 months before.

The authors say that the reported increases in CPE detection during the pandemic were likely caused by a variety of pandemic-related factors.

"The pandemic might have accelerated the problem of resistance to the limited antimicrobial arsenal in the region because of antimicrobial drug misuse, prolonged hospital stays, and a high rate of antimicrobial prescriptions in hospital settings, such as medical wards and ICUs, where a high number of patients with COVID-19 were hospitalized during the first pandemic wave," they write.

They also point out that many countries in the region do not have access to the newly developed antibiotics for treating the multidrug-resistant infections caused by CPE, which has resulted in increased use of last-resort antibiotics like polymyxins.

They conclude, "In an ideal scenario, access to newly developed and approved antimicrobials and tools to guide their prudent use should be guaranteed for the entire world in parallel with current local AMR [antimicrobial resistance] prevention and control strategies, including the prioritization of antimicrobial stewardship and rapid AMR detection."
Oct 12 Emerg Infect Dis report

Non-preferred antibiotics often used for urinary infections at VA hospitals

A study of Veterans Affairs (VA) medical centers found that clinicians prescribed the preferred antibiotic for patients with positive urine cultures less than half of the time, researchers reported today in Antimicrobial Stewardship & Healthcare Epidemiology.

For the study, which aimed to analyze how urinary tract infection management can be improved in VA outpatients, VA researchers extracted data on positive urine cultures collected at 31 VA medical centers from 2016 through 2019.

Cases were classified as cystitis, pyelonephritis, or asymptomatic bacteriuria (ASB) based on documented signs and symptoms, and preferred therapy definitions were applied for each subdiagnosis: ASB (no antibiotics), cystitis (trimethoprim-sulfamethoxazole, nitrofurantoin, and beta-lactams), and pyelonephritis (trimethoprim-sulfamethoxazole and fluoroquinolone). The researchers assessed whether preferred antibiotics were chosen for each subdiagnosis and whether the duration was appropriate. Outcomes included 30-day clinical failure or hospitalization.

Of 3,255 cases reviewed, ASB was identified in 1,628 cases (50%), cystitis was identified in 1,156 cases (36%), and pyelonephritis was identified in 471 cases (15%). Antibiotics were prescribed in 43% of these cases, including 40% with ASB. Of 2,831 cases analyzed, 1,298 (46%) received the preferred therapy selection and duration for cases where it could be defined. The most common antibiotic class prescribed was fluoroquinolones (34%).

Patients prescribed preferred therapy had lower odds of clinical failure than those who received non-preferred therapy (8% vs 10%; unadjusted odds ratio [OR], 0.74; 95% confidence interval [CI], 0.58 to 0.95). They also had lower odds of 30-day hospitalization (3% vs 5%; unadjusted OR, 0.55; 95% CI, 0.37 to 0.81). Odds of clinical treatment failure or hospitalization were higher for beta-lactams relative to ciprofloxacin (unadjusted OR, 1.89; 95% CI, 1.23 to 2.90).

"These findings suggest clinicians could benefit from educational and interventional strategies that target appropriate selection and duration of therapy," the study authors concluded.
Oct 12 Antimicrob Steward Healthc Epidemiology study

News Scan for Oct 12, 2022

News brief

COVID-19 vaccines may help prevent placentitis, stillbirth in pregnancy

COVID-19 vaccination may protect pregnant women and their fetuses against virus-related placentitis (inflammation of the placenta) and stillbirth, concludes a review study published today in the American Journal of Obstetrics & Gynecology. The research will also be presented next week at ID Week in Washington, DC.

The study, led by a Perinatal Pathology Consulting researcher in Atlanta, reviewed nearly 100 articles on the relationship between COVID-19 vaccination and SARS-CoV-2–associated placentitis and stillbirth.

Although placentitis can inhibit oxygen delivery to the fetus and lead to stillbirth or neonatal death, the vast majority of pregnancies in mothers infected with COVID-19 don't result in stillbirth, the team said.

The development of SARS-CoV-2 placentitis is multifaceted, the researchers said, and probably involves both viral and immune-related factors that may differ by virus variant. Unlike most intrauterine infections, which usually lead to stillbirth by directly damaging fetal organs, SARS-CoV-2 tissue damage appears limited to the placenta, the researchers said.

"Because the tissue pathology related to COVID-19 appears to be most prominent in the placenta, where it is highly destructive, it may be possible that effective vaccination of pregnant women can either decrease the severity or even inhibit the development of SARS-CoV-2 placentitis," the authors wrote. "Thus, maternal vaccination for COVID-19 may be live-saving for the fetus as well as the mother."

In a news release from Children's National Hospital in Washington, DC, lead author David Schwartz, MD, of Perinatal Pathology Consulting, noted that none of the mothers described in multiple reports on SARS-CoV-2 placentitis, stillbirth, and neonatal death were vaccinated against COVID-19.

"And although not constituting proof, we're not aware, either personally, via collegial networks, or in the published literature, of any cases of SARS-CoV-2 placentitis causing stillbirths among pregnant women having received the COVID-19 vaccine," he said.
Oct 12 Am J Obstet Gynecol study
Oct 12 Children's National news release

Analysis shows COVID-19 preprint studies hold up to peer review

A new analysis of COVID-19 preprints shows that many studies hold up to peer review when the research is reviewed later, according to a study yesterday in The Lancet Global Health.

The COVID-19 pandemic was the first time biomedical researchers embraced online non–peer-reviewed preprints on a large scale, the authors explained, as delaying information during the months-long peer review process could have dire consequences during a novel pandemic.

To see if the preprints held up to scrutiny, University of Wisconsin (UW)–Madison researchers chose at random 100 COVID-19 studies that had been posted as preprints, then later subjected to peer review and successfully published by journals.

The main outcome was to see how peer reviewed affected four data points: infection-fatality rates and case-fatality rates, basic viral reproduction rates (how many people an infected person is expected to infect) and disease incidence (the number of new people infected in a given time). The researchers investigated more than 1,606 data points.

The authors found that 90% of preprint data points were still included after peer review, and confidence intervals tightened by 7% after peer review, but the change was not statistically significant.

"Wild swings between preprint and published versions would be hard to explain," said senior author B. Ian Hutchins, PhD, a professor in the University of Wisconsin–Madison's Information School, in a press release. "But that's not what we see. There's not a whole lot of change in the data reported and the estimates based on that data,"
Oct 11 Lancet Glob Health study
Oct 11 UW-Madison press release

Global monkeypox cases decline, but Americas remain the hot spot

At the global level, monkeypox cases continue to fall, but levels are rising in 21 countries, mostly in the Americas, the head of the World Health Organization (WHO) said today at a briefing.

Tedros Adhanom Ghebreyesus, PhD, the WHO's director-general, said cases in the Americas account for about 90% of infections reported last week. He warned countries to keep their guard up as cases decline. He also added that the WHO is worried about reports of cases in Sudan, including in refugee camps near the Ethiopian border.

So far, more than 70,000 cases have been reported to the WHO, including 26 deaths. Brazil this week reported its fifth death in a person diagnosed as having monkeypox, a 31-year-old man from Rio de Janeiro state who had been hospitalized since Sep 16, according to Agencia Brasil.

Meanwhile, at a briefing today of the WHO's Pan American Health Organization (PAHO), Director Carissa Etienne, MBBS, said cases in the Americas seem to be slowing, but more than 2,300 new cases were reported in the region last week, most from the United States, but also several from Brazil, Colombia, and Mexico. She added that 95% of cases are in men and 56% have occurred in people who are HIV-positive.

"PAHO has started to deliver vaccines to countries in the Region, and despite limited supplies, they remain an important tool to reduce transmission in high-risk communities," she said.

Yesterday the US Centers for Disease Control and Prevention reported 226 more cases since Oct 7, raising the national total to 26,778.
Oct 12 Tedros speech
Oct 10 Agencia Brasil story
Oct 12 Etienne speech
Oct 11 CDC monkeypox update

WHO airs deep concerns about Haiti's cholera outbreak

WHO officials today said they are deeply concerned about a cholera outbreak in Haiti that is centered around the capital of Port au Prince.

At a WHO headquarters briefing today, Director-General Tedros said Haiti's health ministry said that, as of Oct 8, it had received reports of 224 suspected cases, 16 of them fatal. One quarter of the cases are among children ages 1 to 4.

Also, he said the ministry confirmed an outbreak at a prison in the capital, with 39 suspected cases, 9 of them fatal.

Tedros said the situation is evolving rapidly and that the affected area is very insecure and controlled by gangs, making it difficult to collect samples and confirm cases. He also added that fuel shortages are making it hard for health workers to get to work, causing disruptions in medical care. The WHO is working with the health ministry response, "But to bring this outbreak under control, we need secure access to the affected areas," he added.

At a PAHO briefing today, Director Etienne said limited access to clean water in Haiti is creating perfect conditions for cholera and also noted likely underreporting because of street gangs.

She said PAHO has donated 2 tons of medical supplies and cholera kits and that the group stands ready to help Haiti's health ministry access vaccines.

In 2010, Haiti experienced its first cholera outbreak, a massive event that went on for years, sickening more than 820,000 people, 9,792 of them fatally.

Meanwhile, several other countries are also grappling with cholera outbreaks, including Nigeria, Syria, and Malawi.
Oct 12 Tedros speech
Oct 12 Etienne speech

Avian flu strikes more poultry in 6 states

Six states have reported more highly pathogenic avian flu outbreaks in poultry, including three on commercial farms, according to the latest updates from the US Department of Agriculture (USDA) Animal and Plant Health Inspection Service (APHIS).

In events affecting commercial farms, South Dakota reported an outbreak at a gamebird farm in Gregory County that has 200 birds. In Kansas, the virus struck a duck farm housing 2,000 birds in Neosho County. And Utah reported outbreaks at two more commercial turkey farms in Sanpete County, which combined had more than 65,000 birds.

Meanwhile, the virus struck other types of flocks in five states. Florida reported two outbreaks in backyard birds, in Broward and Martin counties. Colorado, Michigan, and Minnesota also reported more outbreaks in backyard producers. Also, Kansas reported the virus in poultry at a petting zoo in Johnson County.

Since the Eurasian H5N1 strain was first reported in US poultry in early February, outbreaks in 42 states have led to the loss of 47.2 million birds.
USDA APHIS poultry avian influenza outbreak updates

In international H5N1 developments, the United Kingdom's Department for Environment, Food, and Rural Affairs (DEFRA) said in an update this week that Britain is seeing its most outbreaks ever, with more than 170 confirmed across the country since late October 2021. Christine Middlemiss, DVM, the UK chief veterinary officer, said bird flu cases are being confirmed on commercial farms in backyard birds across the country, driven by high levels of disease in wild birds.

"Unfortunately we expect the number of cases to continue to rise over the coming months as migratory birds return to the UK, bringing with them further risk of disease that can spread into our kept flocks," she said.
Oct 10 DEFRA update