Stewardship / Resistance Scan for Sep 30, 2021

News brief

Global point-prevalence survey helps hospital stewardship, survey finds

Results from a worldwide survey of hospitals suggests that the Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) has helped inform stewardship activities, Belgian researchers reported this week in Antimicrobial Resistance and Infection Control.

Launched in 2015, Global-PPS provides hospitals with a standardized method of collecting and assessing antimicrobial prescribing data and has been used by more than 700 hospitals around the world. But little is known about how hospitals are using it to inform antimicrobial stewardship (AMS) activities. To assess its role in AMS efforts and identify barriers to implementing AMS in different resource settings, researchers from the University of Antwerp sent a cross-sectional survey to hospitals within the Global-PPS network.

A total of 248 hospitals from 74 countries participated in the survey; of these, 192 (77.4%) had conducted the PPS at least once. In 96.9% of these 192 hospitals, Global-PPS participation had led to the identification of problems with antimicrobial prescribing. The most common prescription-related problems were a high relative use of certain classes of antibiotics (62%), prolonged surgical antibiotic prophylaxis (60.9%), and a high antimicrobial use prevalence (60.4%). In 69.3% of hospitals, at least one AMS component was related to findings from the Global-PPS. The Global-PPS was mostly used to inform education and communication and the development and review of guidelines.

The level of AMS implementation in hospitals varied by region. Up to 43.1% of all hospitals had a formal AMS strategy, ranging from 10.8% of hospitals in Africa to 60.9% of hospitals in North America. Another 29.7% reported that they were planning to develop a formal AMS strategy. The main barriers to implementing AMS programs were a lack of time (52.7%), knowledge on good prescribing practices (42.0%), and dedicated funding (39.9%). Hospitals in low- and middle-income countries more often reported a lack of prescribing guidelines, insufficient laboratory capacity, and suboptimal use of available lab services.

Despite the substantial variation in hospital AMS programs and the barriers to implementation, the authors say the results show how Global-PPS can contribute to AMS activities.

"Providing all participating hospitals with a personalised feedback report, the Global-PPS allows local teams to identify targets for antimicrobial stewardship without the need to invest time and resources in complex data analyses," they wrote.
Sep 28 Antimicrob Resist Infect Control study

Short-course antibiotics shown effective for Pseudomonas bloodstream infections

A retrospective study of patients with Pseudomonas aeruginosa bloodstream infections (BSIs) found that short-course antibiotic therapy may be as effective as long-course therapy, South Korean researchers reported today in the Journal of Antimicrobial Chemotherapy.

The researchers looked at data on all patients admitted to a tertiary care hospital with uncomplicated P aeruginosa BSIs from April 2010 through April 2020. They compared the primary outcome (a composite rate of recurrent P aeruginosa infection and mortality 30 days after discontinuing antibiotics) among patients who received short-course (7 to 11 days) and prolonged (12 to 21 days) antibiotic therapy. The secondary outcome was a recurrence of P aeruginosa infection at any site within 180 days.

A total of 290 patients met the eligibility criteria. Among them, 97 received short-course therapy (median of 9 days) and 193 underwent prolonged therapy (median of 15 days). Eleven patients in the short-course group (11%) and 30 patients in the long-course group (16%) had recurrent P aeruginosa infection or died within 30 days of completing therapy. Propensity scoring analysis using the inverse probability of treatment weighting (IPTW) method showed that prolonged therapy did not significantly reduce the risk of recurrent infection or death compared with short-course therapy (IPTW-adjusted hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.34 to 1.36).

Recurrent P aeruginosa infection at any site within 180 days of completing therapy occurred in 12 patients in the short-course group (12%) and 37 patients in the prolonged-course group (19%). Prolonged-course therapy did not significantly reduce the risk of this outcome (IPTW-adjusted HR, 0.57; 95% CI, 0.29 to 1.10).

The study authors acknowledge several limitations, including the single-center nature of the study, residual bias, rigorous exclusionary criteria, and wide confidence intervals, and say the study needs to be repeated as a randomized trial with a larger sample size. But they believe the findings could be applied to select patients with uncomplicated P aeruginosa BSIs.

"Our findings reinforce the current tendency to lean toward shorter duration of antimicrobial therapy," they write.
Sep 30 J Antimicrob Chemother abstract

News Scan for Sep 30, 2021

News brief

ECMO patients appeared to have higher mortality as 2020 went on

Critically ill COVID-19 patients who received extracorporeal membrane oxygenation (ECMO) at the end of 2020 had a higher mortality rate than those who received it in the first half of the year, according to a study published yesterday in The Lancet.

Researchers looked at 4,812 COVID-19 patients 16 years and older who received ECMO in 2020 across 349 sites and 41 countries. Using May 1, 2020, as an arbitrary marker of the release of COVID-specific guidelines for ECMO, the patients were divided into three groups: those who received ECMO through May 1, those who received ECMO after that point, and those who received it after May 1 who were also at hospitals that didn't offer COVID-19–related ECMO until after May 1 ("late adopters").

Patients who started ECMO on or before May 1, 2020, had a 90-day in-hospital mortality rate of 36.9%, while 51.9% of those who started ECMO after died. Furthermore, those treated at late-adopter centers had a mortality rate of 58.9%. Centers with more ECMO experience (at least nine patients through May 1) appeared to have better outcomes than those with less experience (risk-adjusted mortality rate, 0.56).

"The selection of the right patient at the right time is guided by clinical principles and experience, as well as availability, which might perversely delay commencement of ECMO," writes Alain Vuylsteke, MD, in a related commentary. "In the report by Barbaro and colleagues, no one knows if some patients survived despite ECMO they did not need, or if some died just because of ECMO, or what happened to those who were denied ECMO—this is still the conundrum to clarify before we decide if ECMO is worth using or not."

"ECMO cannot be blamed for the increased mortality; it is merely a tool and clinicians still need to understand when to use it for the greatest benefit," Vuylsteke concludes.
Sep 29 Lancet study and commentary

COVID vaccination linked to low hospitalization, death in Scotland

Less than 0.05% of Scottish people at least partially vaccinated against COVID-19 were hospitalized or died from the virus, according to a large, population-based study looking at data from Dec 8, 2020, to Apr 18, 2021.

The results, published yesterday in The Lancet, showed that of 2,572,008 Scottish people, 883 needed COVID-19–related hospitalization, and 541 died from COVID-19 infection after the first dose of either the Pfizer/BioNTech (32.7%) or the AstraZeneca/Oxford (67.3%) vaccine. Median follow-up after the first vaccination was 55 days, and of the 27.0% of people who received a second dose within the study period, median follow-up after the second dose was 19 days.

Higher risk was associated with being 80 years or older versus being 18 to 64 (adjusted risk ratio [aRR], 4.75), having five or more comorbidities (aRR, 4.24), being hospitalized in the previous 4 weeks (aRR, 3.00), or being employed in a high-risk occupation (aRR, 2.14). Those who were residents in a care home (aRR, 1.63), socioeconomically deprived (most deprived quintile vs least, aRR, 1.57), male (aRR, 1.27), or an ex-smoker versus a non-smoker (aRR, 1.18) also had higher risks.

On the other hand, the researchers note, having COVID-19 prior to vaccination was protective (aRR, 0.40). Those who had a longer interval between the two doses also appeared to have a lower risk (the United Kingdom extended the vaccine dose intervals to 8- to 12-weeks to maximize supply).

"Restricting booster doses to populations at the highest risk for severe disease will allow maximisation of booster dose benefits, with a minimised effect on global vaccine distribution," write Eyal Lehsem, MD, and others in a related commentary.

"The findings reported by Agrawal and colleagues allow identification and prioritisation of at-risk populations to be considered for boosting. Additionally, characterising the risks, or lack thereof, of delayed dosing schedules can aid policy makers in considering viable alternatives to standard dosing schedules in settings where vaccine availability is limited."
Sep 29 Lancet study and commentary

Study shows wearable biosensors can predict infections like flu, colds

A wearable biosensor can predict when a person is infected with common viruses, including a cold or influenza, even before the person experiences symptoms, according to a study yesterday in JAMA Network Open.

The challenge study collected data from 31 participants inoculated with H1N1 flu and 18 participants inoculated with rhinovirus. A wearable device, called the E4 wristband made by Empatica, Inc, measured heart rate, skin temperature, electrodermal activity, and movement. It accurately picked up 92% of the H1N1 infections and 88% of the rhinovirus infections.

The sensors were able to detect infection 24 hours before symptom onset 90% of the time for H1N1 and 89% of the time for rhinovirus.

This is the first demonstration that wearable devices could detect infections before symptom onset, the authors said, which would allow users to more quickly monitor themselves for illness and prevent spreading infections to others.

"This study shows that it is feasible to use wearable data to predict infection status and infection severity 12 to 36 hours before symptom onset, with most of our models reaching greater than 80% accuracy," the authors concluded. "Presymptomatic detection of respiratory viral infection and infection severity prediction may enable better medical resource allocation, early quarantine, and more effective prophylactic measures."

They add that the technology may hold promise for COVID-19.
Sep 29 JAMA Netw Open study

China reports 2 more H5N6 avian flu cases, 1 fatal

The H5N6 avian flu virus sickened two more people in China, one fatally, part of the country's steady uptick in cases this year, Hong Kong's Centre for Health Protection (CHP) said today.

The first case involves a 55-year-old man from the city of Guilin in Guangxi province, located in southern China. He is from the same city as another case announced yesterday. His symptoms began on Aug 23, and he was hospitalized on Aug 30, where his condition is listed as serious. An investigation found that he may have been exposed at a live-poultry market before he got sick.

The second case relates to a 72-year-old man from the provincial-level city of Chongqing in the southwest. His symptoms began on Sep 16, and he was hospitalized 3 days later, where he died from his infection. The CHP said he had contact with poultry before his symptoms started.

China has now reported 23 H5N6 cases for the year, bringing its total since the virus was first detected in 2014 to 47. H5N6 is known to circulate in poultry, especially in a handful of Asian countries. However, so far, only China and Laos have reported human infections, which are often severe or fatal.
Sep 30 CHP statement

Louisiana announces CWD testing incentive for hunters, taxidermists

The Louisiana Department of Wildlife and Fisheries (LDWF) announced Sep 17 that deer hunters and state taxidermists who submit deer for chronic wasting disease (CWD) sampling will be entered into a lottery for $1,000 and $500 gift cards, respectively.

The event will take place over the 2021-22 deer season, and samples must be from mature bucks harvested in the state. Participants can contact local LDWF field offices to submit samples, and hunters must record the date and parish of harvest on the carcass tag. In addition, hunters must confirm the harvest within 72 hours by phone or online through the LDWF website.

CWD is a fatal prion disease that affects the cervidae family, which includes deer, moose, and elk. It can be spread through contact with the infected body fluids of living or deceased animals and contaminated environments. The LDWF says that while no deer has been reported with CWD in the state, Texas, Arkansas, and Mississippi have all identified positive cases.
Sep 17 LDWF news release

Rabies kills Illinois man who declined vaccination

The Illinois Department of Public Health (IDPH) this week reported its first human rabies case since 1954, which involves a man from Lake County in his 80s who woke up with a bat on his neck in the middle of August.

Animal health authorities captured the bat, and it tested positive for rabies. The patient was encouraged to start postexposure rabies preventive (prophylactic) treatment, but declined. One month later, the man started experiencing rabies symptoms, which included neck pain, headache, and other neurologic problems. Lake County is in the northeast corner of Illinois, north of Chicago.

He died from his infection, and people who had contact with the man's secretions were assessed and given prophylactic treatment as needed.

Mark Pfister, executive director of the Lake County Health Department, said in an IDPH statement that, once symptoms begin, the disease is almost always fatal, making it vital that exposed people receive treatment as soon as possible.

Rabies postexposure prophylaxis consists of a dose of human rabies immune globulin and rabies vaccine given on the day of exposure, followed by doses of the vaccine on days 3, 7, and 14, according to the Centers for Disease Control and Prevention (CDC).
Sep 28 IDPH statement
CDC background