CDC issues new guidance for prevention, treatment of sporadic, bioterrorist-deployed tularemia

News brief

Tularemia pathogen — *Love Employee / iStock*

Today, Morbidity and Mortality Weekly Report published updated guidance from the US Centers for Disease Control and Prevention (CDC) on postexposure prophylaxis (prevention) and treatment of the rare but potentially serious tickborne disease tularemia.

The recommendations are aimed at healthcare providers caring for patients with naturally occurring infections or, in the case of bioterrorist deployment of the pathogen, working with preparedness experts and public health authorities to prepare their clinics, hospitals, and communities.

Tularemia is caused by the gram-negative bacteria Francisella tularensis, which spreads through bites from ticks, deer flies, and mosquitoes. Infections occur naturally in the Northern Hemisphere, with up to 300 cases in the United States each year. But because only a small amount of pathogen is required for infection, tularemia is classified as a bioterrorism agent that could sicken thousands of people.

Intentional release of the pathogen would require public health agencies, first responders, and clinicians to make rapid decisions. "To mitigate the effects of a bioterrorism attack, the US government stockpiles medical countermeasures, and the 21st Century Cures Act mandates development of evidence-based guidelines for their use," the authors wrote.

First-line treatments, group-specific recommendations

To create the guidelines, the CDC conducted systematic literature reviews on human tularemia cases through 2023, analyzed surveillance data, compiled outbreak reports and case series, gathered animal data, and consulted with experts.

In the wake of a bioterrorism attack, initial treatment with two distinct effective antimicrobial classes is recommended because of the risk for engineered antimicrobial resistance.

Key departures from the 2001 guidelines include use of a prophylaxis and treatment framework and designation of fluoroquinolone antibiotics (ciprofloxacin and levofloxacin) and doxycycline as first-line treatments for outbreaks.

Other changes include identification of third-tier treatments if first-line and alternative antimicrobials are unavailable or contraindicated, and guidance for newborns, breastfeeding infants, lactating mothers, patients with weakened immune systems, and older people.

The recommendations don't include information on dispensing treatments, diagnostic testing, triage, or adjunct therapies.

"In the wake of a bioterrorism attack, initial treatment with two distinct effective antimicrobial classes is recommended because of the risk for engineered antimicrobial resistance," the authors wrote.

Treating recurrent C difficile cases cost hospital millions, study finds

News brief

Chris Dall, MA

A study conducted at a community hospital in New Jersey highlights the excess costs associated with recurrent Clostridioides difficile infection (CDI), researchers reported this week in Infection Control & Hospital Epidemiology.

The retrospective study of patient medical records by clinicians at AtlantiCare Regional Medical Center included patients who had three or more inpatient admissions due to CDI from January 2017 through December 2020. Although few studies have looked at the net economic impact of treating recurrent-CDI patients at the hospital level, healthcare costs for recurrent cases are notably higher than they are for an initial CDI case.

CDI is the most common cause of hospital-associated diarrhea, affecting more than 500,000 Americans annually. An initial episode is a known risk factor for recurrence. An estimated 25% to 30% of patients with an initial CDI case experience a recurrence, and 50% to 65% of patients with one recurrence experience subsequent cases.

Net loss of more than $2 million

Among the 29 patients included in the analysis (median age, 58.9 years; 55% female), there were 108 admissions, 1,006 inpatient hospital days, and 74 days in the intensive care unit over the study period. Patients had a median of three admissions, with a median length of stay of 7 days. Total hospitalization costs were estimated to be $3,352,400, and the estimated reimbursement received by the hospital was $1,119,043.

"Thus, we estimated that the community teaching hospital had a net loss of $2,232,997 over the 4-year period due to CDI-related hospitalizations," the study authors wrote. "This translates to a net loss per patient of approximately $77,000 over the 4-year study period."

The authors add that their analysis may underestimate the true financial losses incurred, since they assumed full reimbursement, and that may not always be the case.

They concluded, "Our findings indicate that there is an ongoing cycle of CDI admissions among a subset of patients who experience CDI, which poses a substantial economic impact on the hospital."