Study: 11% of diabetics die within 1 week of hospitalization for COVID-19

The first major study of diabetics hospitalized with COVID-19 shows more than 1 in 10 die within 7 days of admission, and about 1 in 5 is intubated within 1 week. The study appears today in Diabetologia.

The analysis, named the CORONADO study, was conducted across 53 French hospitals from Mar 10 through 31 and included 1,317 patients diagnosed as having COVID-19 and diabetes.  The vast majority (89%) had type 2 diabetes, and 3% had type 1. Men constituted 69% of the patients. Twenty-nine percent of patients either died (140 patients, 10.6%) or were mechanically ventilated by day 7. Only 18.0% of patients were discharged by day 7.

Microvascular and macrovascular diabetic complications were found in 46.8% and 40.8% of cases, respectively, the authors said. Neither long-term glucose control nor current insulin use was found to increase the risk of death. Instead, as in the general population, only age and body mass index (BMI) were associated with worsening outcomes for patients.

"BMI was positively and independently associated with the primary outcome, which is largely driven by tracheal intubation," the authors said. They add that their findings could be reassuring to well-managed type 1 diabetics, as the study found no deaths among type 1 diabetics under the age of 65.
May 29 Diabetologia study

New York COVID-19 case series: High kidney injury, death rates

An analysis of the first 1,000 patients treated for COVID-19 at a large teaching hospital in New York City found that patients had more underlying health conditions, longer intubations, and higher rates of kidney injury compared with similar reports from other countries. New York–based researchers reported their findings—including a 21% death rate—today in BMJ.

The authors examined the electronic medical records of patients hospitalized at New York-Presbyterian/Columbia University Irving Medical Center from Mar 1 to Apr 5. Of the 1,000 patients, 150 came in through the emergency department and 614 were admitted to the hospital, with 236 admitted or transferred to the intensive care unit (ICU).

The most common comorbidities were high blood pressure, diabetes, and obesity. ICU patients tended to be older and male, with longer stays. Acute kidney injury was seen in 78.0% of ICU patients, with 35.2% needing dialysis. The authors saw a dual pattern with regard to intubation following symptom onset, some at 3 to 4 days and another group at 9 days. As of Apr 30, 211 people (21.1%) had died, and 90 (9.0%) were still in the hospital.

The dual pattern for intubation could suggest a biphasic disease course, the researchers wrote, and the renal complication was strikingly higher than other reports, with limited intravenous fluids, toxicity from the disease process, or increased comorbidities as potential contributing factors.

The authors said the findings could help guide clinical practice, especially regarding vigilance the development of breathing problems, even after conditions appear to be stabilizing.
May 29 BMJ study

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

Canadian data show rise in MRSA, VRE blood infections

Data collected from Canadian acute care hospitals show significant increases in methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) bloodstream infections (BSIs) in recent years, according to a study in the Canada Communicable Disease Report (CCDR).

The data, collected from 70 Canadian sentinel hospitals from 2014 through 2018 through the Canadian Nosocomial Infection Surveillance Program, show a 59.1% increase in MRSA BSIs (0.66 to 1.05 infections per 10,000 patient-days) and a 143% increase in VRE BSIs (0.14 to 0.34 infections per 10,000 patient-days).

But Clostridioides difficile infections decreased by 12.5% (from 6.16 to 5.35 infections per 10,000 patient-days). Carbapenem-resistant Enterobacteriaceae infection rates remained low and stable (0.04 infections per 10,000 patient-days), while colonization rates increased by 375% (from 0.04 to 0.19 per 10,000 patient-days).

The authors of the study said the increases in MRSA and VRE BSIs are concerning because of the increased mortality associated with these infections.

"These findings indicate a need for continued vigilance to prevent morbidity and mortality attributable to HAIs [healthcare-associated infections) and AROs [antimicrobial resistant organisms] in the inpatient population," they wrote.
May 28 CCDR study

CARB-X to fund antibiotic for cystic fibrosis-related lung infections

Originally published by CIDRAP News May 28

CARB-X today announced an award of up to $6.1 million to support the preclinical development of an inhaled antibiotic to treat cystic fibrosis (CF)-related pulmonary infections

The funding will help Microbion Corporation of Bozeman, Montana, develop pravibismane, a novel anti-infective that has shown potent activity in laboratory tests against antibiotic-resistant pathogens such as multidrug-resistant Pseudomonas aeruginosa, and the biofilms produced by these pathogens. People with CF are susceptible to chronic bacterial infections caused in part by thick mucus in their lungs that traps bacteria pathogens, which in turn develop protective layers of biofilm that make treatment difficult.

Microbion could receive an additional $5.4 million from CARB-X (the Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator) if certain project milestones are met. The company also received $5.6 million from the Cystic Fibrosis Foundation.

"Beyond their investment, these organizations' expertise in antibiotic-resistant infections, particularly those associated with CF, will prove valuable to advancing our technology as part of a much-needed solution to address the chronic and intractable infections that are a hallmark of CF," Microbion Chairman Karim Lalji said in a CARB-X press release.
May 28 CARB-X press release

Study: Antibiotic use rising in Australian nursing homes

Originally published by CIDRAP News May 28

A nationwide study of antibiotic prescribing in Australian nursing homes found marked increases in use and consumption between 2005 and 2016, researchers reported yesterday in Clinical Infectious Diseases.

Their analysis, which included 502,752 residents and 3,218 nursing homes, covered 424.9 million resident days. Antibiotics were prescribed 5,608,126 million times over the 10-year study period, 88% of them for oral use. The most commonly prescribed antibiotics were cefalexin, amoxicillin-clavulanic acid, and trimethoprim.

Annual prevalence rose from 63.8% to 70.3%, with a 39% relative increase in total consumption of systemic antibiotics. Over the study period, use increased from 67.6 to 93.8 defined daily doses (DDDs) per 1,000 resident days, with an average annual increase of 2.8 DDDs per 1,000 resident days.

The group said the increasingly widespread use of antibiotics in Australian nursing homes is concerning and underscores the need for stronger stewardship efforts in those settings.
May 27 Clin Infect Dis abstract

Review supports WHO guidance against post-surgery antibiotics

Originally published by CIDRAP News May 27

A review and meta-analysis of randomized controlled trials (RCTs) has found no conclusive evidence that post-operative antibiotic prophylaxis reduces incidence of surgical-site infections, a finding that supports the World Health Organization's (WHO's) recommendation for discontinuation of the practice, researchers reported yesterday in The Lancet Infectious Diseases.

The aim of the review, which was conducted by Dutch, Swiss, and US researchers, was to update and reassess the evidence upon which the WHO's 2016 recommendation was based. The WHO's Global Guidelines for the Prevention of Surgical Site Infections, put together by a panel of 20 experts in infection control, recommended that prophylactic antibiotics be administered 2 hours before incision or during the surgery to prevent infections, but not after, based on a lack of evidence that post-surgery antibiotics reduce infections. Despite this advice, the practice remains common worldwide, with antibiotics frequently continued for days after surgery.

The reviewers identified 83 relevant RCTs, with 52 (involving 19,273 participants) comparing post-operative continuation of antibiotics for 1 to 5 days with immediate discontinuation. The initial meta-analysis of those 52 RCTs showed an indication of a benefit of post-operative continuation of antibiotics in preventing surgical-site infection (relative risk [RR], 0.89; 95% confidence interval [CI], 0.79 to 1.00).

But further analysis showed that compliance with best practice standards for surgical antibiotic prophylaxis, such as timely administration of the first dose, modified the results. In the 27 trials that were not compliant with best-practice standards, continuation of antibiotic prophylaxis after surgery was associated with a reduction in surgical-site infections compared with immediate discontinuation (RR, 0.79; 95% CI, 0.67 to 0.94). But in the 24 studies that did meet best practice standards, no benefit was found (RR, 1.04; 95% CI, 0.85 to 1.27).

The meta-analysis also found that, when costs and adverse events were reported, post-operative continuation of antibiotics appeared to increase costs and lead to more adverse events.

"Our findings support WHO recommendations against the practice of continuing surgical antibiotic prophylaxis postoperatively," the authors concluded. "Considering the associated adverse effects—in particular, antimicrobial resistance—this prevalent practice has no basis."
May 26 Lancet Infect Dis abstract

British report highlights high antibiotic use in US livestock, trade concerns

Originally published by CIDRAP News May 27

A new report shows antibiotic use in food-producing animals is much higher in the United States than the United Kingdom, and warns that a potential US trade deal with Britain risks reversing the progress that British farmers have made in reducing antibiotic use in livestock.

Using data from the US Food and Drug Administration, the United Kingdom's Veterinary Medicines Directorate, and the European Medicines Authority, the UK-based Alliance to Save Our Antibiotics compared US and UK antibiotic use by farm-animal species and found that total antibiotic use in US farm animals is more than five times higher than in UK farm animals, with US cattle receiving eight to nine times as many antibiotics as UK cattle. The comparison takes into account the size of the different livestock populations.

The comparison was made to highlight how the United Kingdom's pending exit from the European Union could threaten food safety and animal welfare standards. With the government planning to cut tariffs on importation of meat from countries with which it does not currently have a free trade deal, that could mean a significant increase in meat and dairy imports from the United States, which has less restrictive policies on the use of antibiotics and growth promoters in animals than the UK or the EU. Most imported meat in Britain currently comes from the EU.

"US farmers continue to massively overuse antibiotics despite increasing warnings about the threat this poses to human health," Alliance scientific advisor Cóilín Nunan said in a press release. "British consumers should be concerned if a UK-US trade deal results in increasing imports of US meat and dairy produced in this way, as we know that antibiotic-resistant bacteria can pass to humans through the food chain."

According to the report, US livestock industry representatives and lobbyists have insisted that in any trade deal, UK farmers should adopt US standards. Among the many concerns expressed is that the US government is opposed to banning the use of antibiotics to prevent disease in livestock, as has been recommended by the WHO. An EU ban on preventive antibiotic treatment will go into effect in 2022

The report notes that British farmers cut their antibiotic use by 50% from 2014 through 2018, while antibiotic use on US farms increased by 9% in 2018 after several years of decline. 
May 27 Alliance to Save Our Antibiotics report
May 27 Alliance to Save Our Antibiotics press release

Study: Conventional, organic dairy farmers differ on antibiotic use, resistance

Originally published by CIDRAP News May 27

A study exploring perceptions about antibiotic use and resistance in dairy farming suggests conventional and organic farmers have differing views that align with their respective business practices, researchers from Cornell University report today in PLOS One.

For the study, the researchers conducted semi-structured interviews with farmers representing 20 dairy farms in New York state—15 conventional and 5 US Department of Agriculture–certified organic farmers—and used thematic analysis to compare and contrast the farmers' characterization of their beliefs, values, and concerns. Among the themes they found was that, for conventional farmers, concerns about antibiotic use and resistance mainly related to the near-term impact on their livestock should antibiotics lose their efficacy, rather than the potential impact on human health. Conventional farmers also believed their antibiotic use was judicious, even if it didn't always fit the definition of judicious use, and felt that further regulation on antibiotic use could threaten their cattle's health.

In contrast, organic dairy farmers expressed more concern about antibiotic resistance, frequently framed it as a public health issue, and exhibited a more detailed understanding of judicious antibiotic use. Both groups had similar doubts about shared concerns about the impact of marketing and consumer perceptions on dairy, and emphasized herd health management as an effective preventive tool that could limit the need to antibiotics.

The authors of the study say the findings provide some targets for additional research and educational interventions.

"Given farmers' interest in disease prevention, they would likely be amenable to interventions focused on improving the efficiency and financial viability of their operation through improved herd health practices, including optimal antibiotic use/best practices," they write. "Such interventions would likely be best delivered by a veterinarian given farmers' trust of them."
May 27 PLOS One study 

French study finds high antibiotic use for viral respiratory infections in kids

Originally published by CIDRAP News May 26

An assessment of community antibiotic prescribing in French children found high rates of prescribing for viral respiratory tract infections (RTIs) and broad-spectrum antibiotic use, particularly among clinicians 50 years and older, French researchers reported yesterday in the Journal of Antimicrobial Chemotherapy.

The analysis looked at 221,768 pediatric visits in a national sample of 680 French general practitioners (GPs) and 70 community pediatricians from March 2015 to February 2017. The researchers calculated antibiotic prescription rates per 100 visits separately for GP and pediatricians, and assessed broad-spectrum antibiotic use and duration of treatment for RTIs. The results showed that, overall, GPs prescribed more antibiotics than pediatricians, with a prescription rate of 26.1 per 100 visits (95% CI, 25.9 to 26.3) versus 21.6 for pediatricians (95% CI, 21 to 22).

RTIs accounted for more than 80% of antibiotic prescriptions, with presumed viral RTIs being responsible for 40.8% and 23.6% of all antibiotic prescriptions by GPs and pediatricians, respectively. For RTIs, GPs prescribed more broad-spectrum antibiotics than pediatricians (49.8% vs 35.6%), while antibiotic course duration was similar. After adjustment for diagnosis, antibiotic prescribing rates were not associated with season and patient age, but were significantly higher among GPs over 50.

"We suggest that future antibiotic stewardship campaigns should emphasize: zero antibiotic prescribing for presumed viral RTIs (notably bronchitis, common cold and cough), further reducing broad-spectrum antibiotic prescribing and more effective communication towards GPs, especially those older than 50 years of age," the authors wrote. 
May 25 J Antimicrob Chemother abstract

Higher antibiotic prescribing found in more deprived areas of Wales

Originally published by CIDRAP News May 26

In another study yesterday in the Journal of Antimicrobial Chemotherapy, researchers in Wales reported that antibiotic prescribing is higher among GP practices in poorer parts of the country.

Analyzing data on nearly 3 million patients from 339 GP practices, researchers from Cardiff University found that approximately 9 million oral antibiotics were prescribed from 2013 through 2017. Antibiotic prescribing rates per person varied by levels of socioeconomic status (SES), with the rate in the most deprived areas of the country being 26% higher than in the least deprived. The association between deprivation and antibiotic prescribing persisted after controlling for demographic variables, smoking, chronic conditions, and clustering by GP practice and GP cluster. Those living in areas in the most deprived quintile in Wales received 18% more antibiotic prescriptions (incidence rate ratio [IRR], 1.18; 95% CI, 1.18 to 1.19) than those with similar demographics, chronic conditions and smoking status but living in areas in the least deprived quintile.

The authors of the study say the higher prescribing rates seen in more deprived areas could be because people in lower SES groups consult healthcare providers more frequently and may consult more frequently for infections. In addition, prescribers could be more concerned about increased risk of complications in this group. They say the findings may be generalizable to other countries with similar settings and healthcare delivery systems.
May 25 J Antimicrob Chemother abstract