News Scan for Jul 30, 2021

News brief

US COVID-19 vaccine disparities linked to socioeconomics

US COVID-19 vaccine disparities (CVD) were linked with income, education, political views, and race, according to a study yesterday in the Proceedings of the National Academy of Sciences.

The researchers looked at vaccination rates in 756 counties, or 51.5% of the US population, on Apr 19, when almost half of adults were at least partially vaccinated. Weighted average CVD across counties was 16.0 percentage points, with an average of 35.9% of White people and 19.9% of Black people vaccinated per county. While this was less of a disparity compared with the flu vaccine (18.8 percentage points, 51.6% and 32.8%), stronger associations were seen for most other socioeconomic indicators.

CVD had a negative association with median income (estimate -2.20 vs 1.14 for flu vaccine disparities), proportion of Black residents (-5.24 vs insignificant relationship), and Republican voting in the 2020 election (-6.45 vs -1.52). The greater the disparity in high school graduation in the county, the greater the CVD (2.01 vs 0.19). Vehicle ownership and home IT rate (eg, internet access) were both uncorrelated for CVD.

"To the extent that another pandemic is almost inevitable, our findings underscore the importance of spotlighting the inequity in vaccination rates between Blacks and Whites," the researchers write, noting that the CVD results were consistent when looking at Mar 27, Apr 7, and May 20 data as well.

"A clear theme in our results is the centrality of socioeconomic privilege and political ideology," they continue. "Disparities in high school graduation rates were key drivers of CVD: A county in the 75th percentile of education disparity has a 10.7 percentage point difference in high school graduation rates between White and Black residents, corresponding to an estimated increase in CVD of 2.7 percentage points compared to a county with no high school disparities."
Jul 29 Proc Nat Acad Sci study

**Raw cake batter linked to multistate E coli O121 outbreak**

The Centers for Disease Control and Prevention (CDC) this week announced that an Escherichia coli O121 outbreak associated with cake mix has sickened at least 16 people in 12 states.

So far, all of the identified patients are female, and 75% are children younger than 18—a group known to experience more severe E coli infections. Seven people have been hospitalized, and one developed hemolytic uremic syndrome, a potentially fatal kidney complication. No deaths have been reported.

Illnesses began on Feb 26, and the most recent illness onset was Jun 21. Affected states are spread throughout the United States, with Illinois, Iowa, Nebraska, and Ohio each reporting two cases. The following states reported a single case: Indiana, Massachusetts, Michigan, Oregon, South Carolina, Utah, Virginia, and Washington.

The CDC added that the true number of sick people is likely much higher than what has been reported, given that many people may have recovered and weren't likely tested for E coli.

Of eight people interviewed about the foods they ate, six said they tasted or ate raw batter made from a cake mix. No specific brand or type has been identified, though the Food and Drug Administration (FDA) is conducting a traceback investigation to assess if a common source is involved.

The CDC has said eating raw cake batter poses foodborne disease risks, which can be reduced by baking and cooking. In 2016, a complex investigation identified flour processed from one facility as the source of E coli O121 in an outbreak that sickened 56 people from 24 states.
Jul 28 CDC outbreak announcement
Nov 22, 2017, CIDRAP News story "Report details unlikely culprit of E coli outbreak: flour"

In other E coli developments, Greater Omaha Packing, based in Nebraska, has recalled nearly 300,000 pounds of raw beef intended for nonintact use after routine samples revealed E coli O157:H7, according to a statement yesterday from the US Department of Agriculture Food Safety and Inspection Service (FSIS). The products were sent to processors in Illinois, Indiana, Minnesota, and Nebraska. No illnesses have been reported.
Jul 29 FSIS statement

Vaccine-derived polio infects more people in Africa

Two African countries—Nigeria and Senegal—reported more polio cases this week, both involving circulating vaccine-derived poliovirus type 2 (cVDPV2), according to the latest weekly update from the Global Polio Eradication Initiative (GPEI).

Nigeria reported 18 more cases, 12 from Jigawa state, 2 each from Yobe and Borno states, and 1 each from Adamawa and Bauchi states. The country has now reported 49 cVDPV2 cases this year, compared to 8 for all of 2020.

Senegal reported one more case, involving a patient from Thies, bringing its total for 2021 to 13.
Jul 29 GPEI update

ASP Scan (Weekly) for Jul 30, 2021

News brief

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

OIE report shows countries using fewer antimicrobials in animals

Originally published by CIDRAP News Jul 29

A new report from the World Organisation for Animal Health (OIE) shows a global decline in the use of antimicrobials in animals.

Of the 69 countries that provided data for 2015 through 2017, an overall decrease of 34% was observed, with antimicrobial quantities dropping from 174.01 milligrams per kilogram (mg/kg) to 114.84 mg/kg. Among the 102 countries reporting data for 2017, the estimated amount of antimicrobials used in animals was 107.68 mg/kg.

"The decrease in antimicrobial quantities adjusted by animal biomass in all OIE Regions represents countries' commitment to the responsible use of antimicrobials in animals at the country level," the reported stated.

While the report is the fifth published by the OIE on antimicrobials intended for use in animals, it's the first to analyze trends among countries.

In addition, a record high 160 countries provided data for the report (a 23% increase in participation), and 133 countries reported more detailed quantitative data than in previous reports (a 16% increase). The report attributed that finding to countries continuing to develop their antimicrobial use monitoring systems.

Among other findings, 112 countries (70%) reported that they did not use any antimicrobial agents for growth promotion in animals, regardless of the presence or absence of national legislation. Twenty-three countries reported that a lack of regulatory framework, human resource constraints, and lack of information technology tools were barriers faced in reporting quantities of antimicrobials for use in animals.

Given these challenges, the OIE advises caution in interpreting the data.

"The OIE remains strongly committed to supporting its Members in developing robust and transparent measurement reporting mechanisms for antimicrobial use, but the challenges faced by many of our Members must not be under-estimated," the report said. "While data collection systems further develop, this annual report will provide an essential global and regional analysis of antibiotic use in animals, and changes over time."
Jul 27 OIE report

UK funds project to track resistant pathogens in food, agriculture

Originally published by CIDRAP News Jul 29

The UK government this week announced £19.2 million (US $26.8 million) in funding for a project that will use genomic technology to track foodborne and antibiotic-resistant pathogens through the food-production system.

The funding will help the Pathogen Surveillance in Agriculture, Food and the Environment (PATH-SAFE) program develop a pilot national surveillance network, using the latest DNA sequencing technology and environmental sampling, to improve detection and tracking of pathogens from farm to fork in all four nations of the United Kingdom, according to a press release from the UK's Food Standards Agency.

The focus of the project will be the creation of a database for storing, analyzing, and sharing sequence and source data collected from multiple locations.

"This project is designed to help safeguard UK food, agriculture and consumers by using cutting edge technology to understand how pathogens and AMR [antimicrobial resistance] spread," FSA Chief Scientific Officer Robin May, PhD, said. "Tracking the source of these issues will ultimately help us to develop better control strategies to reduce illness and deaths."
Jul 27 FSA press release

Study: Nursing home intervention led to fewer antibiotics for UTIs

Originally published by CIDRAP News Jul 28

A tailored intervention implemented at nursing homes in Denmark reduced antibiotic prescriptions and unnecessary interventions for urinary tract infections (UTIs) without substantially increasing hospitalizations and mortality, Danish researchers reported last week in The Lancet Infectious Diseases.

In a cluster-randomized trial involving 22 nursing homes, 11 were randomized from June 1, 2017, to June 1, 2018, to receive interactive educational sessions on how to distinguish between a UTI and asymptomatic bacteriuria and evaluate non-specific symptoms, along with an algorithm to determine whether a UTI is likely. The remaining nursing homes continued standard UTI management.

While nursing home staff in Denmark (unskilled workers, nurses, healthcare assistants, and healthcare helpers) don't prescribe antibiotics, the theory behind the intervention was that diagnosis and treatment of UTIs are directly influenced by the staff's knowledge and communication skills.

The primary outcome of the trial was the number of antibiotic prescriptions for acute UTI per residents per days at risk in the intervention and control groups. Secondary outcomes included the appropriateness of antibiotic treatment for UTIs, all-cause hospitalizations, and all-cause mortality.

A total of 1,470 nursing home residents (765 in the intervention group and 705 in the control group) were analyzed for the primary endpoint. The number of prescriptions for UTI per resident was 134 per 84,035 days at risk in the intervention group, compared with 228 per 77,817 days at risk in the control group, for an unadjusted rate ratio (RR) of 0.51 (95% confidence interval [CI], 0.37 to 0.71) and an adjusted RR of 0.42 (95% CI, 0.31 to 0.57).

In terms of secondary outcomes, the risk of receiving appropriate antibiotic treatment (RR, 0.65; 95% CI, 0.41 to 1.06) and inappropriate (RR, 0.33; 95% CI, 0.23 to 0.49) treatment was lower in the intervention group. All-cause hospitalization increased in the intervention group (adjusted RR, 1.28; 95% CI, 0.95 to 1.74), but all-cause mortality was lower (adjusted RR, 0.91: 95% CI, 0.62 to 1.33).

"Our results imply that a broader range of health professionals should be engaged in antibiotic stewardship and that programmes should be tailored to address potential barriers to implementation and should focus on education, reflection, and a structured professional dialogue," the study authors wrote.
Jul 22 Lancet Infect Dis abstract

Study: Use of restricted antibiotics rose after hospital ASP discontinued

Originally published by CIDRAP News Jul 27

The discontinuation of an antimicrobial stewardship program (ASP) at a South Korean hospital led to a rapid return of antibiotic use patterns observed before the ASP was implemented, researchers reported yesterday in Clinical Microbiology and Infection.

The interrupted time-series analysis looked at antibiotic use at the 859-bed hospital from September 2015 through August 2019. The hospital ASP, which focused on restricting the use of certain antibiotics, was implemented in September 2016 and discontinued in March 2018 after an infectious disease (ID) specialist resigned. Infection control measures at the hospital remained largely the same throughout the study period.

Immediately after discontinuation, the use of restrictive antibiotics increased by 41.06 days of therapy (DOT) per 1,000 patient-days in the hospital's general ward and by 391.04 DOT/1,000 patient-days in the intensive care unit (ICU). Increases were driven by the use of carbapenems in the general ward and ICU and glycopeptides in the ICU. In addition, there were positive changes in the slope for the use of restrictive antibiotics in the general ward and the ICU.

While the use of broad-spectrum antibiotics declined after discontinuation of the ASP, the study authors suggest a large proportion of broad-spectrum antibiotic prescribing may have been shifted to restrictive antibiotics.

"Therefore, instead of a reduction in the use of broad-spectrum antibiotics, the use of restrictive antibiotics increased," the authors wrote. "We suggest that the restrictive intervention for antibiotics is probably not educative and is not sustained."

The study notes that the number of active ID specialists in South Korea is limited, and that despite an emphasis on the importance of antimicrobial stewardship, many ASPs have been discontinued because of a shortage of workers.
Jul 26 Clin Microbiol Infect study

FDA rejects new drug application for sulopenem

Originally published by CIDRAP News Jul 27

Pharmaceutical company Iterum Therapeutics said yesterday that the US Food and Drug Administration (FDA) has rejected the company's new drug application (NDA) for approval of its oral antibiotic sulopenem etzadroxil/probenecid.

Iterum is seeking approval of the antibiotic for treatment of UTIs in patients who do not do not respond to treatment with fluoroquinolones. But in a Jul 23 Complete Response Letter (CRL) to the company, the FDA said it could not approve the NDA in its current form.

While the FDA acknowledged the results of a phase 3 clinical trial indicated that patients with ciprofloxacin-resistant UTIs had a better response to oral sulopenem compared with ciprofloxacin, the agency said additional data from another clinical trial are needed to support approval for treatment of women with uncomplicated UTIs caused by fluoroquinolone-resistant pathogens.

The FDA also recommended that Iterum conduct further nonclinical research to determine the optimal dosing regimen.

"We are disappointed in this outcome and believe that the data package submitted was adequate for the approval of oral sulopenem," Iterum Therapeutics Chief Executive Officer Corey Fishman said in a company press release. "Regardless, we will evaluate the points raised in the CRL for discussion with the FDA to determine an expeditious path forward. We remain confident in the value of, and unmet medical need for, oral sulopenem to treat multi-drug resistant infections, including fast-growing quinolone non-susceptible pathogens."

The company says sulopenem has received Qualified Infectious Disease Product and Fast-Track designations from the FDA for seven indications.
Jul 26 Iterum Therapeutics press release

Study: High antibiotic use in COVID patients with no co-infections

Originally published by CIDRAP News Jul 26

Nearly two thirds of COVID-19 patients without bacterial or fungal co-infections in Michigan hospitals received antibiotics during the first wave of the pandemic, University of Michigan researchers reported today in Infection Control & Hospital Epidemiology.

Of the 2,205 patients hospitalized for COVID-19 at 38 Michigan hospitals from Mar 16 through Aug 14, 2020, 141 (6.4%) had a co-infection; 3.0% were community-onset infections, and 3.4% were hospital-acquired. Among those with community-onset co-infection, 49.3% had respiratory infections, and 50.7% had bloodstream infections, while 77.2% of hospital-acquired infections were respiratory, and 22.8% were bloodstream infections. Among the patients with no co-infection, 64.9% received an antibiotic during hospitalization or at discharge.

Assessment of predictors for co-infection found that admission from a long-term care facility (odds ratio [OR], 3.98; 95% CI, 2.34 to 6.76) and admission to intensive care (OR, 4.34; 95% CI, 2.87 to 6.65) were associated with increased risk of community-onset infection. Hospital-acquired co-infection predictors included fever (OR, 2.46; 95% CI, 1.15 to 5.27) and advanced respiratory support (OR, 40.72; 95% CI, 13.49 to 122.93). Both community-onset and hospital-acquired co-infection were associated with higher in-hospital and 60-day mortality.

The findings are in line with previous studies from several countries that have found high rates of antibiotic use in COVID-19 patients, despite low prevalence of co-infection.

The study authors say knowing the incidence and predictors of community-acquired and hospital-onset infections could help efforts to reduce unnecessary antibiotic use in COVID-19 patients.

"Interventions reducing unnecessary antibiotics in COVID-19 patients could potentially reduce the global emergence of multidrug resistant organisms, adverse events such as renal injury, and even mortality," they wrote.
Jul 26 Infect Control Hosp Epidemiol abstract

Study highlights need for better antibiotic stewardship at discharge

Originally published by CIDRAP News Jul 26

A review of electronic health records at three Indiana hospitals found patients receiving prolonged courses of antibiotic therapy for common types of infections, researchers reported last week in Open Forum Infectious Diseases.

The review, conducted from January through June 2019, looked at all adult patients who began antibiotic therapy at the hospitals and continued antibiotic therapy after discharge, focusing on patients with skin/soft tissue infection (SSTI), UTI, community-acquired pneumonia (CAP), or acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The days of therapy (DOT) for each inpatient and outpatient antibiotic prescribed were collected to calculate the total DOT for each patient.

Of the 547 patients included in the review, 233 (42.6%) had CAP, 120 (21.9%) had uncomplicated UTI, 101 (18.5%) had SSTI, and 93 (17%) had AECOPD. The median duration of antibiotic therapy across all indications was 9 days, with a median duration of 9 days for CAP (4 days longer than recommended minimum treatment), 8 days for UTI (3 to 5 days longer), 12 days for SSTI (5 to 7 days longer), and 7 days for AECOPD (2 to 4 days longer). The most common antibiotics prescribed at discharge were cephalosporins, amoxicillin/clavulanate, and fluoroquinolones.

The authors say it is essential that clinicians account for DOT completed during hospital admission to determine the remaining DOT necessary following discharge and prevent excessive antibiotic durations. "Transitions of care remain an area for improvement for hospital antibiotic stewardship programs," they wrote.
Jul 24 Open Forum Infect Dis abstract