Stewardship / Resistance Scan for Aug 24, 2017

News brief

Study shows strong promise for fecal transplants for severe C difficile

A study today involving 111 patients found that early fecal microbiota transplantation (FMT) dramatically improves survival in severe Clostridium difficile infections (CDIs).

Writing in Clinical Infectious Diseases, French researchers noted that they included 66 patients with severe CDI in an FMT group and 45 in an antibiotic-only group. The FMT group received vancomycin for 2 to 4 days before and after transplant, while the non-FMT group received one of several antibiotic therapy options, depending on their clinical status, but the vast majority were prescribed vancomycin. Patients were a median of 82 years old, and follow-up was conducted at 3, 6, and 12 months.

Three-month mortality was 42.2% (19/45) in the antibiotic group and 12.1% (8/66) in the FMT group, a 71% reduction. The investigators estimated that only four patients needed to be treated with FMT to save one life at 3 months. Thirty (45.5%) FMTs were performed using fresh stools and 36 (54.5%) with frozen stools, but the researchers found no significant difference between the two.

The authors concluded, "Risk of bias was low because baseline characteristics were similar and multivariate survival models were used."

In response to a perceived need by some to wait to change C difficile treatment recommendations until randomized, double-blind, controlled trials can be launched, the authors pointed to the expense of such studies, among other factors. They said that, given the promising results of their study, "waiting for double-blind randomized controlled trials to update the recommendations and management of the most vulnerable and severely ill C. difficile-infected patients who are at very high risk of mortality . . . does not seem ethical."

In a related commentary, however, Antoine Andremont, MD, PhD, who was not involved in the study, disagreed. Andremont, from the University Paris-Diderot Medical School, cited several reasons for not changing practice standards just yet, including concerns over stalling other key research of C difficile treatment and prevention (including antibiotic stewardship approaches) and the complex nature of the fecal microbiota.
Aug 24 Clin Infect Dis study
Aug 24 Clin Infect Dis commentary

European data show declining resistance for some gonorrhea antibiotics

New data reported today by the European Centre for Disease Prevention and Control (ECDC) shows antibiotic resistance levels declining for cefixime and ceftriaxone when used to treat gonorrhea. Resistance to azithromycin, however, is on the rise.

The data were gathered from a 2015 antimicrobial susceptibility survey conducted in 24 European Union member states. A total of 2,134 isolates were collected and tested, covering 3% of the gonorrhea cases reported by routine surveillance.

Compared to data from 2014, there was a slightly lower proportion of cefixime resistance in nine member states (1.7% compared to 2.0%), and only one isolate was found to be resistant to ceftriaxone (five were found in 2014). However, five isolates displayed high-level resistance to azithromycin, compared with one in 2014.

The ECDC said the declining resistance levels were partly due to the dual-therapy regimen (ceftriaxone plus azithromycin) currently recommended to treat gonorrhea in the EU. The rising resistance to azithromycin threatens this treatment strategy.

Last year the US Centers for Disease Control and Prevention (CDC) warned of rising azithromycin resistance rates among US gonorrhea cases. Both the CDC and ECDC said that approximately 25% of gonorrhea isolates are now resistant to tetracycline and ciprofloxacin, former first-line treatments for the sexually transmitted disease.
Aug 24 ECDC report
Jul 15, 2016, CIDRAP News story "Gonorrhea growing more resistant to standard treatment"

Forgoing contact precautions not tied to increased MRSA, VRE

Discontinuing contact precautions did not affect the rates of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), according to the results of a retrospective study at a large Detroit hospital published yesterday in the American Journal of Infection Control.

Researchers assessed healthcare-related MRSA and VRE infection rates in the 12 months before and the 12 months after contact precautions were discontinued at an 800-bed teaching hospital in 2013. The study included 36,907 patients treated with contact precautions and 40,439 treated without. Contact precautions include infection-prevention measures in addition to standard precautions, such as gloves, gowns, and private rooms, for serious, easily transmitted diseases.

MRSA and VRE rates for the following infections did not differ significantly in the two study periods: catheter-associated urinary tract infections, ventilator-associated pneumonia, central line–associated bloodstream infections, surgical-site infections, and hospital-acquired MRSA bacteremia.
Aug 23 Am J Infect Control study

News Scan for Aug 24, 2017

News brief

MERS sickens 2 more in Saudi Arabia

The Saudi Arabian Ministry of Health (MOH) reported two new cases of MERS-CoV today, one in Dumah Al Jandal and the other in Hail, both in the north-central part of the country.

A 40-year-old Saudi woman from Dumah Al Jandal is in stable condition after presenting with symptoms of MERS-CoV (Middle East respiratory syndrome coronavirus). Her infection is listed as "primary," which means it's unlikely she contracted the virus from another person. Her illness does not appear to be related to a recent hospital outbreak in the same city.

A 46-year-old man from Hail was also diagnosed with MERS-CoV. He presented with symptoms and is in critical condition. The MOH said investigators are currently reviewing the source of his infection.

Saudi Arabia has now recorded 1,704 MERS-CoV cases, 690 of them fatal, since the first detection in humans in 2012. Twelve people are still receiving treatment for their infections.
Aug 24 MOH update

Texas adds three counties to Zika testing recommendation

The Texas Department of State Health Services (TDSHS) today added three counties to its enhanced Zika virus testing recommendations for pregnant women as well as people with rash and other symptoms of the disease.

The new counties include Kinney, Maverick, and Val Verde counties, all in the southern tip of the state on the border with Mexico. They join six other counties that are already recommended for enhanced testing: Cameron, Hildago, Starr, Webb, Willacy, and Zapata.

There is no evidence of ongoing Zika transmission anywhere in Texas, but the TDSHS said climate and geography in the nine counties are at higher risk for Zika spread by mosquitoes and that reports from Mexico show transmission is still occurring in some of its states, including some at the US border.

Also today, the TDSHS updated its advice for testing pregnant women in the high-risk areas, urging providers to test them 3 times rather than 2 during pregnancy, consistent with a recent recommendation change from the US Centers for Disease Control and Prevention (CDC).

The TDSHS warned that Texas is entering peak mosquito season, and it warned people to protect themselves from mosquito bites by consistently wearing repellent, wearing long sleeves and pants, and using air conditioning or making sure door and window screens are intact.

So far, Texas has only reported one local Zika case this year, an individual from Hildago County whose illness was announced at the end of July.
Aug 24 TDSHS statement

Lower respiratory infections cause 2.74 million deaths worldwide: report

A new global disease burden study published in the journal Lancet Infectious Diseases estimates that lower respiratory tract infections (LRIs) caused 2.74 million deaths worldwide in 2015, making them the fifth leading cause of death, and the second leading cause of death for children under the age of 5 years. The infections also resulted in 103 million disability-adjusted life years lost.

The modeling study looked at rates of LRIs and their four most common etiologies: Pneumococcal pneumonia, Haemophilus influenzae type b (Hib), influenza, and respiratory syncytial virus (RSV).

Though the overall incidence of LRIs has decreased between 2005 and 2015, infections still disproportionally affect the poorest regions in the world. The authors said 75% of deaths from LRIs occur in sub-Saharan Africa and south Asia. Other parts of the world, including east and southeast Asia, central Europe, and tropical Latin America, saw a more than 50% reduction in under-age-5 deaths from LRIs.

Burdens for specific etiologies were also unevenly distributed. Pneumonia, for example, has been reduced worldwide by 36% in the decade between 2005 and 2015, but in sub-Saharan Africa, that reduction is only 21.4%. Overall, pneumonia accounted for 64.1% of LRI deaths worldwide in 2015. After pneumonia, Hib infections, followed by RSV, and influenza, were the most likely to cause death.

In a commentary on the study, Cynthia Whitney, MD, MPH, with the CDC's National Center for Immunization and Respiratory Diseases, writes, "Effective interventions for reducing pneumonia deaths are available, and a vaccine to prevent RSV infection could be available in the near future. With continued resources and attention, modeled estimates of pneumonia deaths, as well as actual numbers, can continue to decrease."
Aug 23 Lancet Infect Dis study
Aug 23 Lancet Infect Dis commentary