Stewardship / Resistance Scan for Jan 06, 2020

News brief

Review: Pediatric stewardship programs have impact, but mainly in US

A systematic review of 113 studies indicates that pediatric antimicrobial stewardship programs (ASPs) have a significant impact on the reduction of targeted and empiric antibiotic use, costs, and antimicrobial resistance in both inpatient and outpatient settings, researchers reported late last week in Antimicrobial Resistance and Infection Control.

Of the 41,916 studies screened from three databases by the team of Italian, US, and UK researchers, 113 were eligible for inclusion in the review. Most of the studies (98/113, 86.7%) were conducted in high-income countries, with more than half (59/113, 52.2%) describing ASPs implemented in US hospitals; the rest covered ASPs implemented in Europe (28/113, 24.4%) and Asia (20/113, 17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The vast majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and 10 (8.8%) in emergency departments.

Ninety of the studies (79.6%) showed a significant reduction in inappropriate antibiotic prescriptions, and 18 (15.9%) showed that compliance after ASP implementation increased. Sixteen of the included studies (14.2%) quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Of the 12 studies that analyzed changes in antibiotic resistance following ASP implementation, 7 showed an increased susceptibility of the bacteria analyzed.

The most interesting results observed in these studies were a decrease in extended spectrum beta-lactamase producers Escherichia coli and Klebsiella pneumoniae; a reduction in the rate of Pseudomonas aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive Streptococcus pyogenes following a reduction in the use of macrolides.

The authors of the review note that while pediatric ASPs have become widespread in the United States, their findings indicate that uptake in Europe, Asia, and Africa is limited, possibly because guidelines developed by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America are designed for the US healthcare system. They conclude that further efforts in developing pediatric ASPs are needed.
Jan 3 Antimicrob Resist Infect Control study

High CRE burden found in Egyptian hospitals

In another study published in Antimicrobial Resistance and Infection Control, a team of US and Egyptian researchers reported a high and increasing burden of carbapenem-resistant Enterobacteriaceae (CRE) in Egyptian intensive care units (ICUs).

Using data from Egypt's healthcare-associated infection (HAI) surveillance program, researchers from the US Centers for Disease Control and Prevention (CDC) and several Egyptian universities analyzed isolates from HAI cases that were reported from 2011 through 2017 and caused by Enterobacteriaceae pathogens (Klebsiella spp, E coli, and Enterobacter spp). Overall, there were 1,598 Enterobacteriacea HAI cases, of which 871 (54.1%) were carbapenem resistant. The most common pathogen for CRE cases was Klebsiella (85.1%), followed by E coli (10.2%) and Enterobacter (4.7%).

The proportion of cases that were CRE rose from 17.6% in 2011 to 54.6% in 2017 (P = 0.003). The overall incidence of HAI due to CRE was 3.7 per 10,000 patient-days. Among the 72 hospitals performing HAI surveillance, 46 (63.9%) reported at least one CRE isolate during the study period. Multivariate regression analysis demonstrated that carbapenem resistance was associated with specimen type, pathogen, location prior to admission, and length of ICU stay.

The authors of the study say the high prevalence of CREs in Egyptian hospitals may result from limitations in implementing ASPs and infection prevention and control (IPC) measures.

"Future implementation of evidence-based IPC strategies to prevent CRE transmission, strengthening microbiology capacity and molecular characterization in addition to including antibiotic stewardship programs, are needed to reduce the burden of CRE and optimize patient treatment strategies," they conclude.
Jan 3 Antimicrob Resist Infect Control study

Targeted approach helps reduce C diff rates in VA hospitals, study finds

Development of a metric to target healthcare facilities where a Clostridioides difficile infection (CDI) prevention initiative would have the most impact helped the Veterans Affairs (VA) healthcare system achieve its CDI reduction goals, researchers reported late last week in Infection Control and Hospital Epidemiology.

To evaluate the performance of the VA's CDI prevention initiative, which was launched in 2012 with the aim of reducing hospital-onset healthcare-facility–associated (HO-HCFA) CDI cases nationwide by 30% within 2 years, researchers have used standardized infection ratios (SIRs), a metric that accounts for differences between facilities and allows for interfacility comparisons. But while SIRs show performance relative to a pre-intervention baseline, they don't provide insight into where resources for additional investment should be targeted for the greatest impact on overall CDI rates. Based on SIRs, HO-HCFA CDI rates in VA facilities declined by only 15% from July 2012 through March 2015.

To determine where resources would best be allocated, VA researchers calculated the cumulative attributable difference (CAD) between facilities, which translates SIRs into an absolute number of infections that must be achieved to reach a pre-specified reduction goal. They then ranked the VA facilities with the 10 highest CAD values and targeted them for periodic conference calls or site visits from January 2016 through September 2019. After implementation of the quality improvement program in the 10 hospitals, the HO-HCFA CDI rate declined by 56%, compared with 44% in the 117 non-intervention VA facilities. That helped the VA achieve a HO-HCFA CDI decline of 37% since 2012.

The authors of the study say that no novel interventions or changes in definitions or testing methods were introduced that could explain the dramatic downturn in CDI rates after implementation of the quality improvement program.

"We achieved a statistically significant decline in CDI rates nationwide coincident with application of the CAD approach to our process improvement program," the authors of the study write. "Focusing on facilities with a larger burden of HAIs [healthcare-associated infections], as identified by the CAD analysis, might make better use of process improvement resources in a large healthcare system; this is a low-cost intervention that is not labor intensive."
Jan 3 Infect Control Hosp Epidemiol abstract

News Scan for Jan 06, 2020

News brief

Ebola detected again in Mambasa, DRC

With two new cases, the total number of Ebola infections in the Democratic Republic of the Congo (DRC) now stands at 3,586, according to the World Health Organization's (WHO) Ebola dashboard. There is one more fatality, raising the death total to 2,233, with 464 suspected cases still under investigation.

The total may be as high as 3,588, as reported by the DRC's Ebola technical committee (CMRE), yesterday. The CMRE's fatalities and suspected case counts are the same as the WHO's.

The CMRE said the two most recent cases come from Mambasa, which had not reported an Ebola case in 66 days. The CMRE also posted daily reports for cases recorded last week, which came from Butembo.

The CMRE said Ebola screening devices had been burned in Biakato Mines on Jan 2. Last week the WHO reported several threats had been made in Biakato Mines over the New Year holiday.
WHO Ebola dashboard
Jan 5 CMRE report
Jan 2 CIDRAP News story "Five more Ebola cases confirmed in past 2 days"

MERS infects 2 more in Saudi Arabia, in Medina and Riyadh

Saudi Arabia's Ministry of Health (MOH) has reported two new MERS-CoV cases, neither of whom had any contact with camels.

One of the MERS-CoV (Middle East respiratory syndrome coronavirus) cases involves a 48-year-old man from Medina who died from his illness, and the other is in a 72-year-old man from Riyadh. Exposure for both men is listed as primary, meaning they weren't likely exposed to another known patient.

In a December update on the disease, the WHO said there have been 2,484 confirmed cases from 2012 through the end of November, at least 858 of them fatal. The vast majority are from Saudi Arabia.
Saudi MOH report for epidemiologic week 1

Multi-season Australian study finds flu vaccine tied to 31% drop in deaths

Data from eight influenza seasons in Australia reveal an overall flu vaccine effectiveness of 31% against mortality for hospital-related flu—but with a wide confidence interval—and no evidence of reduced flu symptoms tied to vaccination, according to a study published today in Clinical Infectious Diseases.

Researchers collected data from 2010 through 2017 from a national Australian hospital-based sentinel surveillance system and used a case-control design for the study. Over those seasons, 14,038 patients were admitted to a hospital with lab-confirmed flu.

The primary analysis, which included 9,298 cases and 6,451 controls (those without lab-confirmed flu) found that overall vaccine protection against mortality was 31%, with a 95% confidence interval ranging from 3% to 51%. The authors found no evidence, however, that the flu vaccine reduced the severity of influenza illness. They report that 84% of the patients in the study were at increased risk of severe outcomes.

The authors conclude, "This study reinforces the public health benefit of the influenza immunisation program in protecting against mortality, as well as reducing the risk of hospitalization." They say the findings are similar to the results of a 2015 longitudinal study involving elderly patients in France.
Jan 6 Clin Infect Dis study