Stewardship / Resistance Scan for Oct 27, 2020

News brief

Panel issues C difficile guidance for low- and middle-income countries

A panel of experts convened by the International Society for Infectious Diseases (ISID) has released a set of recommendations for preventing Clostridioides difficile infections in hospitals in low- and middle-income countries (LMICs).

While epidemiologic studies suggest that the prevalence of C difficile in LMICs is similar to that in higher income countries and may be even higher, existing guidelines for control and prevention of the pathogen in healthcare settings do not specifically address LMICs and the challenges they might face due to insufficient testing capability and overcrowded healthcare facilities. The panel was convened by ISID to address some of these challenges and make evidence-based recommendations for infection prevention that are broadly applicable.

The recommendations, published yesterday in the International Journal of Infectious Diseases, acknowledge that resource-limited settings face distinct challenges in diagnosing and preventing C difficile. The panel recommends that diagnosis of C difficile only be pursued in symptomatic patients with clinical evidence of infection, that surveillance for C difficile infections be conducted to understand local burden and epidemiology, and that hand hygiene following the World Health Organization's 5 Moments of Hand Hygiene be performed.

Other core recommendations from the panel include isolation of patients who have C difficile infection, use of gowns and gloves for care of infected patients, daily cleaning of high-touch hospital surfaces, cleaning of shared medical equipment after each use, terminal cleaning of patient rooms upon discharge, and implementation of antimicrobial stewardship programs to limit unnecessary use of antibiotics.

"The recommendations for C. difficile prevention outlined here support a tailored approach that acknowledges local resources and needs," the authors write. "Individual components of a C. difficile prevention bundle remain valuable in isolation, and should be pursued aggressively even if other components are not feasible to implement in a given setting."
Oct 26 Int J Infect Dis paper

Multispecialty clinical teams tied to less antibiotic use in COVID-19 patients

Implementation of a multispecialty COVID-19 clinical guidance team helped a Tennessee hospital reduce antibiotic use in COVID-19 patients following an initial increase, researchers reported yesterday in Infection Control and Hospital Epidemiology.

In an observational study conducted at Vanderbilt University Medical Center in Nashville, the researchers examined weekly antibiotic use among internal medicine (IM) and medical intensive care unit (MICU) teams treating COVID-19 patients at the hospital and those treating non-COVID-19 patients.

They looked at three different periods: a pre-COVID period (Dec 1, 2019, to Feb 29, 2020) and two post-COVID periods (Mar 1 to Mar 22 and Mar 22 to May 15). The initial post-COVID period started a week after the first confirmed COVID-19 patient in Tennessee, and the second started with the implementation of the COVID-19 clinical guidance team, which included infectious disease physicians with antibiotic stewardship experience who made case-by-case antibiotic recommendations.

When compared with the pre-COVID period, the IM COVID team had an initial increase in weekly antibiotic use of 145.3 days of therapy (DOT) per 1,000 days in the first post-COVID period, and the MICU COVID team had an increase of 204 DOT/1,000 days, compared with non-COVID IM and MICU teams. In the second post-COVID period, the IM and MICU COVID teams saw significant weekly decreases in antibiotic use of 362.3 DOT/1,000 days and 226.3 DOT/1,000 days, respectively. Of the 131 COVID-19 patients treated at the hospital from Mar 1 to May 15, 65.5% received antibiotics.

"This study is the first to describe significant reductions in team-based AU [antibiotic use] after COVID-19 in the context of an institutional systems-based approach, utilizing infectious diseases and stewardship guidance for COVID-19 providers," the authors wrote. "This may be a strategy to mitigate unnecessary AU and optimize COVID-19 patient care moving forward."
Oct 26 Infect Control Hosp Epidemiol abstract

News Scan for Oct 27, 2020

News brief

Experts offer return-to-play guidance for COVID-19 in athletes

Sports cardiologists in JAMA Cardiology yesterday updated guidance for athletes returning to play (RTP) after COVID-19 infection. The authors recommended a risk stratification approach, with screening for cardiac injury only for athletes with severe disease or preexisting cardiovascular (CV) conditions.

The prevalence of cardiac pathology in infected athletes is not fully understood, but publicized reports of athletes with suspected COVID-19–induced myocarditis and studies showing myocardial injury in individuals even with mild or asymptomatic infection have generated concern about how to safely manage COVID-19 in athletes.

The American College of Cardiology issued RTP recommendations in May after data emerged showing cardiac injury in COVID-19–hospitalized patients, including myocardial inflammation and myocarditis. Those recommendations directed asymptomatic athletes to restrict activity for 2 weeks from the date of a positive test result, followed by slow resumption of activity and risk stratification testing—electrocardiogram, echocardiogram, troponin testing, cardiac magnetic resonance (CMR) imaging—only if symptoms of cardiac involvement occurred. Symptomatic athletes were advised to refrain from exercise for 2 weeks following symptom resolution, followed by CV evaluation using biomarkers and imaging, and cardiac magnetic resonance (CMR) imaging if indicated.

The updated recommendations largely align with the earlier guidelines, advising no additional testing or risk stratification for asymptomatic athletes returning to activity after the Centers for Disease Control and Prevention (CDC)-recommended self-isolation period.

The authors recommend that high school athletes have a formal pediatric or pediatric cardiology evaluation with further CV risk stratification and testing only if cardiac symptoms warrant. Similarly, routine RTP CV assessment was not recommended for masters-level athletes (35 years and older) unless they have persistent symptoms or preexisting CV conditions.

Athletes of all ages with moderate or severe COVID-19 infection are recommended to receive comprehensive CV risk stratification with testing that may include a clinical evaluation, electrocardiogram, blood troponin levels, echocardiography, CMR, and ambulatory rhythm monitoring.

Acknowledging the need for further data, the authors observed that risk stratification testing among athletes yielded few cases of cardiac pathology. In an accompanying commentary, three sports medicine experts note, "Although there remains uncertainty, it is promising that early experiences have observed that nearly all athletes who recover from mild COVID-19 infection do not develop significant cardiovascular pathology."
Oct 26 JAMA Cardiol study
Oct 26 JAMA Cardiol commentary

Echocardiograms reveal COVID-related heart damage tied to mortality

An international study yesterday in the Journal of the American College of Cardiology evaluated cardiovascular ultrasound (echocardiogram) data for hospitalized COVID-19 patients, revealing cardiac structural abnormalities and increased in-hospital mortality rates in nearly two thirds of patients with cardiac injury.

Myocardial injury (defined as an elevation in cardiac troponin levels—proteins released when heart muscle is damaged) is common in patients hospitalized with COVID-19, but the mechanisms of cardiac injury remain unclear and imaging data has not yet been evaluated. This multicenter study included 305 hospitalized COVID-19 patients in seven hospitals in New York City and Milan, Italy, who underwent cardiac ultrasound—transthoracic echocardiographic evaluation (TTE)—and electrocardiographic (ECG) evaluation during hospital stays from Mar 5 to May 2.

Myocardial injury was found in 190 patients (62.3%), along with higher rates of ECG abnormalities, higher troponin and inflammatory biomarkers, and an increased prevalence of major TTE abnormalities compared with patients without myocardial injury. In-hospital mortality rates differed markedly: 5.2% in patients without myocardial injury, 18.6% in patients with myocardial injury, and 31.7% in patients with myocardial injury and TTE abnormalities. After the researchers adjusted for variables, they found that myocardial injury with TTE abnormalities was associated with a significantly higher risk of death (odds ratio [OR], 3.87; 95% confidence interval [CI], 1.27 to 11.80; P = 0.02).

In a commentary in the same journal, experts not involved in the study recommended the routine use of biomarkers and TTE as a valuable tool for accurate patient risk stratification, prediction of severe disease, and identification of appropriate patient treatments.

"Early detection of structural abnormalities may dictate more appropriate treatments, including anticoagulation and other approaches for hospitalized and post-hospitalized patients," said study author Valentin Fuster, MD, PhD, in a Mount Sinai Hospital news release.

"Echocardiography is the only imaging modality that can be taken to the bedside and safely used for patients, including those on ventilators," said coauthor Lori Croft, MD, in the Mount Sinai release. "Our findings will help guide care of Covid-19 patients during a critical time."
Oct 26 J Am Coll Cardiol study
Oct 26 J Am Coll Cardiol commentary
Oct 26 Mount Sinai Hospital news release

DRC officials note 2 fatal Ebola cases listed as probable, no new cases

Two more probable cases of Ebola—both fatal—have been reported in the Democratic Republic of the Congo (DRC) outbreak, bringing the total to 130 cases (119 confirmed and 11 probable), 55 deaths (42.3% case-fatality rate), and 75 recoveries.

These numbers, updated in a tweet today, reflect the latest information from the World Health Organization (WHO) Africa regional office as the agency follows the 11th Ebola virus outbreak that started in the nation's Equateur province in June.

Twenty-eight days have gone by without any new confirmed cases, WHO officials said, and if this holds for 12 more days, the outbreak will be officially declared over.
Oct 27 WHO African Region tweet
Oct 1 CIDRAP update
CIDRAP past updates

Russia reports more H5N8 avian flu outbreaks in poultry and wild birds

Animal health officials in Russia reported more highly pathogenic H5N8 avian flu outbreaks in poultry and wild birds, according to three new notifications today from the World Organization for Animal Health (OIE).

Russia has reported a sporadic stream of H5N8 outbreaks in the southwest of the country, and veterinary officials in the United Kingdom have warned about the increased risk for further spread into Europe by migratory birds.

The latest outbreaks in Russian poultry are from newly affected oblasts. One in the Republic of Tatarstan began on Sep 30 in backyard birds, killing 183 of 1,220 susceptible poultry. The rest were culled as part of the outbreak response. Another outbreak occurred at a farm in Kostroma oblast, which started on Oct 10, killing 14,041 of 282,957 poultry. The surviving birds were destroyed.

Also, the country reported two more H5N8 outbreaks in wild birds, both in Tyumen oblast. The events began on Sep 6, involving six waterfowl, apparently found dead in two different locations.
Oct 27 OIE report on H5N8 in Russian backyard birds
Oct 27 OIE report on H5N8 at Russian poultry farm
Oct 27 OIE report on H5N8 in Russian wild birds