Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans
Studies describe Candida auris outbreaks in COVID-19 patients
Two new studies highlight the threat posed by the multidrug-resistant yeast Candida auris to hospitalized COVID-19 patients.
In a case report today in Morbidity and Mortality Weekly Report (MMWR), investigators with the Centers for Disease Control and Prevention (CDC) and the Florida Department of Health describe an outbreak of C auris in a COVID-19 specialty care unit of an acute care hospital in Florida.
After the hospital alerted Florida health officials about four C auris infections in the unit in July 2020, staff conducted a unit-wide point-prevalence survey from Aug 4 through Aug 18 to identify additional patients colonized with the pathogen. The results showed that, among 67 patients admitted to the unit, 35 (52%) were positive, and 6 later had clinical cultures that grew C auris.
Eight of the colonized patients died within 30 days of screening, but it's unclear whether C auriscontributed to those deaths.
Investigators concluded that use of multiple layers of gloves and gowns by healthcare workers, and repeated doffing and donning of secondary layers, may have led to contamination of base layers, which in turn could have contributed to C auris transmission. They also suggest lapses in cleaning and disinfection of shared medical equipment, along with lapses in adherence to hand hygiene, may have played a role.
Jan 8 MMWR case report
In the other study, published today in Clinical Microbiology and Infection, researchers in Mexico describe the clinical and microbiologic characteristics of 12 patients with severe COVID-19 and C auris co-infection at a Mexican hospital in August.
All patients were under mechanical ventilation and had peripherally inserted central lines and urinary catheters. C auris was isolated from blood in 6 patients, urine in 8, and from both sites in two 2. Five of the six patients with bloodstream infections died.
Antifungal susceptibility testing revealed that 8 of 15 isolates (12 from patients and 3 environmental isolates) were multidrug-resistant.
The authors of the study say use of multiple antibiotics and central venous catheters may have contributed to C auris co-infection in these patients, but they also suggest that factors specifically associated with COVID-19, such as excessive corticosteroid use, which can have an immunosuppressive effect, might have also contributed to the problem.
Jan 8 Clin Microbiol Infect study
Policy brief shows support for antibiotic development incentives
Originally published by CIDRAP News Jan 6
Interviews with policymakers and antimicrobial resistance (AMR) experts from 13 countries indicate broad support for financial incentives to boost antibiotic development, despite uncertainty over which incentives are appropriate and how much they'll cost, according to a policy brief released yesterday by the European Union Joint Action Antimicrobial Resistance and Healthcare-Associated Infections (EU-JAMRAI) and the Global AMR Research and Development Hub.
In the interviews, which were conducted to better understand perceptions of antibiotic development incentives and barriers to implementing them, 11 of 13 interviewees expressed high-level, general support for incentive programs. But before selecting a type of incentive, they said they prefer to wait for evidence from the three countries—United Kingdom, Germany, and Sweden—currently testing "pull incentives" models that aim to increase revenues for antibiotics while also ensuring access to them.
Experts from 9 of the 10 European countries said they would prefer a common, European or multinational incentive that's independent of national drug pricing and reimbursement plans.
Policymakers were also clear that incentives should apply only to antibiotics that meet public health needs, and that the public heath value must be demonstrated in clinical trials that test those antibiotics against multidrug-resistant infections.
In addition, 12 of 13 interviewees indicated that shortages of existing antibiotics is a problem in their countries, and 8 of 13 said shortages have resulted in greater use of broad-spectrum antibiotics.
"The results of these interviews point to a clear need for specific, detailed incentives that national policymakers can assess, tailor, and implement," the policy brief said. "These incentives must be designed with the aim of ensuring national access to important antibiotics that meet public health need."
Jan 5 EU-JAMRAI and Global AMR R&D Hub policy brief
High antibiotic prescribing rates found in COVID-19 patients
Originally published by CIDRAP News Jan 5
A rapid review and meta-analysis of studies involving more than 35,000 COVID-19 patients has found that three-quarters received antibiotics even though fewer than 10% had a bacterial co-infection, Canadian researchers reported today in Clinical Microbiology and Infection.
A total of 35,263 patients with laboratory-confirmed COVID-19 were included across 154 studies published from Jan 1 through Jun 9, 2020. Random effects meta-analysis of all combined studies estimated an antibiotic prescribing prevalence of 74.6% (95% confidence interval [CI], 68.3% to 80.0%). The prevalence of antibiotic use was highest in east/southeast Asia (87.5%), followed by the Middle East (86%), China (76.2%), North America (64.8%), and Europe (63.1%). Across healthcare provider settings, antibiotic use was highest in the intensive care unit (86.4%).
On univariable meta-regression, antibiotic prescribing was lower in children compared with adults (prescribing prevalence odds ratio [OR], 0.10; 95% CI, 0.03 to 0.33), higher with increasing patient age (OR, 1.45 per 10-year increase; 95% CI, 1.18 to 1.77), and higher with increasing proportion of patients requiring mechanical ventilation (OR, 1.33 per 10% increase; 95% CI, 1.15 to 1.54).
Among the 31 studies that reported on concomitant bacterial infection, pooled data indicated 8.6% prevalence (95% CI, 4.7% to 15.2%).
"As such, antibiotic prescribing is significantly higher than the prevalence of bacterial co-infection suggesting a large number of antibiotic prescriptions are unnecessary, increasing the risk of preventable harm including adverse events, C. difficile infection, and antimicrobial resistance," the authors wrote.
They concluded that antimicrobial stewardship efforts are urgently needed to help mitigate the impact of COVID-19 on antimicrobial resistance.
Jan 5 Clin Microbiol Infect abstract
CDC study finds sharp drop in outpatient antibiotics in first half of 2020
Originally published by CIDRAP News Jan 4
A new study by researchers from the CDC shows a substantial decrease in the number of outpatients who received antibiotic prescriptions during the first 5 months of 2020 compared with previous years.
In the study, published last week in Clinical Infectious Diseases, CDC researchers looked at data from the IQVIA Total Patient Tracker to estimate the monthly number of patients dispensed prescriptions for commonly used antibiotics from retail pharmacies from January 2017 through May 2020. They averaged estimates from 2017 through 2019 to create a baseline, and defined the percent change from January through May in each year as the seasonally expected change. They then calculated the percent change in January through May 2020 and compared it to the previous years.
The results of the analysis showed that from January through May 2020, the number of outpatients dispensed antibiotic prescriptions fell from 20.3 million to 9.9 million, exceeding seasonally expected decreases by 6.6 million patients and 33 percentage points. The largest differences were observed in April and May, when the number of patients receiving outpatient prescriptions was 39% and 42% lower, respectively, than the 2017-2019 averages for those months.
The largest beyond-expected decreases were observed in prescriptions for penicillins (2.3 million fewer patients), macrolides (1.5 million fewer patients), and cephalosporins (1.1 million fewer patients). Trends in azithromycin prescribing varied slightly, with the number of patients receiving azithromycin climbing by 5% from January through March 2020 and then declining by 71% from March through May. Beyond-expected decreases in dispensed antibiotics were observed across age groups, with the greatest decline occurring in children 4 and under and adults 65 and over.
The authors of the study say it's unclear at this point whether the decreases were driven by declines in non-COVID-19 disease transmission or changes in care-seeking related to the COVID-19 pandemic.
"Ongoing surveillance of antibiotic prescribing, antibiotic-associated adverse events, antibiotic-resistant infections, and complications of common infections is needed to evaluate the longterm impacts of these changes in outpatient antibiotic trends," they wrote. "Shifts in healthcare delivery, particularly the use of telehealth, are likely to be sustained, and should prompt assessment of effective antibiotic stewardship interventions to optimize antibiotic prescribing practices and ensure patient safety."
Dec 28 Clin Infect Dis abstract