News Scan for Nov 23, 2020

News brief

Lung capacity issues, severe health problems in COVID-19 survivors

A Dutch study late last week found reduced lung capacity in 42% of COVID-19 patients 3 months after recovery, with many patients reporting severe problems with fatigue, functional impairment, and quality of life (QoL).

Researchers reporting in Clinical Infectious Disease administered a comprehensive health assessment to 124 recovering COVID-19 patients who had either been admitted to a Netherlands hospital or were referred by physicians for symptoms lasting more than 6 weeks from Apr 23 to Jul 15. Assessments included lung function, walking, and body composition tests, chest computed tomography (CT)/x-ray, and questionnaires on mental, cognitive, health status, and QoL. The median age of patients was 59 years and 60% of patients were male.

The researchers found that nearly all (99%) of discharged patients showed reduced ground-glass opacification—hazy lung tissue appearance consistent with infection—on repeat CT imaging, and 93% of patients with mild disease had normal chest X-rays at the time of the assessment. Despite this observed lung improvement, 91% of discharged patients showed residual lung abnormalities that correlated with reduced lung function.

About 42% of all patients had reduced lung diffusion capacity, a measure of how well oxygen is carried from the lungs to the blood. Critical disease patients had lower lung capacity at 3 months than non-critical patients.

Patients reported low exercise capacity (22%), problems with mental and/or cognitive function (36%), functional impairment in daily life (64%), fatigue (69%) and reduced QoL (72%).

"With the SARS-CoV-2 pandemic still ongoing, we are only at the beginning of understanding long-term sequelae of COVID-19," the study authors wrote. "Longer follow-up studies are warranted," they added.
Nov 21 Clin Infect Dis study

Poor outcomes for COVID-19 patients with bloodstream infections

A second study in Clinical Infectious Disease late last week detailed poor outcomes for hospitalized COVID-19 patients with secondary bloodstream infections (sBSI). COVID-19 patients with sBSI had greater initial disease severity, longer hospital stays, and a 53.1% in-hospital mortality rate.

Limited data suggest higher rates of sBSI—common in patients with flu and other viral respiratory illnesses—in severe COVID-19 patients, perhaps linked to immune dysregulation.

Rutgers researchers studied 375 hospitalized COVID-19 patients—128 with culture-confirmed bacterial or fungal sBSI—admitted to one of three New Jersey hospitals from Mar 1 to May 7, and followed through Jun 3. Median age of sBSI patients was 64 years, 61.1% were male, and most were African American (30.4%) or Hispanic/Latino (29.3%).

Patients with sBSI were less likely to present with cough and fever than patients in the control group, but more likely to exhibit altered mental status (23.4% vs 11.7%; P = 0.003). They also were more likely to be intubated, have septic shock, and be admitted to the intensive care unit compared with patients without sBSI. Median length of hospital stay was longer for the sBSI group (18.5 days vs 7 days; P < 0.001), and more sBSI patients died in the hospital compared with the control group (53.1% vs 32.8%; P = 0.0001).

Central line-associated sBSI was the presumed source of infection for most patients, with numerous cases of Candida fungal infections and infections from Staphylococcus aureus, Enterococcus faecalis, and Escherichia coli bacteria.

The researchers noted that 80% of patients received antimicrobials at some point during hospitalization despite having negative blood cultures.

"This supports the fact that antimicrobial stewardship remains crucial during this unprecedented time," the study authors wrote. "Given the scale of the pandemic, indiscriminate antimicrobial use will inevitably lead to widespread complications such as adverse drug reactions, antimicrobial resistance, and C. difficile infections," they added, referring to Clostridioides difficile.
Nov 20 Clin Infect Dis study

GAO to CDC: Communicate food outbreak decision-making process

The US Centers for Disease Control and Prevention (CDC) should describe its decision-making process for communicating about multistate foodborne illness outbreaks, according to a new report from the Government Accountability Office (GAO).

The CDC estimates that one in six people in the United States are sickened by foodborne illness outbreaks each year, resulting in 128,000 hospitalizations and 3,000 deaths. And while the CDC has created tools to help identify, respond to, and communicate increasingly common multistate outbreaks, the GAO report says it could do more to quickly release accurate, actionable information.

If the CDC would publicize its strategic communications framework it uses to make decisions during outbreaks, the public may have more trust in its guidance, the authors said. "CDC has an internal framework to guide its communications decisions during outbreaks, and it recognizes that stakeholders would like more transparency about these decisions," they said.

The report also said that the CDC hasn't had specific performance goals, monitored progress against goals, or evaluated its multistate foodborne illness outbreak investigations, although the agency is taking steps to address that. "By implementing all elements of a performance assessment system, CDC could better assess its progress toward meeting its goals, identify potentially underperforming areas, and use that information to improve its performance," the authors said.

Another challenge the CDC is working to address is the increasing use of culture-independent diagnostic tests, which diagnose foodborne diseases earlier and cheaper than older methods, but they can reduce the CDC's ability to identify an outbreak because they don't create DNA "fingerprints" that specify the pathogen involved. "By developing a plan, CDC will have greater assurance of continued access to necessary information," the authors wrote.

According to the report, the CDC has agreed with the GAO's recommendations.
Nov 20 GAO report

New Hampshire reports year's 5th case of Jamestown Canyon virus

New Hampshire reported its fifth case this year of the Jamestown Canyon virus (JCV) late last week in an adult who remains hospitalized with left-side weakness, unresponsiveness, and multiple seizures, according to a press release from the New Hampshire Department of Health and Human Services (DHHS).

More than 50 cases of JCV, a rare mosquito-borne arbovirus, have been identified in the United States—mainly in the Midwest and Northeast—in the past 20 years, according to the DHHS JCV fact sheet. This is the 14th case reported in New Hampshire since 2013. The virus circulates broadly in North America from spring to fall, mainly between deer and mosquitoes, but can infect humans, as well.

Most cases are asymptomatic or mild, featuring fever, muscle aches, fatigue, dizziness, and headache, but severe cases can cause encephalitis (inflammation of the brain), meningitis, and death. There is no vaccine or treatment for JCV other than supportive care.

“Although JCV is still a rare disease, we are seeing more infections in NH [New Hampshire], which is concerning,” New Hampshire State Epidemiologist Benjamin Chan, MD, MPH, said in the press release. "Similar to other diseases in NH that are spread through mosquito bites, like West Nile Virus and Eastern Equine Encephalitis, infection with JCV can cause a severe neurologic disease."
Nov 20 New Hampshire DHHS press release and JCV fact sheet

Stewardship / Resistance Scan for Nov 23, 2020

News brief

Danish stewardship intervention tied to improved pneumonia prescribing

An antibiotic stewardship intervention implemented at four regional hospitals in Denmark was associated with significantly lower overall antibiotic exposure for patients who had community acquired pneumonia (CAP) and a higher likelihood of patients being treated with recommended antibiotics, Danish researchers reported late last week in the International Journal of Infectious Diseases.

The intervention, implemented at the hospitals to increase adherence to prescribing guidelines and improve the quality of care for CAP patients, included physician education, feedback to physicians regarding antibiotic choice, pocket cards on CAP treatment, and order sets for CAP in the electronic health system. The study assessed antibiotic prescribing in CAP patients treated at the four hospitals during the baseline period (November 2017 through February 2018) and the follow-up period after implementation of the stewardship program (November 2018 through February 2019).

The primary outcome of the study was the proportion of patients receiving 7 days or less of antibiotics, and the secondary outcomes were the proportion receiving 3 days or less of intravenous (IV) antibiotics and the proportion receiving empiric antibiotics according to Danish national guidelines. Univariable and multivariable logistic regression models were used to calculate odds ratios for all outcomes. The researchers also performed a subgroup analysis for patients who were stable within 72 hours of admission.

A total of 771 patients were included in the study. Compared to pre-intervention, the unadjusted odds ratio (OR) for ≤ 7 days of total antibiotic treatment was 1.84 (95% confidence interval [CI], 1.34 to 2.54) for the whole population and 2.08 (95% CI, 1.41 to 3.10) for the stable patients. The OR for ≤ 3 days of intravenous antibiotics were 1.16 (95% CI, 0.87 to 1.54) and 1.38 (95% CI, 0.87 to 2.22), respectively. The OR for correct empiric antibiotics was 1.96 (95% CI, 1.45 to 2.68) and 1.82 for stable patients (95% CI, 1.23 to 2.69).

"Due to the solid methodology, the results of our study strengthen the results of other publications on stewardship programmes in CAP," the authors wrote. "Similar interventions led to similar results in different settings worldwide. Therefore, we believe that the positive impact of stewardship programmes in CAP cannot be denied."
Nov 21 Int J Infect Dis study

Jordanian hospital ASP linked to lower broad-spectrum antibiotic use

A multifaceted antibiotic stewardship program (ASP) at a hospital in Jordan was associated with reduced use of several broad-spectrum antibiotics and reduced levels of carbapenem-resistant Acinetobacter baumannii (CRAb) in hospitalized patients, researchers reported last week in the Journal of Antimicrobial Chemotherapy.

In a retrospective ecological assessment conducted at a King Abdullah University Hospital over 6 years (January 2014 through December 2019), researchers evaluated the impact of an ASP implemented in February 2018. The ASP included education, antibiotic guidelines, antibiotic restriction policy with prior approval, and audit and feedback. Using time-series methods, the researchers looked at the ASP's impacts on several restricted antibiotics, including imipenem/cilastatin, ertapenem, meropenem, vancomycin, piperacillin/tazobactam, colistin, and ciprofloxacin, and the effect of any reductions on CRAb in hospitalized patients.

After introduction of the ASP, statistically significant decrease in levels of use were observed for imipenem/cilastatin (P = 0.0008), all carbapenems (P = 0.0001), vancomycin (P = 0.0006), colistin (P = 0.0016), and third-generation cephalosporins (P = 0.0044).

The researchers also observed a statistically significant decrease in slope, after the introduction of the ASP, for ertapenem (P = 0.0044) and ciprofloxacin (P = 0.0117). They also observed that a significant increasing trend in the use of piperacillin/tazobactam before the introduction of the ASP (P = 0.0208) was halted after introduction of the ASP (P = 0.4574).

The introduction of the ASP was associated with a significant reduction in CRAb levels (P = 0.0237).

"Reports on effective and feasible antimicrobial stewardship interventions in [low- and middle-income countries] are limited, and this study provides evidence supporting successful implementation of an effective ASP," the authors of the study wrote. "The interventions contributed to a reduction in the use of several broad-spectrum antibiotics, reversed the increasing trends of use of other antibiotics, and were associated with a significant reduction in CRAb in the study site hospital."
Nov 21 J Antimicrob Chemother study