News Scan for Sep 17, 2020

News brief

High COVID-19 viral load in hospital patients tied to higher risk for death

High SARS-CoV-2 viral load at hospital admission may place patients with and without cancer at higher risk for death, a new multicenter observational study published in Cancer Cell suggests.

Researchers at Weill Cornell Medicine used surrogate markers to measure the viral load of SARS-CoV-2, which causes COVID-19, in 100 cancer patients and 2,914 patients without cancer admitted to one of three New York City hospitals from Mar 15 to May 14.

The in-hospital death rate was 38.8% in all patients with a high viral load, 24.1% among those with a medium viral load, and 15.3% among those with a low viral load (P < 0.001).

Similarly, cancer patients with a high viral load had the highest death rate (45.2%), while 28.0% of cancer patients with a medium load and 12.1% with a low load died (P = 0.008). Patients with hematologic cancers (affecting blood and blood-forming organs), especially those who had undergone chemotherapy or targeted treatments, had higher median viral loads than non-cancer patients. "We suspect that this finding may be from the underlying immunodeficiencies conferred by either the hematologic malignancies or the administered therapies, which may decrease the ability to inhibit proliferation of SARS-CoV-2," said co- author Lars Westblade, PhD, a pathologist at Weill Cornell Medicine, in a Cell Press news release.

High viral loads at admission were associated with increased age; underlying conditions such as congestive heart failure, diabetes, chronic kidney disease; and use of inhaled or oral steroids before hospitalization. Hispanic patients were less likely than those of other ethnicities to carry a high viral load at admission.

Cancer patients were more likely than patients without cancer to be white (42.0% vs 21.2%; P < 0.001), be former smokers (29.0% vs 16.5%; P = 0.001), have coronary artery disease (25.0% vs 14.8%; P = 0.004), and have congestive heart failure (14.0% vs 6.2%; P = 0.002). Proportions of cancer and non-cancer patients requiring oxygen support, intubation, and vasopressors (to regulate blood pressure) and who died in the hospital were similar.

"These findings highlight the critical role of viral load in SARS-Co-V pathogenesis and suggest that providing [viral load] value results to clinicians could serve as a valuable tool in the care of hospitalized patients with COVID-19," they wrote.
Sep 15 Cancer Cell study and news release

Eastern equine encephalitis case reported in Indiana

State health officials in Indiana this week reported a probable human case of eastern equine encephalitis (EEE) and the detection of the virus in horses in northern Indiana.

The Indiana State Department of Health (ISDH) identified the probable case in a LaPorte Country resident. Three horses in northern Indiana have also tested positive for the virus. Health officials are urging residents of northern Indiana to protect themselves from mosquito bites.

EEE is rare but can cause serious illness and death in people, with a fatality rate of around 33% or higher. Children under 15 and adults over 50 are at greatest risk of severe illness if infected.

"Eastern equine encephalitis virus disease is rare in humans but can cause permanent complications and even death," State Health Commissioner Kris Box, MD, said in a press release. "While all Hoosiers are at risk for mosquito-borne diseases, northern Indiana residents need to be especially vigilant right now."

Health officials recommend that people avoid being outdoors when mosquitoes are active, use an Environmental Protection Agency–approved insect repellent, cover exposed skin in places where mosquitoes are active, and eliminate mosquito breeding grounds from their property.
Sep 15 ISDH press release

High-path H5 avian flu outbreaks hit poultry in Kazakhstan

Animal health officials in Kazakhstan today reported seven highly pathogenic H5 avian flu outbreaks in poultry in the north near the Russian border, where several similar outbreaks were recently reported, according to a notification today from the World Organization for Animal Health (OIE).

The outbreaks began from Sep 11 to Sep 14, striking backyard and village poultry. The virus killed 1,763 of 67,794 susceptible birds, and response actions include movement restrictions, vaccination, and disinfection.

The report said the source of the virus is contact with wild birds and that the outbreaks mark the first appearance of the virus in Kazakhstan.

Russia recently reported a spate of H5 outbreaks, including some involving H5N8 in southwestern Siberia, which isn't far from Kazakhstan's outbreak area. UK veterinary officials have noted that similar outbreaks in Russia in the summer of 2016 heralded widespread H5N8 outbreaks in Europe that winter, and they urged poultry owners to remain vigilant.
Sep 17 OIE report on H5 in Kazakhstan
Sep 14 CIDRAP News scan "H5N8 avian flu strikes more poultry in Russia"

Stewardship / Resistance Scan for Sep 17, 2020

News brief

Phase 3 trial shows some promise for bacteriophages for UTI treatment

The results of a randomized, controlled clinical trial show that intravesical bacteriophage treatment was non-inferior to standard-of-care antibiotic treatment and safe for treating urinary tract infection (UTI) patients, but it was not superior to placebo in terms of efficacy or safety, researchers reported yesterday in the Lancet Infectious Diseases.

In the trial, which was conducted by Swiss and Georgian researchers at a urology clinic in Tblisi, Georgia, 113 men who had complicated UTI or recurrent uncomplicated UTI and were scheduled for transurethral reaction of the prostate (TURP) were randomized 1:1:1 to receive three different treatments for 7 days: the bacteriophage cocktail Pyophage (37 men), bladder irrigation with an intravesical placebo solution (38), or systematically applied antibiotics (38). The primary outcome was microbiologic treatment response after 7 days, measured by urine culture. Secondary outcomes included clinical and safety parameters.

Rates of treatment success did not differ significantly between the three groups. After 7 days of treatment, normalization of urine culture was achieved in 27 of 97 patients (28%): 5 of 28 (18%) in the Pyophage group, compared with 9 of 32 (28%) in the placebo group (odds ratio [OR], 1.60; 95% confidence interval [CI], 0.45 to 5.71; P = 0.47) and 13 of 37 (35%) in the antibiotic group (OR, 2.66; 95% CI, 0.79 to 8.22; P = 0.11). Adverse events occurred in 6 of 28 patients (21%) in the Pyophage group compared with 13 of 32 patients (41%) in the placebo group and 11 of 37 patients (30%) in the antibiotic group.

The authors of the study say that while the results revealed little about the efficacy of bacteriophage therapy for treating UTI patients undergoing TURP, they confirm the safety profile of bacteriophage application.

"In conclusion, our findings are encouraging and provide important stimuli for physicians and authorities to support further large-scale clinical studies using bacteriophages for otherwise virtually untreatable infections, in order to further establish their efficacy," they wrote.
Sep 16 Lancet Infect Dis abstract

Study: Long antibiotic duration for many common conditions

An analysis of the duration of antibiotic therapy for common outpatient conditions found that in many cases prescribers are exceeding guideline-recommended durations, researchers from the Centers for Disease Control and Prevention and the University of Utah reported yesterday in Clinical Infectious Diseases.

Using the National Disease and Therapeutic Index dataset for 2017, the researchers identified antibiotic prescriptions (excluding azithromycin) associated with sinusitis, pharyngitis, acute otitis media (AOM), community-acquired pneumonia (CAP), skin and other soft-tissue infection (SSTI), and acute cystitis, including adult and pediatric prescriptions. They then estimated the proportions of prescriptions by course duration and median duration and interquartile range (IQR) and calculated potentially excessive days above minimum recommended duration.

Among more than 28 million prescriptions, median antibiotic course duration was 10 days for every condition except acute cystitis, for which the median duration was 7 days (IQR 5 to 7 days). Overall, 55% (95% CI, 53% to 58%) of non-azithromycin courses exceeded the guideline-recommended minimum effective durations, translating to up to 54,496,316 excessive days of therapy.

The authors of the study note that recent guidelines recommend shorter antibiotic courses of 5 to 7 days for many of these conditions, and that the longer-than-necessary courses are likely driven by clinician habit.

"For some conditions and age groups, such as pharyngitis, pediatric sinusitis, and pediatric AOM, 10 days of antibiotic therapy aligns with guidelines. However, for many conditions, specifically sinusitis and CAP in adults and cellulitis, 10 days of antibiotic therapy is likely excessive for most patients based on guideline recommendations," the authors wrote.

"Increased focus on appropriate duration of antibiotic therapy for these common conditions could reduce unnecessary outpatient antibiotic use," they concluded.
Sep 16 Clin Infect Dis abstract