Rates of antimicrobial resistance (AMR) in urinary Escherichia coli isolates are rising in both hospital and community settings in Australia, researchers reported last week in the Journal of Global Antimicrobial Resistance.

For the study, Australian researchers analyzed 108,262 urinary E coli isolates collected from a public hospital-based laboratory (34, 103 isolates) and a private community-based laboratory (74,159 isolates) in the Illawarra Shoelhaven region in New South Wales from 2007 to 2019. They tested the isolates for susceptibility to ampicillin, amoxicillin-clavulanate, cephalexin, norfloxacin, and trimethoprim, and used linear regression analysis to identify any significant changes in AMR rates over time. Up to 80% of all urinary tract infections (UTIs) are caused by E coli.

For all antibiotics other than ampicillin, the results of the linear regression analysis showed the AMR trends increased significantly over the 12-year period for both laboratory settings, with AMR rates consistently higher in the public hospital-based setting. But the study authors note that the volume of resistant isolates for commonly used antibiotics like trimethoprim and ampicillin were much higher in the community-based setting, where the vast majority of UTI treatments occur.

"There is a need for localised and regional surveillance of AMR," they wrote. Given that the largest volume is in the outpatient setting, and >90% of all antibiotic prescriptions are issued in primary care, interventions that incorporate the outpatient setting are critical to addressing AMR."

Adapting COVID-19 standards of care (SOC) to evolving information about optimal treatments may have shortened recovery and reduced deaths in hospitalized adults during some pandemic phases, according to an observational study today in the Annals of Internal Medicine.

A team led by researchers from the US National Institute of Allergy and Infectious Diseases analyzed data from the Adaptive COVID-19 Treatment Trial (ACTT), a staged, phase 3, randomized, controlled trial that assessed 28-day recovery and mortality from February 2020 to May 2021. The trial was conducted in 94 hospitals in 10 countries, with roughly 500 patients per group and 86% of participants from the United States.

ACTT-1 compared the antiviral remdesivir plus SOC to placebo plus SOC, while remdesivir plus SOC was the control group in ACTT-2 and ACTT-3. In ACTT-3 and ACTT-4, the analysis was repeated for participants who received remdesivir plus the anti-inflammatory dexamethasone plus SOC. ACTT-4 compared remdesivir plus the immune inhibitor baricitinib to remdesivir plus dexamethasone.

Outcomes were marginally improved in ACTT-2 over ACTT-1 (adjusted hazard ratio [aHR] for recovery, 1.04; aHR for death, 0.90). Patients were less likely to be intubated in ACTT-2 than in ACTT-1 (odds ratio, 0.75), and hydroxychloroquine use fell.

Outcomes improved from ACTT-2 to ACTT-3 (aHR for recovery, 1.43; aHR for death, 0.45). Explanations for the differences, including changing case loads, SOC, and SARS-CoV-2 variants, were comparable in ACTT-2 and ACTT-3, except for greater dexamethasone use (11% to 77%). ACTT-3 and ACTT-4 outcomes were similar. Across all stages, antibiotic use decreased.

"Although our unadjusted HR estimates describe differences in outcomes between trial stages, the propensity score-weighted HRs account for changes in patient composition over time and represent a 'stage effect' attributed to the SOC received during different stages," they wrote.

The authors noted that they found no improvements in recovery or mortality from August 2020 to May 2021, perhaps because the SOC didn't change much during that time. "These findings support the exclusion of nonconcurrent controls when analyzing data from platform trials, particularly for COVID-19 treatments and vaccines," they concluded.

An analysis of outpatient antibiotic prescriptions from primary healthcare facilities (PHFs) in six Chinese provinces found that more than 70% were inappropriate, Chinese researchers reported last week in Clinical Microbiology and Infection.

In the nationwide survey of outpatient antibiotic prescriptions ordered from Chinese primary care facilities, researchers at Peking University collected data on all outpatient-visit prescriptions from 269 Chinese PHFs in 31 cities in six provinces from 2017 to 2019. They randomly selected 100 outpatient antibiotic prescriptions from each facility, then classified them as appropriate, potentially appropriate, and inappropriate based on the diagnosis for which they were prescribed. They also analyzed the type of antibiotics prescribed and the costs associated with inappropriate prescribing.

Of the 641,732 prescriptions analyzed, 209,662 (32.7%) included at least one antibiotic. Of those antibiotic prescriptions, 4.8% were classified as appropriate, 20.6% as potentially appropriate, and 70.5% as inappropriate. Upper respiratory tract infections, acute bronchitis, and non-infectious gastroenteritis were responsible for 68.9% of inappropriately antibiotic prescriptions. A total of 256,474 individual antibiotics were prescribed, of which 82.2% were broad-spectrum antibiotics, with second-generation cephalosporins (15.1%) and third-generation cephalosporins (14.6%) being the most commonly prescribed subgroups.

Higher inappropriate antibiotic prescribing rates were observed in children aged 0 to 5 years (78.5%) and patients living in economically undeveloped areas (77.5%). Cumulative spending on inappropriate antibiotics accounted for 66.8% of the total cost of antibiotics.

The study authors say antibiotic stewardship efforts should target certain conditions (i.e., upper respiratory tract infections, acute bronchitis, and non-infectious gastroenteritis) and on clinicians and children in cities of lower economic status.

"Real-world evidence is increasingly appreciated as fundamental to the development of antibiotic stewardship and interventions aiming at modifying antibiotic prescribing and improving patients' health," they wrote. "Tailored training and continuous education for primary clinicians that promote accurate diagnosis and evidence-based treatment based on clinical guidelines are urgently needed."

Today in Annals of Internal Medicine, researchers show that, compared to 2020, mortality rates due to COVID-19 infections among young adults increased significantly in 2021, suggesting younger people had lower vaccine uptake and adhered to fewer COVID precautions than older adults in the United States

To understand the age shift that occurred among COVID-19 deaths in the United States, researchers used Years of Life Lost (YLL) rather than mortality during March to December of 2020 and March to December of 2021. The study was based on data from the CDC WONDER (Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research), with life expectancies based on the World Health Organization global health estimate from 2017.

During those two periods, the median age of COVID-19 deaths decreased from 78 years in 2020 to 69 years in 2021, and YLL due to COVID-19 increased to 7.4% more years of life lost in the second pandemic year due to a 35.7% increase in YLL per COVID-19 death. Despite those changes, there were 20.8% less COVID-19 deaths in 2021 versus 2020.

"Further investigation should determine the extent to which this downward age shift in COVID-19 mortality is attributable to high early-pandemic COVID-19 death rates among older adults (for example, involving nursing homes and long-term care facilities), relatively higher vaccine coverage and adherence with nonpharmaceutical interventions among older versus younger adults later in the pandemic, age-related risk differences associated with coronavirus variant viruses, or other mechanisms," the authors said.

The analysis showed other changes to YLL during 2020 to 2021: YLL and deaths due to unintentional injuries increased considerably, owing in part to record-high drug overdose deaths, up 15% (nearly 14,000 deaths) in 2021 compared with 2020, the authors said.

"A shift in COVID-19 mortality to relatively younger people in the second pandemic year contributed to markedly increased premature mortality from this increasingly preventable death," said corresponding author Mark Czeisler, PhD, medical student at Harvard Medical School, in a press release. "Understanding the factors that contribute to this age shift is critical as we continue developing our knowledge of the COVID-19 pandemic."

Six states reported more highly pathogenic avian flu outbreaks in poultry flocks over the past few days, including three that reported large losses in commercial poultry, according to updates from the US Department of Agriculture (USDA) Animal and Plant Health Inspection Service (APHIS).

Last week, the mounting poultry losses matched the record of 50.5 million set during multistate outbreaks in 2015. Outbreaks reported over the past few days boosted the national total for the year to 52.5 million from 46 states.

In one of the newly reported outbreaks, the virus struck a large layer farm in Nebraska's Dixon County that houses 1.7 million birds. Also, South Dakota reported four more outbreaks from commercial turkey farms in three counties (Beadle, Spink, and Faulk) which taken together had more than 222,000 birds. Also, Minnesota reported another outbreak at a turkey farm, this time at a facility in Todd County that had 44,500 birds.

Four states reported more outbreaks in backyard flocks, including Alaska, South Dakota, Florida, and Oregon.

First high-path outbreak in Ecuador

In international developments, Ecuador reported its first highly pathogenic avian flu outbreak in poultry, likely part of a recent incursion of the Eurasian H5N1 strain into South America. The virus is awaiting full subtyping.

The outbreak occurred at a layer farm near the city of Latacunga in north-central Ecuador that had experienced unusual morality, according to a notification from the World Organization for Animal Health (WOAH). The virus killed 49,900 of 180,100 birds.

The development comes in the wake of recent H5N1 detections in South American birds, including events in Peru and Colombia.