News Scan for Apr 13, 2020

News brief

DRC reports another new Ebola death

The Democratic Republic of the Congo (DRC) reported a second new Ebola case, which involves an 11-month-old girl who was treated at the same Beni hospital as a man whose illness was announced on Apr 10.

The girl died from her infection, as did the 26-year-old man whose illness was announced a few days ago, dashing hopes that the country would soon be declared free of the viral disease, Reuters reported, citing Boubacar Diallo, deputy incident manager for the World Health Organization (WHO) Ebola response.

So far, it's not clear how the man contracted the virus. He wasn't a known contact of an earlier case and was not a survivor who experienced an illness relapse.

The WHO had identified 215 of the man's contacts, including 53 healthcare workers from three facilities. Diallo said a group of men threw stones at a WHO team and Beni's deputy mayor who arrived to decontaminate the man's home. The girl's illness raises the outbreak total to 3,456 cases, 2,266 of them fatal, according to the WHO's online Ebola dashboard.
Apr 13 Reuters story
Apr 10 CIDRAP News scan "WHO confirms new Ebola case in DRC, prolonging outbreak"
WHO online Ebola dashboard

Study finds tickborne Heartland virus infection in 19% of people tested

Researchers with the US Centers for Disease Control and Prevention (CDC) reported a 19% rate of tickborne Heartland virus infection among 85 people tested in seven states in a study published late last week in Open Forum Infectious Diseases.

The first known US Heartland virus infection occurred in 2012. The disease spreads via lone star ticks, found in the eastern and central United States. Because it is caused by a virus, it will not respond to antibiotics, as opposed to other tickborne diseases like Lyme.

From June 2013 to December 2017, the CDC instituted national procedures to test subjects for the virus; determine its geographic distribution, epidemiology, and clinical findings; and formulate diagnostic tests. The investigators collected data on patients 12 years and older whose clinicians had suspected possible Heartland infection.

They also screened the patients for recent fever with leukopenia (low white blood cell count) or thrombocytopenia (low platelet count), which are common signs of the disease, and tested their blood for viral RNA and neutralizing antibodies.

Of the 85 people tested, 16 (19%) had evidence of current Heartland infection, while 1 (1%) was previously infected. Of the infected patients, 12 (75%) were male, and the median age was 71 years (range, 43 to 80). All had thrombocytopenia and leukopenia.

Illness onset ranged from April to September, with 8 cases (50%) occurring in June. Most infected participants reported fatigue, loss of appetite, nausea, headache, confusion, joint pain, and muscle aches. Fourteen (88%) were hospitalized, and 2 (13%) died.

Fourteen of the patients said that they had found an attached tick in the 2 weeks before symptom onset. Infected subjects were significantly older (P < 0.001) and more likely to say they had an attached tick (P = 0.03) than uninfected participants.

The authors urged clinicians to consider testing for Heartland in patients with fever and leukopenia or thrombocytopenia unexplained by another condition or who were thought to have a tickborne illness but did not recover after appropriate antibiotic therapy. "Future research is needed to understand the clinical spectrum and further geographic distribution of Heartland disease, including determination of whether asymptomatic infections can occur," they wrote.
Apr 11 Open Forum Infect Dis study
Jul 22, 2013, CIDRAP News story "Researchers trace novel Heartland virus to Missouri ticks"

WHO confirms yellow fever outbreak in South Sudan

South Sudan has two lab-confirmed yellow fever cases in a new outbreak, according to the WHO. The cases were reported in Kajo Keni County in Central Equatoria state.

Officials detected the cases during cross-border surveillance, and they are linked to an outbreak in the bordering Moyo district of Uganda. Neither patient has died.

"To respond to the outbreak, a targeted reactive vaccination campaign was mounted in the affected area," the WHO said.

Yellow fever is a viral hemorrhagic disease transmitted by mosquitoes. The last yellow fever outbreak confirmed in South Sudan was in November of 2018, and the last deadly outbreak took place in 2003.
Apr 10 WHO update

Stewardship / Resistance Scan for Apr 13, 2020

News brief

Study: Diagnostic stewardship tied to benefits for C diff testing

Applying diagnostic stewardship to molecular testing for Clostridioides difficile infection (CDI) at a hospital system in California was associated with to a significant reduction in testing, cases, and costs, researchers reported today in Infection Control and Hospital Epidemiology.

In the multicenter study, researchers at Scripps Mercy Hospital in San Diego evaluated two 6-month periods before and after an intervention at the four-hospital Scripps Healthcare system in which polymerase chain reaction (PCR) testing for C difficile had to be separately ordered by a clinician if enzyme immunoassay (EIA) test results were indeterminate.

Prior to the intervention, the hospital system's C difficile testing algorithm reflexively ordered PCR tests as a "tie breaker" in indeterminate cases, but PCR tests can lead to overdiagnosis because they don't distinguish between C difficile colonization and active infection. The primary outcome of the study was the change in the number of CDI diagnoses between periods, and secondary outcomes included the number of PCR tests performed, adverse events, and healthcare cost savings.

In total, 500 EIA-indeterminate C difficile test results were evaluated: 281 before the intervention and 219 thereafter. CDI was diagnosed by PCR among EIA-indeterminate cases in 182 (64.8%) in the preintervention period versus 94 patients (42.9%) in the postintervention period (48.4% reduction; P < .01). PCR testing was performed in 99.6% of indeterminate cases (280 of 281) in the preintervention period versus 65.8% (144 of 219) in the postintervention period (33.8-percentage-point reduction; P < .01). Researchers observed no differences between study periods in 30-day all-cause (P = .96), gastrointestinal illness-related (P = .93), or C difficile (P = .47) hospital readmissions, nor in 30-day C difficile infections (P > .99).

No patient without a PCR test in the postintervention period and not treated was later diagnosed as having CDI. Each reflexive PCR test not performed led to a cost savings of $4,498 per patient.

"The study results presented here highlight the importance of diagnostic stewardship in ordering C. difficile PCR tests in the inpatient setting and the benefits of a simple change from reflexive to clinician-required ordering for PCR testing among EIA antigen+/toxin− cases," the researchers write.
Apr 13 Infect Control Hosp Epidemiol abstract

Quality improvement linked to appropriate prescribing in Scotland

Prescribing of gentamicin and vancomycin in Scotland improved following the development of revised guidelines and other quality improvement (QI) resources, Scottish researchers reported recently in the Journal of Antimicrobial Chemotherapy.

The QI resources were developed by five pharmacists in collaboration with Scottish antimicrobial stewardship teams following studies in 2011 that showed the limitations of national guidance on gentamycin and vancomycin prescribing introduced in 2009. Among the findings of those studies were that only 44% of gentamicin dosage recommendations and 55% of vancomycin dosage recommendations were in accordance with the guidelines, that the existence of guidelines alone was insufficient to ensure appropriate prescribing and monitoring, and that poor communication, unmet educational needs, and inappropriate staffing were some of the obstacles.

Through a series of meetings, workshops, and face-to-face discussions, the team developed revised guidelines, online and mobile dose calculators, educational material, and specialized prescribing and monitoring charts that were implemented from 2013 through 2016. An online survey conducted in 2017 found that 80% of the Scottish health boards that responded (12 of 15) were using the revised guidelines, electronic calculators, and gentamicin prescription chart (8 used the vancomycin chart).

A before-and-after point prevalence study to evaluate the impact of the QI resources found that, from 2011 to 2018, the percentage of patients who received the recommended dose of gentamicin increased from 44% to 89% (odds ratio [OR], 10.99; 95% confidence interval [CI], 6.37 to 18.95). For vancomycin, the correct loading dose increased from 50% to 85% (OR, 5.69; 95% CI, 2.76 to 11.71) and the correct maintenance dose rose from 55% to 90% (OR, 7.17; 95% CI, 3.01 to 17.07).

"Strong leadership from a dedicated team of healthcare professionals in collaboration with national and local multidisciplinary networks facilitated the success of these developments," the authors of the study write. "This improvement methodology could be adapted for other areas of prescribing practice with the aim of improving the use of antimicrobial prescribing at scale within the hospital setting."
Apr 11 J Antimicrob Chemother abstract