News Scan for Jul 02, 2018

News brief

First H3N2v case of season detected in Indiana

The Indiana State Department of Health (ISDH) announced the first case of variant influenza H3N2 (H3N2v) detected this year in a county fairgoer who was in close proximity to pigs. The Centers for Disease control and Prevention (CDC) confirmed the infection on Jun 29.

This is the first human case of H3N2v recorded in Indiana since 2013. The ISDH said the patient is recovering. No additional details about the patient or the county fair were being released at this time in an effort to protect the patient's privacy, but the county in question had been alerted to the case.

H3N2v can be transmitted from swine to humans through contact, but not through eating pork or other animal products.

More than 400 cases of H3N2v have been identified in people in the United States since 2011. More than one-third of those cases have occurred in Indiana.

The ISDH said summer fairgoers need to practice good handwashing hygiene, and exhibitors should monitor animals for signs of illness.
Jun 29 ISDH statement
CDC H3N2 fact page

MSF announces handover of Ebola activities to DRC and its partners

Doctors Without Borders (MSF) announced today that after a 2-month response in the Democratic Republic of Congo (DRC), its teams have started handing its activities to the country's health ministry and other nongovernmental organizations in Mbandaka, Bikoro, Itipo, and Iboko.

Henry Gray, MSF's emergency coordinator in Equateur Province, said in a press release, "This Ebola outbreak is not officially over, but we are very pleased with the progress that has been made." He said with the low volume of cases and increased local expertise, the health ministry is well positioned to finish the work.

MSF said the handover process began with the closure of the Ebola Transit Center on Jun 20 at Itipo General Reference Hospital, with new suspected cases to be handled at a nearby Ebola treatment center run by the Alliance for International Medical Action (ALIMA). On Jun 25 MSF handed over the Ebola treatment center at Bikoro to the health ministry and its partners.

The DRC declared the outbreak on May 8, and its teams with support from MSF have cared for 38 patients with confirmed infections, including 24 who survived and returned home. Fourteen of those who were treated died from their illnesses. Over the course of the outbreak, which is in its final 21-day countdown, 120 patients with symptoms were isolated and tested, but were negative for the Ebola.

In a related development, MSF said one of its teams is constructing a small isolation unit at Mbandaka General Reference Hospital, which will be used to isolate and test any new suspected patients. A 40-bed Ebola treatment center constructed by MSF on the outskirts of Mbandaka will be disinfected and taken down by early July.

Symptom onset for the DRC's last confirmed case was Jun 2, and last week the monitoring period ended for all contacts, including those of the last patient.
Jul 2 MSF press release

Study: Viruses most commonly identified cause of meningitis in UK

Most cases of meningitis diagnosed in the United Kingdom are viral in origin, according to a major study looking at the causes of meningitis published today in The Lancet Infectious Diseases.

A team of researchers from the University of Liverpool Institute of Infection and Global Health looked at the diagnoses and treatment of 1,126 patients diagnosed as having meningitis in the UK from 2011 to 2014. Only 16% percent of those cases were bacterial, 26% were viral, 42% had an unknown cause, and 6% of cases had other causes for their illnesses. The authors estimate the annual incidence of confirmed viral meningitis in UK adults to be 2.73 per 100,000 people.

Enteroviruses accounted for just above 50% of all confirmed viral meningitis cases, and herpesviruses accounted for 44% of viral cases. Moreover, although viral meningitis was once thought of as benign, the authors said a majority of patients complained of mental health problems in the months following a diagnosis.

"This study shows that viruses are the major cause of meningitis in adults in the UK, and impose a considerable clinical burden, both acutely and longer term," the authors concluded. "To improve management and reduce costs, there is a pressing need for better diagnostic practices, including rapid tests and the delivery of high-quality viral diagnostics locally."

In a commentary published adjacently to the study, two scientists from the Academic Medical Centre in Amsterdam write that meningitis patients in the UK suffer from a delay in diagnosis. In the University of Liverpool study, the median time to lumbar puncture after emergency room admittance was 17 hours, and in 25% of patients it took more than 29 hours before a lumbar puncture was done.
Jun 29 Lancet Infect Dis study
Jun 29 Lancet Infect Dis comment

Stewardship / Resistance Scan for Jul 02, 2018

News brief

Study: Stewardship module increases antimicrobial reviews, interventions

A new study by researchers with the University of Chicago Medical Center has found that use of a clinical decision support system at the hospital significantly increased the number of antimicrobial reviews and interventions while maintaining a sustained impact on antimicrobial utilization.

The single-center retrospective cohort study, published in Infection Control and Hospital Epidemiology, assessed the impact of the Epic Antimicrobial Stewardship Module (EAM) on antibiotic stewardship program (ASP) interventions by comparing the total number of interventions during the preimplementation period (February 2014 through January 2015) versus the postimplementation period (May 2016 through April 2017). EAM uses specific criteria to generate a list of alerts for the ASP team to review, including new start restricted antimicrobials, intravenous to oral administration, azole therapeutic drug monitoring, anti-retrovirals, pathogen-drug mismatch, and Staphylococcus aureus or yeast in blood culture. The EAM also provides a list of patients with specific pathogens, such as multidrug-resistant organisms or organisms with elevated minimum inhibitory concentrations to certain antibiotics.

Results of the analysis showed that prior to EAM implementation, the ASP team documented 5,433 antimicrobial reviews and made 1,436 interventions (119.7 interventions per month). After EAM implementation, the ASP team documented 8,288 reviews and made 7,444 interventions (620.3 interventions per month). A marked increase in the rate of all types of interventions was observed, with optimization and monitoring of antimicrobial therapy constituting most interventions pre-EAM and post-EAM (46.8% and 54.3%), followed by safety/monitoring (37.2% and 28.2%). Interventions were accepted more than 96% of the time.

Analysis of secondary outcomes showed that days of therapy (DOT) for all target antimicrobials per 1,000 patient-days per group decreased from 5,338.5 pre-EAM to 4,753.2 post-EAM (P = 0.4), while the percentage of antimicrobial drug expenditures relative to overall drug expenditures did not change significantly (7.14% pre-EAM and 8.32% post-EAM, P > .05). The average length of stay was similar between both groups (9.2 days vs. 9.0 days, P > .05), but the overall inpatient all-cause mortality rate was higher in the pre-EAM group (0.39 vs. 0.20, P < .01).

"The improved process for identification of patients requiring ASP review and/or intervention as well as streamlined documentation resulting from the EAM have broadened our ability to ensure optimal, safe, and judicious use of antimicrobials," the authors write. "Based on our experience, hospitals looking to establish or improve upon existing ASP practices should consider investing in a comprehensive clinical decision support system to improve efficiency and document value."
Jun 28 Infect Control Hosp Epidemiol abstract

Dutch report shows small increase in animal antibiotic use

A new report by Dutch public health, veterinary, and food safety officials shows that sales of antibiotics for animals in the Netherlands in 2017 rose slightly compared to 2016, while the presence of antibiotic-resistant bacteria in chickens fell.

The MARAN 2018 report (Monitoring of Antimicrobial Resistance and Antibiotic Usage in Animals in the Netherlands) shows an increase of 3% in sales of antimicrobial veterinary medicinal products in 2017 (181 tonnes) compared to 2016 (176 tonnes), with significant reductions in antibiotic use observed in broilers and turkeys, smaller reductions observed in pigs, and veal calves, and a small increase observed in dairy cattle. The use of antibiotics of critical importance to human healthcare (fluoroquinolones, 3^rd and 4^th generation cephalosporins, polymixins, and trimethoprim/sulfonamides) continued to drop, with steep declines noted in comparison with 2011 sales.

Analysis of antimicrobial resistance data found that resistance in indicator Escherichia coli from fecal samples to most antibiotics tested decreased in broilers from 2016 to 2017, stabilized in pigs, and showed a slight increase in veal calves. The proportion of resistant E coli remained low in dairy cattle. As in previous years, levels of resistant E coli were substantially higher in chicken and turkey meat than in pork and beef. The proportion of E coli isolates resistant to 3^rd generation cephalosporins was low in fecal samples from broilers and pigs and not detected in dairy cattle and veal calves.

Selective culturing of fecal samples found that 22.6% were positive for ESBL/AmpC-producing E coli, with a sharp decrease noted in broilers (from 56.5-50.3% in 2015-2016 to 32.6% in 2017); the prevalence in pigs and dairy cows also decreased and stabilized at around 10%. For the second year in a row, an increase was observed in white and rose veal calves carrying ESBL/AmpC-producing E coli, and 2017 was the first year a higher prevalence was recorded in veal calves than in broilers (36.7% vs. 32.6%). The overall presence of ESBL/AmpC-producing E coli in meat samples in 2017 was 9.6%.

No carbapenemase-producing Enterobacteriaceae were detected in active surveillance of livestock, and the colistin-resistance gene MCR-1 was detected in 1.2% of E coli from livestock 7.7% of E coli from chicken meat. The authors of the report say the higher prevalence of MCR-1 in chicken meat compared to fecal broiler samples could be explained by the fact that some retail chicken meat in Dutch supermarkets comes from countries where colistin is used in livestock production.
Jun 27 MARAN 2018 report