News Scan for Apr 12, 2021

News brief

Audit and feedback, prior approval may reduce fluoroquinolone use

A study of Veterans Affairs (VA) hospitals found that prospective audit and feedback (PAF) and prior-approval strategies focused on fluoroquinolone use were associated with lower fluoroquinolone prescribing rates, US researchers reported today in Infection Control & Hospital Epidemiology.

Despite multiple safety warnings on fluoroquinolones from the Food and Drug Administration and concerns about antibiotic resistance and Clostridioides difficile infection, the antibiotics are frequently prescribed in US healthcare settings. In the two-part study, conducted at 15 VA acute-care medical centers, researchers surveyed antimicrobial stewardship program (ASP) leaders about the local implementation and acceptability of different strategies to improve fluoroquinolone prescribing, along with analysis of data on antibiotic administration at each hospital in 2017 and 2018. The researchers then compared fluoroquinolone days of therapy (DOT) per 1,000 days present (DP) for sites with and without PAF and/or prior approval.

The surveys showed that 9 of the 15 hospitals (60%) had PAF or prior-approval strategies for fluoroquinolones. Compared with sites using neither strategy, fluoroquinolone prescribing rates were lower for sites that implemented PAF and/or prior approval (64.4 DOT/1,000 PD vs 35.5 DOT/1,000 PD) and decreased from 2017 to 2018. That decrease occurred without a corresponding increase in advanced-generation cephalosporin prescribing, a common alternative.

Total antibiotic rates were 13% lower for sites with PAF and/or prior approval, but this difference did not reach statistical significance. In the hospitals where stewardship leaders reported that PAF and/or prior approval were "completely" accepted, fluoroquinolone prescribing rates were lower than at sites where it was "moderately" accepted (34.2 DOT/1,000 PD vs 48.6 DOT/1,000 PD).

Stewardship leaders also reported that clinical pathways and/or local guidelines (93%), prior approval (93%), order forms (80%), and infectious disease consults (73%) "would" or "may be" effective in improving fluoroquinolone use.

"Additional research should be conducted to provide further insight as to facilitators and barriers to implementing persuasive and restrictive strategies on the use of fluoroquinolones," the authors wrote. "In addition, appropriate antibiotic substitutes for these agents should be identified based on safety, local sensitivities, and as recommended in treatment guidelines."
Apr 12 Infect Control Hosp Epidemiol abstract

WHO issues report on AMR in water and the environment

A report released today by the World Health Organization (WHO) proposes actions for assessing and managing the risk to human health from antimicrobial resistance (AMR) in water and the environment.

As a result of decades of use and overuse of antibiotics and other antimicrobial agents in human and animal medicine, antibiotic residues and their metabolites, drug-resistant bacteria, and AMR genes are common, widespread contaminants in water and the environment. But WHO guidelines for drinking water, recreational water, and use of wastewater and excreta in agriculture and aquaculture contain no specific advice on how to assess, manage, or minimize human exposure or the potential human health risks associated with the presence of these contaminants.

"Because the presence of antimicrobial-resistant bacteria and their AMR genes in water, wastewater, wastewater-irrigated foods, and aquacultural systems is now widely recognized, greater and more harmonized consideration of them as an environmental health hazard is needed," the authors note.

To better assess the risk for human exposure, the document from the WHO's Water, Sanitation and Hygiene (WASH) team calls for improved identification of drug-resistant bacteria and AMR genes in human and animal wastes, and more research into the movement of those bacteria and genes through the environment and the various pathways for human exposure. It also recommends developing approaches to estimate the health risks associated with exposure via routes such as ingestion, inhalation, skin and eye contact, and food.

To manage the risks, the WHO proposes developing systems for tracking and monitoring antibiotics, resistant bacteria, and AMR genes in water and the environment, identifying technologies that can minimize the presence of these contaminants in water, and implementing strategies to combat the widespread use and overuse of antibiotics in human and animal health.

The document also calls on the WHO to develop new guidance to inform and support efforts to control the presence of antibiotics and antimicrobial-resistant bacteria in human and animal waste and the environment and reduce or minimize human exposure.
Apr 12 WHO briefing note

USDA issues alert for ground turkey tied to Salmonella cases in 12 states

The US Department of Agriculture's Food Safety and Inspection Service (FSIS) announced it's investigating a 12-state outbreak of 28 Salmonella Hadar illnesses and issued a public health alert concerning 211,000 pounds of raw ground turkey products produced by Plainville Brands, LLC, of New Oxford, Pennsylvania.

The FSIS did not issue a recall of the food items, because it believes the products are no longer available for consumers to buy. The agency is concerned, however, that consumers may still have the products in their freezers.

The products in question were produced from Dec 18 through 29, 2020, and all have a sell-by-dates no later than Jan 10, 2021. They include 1- to 3-pound packages of ground, raw turkey.

So far the FSIS and the Centers for Disease Control and Prevention (CDC), have identified 28 cases of illness caused by Salmonella Hadar. An investigation into one case-patient showed the person consumed ground turkey produced by Plainville Brands, and an unopened package of Plainville Brands' ground turkey collected from the person's home tested positive for Salmonella Hadar.

The FSIS said, however, "Evidence collected to date does not link all illnesses to this establishment. Based on the continuing investigation, additional product from other establishments may be involved. FSIS continues to work with CDC and state and local public health partners on this investigation and will provide updated information as it becomes available."
Apr 10 FSIS public health alert

H5N8 avian flu outbreaks strike more poultry in Germany

Animal health officials in Germany recently reported several highly pathogenic H5N8 avian flu outbreaks in poultry that affected three areas since late February, according to notifications from the World Organization for Animal Health (OIE).

The hardest-hit area was North Rhine-Westphalia state in the west, where the outbreaks began on Feb 28 and affected 10 locations—9 farms and 1 backyard bird holding. Taken together, the virus killed 3,049 of 111,126 birds, and the rest were culled to control the spread of the virus.

Officials also reported outbreaks at two locations in Saxony-Anhalt state, also in the west. One was at a farm, and the other affected backyard birds. The events began on Mar 15, and in total, 12 of 45 birds died, and the rest were destroyed as part of the outbreak response. Also, officials reported an outbreak in backyard birds in Berlin that began on Feb 28, killing all 10 poultry.

In developments involving wild birds, Russia confirmed highly pathogenic H5N5 in wild birds in Dagestan in the far south on Mar 23. Also, Ukraine officials reported a highly pathogenic H5 outbreak that began on Apr 1 and affected birds in a forest in Mykolaiv oblast in the south.
Apr 8 OIE report on H5N8 in Germany's North Rhine-Westphalia state
Apr 9 OIE report H5N8 in Germany's Saxony-Anhalt state
Apr 8 OIE report on H5N8 in Berlin
Apr 7 OIE report on H5N5 in Russian wild birds
Apr 5 OIE repot on H5 in Ukrainian wild birds

COVID-19 Scan for Apr 12, 2021

News brief

Pfizer COVID vaccine shows varied effect against variants, study suggests

One dose of the Pfizer/BioNTech COVID-19 vaccine appears to be not very protective against the B117 variant, and two doses may not be as effective against the B1351 variant, according to a non–peer-reviewed, real-world Israeli study posted late last week on the medRxiv preprint server.

Led by researchers at Tel Aviv University, the case-control study compared nearly 400 people who had received one or two doses of the Pfizer vaccine and were infected by SARS-CoV-2 with matched unvaccinated, infected controls.

Vaccinated participants were infected either at least 1 week after their second dose or between at least 2 weeks after the first dose and before 1 week after the second one. Overall, most infections involved B117, which was first identified in the United Kingdom.

"We see evidence for reduced vaccine effectiveness against the British variant, but after two doses—extremely high effectiveness kicks in," senior study author Adi Stern, PhD, said on Twitter.

B1351, first detected in South Africa, made up about only 1% of all coronavirus cases, but in infected patients who had received two doses of the vaccine, the variant caused eight times more cases than in unvaccinated controls (5.4% vs 0.7%)."We see evidence for reduced vaccine effectiveness against the [South African] variant, but it does not spread in Israel," Stern said.

"Furthermore, focusing on the partially immunized, we noted more breakthroughs by the 'British' variant," she said. "We think this might explain why during the early stages of the vaccination rollout in Israel, it took a while till vaccination effects were noted and cases began to drop."

They added that their findings suggest that the vaccine is less effective against both variants in different dosage and timing scenarios, but cautioned that their study had few participants with B1351 infections. They also said that their study wasn't designed to determine overall vaccine effectiveness against variants, because the participants had already been infected with COVID-19.

"These results overall suggest that vaccine breakthrough infection is more frequent with both [variants of concern], yet a combination of mass-vaccination with two doses coupled with non-pharmaceutical interventions control and contain their spread," the authors wrote.
Apr 9 medRxiv study
Apr 10 SternLab Twitter thread

Study finds 31% of children hospitalized for COVID-19 have severe disease

Editor's Note: This scan was revised on Apr 16. It originally said 12% of children with COVID-19 were hospitalized, which is not correct. We apologize for the error.

Among a cohort of 20,714 US children who sought care from a healthcare provider or emergency department for COVID-19, more than 1 in 10 (11.7%) were hospitalized, of whom 31.1% (756) had severe COVID-19, according to a research letter late last week in JAMA Network Open.

Severe COVID-19 was defined as requiring admission to an intensive care unit (ICU), mechanical ventilation, or comparable treatment.

Discharge data from 869 US medical facilities from Mar 1 to Oct 31, 2020 showed that most hospitalized COVID pediatric patients were girls (52.8%) and 12 to 18 years of age (53.8%); 29.2% had at least one chronic condition. Similar to COVID studies in adult populations, Hispanic and Black populations were overrepresented at 39.3% and 24.4%, respectively. However, when the researchers looked at factors for severe COVID-19, race did not have any significant associations, and neither did insurance type.

The likelihood for severe COVID-19 increased if the patient had at least one chronic condition (adjusted odds ratio [aOR], 3.27; 95% confidence interval [CI], 2.44 to 4.37) or male (aOR, 1.52; 95% CI, 1.26 to 1.83). Likelihood also increased if the child was 2 to 5 or 6 to 11 years of age versus a teenager (aORs, 1.53 for both; 95% CIs, 1.11 to 2.13 and 1.04 to 2.23, respectively).

"Although admission to an intensive care unit for younger children may indicate an abundance of caution by clinicians or facility and administrative requirements rather than disease severity, this finding has important clinical and resource planning implications for facilities and clinicians," the researchers write. "Understanding factors associated with severe COVID-19 disease among children could help inform prevention and control strategies."
Apr 9 JAMA Netw Open research letter

Analysis reveals lower COVID-19 viral load, growth in children

Children may transmit COVID-19 infections less than adults do, according to a study late last week in the Canadian Medical Association Journal (CMAJ). The researchers looked at viral samples from 305 children and adults infected with COVID-19 in Manitoba and found that children's samples had lower viral growth in cultures and higher cycle threshold (Ct) values, indicating less viral load.

Samples were collected March to December 2020 and represent 1.5% of positive COVID samples in Manitoba at the time and 7.2% of the province's positive samples in children. Children were more likely to be symptomatic (37.7% vs 6.9%). For symptomatic children, the researchers note, the duration between symptom onset and testing was not associated with viral culture results.

The researchers were able to successfully culture 30.5% of the samples. They grew viruses in lab culture for 18.6% of samples in children 10 or younger and in 23.1% of samples from children 11 and 17 years—compared with a 43.8% rate in adults, or 55% higher.

Ct values were 25.1 in those 10 and younger, 22.2 in those 11 to 17 years, and 18.7 in adults. The researchers also measured 50% tissue culture infectious dose and found that it was 316 in children 11 to 17 years and 5,620 in adults.

"We found that SARS-CoV-2 grew from pediatric samples less often than adult samples, and when the virus was successfully cultured, significantly less viable virus was present," the researchers conclude. "Finally, we cannot be certain that our findings apply to novel SARS-CoV-2 variants that have shown higher levels of infectivity, as such variants were not commonly circulating during the study period."

In a CMAJ press release, principal investigator Jared Bullard, MD, of the University of Manitoba, added, "If younger children are less capable of transmitting infectious virus, daycare, in-person school and cautious extracurricular activities may be safe to continue, with appropriate precautions in place, and with lower risk to child care staff, educators and support staff than initially anticipated."
Apr 9 CMAJ study
Apr 9 CMAJ press release