More stewardship strategies linked to fewer discharge antibiotics

An analysis conducted at hospitals in Michigan found that the more antibiotic stewardship strategies a hospital reported, the lower its overuse of antibiotics at discharge, researchers reported yesterday in Clinical Infectious Diseases.

To assess the association of different types of stewardship strategies with antibiotic overuse at discharge, researchers developed the ROAD (Reducing Overuse of Antibiotics at Discharge) Home Framework, which identifies potential strategies for improving antibiotic prescribing at discharge across three tiers: Tier 1 (critical infrastructure), Tier 2 (broad inpatient interventions), and Tier 3 (discharge-specific strategies). Using this framework, the researchers surveyed 39 Michigan hospitals on their antibiotic stewardship strategies.

The 39 hospitals had been part of a previous study describing antibiotic overuse at discharge in patients treated for community-acquired pneumonia (CAP) and urinary tract infection (UTI). The study found that nearly half (49.1) of CAP and UTI patients at 46 Michigan hospitals had antibiotic overuse at discharge. From July 2017 through July 2019, the 39 hospitals treated 20,444 patients for CAP and UTI.

The hospitals reported a median of 12 of 34 possible stewardship strategies. On analysis of individual strategies, only a Tier 3 strategy—review of antibiotics at discharge—was associated with fewer days of antibiotic overuse at discharge for CAP and UTI combined (46% reduction; adjusted incident rate ratio [aIRR], 0.543; 95% confidence interval [CI], 0.335 to 0.878). When weighted by ROAD Home tier, having more weighted stewardship interventions was associated with fewer days of antibiotic overuse at discharge overall (aIRR, 0.957; 95% CI, 0.927 to 0.987 per weighted intervention).

This means that a hospital with the most interventions (16) would be predicted to have 45.3% fewer days of antibiotic overuse at discharge than a hospital with the least (2) interventions.

The study authors say the findings suggest that different pathways to reducing antibiotic overuse at discharge exist and that discharge strategies should be targeted to an individual hospital's resources and needs.

"Specifically, hospitals with limited existing resources and infrastructure should consider implementing a discharge-specific strategy straightaway while hospitals with substantial existing infrastructure may benefit the most from incorporating discharge practices into their existing inpatient stewardship strategies," they wrote.
Feb 10 Clin Infect Dis abstract

 

Two deer on Wisconsin farm test positive for chronic wasting disease

Two white-tailed bucks on a farm in Waukesha County, Wisconsin, have tested positive for chronic wasting disease (CWD), which is always fatal, the Wisconsin Department of Agriculture, Trade and Consumer Protection (DATCP) said yesterday in a news release.

Both deer were 3 years old. The 9-acre farm had been under quarantine since November 2021 after a white-tailed deer transported from its herd tested positive at an Eau Claire County ranch. The farm will remain under quarantine while DATCP and US Department of Agriculture scientists complete their epidemiologic investigation.

The samples were confirmed positive for the prion disease by the National Veterinary Services Laboratories in Ames, Iowa.

CWD, which affects cervids such as deer, elk, and moose, has been detected in 29 US states and in four Canadian provinces. CWD-infected deer may show signs of weight loss, excess salivation, frequent drinking and urination, coordination problems, and a lack of fear of people.

CWD has yet to be detected in people, but the US Centers for Disease Control and Prevention warns against eating cervid meat that tests positive for the disease.
Feb 10 Wisconsin DATCP news release

 

High-path H5 avian flu turns up in Delaware, New Hampshire waterfowl

Federal health officials reported 48 more highly pathogenic H5 avian flu detections, some already characterized at H5N1, in waterfowl on the East Coast, including two newly affected states: Delaware and New Hampshire.

According to the US Department of Agriculture Animal and Plant Health Inspection Service (APHIS), Delaware had three detections in Kent County, all in hunter-harvested birds that were tested as part of surveillance activities. Kent County is in the central part of the state on the Delaware Bay. New Hampshire has 20 detections, all involving live testing of mallards from Rockingham County, located in the state's southeast corner, on the Atlantic shore.

APHIS also detailed more detections in already affected counties in North Carolina. There are now 139 H5 detections in waterfowl on the East Coast, stretching as far south as Florida. The Eurasian H5N1 strain has been implicated in the detections, which have also been found in Canada and have sparked poultry outbreaks in Canada and most recently the United States, involving a turkey farm in Indiana.

The virus is fueling outbreak in on multiple continents, leading to large poultry losses, especially in Europe. The strain has also been tied to a small number of detections in mammals and a few human illnesses, which occurred in people who had extensive contact with poultry. The infections were mild, with no known onward transmission.

In a related development today, APHIS announced it is expanding surveillance into the Mississippi and Central migratory bird flyways, in an effort to track avian flu viruses in all four of the nation's flyways. Surveillance was already under way in the Atlantic Flyway, where the extensive H5N1 findings have been reported, and in the Pacific Flyway.

APHIS said its goal is to adding the Mississippi and Central flyways will collect an additional 14,500 samples, for a total of 31,000 samples from 49 states.
USDA APHIS high-path avian flu page
Feb 11 USDA APHIS announcement

 

Afghanistan reports first polio case of 2022

Four countries reported new polio cases this week, including the first wild poliovirus type 1 (WPV1) case of the year, which was reported in Afghanistan, according to a weekly update from the Global Polio Eradication Initiative (GPEI).

Afghanistan's WPV1 case was in Paktika province, located in the east. WPV1 detections have declined sharply in Afghanistan and Pakistan. Last year, Afghanistan reported only four cases.

Elsewhere, three African countries reported more circulating vaccine-derived poliovirus type 2 cases (cVDPV2). The Democratic Republic of the Congo reported 1 case, which involves a patient from Maniema province. The illness is counted in its total for 2021, which now stands at 25. Niger reported 5 more cases in four provinces, all included in last year's total, which is now at 15.

Also, Nigeria reported 2 more cases, 1 each from Gombe and Plateau states, lifting its case total for 2021 to 397 cases.
Feb 10 GPEI update

 

WHO notes large measles spike in Afghanistan

Afghanistan is reporting a spike in measles cases that has been unmatched in recent years, with weekly cases now approaching 1,500, the World Health Organization (WHO) said in an update yesterday.

Afghan officials reported 35,319 suspected cases from Jan 1, 2021, through Jan 29, 2022. Of those, 3,221 (9%) were lab-confirmed. The vast majority (91%) of suspected cases were in children younger than 5 years. Cases and deaths increased 18% and 40%, respectively, in the first week of February compared with the previous week.

Measles is endemic in Afghanistan, with almost all provinces reporting cases. "Amid the humanitarian crisis in Afghanistan, weekly notifications of suspected measles cases have been increasing in all provinces since the end of July 2021," the WHO said.

The most affected provinces are Balkh, Ghazni, Helmand, Kandahar, Kabul, Paktika, and Paktya. In December 2021, a measles immunization campaign reached more than 1.5 million children under age 5 in Balk, Ghazni, Ghor, Helmand, Kandahar, and Paktika provinces.

The WHO is providing technical support on surveillance, vaccination, laboratory testing, case management, and risk communication.

"Afghanistan is considered a fragile, conflict-affected and vulnerable setting," the WHO said. "According to UNICEF, 14 million people in Afghanistan are facing acute food insecurity, and an estimated 3.2 million children under five years suffer from acute malnutrition." The measles increase is due to a variety of factors, the agency said, including low vaccine uptake.
Feb 10 WHO update

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ASP Scan (Weekly) for Feb 11, 2022

News brief

Our weekly wrap-up of antimicrobial stewardship & antimicrobial resistance scans

More stewardship strategies linked to fewer discharge antibiotics

An analysis conducted at hospitals in Michigan found that the more antibiotic stewardship strategies a hospital reported, the lower its overuse of antibiotics at discharge, researchers reported yesterday in Clinical Infectious Diseases.

To assess the association of different types of stewardship strategies with antibiotic overuse at discharge, researchers developed the ROAD (Reducing Overuse of Antibiotics at Discharge) Home Framework, which identifies potential strategies for improving antibiotic prescribing at discharge across three tiers: Tier 1 (critical infrastructure), Tier 2 (broad inpatient interventions), and Tier 3 (discharge-specific strategies). Using this framework, the researchers surveyed 39 Michigan hospitals on their antibiotic stewardship strategies.

The 39 hospitals had been part of a previous study describing antibiotic overuse at discharge in patients treated for community-acquired pneumonia (CAP) and urinary tract infection (UTI). The study found that nearly half (49.1) of CAP and UTI patients at 46 Michigan hospitals had antibiotic overuse at discharge. From July 2017 through July 2019, the 39 hospitals treated 20,444 patients for CAP and UTI.

The hospitals reported a median of 12 of 34 possible stewardship strategies. On analysis of individual strategies, only a Tier 3 strategy—review of antibiotics at discharge—was associated with fewer days of antibiotic overuse at discharge for CAP and UTI combined (46% reduction; adjusted incident rate ratio [aIRR], 0.543; 95% confidence interval [CI], 0.335 to 0.878). When weighted by ROAD Home tier, having more weighted stewardship interventions was associated with fewer days of antibiotic overuse at discharge overall (aIRR, 0.957; 95% CI, 0.927 to 0.987 per weighted intervention).

This means that a hospital with the most interventions (16) would be predicted to have 45.3% fewer days of antibiotic overuse at discharge than a hospital with the least (2) interventions.

The study authors say the findings suggest that different pathways to reducing antibiotic overuse at discharge exist and that discharge strategies should be targeted to an individual hospital's resources and needs.

"Specifically, hospitals with limited existing resources and infrastructure should consider implementing a discharge-specific strategy straightaway while hospitals with substantial existing infrastructure may benefit the most from incorporating discharge practices into their existing inpatient stewardship strategies," they wrote.
Feb 10 Clin Infect Dis abstract

 

Study finds higher risk of group A Strep skin infections among homeless

Originally published by CIDRAP News Feb 10

A study conducted in San Francisco found that homeless residents were more than four times as likely to have group A Streptococcus (GAS) skin infections as people with stable housing, researchers reported yesterday in JAMA Dermatology.

The retrospective, cross-sectional study analyzed inpatients seen by dermatology services at two San Francisco hospitals for bacterial skin and other soft-tissue infections (SSTIs) from March 2018 through March 2020. Patients were classified as persons experiencing homelessness (PEH) if they reported no primary address or an institutional primary address within the past 12 months. Researchers used logistic regression to determine associations between housing status and both GAS SSTI and methicillin-resistant Staphylococcus aureus (MRSA) SSTI.

Of the 181 patients included in the study, 52 were PEH and 129 had stable housing. Among PEH, 42% had GAS-positive cultures and 33% had MRSA-positive cultures, compared with 15% and 23% of patients with stable housing, respectively. After controlling for confounders, PEH had significantly higher odds of GAS SSTI (odds ratio [OR], 4.25; 95% CI, 1.86 to 9.70; P = .001) and non-significantly higher odds of MRSA SSTI (OR, 1.49; 95% CI, 0.68 to 3.27; P = .33).

The analysis also found that PEH had significantly higher rates of first-line MRSA antibiotic coverage than patients with stable housing (90% vs 70%) and non-significantly reduced rates of first-line GAS coverage (30% vs 47%), a finding the study authors say suggests providers may prioritize MRSA among homeless patients presenting with SSTI.

"Given that 42% of PEH had cultures that tested positive for GAS and PEH had 4.25 times higher odds of GAS SSTI, the present study results suggest that health care professionals may need to consider GAS more strongly among PEH presenting with SSTI," they wrote.
Feb 9 JAMA Dermatol study

 

UK white paper suggests ways to transform infection management

Originally published by CIDRAP News Feb 10

A newly formed coalition of pharmaceutical and diagnostics companies and research organizations yesterday published a white paper with recommendations to transform the way infections are detected, monitored, managed, and prevented across all facets of England's National Health Service (NHS), with a focus on mitigating the harms from antimicrobial resistance (AMR).

The paper from the Infection Management Coalition (IMC) presents 29 recommendations to nurture a patient-centered, holistic approach to infection management and help achieve the UK government's 20-year vision of a world in which AMR is effectively contained. The groups say the recommendations support development of a roadmap that will help "accelerate the creation of a system which is resilient and mature with regard to: outbreak and pandemic preparedness; infection prevention; rapid recognition, diagnosis and treatment of time-critical viral and bacterial infections; and to, ultimately, deliver effective AMS [antimicrobial stewardship]."

The recommendations presented in the paper include the development and implementation of a data registry for patients entering the healthcare system with an infection that would track the medicines used and monitor outcomes and recovery, along with a requirement that clinicians input infection data into electronic patient records so that the systems know exactly which antibiotics work for patients.

The paper also calls for greater integration of point-of-care diagnostics; allowing sepsis, infection, and AMR to be registered as actual causes of death; development of more robust surveillance systems to track infections and resistant pathogens; creation of a 5-year national plan to explore development of new antibiotics and cutting-edge diagnostics; and establishing the "human face" of AMR.

"Infection is managed across all specialties in healthcare because it is common and has diverse implications," the paper states. "To address AMR and to maintain antimicrobial stewardship, we need to approach infection management holistically."
Feb 9 IMC white paper

 

Procalcitonin testing during COVID tied to initial drop in UK antibiotic use

Originally published by CIDRAP News Feb 8

The introduction of procalcitonin (PCT) testing at UK hospitals during the first wave of the COVID-19 pandemic was associated with an immediate but not sustained decline in antibiotic prescribing, researchers reported today in the Journal of Antimicrobial Chemotherapy.

During the first wave of the pandemic, many NHS hospitals introduced PCT testing, which looks for an inflammatory biomarker that rises in bacterial respiratory tract infections, to guide antibiotic decision-making, particularly in emergency departments (EDs) and acute medical units (ACUs).

To evaluate the impact of PCT testing on antibiotic use, a team of researchers conducted a retrospective, controlled interrupted time series analysis of antibiotic dispensing, hospital activity, and PCT testing at 105 NHS hospitals/hospital trusts in England and Wales from Feb 24 to Jul 5, 2020.

In the main analysis, there was a statistically significant decrease of –1.08 (95% CI, –1.81 to –0.36) defined daily doses (DDD) per admission per week per trust immediately following the introduction of PCT testing in EDs/ACUs. But that was followed by a statistically significant increase of 0.05 (95% CI, 0.02 to 0.08) DDD per admission per week per trust. Similar results were found specifically for first-line antibiotics for community-acquired pneumonia and for COVID-19 admissions. PCT testing was not associated with any change in antibiotic prescribing in the intensive care unit.       

"We found that the initial impact of PCT testing was gradually lost over time," the study authors write. "Of note, this is an absolute effect, not relative to other trusts/hospitals, and is likely related to sustainability, which is a challenge for any antibiotic stewardship intervention."

The authors add, however, that the initial impact of PCT testing represents an 18% reduction from the national median of 5.9 DDD per admission per week per trust, and that further research should be done to determine the patient-level impact and its potential for clinical effectiveness.
Feb 8 J Antimicrob Chemother abstract

 

Three cases of ceftriaxone-resistant gonorrhea reported in England

Originally published by CIDRAP News Feb 8

The UK Health Security Agency (UKHSA) yesterday reported three new cases of ceftriaxone-resistant gonorrhea.

The recently diagnosed cases involve a woman in London in her 20s and a heterosexual couple from the Midlands in their 20s. There are currently no known connections between the cases.

Ceftriaxone-resistant strains of gonorrhea are most common in the Asia-Pacific region but have been occasionally identified in people who've travelled or moved to the United Kingdom from that region. On Dec 24, 2021, UKHSA reported a case of ceftriaxone-resistant gonorrhea in a man who acquired the infection in London in November.

Since 2019, ceftriaxone has been the primary antibiotic used to treat gonorrhea infections in the United Kingdom. Previous treatment guidelines recommended dual therapy with ceftriaxone and azithromycin, but azithromycin is no longer recommended because of high levels of resistance.

"After a couple of years without any cases of this hard-to-treat form of gonorrhoea, we have now seen 4 cases in the last 2 months," Katy Sinka, PhD, who heads the UKHSA's Sexually Transmitted Infection (STI) section, said in a press release. "It's too soon to say whether this will be the start of a longer-term trend, but we do know that STIs are on the rise in general."

UKHSA officials say they are awaiting follow-up tests in the three cases to see if treatment has been successful.
Feb 7 UKHSA press release
Dec 24 UKHSA press release

 

Study finds high rates of antimicrobial resistance in Benin hospital

Originally published by CIDRAP News Feb 7

A study of blood cultures collected at a semi-rural hospital in Benin found unexpectedly high rates of AMR among gram-negative bacteria, researchers reported last week in BMC Infectious Diseases.

From October 2017 to February 2020, 3,140 blood cultures were collected from 3,082 suspected bloodstream infection (BSI) episodes at Boko Hospital, a secondary hospital in Benin, and a nearby university hospital. Isolates retrieved from the blood cultures were processed locally and later shipped to Belgium for reference identification and antimicrobial susceptibility testing. Most of the cultures (78.7%) were from children under 15 years of age.

Pathogens were recovered from 383 blood cultures (12.4%), corresponding to 381 confirmed BSIs. The most common pathogens were Klebsiella pneumoniae (15.6%), Salmonella Typhi (15.3%) and S aureus (13.5%). AMR rates were high among Enterobacterales, with resistance to third-generation cephalosporins found in 77.6% of K pneumoniae isolates, 12.8% of Escherichia coli isolates, and 70.5% of Enterobacter cloacae isolates. Carbapenemase production was detected in two E coli and two E cloacae isolates, all of which were of the New Delhi metallo-beta lactamase type. Methicillin resistance was present in 22.4% of S aureus isolates.

The study authors say the findings highlight the feasibility and importance of having clinical bacteriology laboratories at secondary hospitals in low- and middle-income countries (LMICs), particularly those in sub-Saharan Africa, where AMR data are scarce.

"Unbiased estimates for AMR are difficult to obtain in LMIC, but our experiences highlight the potential for surveillance of AMR in the community through strengthening of clinical microbiology laboratories in remote, non-tertiary settings," they wrote.
Feb 3 BMC Infect Dis abstract

COVID-19 Scan for Feb 11, 2022

News brief

Maternal COVID-19 vaccination not tied to poor infant outcomes

A new study on outcomes among infants whose mothers received the Pfizer-BioNTech mRNA vaccine in pregnancy showed that no detrimental outcomes were associated with maternal vaccination, including preterm birth, small birth weight for gestational age (SGA), congenital malformations, and infant death.

It was published yesterday in JAMA Pediatrics.

The population-based cohort study, which included all singleton live births in March through September 2021, included women and infants seen within a large state-mandated healthcare organization in Israel. A total of 24,288 eligible newborns were included, of whom 16,697 were expose in the first (2,134 infants) or second (9,364) trimester to maternal vaccination in utero.

In January 2021, Israel officially recommended vaccination with the two-dose Pfizer vaccine for all pregnant women. Women who were vaccinated in pregnancy tended to be older, more affluent, and have higher uptake of the seasonal influenza vaccine.

The risk of any congenital malformation was not significantly different among exposed or unexposed infants, with a risk ratio (RR) of  0.69 (95% confidence interval [CI], 0.44 to 1.04), similar to the RR for heart malformations of 0.75 (95% CI, 0.43 to 1.26). The risk for major heart malformations was lower among the exposed group, with an RR of 0.46 (95% CI, 0.24 to 0.82), the authors found. There were no differences observed for hospitalization.

"This large, nationally representative study examined various congenital outcomes and detected no increased risk for early infant morbidity or mortality among live-born infants prenatally exposed to BNT162b2 [Pfizer] vaccination as compared with unexposed infants," the authors concluded.
Feb 10 JAMA Pediatr study

 

Mix 'n' match COVID-19 vaccine boosting may lower breakthrough cases

A study this week in the New England Journal of Medicine (NEJM) finds that receiving a booster dose of a different brand of COVID-19 vaccine after receiving the Johnson & Johnson (J&J) vaccine in the primary series may prevent more breakthrough infections.

Researchers at the Veterans Affairs Pittsburgh Healthcare System studied 4,806,026 veterans in a database containing information on all veterans diagnosed as having COVID-19.

The veterans were grouped according to whether their primary series was with either the J&J vaccine (43,394 participants) or the Pfizer-BioNTech or Moderna mRNA COVID-19 vaccines (965,063). Each participant who received a different (heterologous) vaccine as a booster dose was matched with a peer who received the same (homologous) vaccine.

Among the veterans who had received the J&J primary series, there were 415 COVID-19 infections, including 34 with moderate illness and 12 with severe or critical disease. Of the infections, 278 occurred in veterans who had received a homologous booster, and 137 occurred in those given a heterologous booster, for a roughly 50% lower incidence among the heterologous group (adjusted rate ratio [aRR], 0.49). Likewise, the aRRs for moderate and severe illness were lower in the heterologous group.

Among participants whose primary series was with the Pfizer or Moderna vaccine, there were 362 infections, including 23 veterans with moderate illness and 8 with severe or critical disease. There was no difference between the incidence of COVID-19 infection of any severity among veterans in the heterologous or homologous group (aRR, 1.10), and outcomes were comparable in those who received either mRNA vaccine.

The authors noted that recent clinical trials of COVID-19 boosters have found that heterologous boosting provokes a greater antibody response than homologous doses in healthy adults.

"Our findings support the results of these clinical trials since we observed the largest number of documented breakthrough infections in participants who had received a homologous Ad26.COV2.S [J&J] booster," the study authors wrote. "Our analysis provides further evidence that the infection rate is lower in persons who are boosted with a heterologous mRNA vaccine."
Feb 9 NEJM research letter

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