News Scan for May 21, 2021

News brief

Report: COVID-19 outbreaks affected 6% of DC child care facilities

While one in four Washington, DC, child care facilities reported at least one COVID-19 case from July to December 2020, only 5.8% had COVID-19 facility-associated outbreaks, according to yesterday's Morbidity & Mortality Weekly Report. A facility-associated outbreak was defined as two or more lab-confirmed cases at a child care site within 14 days.

Out of 469 child care facilities in DC, 112 (23.9%) submitted 269 COVID-19 reports to the DC Office of the State Superintendent of Education (85 reports were excluded because of missing, duplicated, or inaccurate information). Officials confirmed 319 cases, including 3 found through contact tracing.

Outbreaks occurred in 27 (5.8%) facilities and accounted for 48.9% of the total reported cases, but the researchers note that five sites made up 44.2% of the facility-associated cases. About one in five infections (21.3%) were in asymptomatic patients, with 63.2% of these found in children. Overall, teachers and staff made up 56.4% of patients.

Most cases (72.4%) were reported after Oct 27, which was when community cases began increasing, the researchers write. Data showed five close contacts per child care patient versus 1.2 per community patient.

Facilities were more likely to have an outbreak if they had people who received COVID-19 tests 3 or more days post–symptom onset (relative risk [RR], 2.03), had asymptomatic cases (RR, 2.10), or were in operation for 3 years or less (RR, 3.29). The researchers suggest that more experienced facilities may have had more resources or been better at implementing COVID mitigation measures such as cohorting.

"Similar to outbreaks reported in school settings, those associated with child care facilities, including outbreak-associated cases, remained low," the researchers write. "Implementation and maintenance of multiple prevention strategies, including vaccination, masking, physical distancing, cohorting, screening, and reporting, are important to reduce transmission of SARS-CoV-2 in child care facilities and to facilitate a timely public health response to prevent outbreaks."
May 20 MMWR study

Half of critical COVID-19 patients in African hospitals died, study says

Almost half of patients hospitalized with critical COVID-19 infections died in the hospital within 30 days across 10 African countries, according to a Lancet study today. The researchers say that, compared with the global average, this translates to 11 to 23 excess deaths per 100 patients.

The African COVID-19 Critical Care Outcomes Study (ACCCOS) looked at 3,140 patients in intensive care or high-care units in 64 hospitals in 10 African countries from May to December 2020.

Factors associated with 30-day in-hospital mortality included a sequential organ failure assessment score of 3 or higher at admission (odds ratio [OR], 3.66), chronic liver disease (OR, 3.48), delay in admission due to resource shortages (OR, 2.14), HIV/AIDS infection (OR, 1.91), and increasing age per year (OR, 1.03). Patients who needed respiratory support of any type or had cardiorespiratory arrest within 24 hours of admission had similar or higher odds of mortality.

The researchers found high rates of physician and nurse coverage, so they speculate that resource shortages as well as underused resources due to lack of training or machine breakdown may have affected mortality rate. For instance, dialysis was available in 39 of 57 sites yet only offered to 330 patients. Placing patients in the prone position, they write, should have been used for at least six times as many patients, and access to extracorporeal membrane oxygenation was 14 times lower than what it should have been. Additionally, half the patients died without receiving oxygen.

"This study has several strengths, including a large sample size, robust analyses, as well as having a multisite and prospective design," write Bruce J. Kirenga, MBChB, MMed, PhD, and Pauline Byakika-Kibwika, MBChB, MMed, PhD, in a commentary.

"However, the authors also recognise some limitations, including that the study was done in tertiary hospitals. Moreover, 23 (36%) of 64 hospitals were in South Africa and Egypt, which are better resourced countries compared with some other African countries; mortality is probably higher in lower-income African countries."
May 22 Lancet study and commentary

CDC confirms 163 Salmonella illnesses linked to backyard poultry

The Centers for Disease Control and Prevention (CDC) has confirmed 163 new Salmonella infections in 43 states that are linked to backyard poultry.

A total of 34 people have been hospitalized, but no deaths have been recorded. Case-patients range in age from less than 1 to 87 years, with a median age of 24. But a third of the cases occurred in children under the age of 5 years, the CDC said.

Of 92 patients interviewed, 81 (88%) reported contact with backyard poultry before falling ill.

"Interviews with sick people show that contact with backyard poultry is the likely source of the outbreaks," the agency said in a press release. "Backyard poultry can carry Salmonella germs even if they look healthy and clean. These germs can easily spread in areas where they live and roam."

Officials in Ohio who collected samples from a sick person's ducklings noted that whole-genome sequencing (WGS) showed that Salmonella serotype Hadar in duckling poop was closely related to bacteria from sick people. Investigators also used WGS to determine that about half of 125 sick people's samples showed resistant to one or antibiotic.

The CDC recommends that children younger than 5 not touch the birds (including chicks and ducklings) or anything in the area where the birds live and roam. Young children, the immunocompromised, and the elderly are most at risk for serious Salmonella infections.
May 20 CDC update
May 20 CDC press release

Four countries add more vaccine-derived polio cases

Four countries reported more vaccine-derived polio cases this week, two in Africa and two in the Middle East, according to the latest weekly update from the Global Polio Eradication Initiative (GPEI). All involved circulating vaccine-derived poliovirus type 2 (cVDPV2).

In Africa, Mali reported a case in Koulikoro region in the country's southwest. The illness is counted in the 2020 total, which is now at 47. Nigeria also reported one new case, which involves a patient from Kebbi state in the country's northwest. The detection lifts the country's total this year to six.

Meanwhile Afghanistan reported 5 cVDPV2 cases in four different provinces, lifting its total for 2021 to 38. Also, Pakistan reported one case, which involved a patient from Balochistan, putting its total for the year at seven.
May 20 GPEI update

Stewardship / Resistance Scan for May 21, 2021

News brief

High level of antibiotic use found in dying organ donors

In a first-of-its-kind study, a team of US researchers reported this week in Clinical Infectious Diseases that nearly all of more than 400 deceased organ donors received at least one antibiotic dose during their terminal hospitalization, a finding that study authors say highlights the need for antibiotic stewardship in this population.

While there is concern about the use of donated organs that are infected or colonized with multidrug-resistant organisms (MDROs) and the potential for donor-derived infection (DDI), to date there have been no studies on antibiotic use among deceased organ donors, which is considered an important risk for MDRO colonization or infection. To investigate the level of antibiotic use in this group, a team led by researchers with the University of Pennsylvania Perelman School of Medicine examined data on 440 organ donors at four transplant centers in the Philadelphia region. Details on all antibiotics administered during terminal hospitalization, including those given leading up to and during organ procurement, were included.

Of the 440 organ donors, 427 (97%) received at least one course of antibiotics during terminal hospitalization, and 400 (91%) received at least one dose outside of the peri-procurement period. A total of 312 donors (71%) received a broad-spectrum antibiotic, with 299 (68%) receiving a broad gram-negative agent and 103 (23%) receiving a broad gram-positive agent. Sixty-three donors (14%) received potentially redundant antibiotics. The most frequently used antibiotics were first-generation cephalosporins (337 donors, 77%), and the median number of total antibiotic days of therapy was 4.

"In conclusion, our study identified widespread use of broad-spectrum antibiotics and many instances of potentially redundant antibiotic prescription among deceased organ donors," the study authors wrote. "Since brief antibiotic exposures may increase the risk for donor MDRO colonization and subsequent MDRO DDIs in the recipient, the organ donor population is an important future target of antibiotic stewardship interventions."
May 20 Clin Infect Dis abstract

Stewardship helped limit antibiotics early in pandemic, hospital study finds

Strategies implemented by the antimicrobial stewardship team (AMST) at a hospital in Spain to minimize antibiotic use during the first wave of the COVID-19 pandemic contributed to an overall reduction in antibiotic use in 2020, researchers reported today in Infection Control & Hospital Epidemiology.

In a letter to the editor, clinicians and pharmacists at Moises Broggi Hospital in Barcelona report that antibiotic consumption at the hospital in 2020 was lower than in 2019, except for March, when the onset of the pandemic caused in increase in the use of azithromycin and ceftriaxone. Measured in defined daily doses (DDD) per 100 bed-days, the mean global consumption of antibiotics during hospitalization was 57.8 DDD/100 bed-days in 2020, compared with 64.7 DDD/100 bed-days in 2019.

The study authors say that while the AMST was unable to carry out its work from March through May 2020, protocols established for the management of COVID-19 patients, including recommended antibiotic regimens (azithromycin and ceftriaxone) and recommended durations (5 and 3 days, respectively) and review of antibiotic treatment by the AMST pharmacist, made it possible to control antibiotic consumption during the first wave.

"After the first wave, hospital activity began to normalize and allowed for the usual individualized AMST intervention," the study authors wrote. "This made it possible to maintain the levels of antibiotic consumption below those observed in the previous year."
May 21 Infect Control Hosp Epidemiol abstract

ASP Scan (Weekly) for May 21, 2021

News brief

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

High level of antibiotic use found in dying organ donors

Stewardship helped limit antibiotics early in pandemic, hospital study finds

Pneumococcal vaccines may affect use of kids' antibiotics

Originally published by CIDRAP News May 20

Antibiotic prescribing for young children in Israel sharply declined following implementation of pneumococcal conjugate vaccine (PCV), Israeli researchers reported today in Clinical Infectious Diseases.

Using data from the country's largest health maintenance organization, the researchers conducted an interrupted time series analysis of dispensed antibiotic prescription (DAP) rates for Israeli children under the age of 5 from July 2005 through June 2018. The 7-valent vaccine (PCV7) was introduced into Israel's National Immunization Plan (NIP) in 2009, and the 13-valent vaccine (PCV13) has gradually replaced it since 2010. Since then, a marked reduction in respiratory tract infections (RTIs) in Israeli children has been observed, but the impact on antibiotic prescribing has not been investigated.

The study also included a comparison of the DAP rate between Jewish and Bedouin populations in southern Israel, as prior to PCV implementation, pneumococcal diseases and RTIs were more prevalent among Bedouin children. PCV uptake was similar in Jewish and Bedouin children.

Following the implementation of PCV7/PCV13, DAP rates for children under 5 abruptly and significantly declined, largely driven by a decrease in amoxicillin and amoxicillin-clavulanate prescriptions, which prior to PCV implementation accounted for 75% of pediatric DAPs. The decline continued and stabilized at a reduced level within 5 years. Children younger than 2 and Bedouin ethnicity were significantly associated with higher pre-PCV DAP rates, but also with a faster and greater decline post-PCV, achieving near elimination of gaps between ages and ethnic groups.

Among all children under 5, the annual mean reduction (per 1,000 child-years) of DAPs ranged between an absolute incidence rate ratio of 344.7 and a relative incidence rate ratio of 110.4. For amoxicillin/amoxicillin-clavulanate, the respective reductions were 300.2 and 142.3. Azithromycin was the only drug with increasing trends following PCV implementation.

"The overall DAP reduction rate translates into reduced pressure on the entire body microbiota," the study authors wrote. "However, consumption still remains high. Therefore, although PCV implementation is an important tool against antimicrobial resistance, efforts to develop other tools such as improvement of stewardship programs must be continued."
May 20 Clin Infect Dis abstract

New expert panel to advise global health leaders on zoonotic disease

Originally published by CIDRAP News May 20

Four international organizations today announced the formation of a new expert panel to improve understanding, and stop the emergence and spread, of zoonotic diseases.

Operating under the One Health approach, which recognizes the links between the health of people, animals, and the environment, the One Health High-Level Expert Panel will advise the United Nations Food and Agriculture Organization of the United Nations (FAO), the World Organization for Animal Health, the United Nations Environment Programme, and the World Health Organization (WHO) on the development of a long-term action plan to avert outbreaks of infectious diseases that emerge in animals.

According to a WHO press release, the ultimate aim of the panel will be to develop evidence-based recommendations for global, regional, national, and local action to help prevent zoonotic disease outbreaks that could trigger pandemics. Among the first steps will be conducting systematic analyses of research around factors that lead to disease transmission between animals and humans, developing risk assessment and surveillance frameworks, and identifying good practices for preventing zoonotic disease outbreaks.

The panel plans to focus on a few critical areas that could contribute to the emergence of diseases similar to H5N1 avian flu, Middle East respiratory syndrome (MERS), Ebola, and Zika, including food production and distribution, urbanization and infrastructure development, international travel and trade, and activities that affect biodiversity loss and climate change.

"This panel will contribute to advancing the One Health agenda, by helping to better understand the root causes of disease emergence and spread, and informing decision-makers to prevent long-term public health risks," FAO Director General Qu Dongyu said at a press conference announcing the panel. "I encourage it to be a shining example of silo-breaking, systems thinking and open dialogue."
May 20 WHO press release

CARB-X funds development of novel antibiotic for gram-negative infections

Originally published by CIDRAP News May 19

CARB-X announced today that it is awarding Swiss drug maker Basilea Pharmaceutica International up to $2.7 million to develop a novel class of antibiotics to treat gram-negative bacterial infections.

The award from CARB-X (the Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator) will help Basilea develop small-molecule inhibitors of the DXR enzyme, which is essential for the survival of many gram-negative pathogens, including carbapenem-resistant Enterobacterales (CRE) and Acinetobacter baumannii and multidrug-resistant Pseudomonas aeruginosa.

"The Basilea project is in the early stages of development, with a novel chemical class working with a novel mechanism of inhibition of bacterial growth," CARB-X Research and Development Chief Erin Duffy, PhD, said in a CARB-X press release.

"Together, these offer a potential advantage where the development of resistance is concerned and—as such—offer great promise for a new therapy to treat serious hospital infections."
May 19 CARB-X press release

Hospital stewardship linked to reduced MDR pathogen colonization

Originally published by CIDRAP News May 19

A systematic review and meta-analysis of more than 60 studies found that antimicrobial stewardship programs (ASPs) were associated with reduced multidrug-resistant Enterobacterales (MDR-E) colonization in hospital patients, researchers reported last week in the Journal of Infection.

The aim of the study, conducted by scientists from Israel, Germany, and Spain, was to evaluate the comparative effectiveness and safety of different interventions for the prevention of MDR-E colonization and infections in hospitalized patients. The co-primary outcomes were reduction in mortality and infections caused by MDR-E, and secondary outcomes included colonization with MDR-E.

A total of 63 studies were included, with 23 that assessed ASPs as the main intervention. Meta-analysis of those studies found no significant difference between ASPs and control groups for all-cause mortality (relative risk [RR], 1.o; 95% confidence interval [CI], 0.95 to 1.07), intensive care unit mortality (RR, 1.01; 95% CI, 0.93 to 1.10), or MDR-E infection (incidence ratio [IR], 0.88; 95% CI, 0.71 to 1.10). But significantly reduced MDR-E colonization was observed with ASPs (IR, 0.69; 95% CI, 0.57 to 0.82).

Seventeen studies examining decolonization strategies found no significant differences in any outcomes. Few other intervention strategies were studied.

The authors say that the finding of reduced colonization is noteworthy, since roughly one-third of patients with MDR-E colonization will develop an infection.

"Though effect on infection was not demonstrated in our meta-analysis, it is possible that additional future studies and a larger sample size would demonstrate a significant difference," they wrote.
May 14 J Infect abstract

VHA survey finds stewardship programs reliant on pharmacists

Originally published by CIDRAP News May 19

Interviews conducted at Veterans Health Administration (VHA) hospitals without on-site infectious diseases (ID) support found that ASPs are largely a pharmacy-driven process, researchers reported this week in Infection Control & Hospital Epidemiology.

A team led by researchers with the Iowa City Veterans' Affairs Health Care System found that four themes emerged from site visits (two conducted virtually because of the pandemic) and interviews with 42 ASP team members at seven VHA hospitals lacking on-site ID support.

The first was that the ASP pharmacy champion wears many hats and fills many roles, and was consistently recognized as the leader of the ASP. The second was that ASP pharmacy champions had to build rapport with clinicians in order to get support for stewardship recommendations, a task that was difficult at hospitals that relied heavily on contract physicians.

The third theme that emerged was that access to an off-site ID specialist via electronic consultation helped give credibility to both the ASP pharmacists' recommendations and to any stewardship initiatives the ASP team was trying to move forward. Finally, most ASP pharmacy champions spoke of the difficulty of gaining institutional buy-in and funding for their efforts.

The authors say the findings have broader implications, since a large proportion of US hospitals lack an on-site ID support but are still required to have an ASP.

"Given the ongoing need to improve antibiotic use and expand the implementation of ASPs across the spectrum of healthcare, our findings could inform future work on ASP implementation in these settings," they wrote.
May 17 Infect Control Hosp Epidemiol abstract

CARB-X to fund development of novel antibiotic for CRE infections

Originally published by CIDRAP News May 18

CARB-X announced today that it is awarding up to $4.1 million to Summit Therapeutics of Cambridge, Massachusetts, to develop a first-in-class antibiotic to treat multidrug-resistant bacterial infections.

The money will help fund development of SMT-738, the first candidate from a novel class of antibiotics that target CRE via the LoICDE complex, an essential lipid transport system in gram-negative bacteria. The company says SMT-738 has shown potent in vitro activity against CRE isolates, including strains carrying the New Delhi Metallo-beta-lactamase (NDM) enzyme, and that it hopes to begin phase 1 clinical trials in 2023.

Under the award from CARB-X, Summit could receive an additional $3.7 million if certain project milestones are achieved.

"SMT-738 has the potential to save the lives of patients, as yet with untreatable infections through a novel drug class with a low propensity for resistance development," Summit Chairman and Chief Executive Officer Robert Duggan said in a CARB-X press release. "We are excited and optimistic to take on the real challenge of antibiotic resistance and are grateful to CARB-X for partnering with us in support of this important mission."

The Centers for Disease Control and Prevention (CDC) estimates that infections caused by CRE, dubbed "nightmare bacteria," kill an estimated 1,100 hospital patients a year.

CARB-X is now funding 58 active projects focused exclusively on drug-resistant bacteria.
May 18 CARB-X press release