ASP Scan (Weekly) for Jan 07, 2022

News brief

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

Study describes outbreak of highly resistant, deadly Klebsiella in India

Indian researchers yesterday reported on a hospital outbreak of two strains of extensively drug-resistant Klebsiella pneumoniae. Their findings appeared in Antimicrobial Resistance and Infection Control.

The outbreak in the tertiary care hospital in Varanasi, India, was first identified between April and June, 2017, when a sudden surge of neonatal sepsis cases caused by K pneumoniae occurred in the hospital's neonatal intensive care unit (NICU); twelve of the 14 infants died. Subsequent environmental surveillance uncovered K pneumoniae in the hand-wash used in the NICU, and in the wash basin in the labor room. Further investigation revealed an adult infected with K pneumonia on Apr 3 in the intensive care unit (ICU) was the hospital's primary case. An additional 18 K pneumoniae infections were reported in the ICU until July 2017.

Analysis of 45 K pneumoniae isolates from the ICU, NICU, other wards, and the hospital environment found all of the NICU isolates and 94.4% of the ICU isolates were resistant to all tested antibiotics, including colistin and carbapenems. More than half of the isolates carried a combination of extended-spectrum beta-lactamase and carbapenemase genes. Clonal typing found two distinct sequence types, ST5235 and ST5313, with ST5235 predominantly found in the NICU.

The outbreak was contained through strengthening of infection control procedures and an unrelated hospital closure. No further cases were identified after Jul 6, 2017.

The study authors say the findings highlight concerns about the rising use of colistin and poor infection control measures in Indian hospitals, and call for the global impact of ST5235 and ST5315 to be further studied.
Jan 6 Antimicrob Resist Infect Control study

Trial finds three rounds of azithromycin better than one for yaws reduction

Originally published by CIDRAP News Jan 6

The results of a randomized trial in Papua New Guinea suggest three rounds of mass administration of azithromycin led to a greater reduction in the prevalence of yaws than a single round, researchers reported today in the New England Journal of Medicine.

In the community-based, open-label trial, conducted in an area of Papua New Guinea where yaws—an infection of the skin, bone, and cartilage caused by the bacterium Treponema pallidum subspecies pertenue—is endemic, an international team of investigators randomly assigned more than 56,000 villagers in 38 wards to receive one round of mass administration of azithromycin (the control group) or three rounds at 6-month intervals (the experimental group). The current World Health Organization strategy for eradicating yaws by 2030 involves one round of azithromycin followed by active case detection surveys and targeted treatment every 6 months, but previous studies in Papua New Guinea, the Solomon Islands, and Ghana have found that this strategy has not been enough to stop transmission.

The coprimary endpoints of the trial, conducted from April 2018 through October 2019, were the prevalence of active yaws cases in the two groups at 18 months, and the prevalence of latent yaws in a subgroup of asymptomatic children.

At 18 months, the prevalence of active yaws had decreased from 0.46% (102 of 22,033 people) to 0.16% (47 of 29,954) in the control group, and 0.43% (87 of 20,331) to 0.04% (10 of 25,987) in the experimental group (relative risk adjusted for clustering, 4.08; 95% confidence interval [CI], 1.90 to 8.76). The prevalence of latent yaws at 18 months was 6.54% among 994 children in the control group and 3.28% in the experimental group (relative risk adjusted for clustering of age, 2.03; 95% CI, 1.12 to 3.70). Molecular analysis of three cases of yaws found mutations associated with macrolide resistance.

"Our data suggest more than one round of mass drug administration should be considered as part of the strategy for yaws eradication," the authors write. But they caution that the failure to completely eliminate yaws, and the finding of resistance mutations, highlight the need for further clinical and molecular surveillance for the emergence of antimicrobial resistance.
Jan 6 N Engl J Med study

High mortality persists for Candida bloodstream infections

Originally published by CIDRAP News Jan 6

Bloodstream infections (BSIs) caused by Candida species were associated with a more than two-fold increased risk of mortality, researchers reported yesterday in Clinical Infectious Diseases.

The single-center study by researchers with Washington University in St. Louis School of Medicine, frequency-matched 626 adult patients with Candida BSIs with 6,269 control patients who had at least one risk factor for Candida BSI but did not develop one. They calculated 90-day all-cause mortality attributable to Candida BSI using propensity score matching, matching by inverse-weighting of propensity score, and stratified analysis by quintile.

The 90-day crude all-cause mortality for patients with Candida BSI was 42.4%, compared with 17.1% for the frequency-matched controls, with a crude mortality rate difference of 25.3%. In the propensity-scored matched pairs analysis, the hazard ratio (HR) for 90-day all-cause mortality associated with Candida BSI was 2.1 (95% CI, 2.0 to 2.3), with an attributable risk difference of 28.4%. In the analysis using inverse-weighting by the propensity score, the HR for 90-day all-cause mortality associated with Candida BSI was 2.1 (95%, 2.0 to 2.3).

In the stratified analysis, the risk for mortality at 90 days was highest in patients in the lowest risk quintile to develop Candida BSI (HR, 3.13; 95% CI, 2.33 to 4.19), a finding the researchers attribute to a higher proportion of these low-risk patients going untreated.

"Overall, Candida BSI was associated with 2.3-fold increased risk of 90-day all-cause mortality," the study authors wrote. "High mortality observed has persisted over decades despite treatment advances, though mortality attributable to Candida BSI has decreased compared to most historical studies. It is imperative that clinicians maximize efforts to adhere to guideline recommendations and seek Infectious Disease consultation to assist in timely, efficacious treatment of Candida BSI."
Jan 5 Clin Infect Dis abstract

Candida auris infections identified in Oregon

Originally published by CIDRAP News Jan 3

The Oregon Health Authority (OHA) announced last week that it's investigating the state's first cases of the multidrug-resistant fungus Candida auris.

The C auris cases were identified in three Salem Health patients. The first case was identified on Dec 11 in a patient who had recent international healthcare exposure, and the second and third cases had no international healthcare exposure but were epidemiologically linked to the first case, indicating healthcare-associated spread.

Salem Health officials say the infections appear to be responding to current treatments and that the hospital is working with OHA, local public health partners, and the CDC to identify additional cases and ensure appropriate infection control procedures are in place.

"Salem Health is working with OHA and the CDC to execute a rigorous plan, implementing aggressive eradication measures that have been shown in other hospitals to be successful in eliminating Candida auris," Jasmin Chaudhary, MD, Salem Health's medical director of infection prevention, said in an OHA press release. "These include proactive steps that will assist in preemptively identifying new cases to prevent spread."

In its most recent update, the CDC reported a total of 938 confirmed C auris infections in 21 states from September 2020 through August 2021, along with 3,034 patients colonized with the organism. The multidrug-resistant yeast, which spreads easily in healthcare settings and can cause severe and deadly invasive infections in immunocompromised patients, was first identified in Japan in 2009 and first appeared in the United States in 2013.
Dec 28 OHA press release
Oct 27 CDC Candida auris update

Flu Scan for Jan 07, 2022

News brief

US flu activity continues steady rise

For the week ending Jan 1, most US flu indicators rose, with the season still dominated by H3N2 and now affecting a range of age-groups and hitting the northeastern and central regions hardest, the US Centers for Disease Control and Prevention (CDC) said today in its latest weekly update.

Nationally, the percentage of clinic visits for flulike illness rose to 4.8%, up from 3.8% the previous week. The CDC has said that other circulating respiratory viruses are likely contributing to the respiratory illnesses that health providers are seeing. The percentage of respiratory samples that tested positive for flu dropped to 3.8%, down from 6.2% the week before.

Thirty-one states are reporting very high or high flu activity, another marker that tracks clinic visits. The number is up sharply from 19 states reported the previous week.

The cumulative hospitalization rate for flu rose to 2.6 per 100,000 population, up from 1.8 per 100,000 population the week before. However, the CDC said the level for this point in the season is well below the rate seen at this point in the four flu seasons that preceded the pandemic.

No new pediatric flu deaths were reported, keeping the total at two.

The CDC said the flu season is just starting and urged people to get vaccinated, noting that early indications show that uptake is down this season, compared with the last season.
Jan 7 CDC FluView update

H5N1 avian flu strikes poultry in Niger and Vietnam

Two countries—Niger and Vietnam—reported new highly pathogenic H5N1 avian flu events in poultry, according to the latest notifications from the World Organization for Animal Health (OIE).

Niger reported an outbreak at a layer farm near Niamey, the country's capital. The event began on Dec 31, killing 1,400 of 18,575 susceptible birds. Its last H5N1 outbreak occurred in July 2021.

Elsewhere, Vietnam reported five outbreaks in village birds from five different provinces: Binh Phuoc, Nghe An, Ninh Binh, Quang Tri, and Tay Ninh. The outbreaks started between Nov 19 and Dec 28, and taken together, the virus killed 6,810 of 18,144 birds.

In other avian flu developments, European countries continue to report highly pathogenic avian flu in wild birds, including Portugal with two H5N1 events and Denmark with an outbreak involving H5N8.
Jan 6 OIE report on H5N1 in Niger
Jan 6 OIE report on H5N1 in Vietnam
Jan 5 OIE report on H5N1 in wild birds in Portugal
Jan 4 OIE report on H5N1 in wild birds in Portugal
Jan 3 OIE report on H5N8 in wild birds in Denmark

News Scan for Jan 07, 2022

News brief

Study finds little menstrual cycle change after COVID vaccination

Despite anecdotal reports of alternations in menstrual cycle following COVID-19 vaccination, a study looking at the connection found little impact. A research team based at Oregon Health & Science University published their findings this week in Obstetrics & Gynecology.

The study was part of $1.67 million that the National Institutes of Health (NIH) put toward exploring the issue. Little is known about how vaccines against COVID-19 and other diseases impact the menstrual cycle.

For the study, researchers analyzed data from a fertility tracking app called Natural Cycles. For vaccinated women, researchers compared three consecutive cycles before vaccination with three more cycles after vaccination. The study included 3,959 women, 2,403 vaccinated and 1,556 unvaccinated. Most of the vaccinated women had received an mRNA vaccine.

Researchers found a 0.71 increase in cycle length associated with the first dose and a 0.91-day increase linked to the second dose. They saw no change in unvaccinated app users. Overall, users vaccinated over two cycles had an increased cycle length of less than a day, with no changes in the number of bleeding days.

The changes are well within normal menstrual cycle variability, the authors concluded.

In a NIH press release, Diana Bianchi, MD, with the NIH's Eunice Kennedy Shriver National Institute of Child Health and Human Development, said finding that the changes were small and temporary was reassuring. "These results provide, for the first time, an opportunity to counsel women about what to expect from COVID-19 vaccination so they can plan accordingly," she said.
Jan 5 Obstet Gynecol abstract
Jan 6 NIH press release

CDC tracks 3 rabies deaths in the United States linked to bats

The Centers for Disease Control and Prevention (CDC) said three people in the United States—including one child—died from rabies between September and November 2021. The deaths bring the total number of rabies fatalities in 2021 to five. No rabies deaths were reported in 2019 or 2020.

The three most recent fatalities, reported in Idaho, Illinois, and Texas, all were confirmed to have direct contact with bats in and around their homes. None of the three received postexposure prophylactic (PEP) shots, which can prevent death.

Bats are the most common route of human exposure to rabies in the United States: The CDC estimates that 60,000 people each year receive rabies PEP following animal exposures, and approximately two-thirds of these may be attributed to bats.

"We have come a long way in the United States towards reducing the number of people who become infected each year with rabies, but this recent spate of cases is a sobering reminder that contact with bats poses a real health risk," said Ryan Wallace, DVM, MPH, a veterinarian and rabies expert in the CDC’s Division of High-Consequence Pathogens and Pathology in a press release on the cases.
Jan 7 CDC press release
Jan 7 Morbidity and Mortality Weekly Report note

Study describes outbreak of highly resistant, deadly Klebsiella in India

The outbreak was contained through strengthening of infection control procedures and an unrelated hospital closure. No further cases were identified after Jul 6, 2017.