Hong Kong: Two Hospital Clusters Of MDR Acinetobacter Infections

Credit CDC PHIL

 

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Because it is such an international city, and boasts one of the most diligent (and open) public health agencies in the world (Centre For Health Protection), Hong Kong has become a terrific  barometer for the growth of multiple drug resistant infections from around the world.

 

One of the toughest bacteria that hospitals must deal with is called multidrug-resistant (MDR) Acinetobacter baumannii, which in recent years has made headlines as the cause of difficult to treat wound infections among our troops serving in the Middle East.

 

Acinetobacter (of which there are many varieties, but A. baumannii is most often linked to human infection ) are ubiquitous in nature, and can be found in soil, water, animals and humans. A very hardy species, they can survive for extended period of time on inanimate surfaces, making them difficult to control in a health care setting (see AJIC report Hospital cleaning protocol ineffective against A. baumannii)..

And like with MRSA, many people can be colonized, but not show signs of infection.  Often very serious infections develop among those who are very ill, wounded, or immunocompromised.

 

Today Hong Kong’s CHP has published two reports on hospital clusters of MDR  Acinetobacter infection.

 

Cluster of Multi-drug Resistant Acinetobacter cases in Queen Elizabeth Hospital

The following is issued on behalf of the Hospital Authority:

The spokesperson for Queen Elizabeth Hospital (QEH) made the following announcement today (July 22):

Five male patients (aged 35 to 80) of a Ventilator Ward have been confirmed as having Multi-drug Resistant Acinetobacter (MDRA) since July 14. Two of them are infected cases and are still hospitalised at QEH. The remaining three patients were confirmed to be MDRA carriers without clinical symptoms. Out of these cases, two are still hospitalised under medical surveillance and isolation at QEH. The remaining patient has been transferred to Hong Kong Buddhist Hospital. All of the five patients are in stable condition.

(Continue. . . )

Cluster of Multi-drug Resistant Acinetobacter cases in Caritas Medical Centre

The following is issued on behalf of the Hospital Authority:

     The spokesperson of Caritas Medical Centre made the following announcement today (July 22):

Three patients (aged 37 to 88) of a male Medicine and Geriatrics Ward have been confirmed as having Multi-drug Resistant Acinetobacter (MDRA) since July 17. Two of them are infected cases. The patients are still hospitalised under medical surveillance and isolation. Two of them are in stable condition, while the other one is in serious condition.

(Continue . . .)

 

 

Just yesterday, Hong Kong reported a Case of NDM-5 Carbapenemase-producing Enterobacteriaceae under CHP investigation in a 30-year-old woman with a urinary tract infection.  

 

NDM-5 is a novel variant of the NDM-1 enzyme which first made headlines four years ago when  The Lancet published a study (see NDM-1: A New Acronym To Memorize)  by Walsh, Toleman, Livermore, et al.  on the emergence and growing prevalence of the antibiotic resistant enzyme on the Indian sub-continent.

While still relatively rare – at least in the United States and Europe – this growing rogues gallery of new, multi-drug resistant organisms continues to gain traction around the world, threatening an early demise for much of our current antibiotic arsenal. 

 

In early 2012 World Health Director-General Margaret Chan expressed a dire warning about our dwindling antibiotic arsenal (see Chan: World Faces A `Post-Antibiotic Era’) – a sentiment echoed a year later by CDC Director Thomas Frieden during the release of a major US report on the threat (see McKenna On CDC Antibiotic Resistance Report).

 

Dark, if not Inevitable conclusions, backed up by a long list of reports and studies showing the inexorable erosion the effectiveness of our current antibiotics to deal with rapidly evolving bacteria.   Some of these reports I’ve covered in the past include:

 

EID Journal: Acquisition of Drug Resistant Genes Through International Travel

AAP/CDC: New Guidance On For Antibiotics For Children

The Lancet: Antibiotic Resistance - The Need For Global Solutions

UK CMO: Antimicrobial Resistance Poses `Catastrophic Threat’

MMWR Vital Signs: Carbapenem-Resistant Enterobacteriaceae (CRE)

 

 

For a more complete look at the complex issues of antibiotic resistance, and the dearth of new drugs on the horizon, I can think of no resource better than Maryn McKenna’s superb book (and recent winner of the 2013 June Roth Memorial Book Award, American Society of Journalists and Authors) Superbug: The Fatal Menace of MRSA.

And while I dabble in writing about the issues of antibiotic resistance, undoubtedly the best coverage can be found on Maryn’s Superbug blog.

WHO: Antibiotic Resistance – Serious, World-Wide Threat

WHO Report 257 pg PDF

 

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For years we’ve heard dire warnings that our limited arsenal of antibiotics was in danger of being rendered useless against a growing army of resistant bacteria, and we could be facing a `post-antibiotic’ world.   Today, the World Health Organization released an in-depth report showing just how close we are to finally seeing that grim future realized.

 

First, an excerpt from the press release, and then some links to some other reportage on the situation, after which I’ll be back with a bit more.

 

 WHO’s first global report on antibiotic resistance reveals serious, worldwide threat to public health

New WHO report provides the most comprehensive picture of antibiotic resistance to date, with data from 114 countries

News release

30 April 2014 | Geneva - A new report by WHO–its first to look at antimicrobial resistance, including antibiotic resistance, globally–reveals that this serious threat is no longer a prediction for the future, it is happening right now in every region of the world and has the potential to affect anyone, of any age, in any country. Antibiotic resistance–when bacteria change so antibiotics no longer work in people who need them to treat infections–is now a major threat to public health.

“Without urgent, coordinated action by many stakeholders, the world is headed for a post-antibiotic era, in which common infections and minor injuries which have been treatable for decades can once again kill,” says Dr Keiji Fukuda, WHO’s Assistant Director-General for Health Security. “Effective antibiotics have been one of the pillars allowing us to live longer, live healthier, and benefit from modern medicine. Unless we take significant actions to improve efforts to prevent infections and also change how we produce, prescribe and use antibiotics, the world will lose more and more of these global public health goods and the implications will be devastating.”

Key findings of the report

The report, "Antimicrobial resistance: global report on surveillance", notes that resistance is occurring across many different infectious agents but the report focuses on antibiotic resistance in seven different bacteria responsible for common, serious diseases such as bloodstream infections (sepsis), diarrhoea, pneumonia, urinary tract infections and gonorrhoea. The results are cause for high concern, documenting resistance to antibiotics, especially “last resort” antibiotics, in all regions of the world.

Key findings from the report include:

• Resistance to the treatment of last resort for life-threatening infections caused by a common intestinal bacteria, Klebsiella pneumoniae–carbapenem antibiotics–has spread to all regions of the world. K. pneumoniae is a major cause of hospital-acquired infections such as pneumonia, bloodstream infections, infections in newborns and intensive-care unit patients. In some countries, because of resistance, carbapenem antibiotics would not work in more than half of people treated for K. pneumoniae infections.
• Resistance to one of the most widely used antibacterial medicines for the treatment of urinary tract infections caused by E. coli–fluoroquinolones–is very widespread. In the 1980s, when these drugs were first introduced, resistance was virtually zero. Today, there are countries in many parts of the world where this treatment is now ineffective in more than half of patients.
• Treatment failure to the last resort of treatment for gonorrhoea–third generation cephalosporins–has been confirmed in Austria, Australia, Canada, France, Japan, Norway, Slovenia, South Africa, Sweden and the United Kingdom. More than 1 million people are infected with gonorrhoea around the world every day.
• Antibiotic resistance causes people to be sick for longer and increases the risk of death. For example, people with MRSA (methicillin-resistant Staphylococcus aureus) are estimated to be 64% more likely to die than people with a non-resistant form of the infection. Resistance also increases the cost of health care with lengthier stays in hospital and more intensive care required.

            (Continue . . .)

 

Some related articles on today’s announcement include:

 

• Maggie Fox at NBC news writes :  Drug-Resistant Bugs a Global Threat, WHO Says
• Kai Kupferschmidt writing for Science Insider has First Global Resistance Overview Paints Grim Picture
• And Yesterday Maryn Mckenna penned a piece for Wired.com  called NDM: “A Great Challenge for the Future of Healthcare”

 

 

In early 2012 World Health Director-General Margaret Chan expressed a dire warning about our dwindling antibiotic arsenal (see Chan: World Faces A `Post-Antibiotic Era’) – a sentiment echoed a year later by CDC Director Thomas Frieden during the release of a major US report on the threat (see McKenna On CDC Antibiotic Resistance Report).

 

Inevitable conclusions backed up by a long list of reports and studies showing the inexorable erosion the effectiveness of our current antibiotics to deal with rapidly evolving bacteria.   Some of these reports I’ve covered in the past include:

 

EID Journal: Acquisition of Drug Resistant Genes Through International Travel

AAP/CDC: New Guidance On For Antibiotics For Children

The Lancet: Antibiotic Resistance - The Need For Global Solutions

UK CMO: Antimicrobial Resistance Poses `Catastrophic Threat’

MMWR Vital Signs: Carbapenem-Resistant Enterobacteriaceae (CRE)

And for a far more complete discussion of antimicrobial resistance issues, I can think of no better primer than Maryn McKenna’s book SUPERBUG: The Fatal Menace of MRSA.

Superbug (MRSA) Book

Meanwhile, Maryn’s SUPERBUG Blog, continues to provide the best day-to-day coverage of these issues, and I expect she’ll post something on today’s WHO report later today.

India: MSF Calls For `Rational’ Antibiotic Use In Treating TB

MSF Briefing Report

 

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Tomorrow (March 24th) is World TB Day, and the focus this year is on multidrug-resistant tuberculosis (MDR TB) (see ECDC/WHO: World TB Day - Focus On MDR & XDR Treatment Outcomes), a growing concern around the world, but no more so than in India where more than 25% of all new TB cases reported in 2012 are to be found.

 

On Friday, Médecins Sans Frontières (MSF) released a sharply worded statement admonishing the Indian government for failing to regulate the sale and use of antibiotics for the treatment of Tuberculosis.

 

They warned that the inappropriate prescribing of antibiotics risks fueling the expansion of drug-resistant TB in that nation. The following excerpts come from a press release from MSF.

 

Patients in India suffer the consequences of poor regulation of TB drugs

March 21, 2014

The Ministry of Health must act to stop drug resistance from spiralling

New Delhi/Mumbai, March 21, 2014: Immediate action from the Indian government is needed to prevent the unregulated sale and inappropriate prescription of tuberculosis (TB) drugs in the private healthcare sector, a practice that has had a significant role in the emergence of drug-resistant TB in the country, warned the international medical humanitarian organisation Doctors Without Borders/Médecins Sans Frontières (MSF) in a statement released today in advance of World TB Day.

“It is the patients who suffer the consequences of poor regulation of TB drug formulations in India. An increasing number of our patients are being diagnosed with drug resistant TB (DR-TB). We encounter a spectrum of resistance patterns which range from mono-drug-resistant TB all the way through to extensively drug-resistant TB (XDR-TB),” said Dr Simon Janes, medical coordinator with MSF in India. “This makes it even more difficult for treatment providers like MSF and the government’s TB Control Programme to accurately diagnose and treat the different forms of drug-resistant tuberculosis.”

Read the briefing report

DR-TB infections are on the rise in India. The rising incidence has made the disease more difficult and considerably more expensive to treat. The conditions for emergence of drug resistance are increasingly being linked to poor drug regulation in India.

India has the largest private TB drug market, with rampant proliferation of first-line TB drugs in a wide variety of dosages and combinations.

Lack of oversight from the drug regulatory authority - the Drug Controller General of India (DCGI) - has made even basic treatment of drug-sensitive TB difficult to monitor. In the face of so many different formulations available in pharmacies across the country, ensuring the correct prescription of first-line TB drugs in the private sector is almost an impossible task for the Central TB Division (CTD).

As a result, poor compliance to World Health Organization (WHO) treatment guidelines is common among private doctors. TB patients being treated by private doctors in India might be facing a grave risk of developing drug-resistant TB due to irrational prescribing practices or indiscriminate use of non-WHO-recommended drug regimens.

“In our experience of working in India since 1999, we have seen prescriptions from private health providers that were completely inappropriate. For example we have seen many prescriptions that prescribe three out of the four first-line TB drugs in combination with a quinalone (antibiotic)”, said Dr Homa Mansoor, the TB Medical Referent for MSF India. “The alarm on drug resistance has been sounded, and the Health Ministry must act now to address this public health crisis."

(Continue . . . )

 

This coming week will no doubt bring many more reports on the challenges, and the progress being made, in the battle against TB.  For more on World Tuberculosis Day, the WHO has released the following brochure:

Reach the 3 million: Find. Treat. Cure TB

Authors:
WHO. Stop TB Partnership. The Global Fund to Fight AIDS, TB and Malaria

Publication details

Number of pages: 17
Publication date: March 2014
Languages: English

Downloads

Brochure: Reach the 3 million
pdf, 1.72Mb

 

While currently the biggest antibiotic-resistance crisis in India, TB is far from being the only concern.

 

Three and a half years ago The Lancet published a study (see NDM-1: A New Acronym To Memorize)  by Walsh, Toleman, Livermore, et al. that sounded the alarm on the emergence and growing prevalence of the NDM-1 enzyme on the Indian sub-continent.

 

Of particular concern, this NDM enzyme is carried by a plasmid – a snippet of portable DNA  - that can be easily transferred to other types of bacteria (see Study: Adaptation Of Plasmids To New Bacterial Species).

 

Six months after the first Lancet article - in April, 2011 - the same researchers published another study that found the NDM-1 enzyme in 4% of New Delhi’s sampled drinking water sources, and 30 per cent of the sewage tested. Most alarmingly, the researchers also identified 11 new species of bacteria carrying the NDM-1 gene, including strains which cause cholera and dysentery.

 

The rise of antibiotic resistance - including these emerging NDM enzymes - has long been linked to the overuse and misuse of antibiotics. A practice that is still widespread in many parts of the world, but has been particularly rampant on the Indian sub-continent.

 

After years of delay and debate, India this month finally placed restrictions on the sale of antibiotics without a prescription (see Times of India report 46 drugs under strict prescription norm), although pharmacists are already chaffing under the rules (see Pharmacists oppose sales record rule), and it remains to be seen just how effective these new rules will end up being.

 

Short of seeing an extremely high mortality influenza pandemic, it is hard to envision a looming medical crisis more dire than the growing threat of antimicrobial resistance. The World Health Organization, the ECDC, and the CDC all consider the spread of antibiotic resistant organisms to be a major public health concern.

 

For a more complete look at the complex issues of antibiotic resistance, and the dearth of new drugs on the horizon, I can think of no resource better than Maryn McKenna’s superb book (and recent winner of the 2013 June Roth Memorial Book Award, American Society of Journalists and Authors)  Superbug: The Fatal Menace of MRSA.

And while I dabble in the issues of antibiotic resistance, undoubtedly the best coverage can be found on Maryn’s Superbug blog.

CDC Telebriefing (March 4th): Improving Antibiotic Prescribing Practices

 

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For years we’ve heard dire warnings of a future where most of our most important antibiotics are rendered impotent against drug resistant infections, and increasingly, those predictions are coming true.  Last September the CDC issued a major threat report called Antibiotic resistance threats in the United States, 2013 that provided  a snapshot of the effects of growing antibiotic resistance across the United States.

 

Among their (conservative) findings:

 

Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections. Many more people die from other conditions that were complicated by an antibiotic-resistant infection.

 

The rise of antibiotic resistance has long been linked to the overuse and misuse of antibiotics. A problem that is wide spread in many parts of the world where antibiotics are not well regulated, but also right here in the United States, where there remains a great variance in prescribing practices among physicians.

 

Last November, in AAP/CDC: New Guidance On For Antibiotics For Children, we saw guidelines issued – in part – due to the geographic disparity in the amount of antibiotics being prescribed across this country, with doctors some regions much quicker write ABx scripts than doctors in other areas (see map below).

 

Tp address this growing problem, tomorrow (March 4th) the CDC will hold a Telebriefing on Antibiotic prescribing practices (details below).

 

CDC Telebriefing: New Vital Signs Report - Are Prescribing Practices Putting Hospital Patients at Risk?

What

Poor antibiotic-prescribing practices in hospitals can needlessly put patients at risk for Clostridium difficile infection (deadly diarrhea) and future drug-resistant infections. This month, the CDC Vital Signs report looks at prescribing practices and variations, and calls on all U.S. hospitals to improve antibiotic-prescribing practices.

Who

Tom Frieden, M.D., M.P.H., Director, Centers for Disease Control and Prevention
John R. Combes, M.D., Senior Vice President, American Hospital Association

When

Tuesday, March 4 at Noon ET   (Content embargoed until 1pm ET)

DIAL-IN:

Media: 888-795-0855
Non-Media: 800-369-1605
International: 1-630-395-0331
PASSCODE: CDC MEDIA

Important Instructions: If you would like to ask a question during the call, press *1 on your touchtone phone. Press *2 to withdraw your question. You may queue up at any time. You will hear a tone to indicate your question is pending.

TRANSCRIPT
A transcript of this media availability will be available following the briefing at CDC’s web site: www.cdc.gov/media.

###

 

For more on the importance of proper antibiotic stewardship, you may wish to revisit these earlier blogs.

Chan: World Faces A `Post-Antibiotic Era’

Get Smart About Antibiotics Week

IDSA: Educational Guidelines Lower Antibiotic Use

And for a far more complete discussion of antimicrobial resistance issues, I can think of no better primer than Maryn McKenna’s book SUPERBUG: The Fatal Menace of MRSA.

Superbug (MRSA) Book

Meanwhile, Maryn’s SUPERBUG Blog, continues to provide the best day-to-day coverage of these issues.

AAP/CDC: New Guidance On For Antibiotics For Children

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As the graphic above shows, there is considerable geographic disparity in the amount of antibiotics being prescribed across this country, with doctors some parts of the country being much quicker write ABx scripts than doctors in other regions.

 

In an attempt to bring some sensible level of standardization to the prescribing these drugs – and in so doing, hopefully reduce the creation and spread of antibiotic resistant bacteria - the American Academy of Pediatrics (AAP) and the CDC have produced a new set of guidelines for doctors to encourage  the judicious use of antibiotics when treating children with suspected bacterial infections.

 

First, some excerpts from the CDC’s press release, and then a link to the article in the journal Pediatrics.

 

New guidance limits antibiotics for common infections in children

Get Smart About Antibiotics Week 2013 calls for responsible antibiotic prescribing

Every year as many as 10 million U.S. children risk side effects from antibiotic prescriptions that are unlikely to help their upper respiratory conditions. Many of these infections are caused by viruses, which are not helped by antibiotics.

This overuse of antibiotics, a significant factor fueling antibiotic resistance, is the focus of a new report Principles of Judicious Antibiotic Prescribing for Bacterial Upper Respiratory Tract Infections in Pediatrics by the American Academy of Pediatrics (AAP) in collaboration with the Centers for Disease Control and Prevention (CDC).

Released today during Get Smart About Antibiotics Week, the report amplifies recent AAP guidance and promotes responsible antibiotic prescribing for three common upper respiratory tract infections in children: ear infections, sinus infections, and sore throats.

Antibiotic resistance occurs when bacteria evolve and are able to outsmart antibiotics, making even common infections difficult to treat. According to a landmark CDC report from September 2013, each year more than two million Americans get infections that are resistant to antibiotics and 23,000 die as a result.

For Clinicians:

3 Principles of Responsible Antibiotic Use

1. Determine the likelihood of a bacterial infection: Antibiotics should not be used for viral diagnoses when a concurrent bacterial infection has been reasonably excluded.
2. Weigh benefits versus harms of antibiotics: Symptom reduction and prevention of complications and secondary cases should be weighed against the risk for side effects and resistance, as well as cost.
3. Implement accurate prescribing strategies: Select an appropriate antibiotic at the appropriate dose for the shortest duration required.

“Our medicine cabinet is nearly empty of antibiotics to treat some infections,” said CDC Director Tom Frieden, M.D., M.P.H.  “If doctors prescribe antibiotics carefully and patients take them as prescribed we can preserve these lifesaving drugs and avoid entering a post-antibiotic era.”

By providing detailed clinical criteria to help physicians distinguish between viral and bacterial upper respiratory tract infections, the recommendations provide guidance for physicians that will improve care for children. At the same time, it will help limit antibiotic prescriptions, giving bacteria fewer chances to become resistant and lowering children’s risk of side effects.

(Continue . . .)

 

The entire 11 page PDF is available online from the American Academy of Pediatrics (see link below).  The authors describe this guidance:

 

This clinical report focuses on antibiotic prescribing for key pediatric URIs that, in certain instances, may benefit from antibiotic therapy: AOM, acute bacterial sinusitis, and  pharyngitis. The specific recommendations are applicable to healthy children who do not have underlying medical conditions (eg, immunosuppression) placing themat increased risk of developing serious complications. The purpose of this report is to provide practitioners specific context using the most current recommendations and guidelines while applying 3 principles of judicious antibiotic use: (1) determination of the likelihood of a bacterial infection, (2) weighing the benefits and harms of antibiotics, and (3) implementing judicious prescribing strategies.

 

Follow the link to read and download the entire report:

 

Principles of Judicious Antibiotic Prescribing for Bacterial Upper Respiratory Tract Infections in Pediatrics

Adam L. Hersh, Mary Anne Jackson, Lauri A. Hicks and the COMMITTEE ON INFECTIOUS DISEASES

DOI: 10.1542/peds.2013-3260 ; originally published online November 18, 2013; Pediatrics

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2013/11/12/peds.2013-3260

 

For more on this week’s focus on better stewardship of our antibiotic arsenal, you may wish to visit these recent blogs:

 

Surviving Winter’s Ills Without Abusing Antibiotics

The Lancet: Antibiotic Resistance - The Need For Global Solutions

ECDC: Antibiotic Resistance In the EU – 2012

Surviving Winter’s Ills Without Abusing Antibiotics

Credit CDC, FDA, HHS

 

 

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As mentioned yesterday (see The Lancet: Antibiotic Resistance - The Need For Global Solutions), today marks European Antibiotic Awareness day and kicks off the CDC’s Get Smart About Antibiotics Week.  With each year that passes, more and more bacterial strains are finding ways to evade our dwindling arsenal of antibiotics – and so public health officials are working hard to improve the stewardship of the ones that still remain effective.

 

To that end, this week agencies like the World Health Organization, the CDC, and the ECDC are working to educate the public on when antibiotics are appropriate treatments, and when they are not.  Since most winter respiratory illnesses are viral in nature, antibiotics simply don’t work – and using them inappropriately can lead to increased resistance.

 

So today, a quick tour of (and some excerpts from) the messaging coming from these organizations.

 

From the World Health Organization we get European Antibiotic Awareness Day 2013: everyone is responsible.

18-11-2013

Antibiotic resistance affects the entire WHO European Region, driven by the overuse, underuse and misuse of antibiotics. Although some efforts have been made to combat indiscriminate use, many countries have no national regulation or enforcement on antibiotic usage; healthy animals are given antibiotics to promote growth or prevent disease, and commercial companies promote antibiotics irresponsibly. In too many countries, members of the general public can buy antibiotics over the counter (without a prescription) and use them at will. Doctors often prescribe antibiotics easily or inappropriately, and people take them to treat viral infections such as influenza and the common cold, against which they do not work.

(Continue . . .)

 

While today Public Health England is in myth busting mode, explaining that:

 

Green phlegm and snot ‘not always a sign of an infection needing antibiotics

Advice on European Antibiotics Awareness Day (18 November) to raise awareness of the risks of inappropriate use of antibiotics.

Having green phlegm or snot is not always a sign of a bacterial infection that will require antibiotics to get better, says Public Health England (PHE) and the Royal College of General Practitioners (RCGP).

 

This advice is issued on European Antibiotics Awareness Day (18 November) which aims to raise awareness of the risks associated with the inappropriate use of antibiotics and how to use them responsibly.

Research by PHE’s Primary Care Unit has found that 40% of the general public believed that antibiotics would help a cough with green phlegm get better more quickly rather than clear phlegm (6%).

 

White blood cells are produced by the body to attack any foreign materials the body does not recognise such as pollutants, dirt, pollen or microbes, and are carried in your phlegm and snot. Some white blood cells contain a green substance (a protein) so if more of these cells are present the greener your phlegm or snot will be.

 

Phlegm therefore comes in a range of colours from white to mustard-yellow to varying shades of green. Coloured phlegm or snot does not mean you need antibiotics.

 

In most healthy people, phlegm or snot production with or without a cough will stop as your cold or flu-like illness clears up, although it may take up to 3 to 4 weeks.

 

And from the CDC, some advice on how to deal with the miseries of a winter illness without resorting to antibiotics.

 

How to Feel Better

What can I do to feel better if antibiotics won’t treat my illness because it’s caused by a virus?
For upper respiratory infections, such as sore throats, ear infections, sinus infections, colds, and bronchitis, try the following:

• Get plenty of rest
• Drink plenty of fluids
• Use a clean humidifier or cool mist vaporizer
• Avoid smoking, second-hand smoke, and other pollutants (airborne chemicals or irritants)
• Take acetaminophen, ibuprofen or naproxen to relieve pain or fever (read about what is safe to give your child)

For children and adults, over-the-counter pain relievers, decongestants and saline nasal sprays may help relieve some symptoms. Remember, always use over-the-counter products as directed. Many over-the-counter products are not recommended for children younger than certain ages.

Over-the-counter medicines may help relieve symptoms such as runny nose, congestion, fever and aches, but they do not shorten the length of time you or your child is sick.

Learn more by reading below about over-the-counter medicines. Here are some helpful tips for how to feel better depending on how you or your child feels.

Sore Throat

• Soothe a sore throat with ice chips, sore throat spray, or lozenges (do not give lozenges to young children)
• Use a clean humidifier or cool mist vaporizer
• Take acetaminophen, ibuprofen or naproxen to relieve pain or fever (read about what is safe to give your child)

Ear Pain

• Put a warm moist cloth over the ear that hurts
• Take acetaminophen, ibuprofen or naproxen to relieve pain or fever (read about what is safe to give your child)

Runny Nose

• Use a decongestant or saline nasal spray to help relieve nasal symptoms (read about what is safe to give your child)

Sinus Pain/Pressure

• Put a warm compress over the nose and forehead to help relieve sinus pressure
• Use a decongestant or saline nasal spray
• Breathe in steam from a bowl of hot water or shower
• Take acetaminophen, ibuprofen or naproxen to relieve pain or fever (read about what is safe to give your child)

Cough

• Use a clean humidifier or cool mist vaporizer or breathe in steam from a bowl of hot water or shower (read about what is safe to give your child)

Over-the-Counter (OTC) Medicines

Questions and Answers for Parents about Over-the-Counter (OTC) Medicines

Related Materials

The Lancet: Antibiotic Resistance - The Need For Global Solutions

Credit CDC Vital Signs

 

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With tomorrow (Nov. 18th) marking Antibiotic Resistance Awareness Day in Europe, and kicking off the Get Smart About Antibiotics week in the United States, today The Lancet has published a special collection of reports and articles on the growing problems of antimicrobial resistance (note: Free registration required to access articles).

 

Antibiotic resistance—the need for global solutions

Published November 17, 2013

Executive summary

The causes of antibiotic resistance are complex and include human behaviour at many levels of society; the consequences affect everybody in the world. Similarities with climate change are evident. Many efforts have been made to describe the many different facets of antibiotic resistance and the interventions needed to meet the challenge. However, coordinated action is largely absent, especially at the political level, both nationally and internationally. Antibiotics paved the way for unprecedented medical and societal developments, and are today indispensible in all health systems. Achievements in modern medicine, such as major surgery, organ transplantation, treatment of preterm babies, and cancer chemotherapy, which we today take for granted, would not be possible without access to effective treatment for bacterial infections. Within just a few years, we might be faced with dire setbacks, medically, socially, and economically, unless real and unprecedented global coordinated actions are immediately taken. This Commission describes the global situation of antibiotic resistance, its major causes and consequences, and identify key areas in which action is urgently needed.

The Lancet Infectious Diseases Commission

Antibiotic resistance—the need for global solutions

Ramanan Laxminarayan, Adriano Duse, Chand Wattal, Anita K M Zaidi, Heiman F L Wertheim, Nithima Sumpradit, Erika Vlieghe, Gabriel Levy Hara, Ian M Gould, Herman Goossens, Christina Greko, Anthony D So, Maryam Bigdeli, Göran Tomson, Will Woodhouse, Eva Ombaka, Arturo Quizhpe Peralta, Farah Naz Qamar, Fatima Mir, Sam Kariuki, Zulfiqar A Bhutta, Anthony Coates, Richard Bergstrom, Gerard D Wright, Eric D Brown, Otto Cars

Related articles and comments in this issue also include:

Antibiotic resistance: global response needed

Simon J Howard, Mike Catchpole, John Watson, Sally C Davies

Global collaboration to encourage prudent antibiotic use

Sarah Earnshaw, Andrea Mendez, Dominique L Monnet, Lauri Hicks, Marilyn Cruickshank, Lynn Weekes, Howard Njoo, Stacie Ross

Antibiotic effectiveness and child survival

Mark Young, Mickey Chopra, Atieno Ojoo

Antibiotic resistance in Ghana

Martha Gyansa-Lutterodt

Light at the end of the tunnel of antibiotic development

Glenn S Tillotson

Antibiotic Action: helping deliver action plans and strategies

Laura JV Piddock

 

Perseverance, persistence, and the Chennai declaration

Abdul Ghafur

Related content published in The Lancet Infectious Diseases

Antibiotic resistance: long-term solutions require action now

 

Despite decades of warnings, the persistent overuse of antibiotics has led us to the precipice, and we now face an uncertain and potentially frightening future where previously curable infections may run rampant.  A few recent warnings include:

 

ECDC: Antibiotic Resistance In the EU – 2012

UK CMO: Antimicrobial Resistance Poses `Catastrophic Threat’

MMWR Vital Signs: Carbapenem-Resistant Enterobacteriaceae (CRE)

CDC HAN Advisory: Increase In CRE Reports In The United States

PNAS: Abundant Antibiotic Resistance Genes In Chinese Swine Farms

Chan: World Faces A `Post-Antibiotic Era’

 

For a more complete look at the complex issues of antibiotic resistance, and the dearth of new drugs on the horizon, I can think of no resource better than Maryn McKenna’s superb book (and recent winner of the 2013 June Roth Memorial Book Award, American Society of Journalists and Authors)  Superbug: The Fatal Menace of MRSA.

And while I dabble in writing about the issues of antibiotic resistance, undoubtedly the best coverage can be found on Maryn’s Superbug blog.

ECDC: Antibiotic Resistance In the EU – 2012

 

 

# 7980

 

 

Last September, in Referral: McKenna On CDC Antibiotic Resistance Report,  we looked at a new report from the CDC on the growing threat of antibiotic resistance – with  with Director Thomas Frieden warning, `“If we are not careful, we will soon be in a post-antibiotic era.”

 

This stark forecast echoed the sentiments that World Health Director-General Margaret Chan expressed a year ago (see Chan: World Faces A `Post-Antibiotic Era’).

 

On November 18th, the ECDC, Hong Kong’s CHP, and the United State’s CDC will kick off their antibiotic resistance awareness campaigns for 2013.  Here in the US, it signals the start of Get Smart About Antibiotics Week. 

 

Today, the ECDC has released a massive (218 pages) surveillance report report called Antimicrobial resistance surveillance in Europe 2012, along with a smaller (10 page) summary which will be easier to digest.

 

Highlights on antibiotic resistance

• Antibiotic resistance is a serious threat to public health in Europe, leading to increasing healthcare costs, prolonged hospital stays, treatment failures, and sometimes death.
•   
  Over the last four years (2009 to 2012), resistance to third-generation cephalosporins in K. pneumoniae and E. coli increased significantly at EU/EEA level. Combined resistance to third-generation cephalosporins and two other important antimicrobial groups (fluoroquinolones and aminoglycosides) also increased significantly at EU/EEA level for K. pneumoniae, but not for E. coli. 
• The increasing trend of combined resistance in K. pneumoniae means that only a few therapeutic options (e.g., carbapenems) remain available for treatment of infected patients. 
• Carbapenems form a major last-line class of antibiotics to treat infections with multidrug-resistant Gram-negative bacteria such as K. pneumoniae and E. coli, both common causes of pneumonia, urinary tract infections and bloodstream infections. However, the percentage of carbapenem-resistant K. pneumoniae is already high and increasing in some countries in the EU.
• Antimicrobial resistance data for Acinetobacter spp. are available in EARS-Net for the first time. Data for 2012 show large inter-country variations in Europe, and high levels of resistance (>25%) to carbapenems in nearly half of the reporting countries. 
• In contrast, in the past few years, the percentage of meticillin-resistant Staphylococcus aureus (MRSA) has shown a significant decreasing trend at EU/EEA level, and either a continuous decrease or a stabilising trend was observed in most EU/EEA countries during the last four years. Nevertheless, MRSA remains above 25% in almost one fourth of the reporting countries, mainly in southern and eastern Europe. 
• Prudent antibiotic use and comprehensive infection control strategies targeting all healthcare sectors (acute care hospitals, long-term care facilities and ambulatory care) are the cornerstones of effective interventions that aim to prevent selection and transmission of antibiotic-resistant bacteria.

 

Also released today is an ECDC Technical Report called Carbapenemase-producing bacteria in Europe which provides Interim results from the European survey on carbapenemase-producing Enterobacteriaceae (EuSCAPE) project 2013.

Bacteria resistant to the Carbapenem class of antibiotics (a class that includes imipenem, meropenem, doripenem, and ertapenem) – are called carbapenemases –  are of particular concern since Carbapenems are often the drug of last resort for treating difficult bacterial infections.

 

Short of seeing an extremely high mortality influenza pandemic, I can think of no looming medical crisis more dire than the growing threat of antimicrobial resistance. The World Health Organization, the ECDC, and the CDC all consider the spread of antibiotic resistant organisms to be an extremely urgent public health concern.

 

So I expect I’ll be devoting a good deal of blog space to this topic over the next couple of weeks.

Study: Risks & Benefits Of Antibiotics For Acute Respiratory Infections

 

Credit CDC Get Smart Campaign

 

 

# 7021

 

One of the most common ailments seen by family physicians and emergency departments is the ARI, or acute respiratory infection.

 

Typically the result of a viral infection (e.g. influenza, rhinovirus, adenovirus, coronavirus, parainfluenzavirus, etc.) – conditions that do not respond to antibiotics – they can occasionally progress into a life threatening bacterial pneumonia.

 

For that reason many patients insist on having a round of antibiotics `just in case’.  A practice of long-standing that has been linked to the rapidly growing problem of increased antibiotic resistance.

 

Caught in between are busy doctors who must quickly balance each individual patient’s needs (based on patient age, history, frailty - and  sometimes - just how `sick’ they look), against prudent public health policy.

 

 

To avoid a protracted discussion, all-but-predictable disgruntled patient returns – and the remote, but real possibility of a patient progressing to a bacterial pneumonia – doctors will often oblige and prescribe a course of prophylactic antibiotics.

 

Today, we’ve a reassuring study appearing in the Annals of Family Medicine, that helps to quantify the risks of not prescribing antibiotics for acute nonspecific respiratory infections (ARIs). 

 

Researchers in the UK used cohort of more than 1.5 million adult patient visits with ARI visits to their primary care provider over a 20 year period (1986-2006). Of these 65% received antibiotics.

Patients receiving antibiotics saw an overall small decrease in the rate of bacterial pneumonia hospitalizations – roughly 8.16 fewer per 100,000 (95% CI, –13.24 to –3.08; P = .002) than those not prescribed antibiotics.

 

First a link to the study and then a Reuters report, after which I’ll be back with more.

 

 

Risks and Benefits Associated With Antibiotic Use for Acute Respiratory Infections: A Cohort Study

Sharon B. Meropol, MD, PhD, A. Russell Localio, PhD and Joshua P. Metlay, MD, PhD

RESULTS The cohort included 1,531,019 visits with an ARI diagnosis; prescriptions for antibiotics were given in 65% of cases.

 

The adjusted risk difference for treated vs untreated patients per 100,000 visits was 1.07 fewer adverse events (95% CI, −4.52 to 2.38; P = .54) and 8.16 fewer pneumonia hospitalizations (95% CI, −13.24 to −3.08; P = .002).

 

The number needed to treat to prevent 1 hospitalization for pneumonia was 12,255.

 

And this report from Reuters Health.

 

Antibiotics not worth risk in most chest colds: study

By Andrew M. Seaman

NEW YORK | Thu Mar 21, 2013 4:12pm EDT

(Reuters Health) - Doctors need to give antibiotics to more than 12,000 people with acute respiratory infections to prevent just one of them from being hospitalized with pneumonia, according to a new study.

 

And that small benefit is outweighed by the very real risks that go along with antibiotics - both from serious side effects and the promotion of resistant "superbugs," researchers say.

(Continue . . . )

 

The practice of medicine is still very much an art, dependent upon the skill and yes, the intuition, of the health care provider. Patients are not statistics, and a one size-fits-all policy for dispensing antibiotics is neither practical or desirable. 

 

But despite decades of warnings, the persistent overuse of antibiotics has led us to the precipice, and we now face an uncertain and potentially frightening future where previously curable infections may run rampant.  

 

A few recent warnings include:

 

UK CMO: Antimicrobial Resistance Poses `Catastrophic Threat’

MMWR Vital Signs: Carbapenem-Resistant Enterobacteriaceae (CRE)

CDC HAN Advisory: Increase In CRE Reports In The United States

PNAS: Abundant Antibiotic Resistance Genes In Chinese Swine Farms

 

Chan: World Faces A `Post-Antibiotic Era’

 

 

The bottom line is that our antibiotic development pipeline is pathetically inadequate, and that bacteria are rapidly learning to evade our current arsenal. 

 

If we fail to control the rise in antibiotic resistance, and our current antimicrobial armamentarium fails, the decision whether to give – or not give – antibiotics will eventually become moot.

 

While it is unlikely to sway many patient’s opinions, hopefully today’s study will provide doctors with a little more reassurance when they opt not to prescribe antibiotics for routine ARIs. 

 

For a more complete look at the complex issues of antibiotic resistance, and the dearth of new drugs on the horizon, I can think of no resource better than Maryn McKenna’s superb book (and recent winner of the 2013 June Roth Memorial Book Award, American Society of Journalists and Authors)  Superbug: The Fatal Menace of MRSA.

And while I dabble in the issues of antibiotic resistance, undoubtedly the best coverage can be found on Maryn’s  Superbug blog.

Hong Kong: Scarlet Fever In 2012

Photo Credit – CDC 

 

# 6843

 

Over the past two years Hong Kong has experienced  a dramatic increase in the number of Scarlet Fever cases, while at the same time, cases in Mainland China have been reportedly surged as well.

 

The chart below illustrates Hong Kong’s  7-to-9 fold increase over 2005-2010.

 

Credit Hong Kong CHP

 

Scarlet fever is caused by the same bacteria that causes `strep throat’ (Group  A Streptococcus), and is characterized by fever, a very sore throat, a whitish coating or sometimes `strawberry’ tongue, and a `scarlet rash’ that first appears on the neck and chest.

 

It primarily affects children under the age of 10.  Adults generally develop immunity as they grow older. Untreated, this bacterial infection can lead to:

 

• Rheumatic fever
• Kidney disease
• Ear infections
• Skin infections
• Abscesses of the throat
• Pneumonia
• Sepsis
• Arthritis

 

For more on the disease, here is the CDC’s Scarlet Fever: A Group A Streptococcal Infection information page.

 

In the summer of 2011, we saw reports that many of these recent Hong Kong infections were resistant to erythromycin, but still responded to Penicillin. 

 

The CHP also reported:

 

A new genome fragment was discovered by the Department of Microbiology of the University of Hong Kong (HKU) upon sequencingthe whole genome of a GAS isolate from a child suffering from SF and invasive GAS infection admitted to QMH.

 

Subsequent testing by the PHLSB on other GAS isolates found that 70-80% of emm type 12 strains and 50-60% of emm type 1 strains carried this new genomefragment. The contribution of new GAS clone(s) with altered genetic characteristics (such as the new genome fragment) causing the current upsurge of SF remains to be investigated.

 

 

Today, Hong Kong’s Centre For Health Protection  released their latest Communicable Disease Watch, which includes a detailed epidemiological look the past year’s Scarlet Fever activity.

 

 

Scarlet fever – local epidemiology and severe cases in 2012

Reported by Miss Amy Li, Scientific Officer, Respiratory Disease Office, Surveillance and Epidemiology Branch, CHP.

Scarlet fever (SF) is a bacterial infection caused by Group A Streptococcus (GAS) and is a statutorily notifiable disease in Hong Kong. The main symptoms are fever, sore throat and erythematous rash with sand-paper texture. The tongue may have a distinctive "strawberry"-like (red and bumpy) appearance. SF can be treated by antibiotics effectively. Although the illness is usually mild, severe cases can occur and complications may include middle ear infection, throat abscess, pneumonia, sepsis, shock, septicaemia, meningitis, and toxic shock syndrome.This article reviews the local epidemiology and severe cases of SF in 2012.

From 2006 to 2010, the annual number of SF cases ranged between 128 and 235. In 2011, there was an upsurge in SF cases resulting in an annual total of 1526 cases. During the same period of time, there was a simultaneous increase of SF cases in Mainland China and Macao, suggesting the rise of SF cases in Hong Kong was likely a regional phenomenon.

 

The related details were reported in June and July 2011 (http://www.chp.gov.hk/files/pdf/cdw_v8_13.pdf and http://www.chp.gov.hk/files/pdf/cdw_v8_14.pdf). In 2012, the number of SF cases reported to CHP reached 1508* cases which was comparable to that of 2011 (Figure 1). In Hong Kong, relatively more cases occur from December to May though this seasonal pattern was not consistently observed every year (Figure 2). The local activity of SF has been high recently, with cases gradually increased from 65 in October to 132 in November and 119 in December 2012*.

(SNIP)

In view of the high activity of SF recently, people who are suspected to have SF should consult their doctor promptly. Patients who are suffering from SF should not go to schools or child care centres until they fully recover.To prevent SF,people should:

• Maintain good personal and environmental hygiene;
• Keep hands clean and wash hands properly;
• Wash hands when they are dirtied by respiratory secretions, e.g., after sneezing;
• Cover nose and mouth while sneezing or coughing and dispose of nasal and mouth discharge properly; and
• Maintain good ventilation.

 

As we saw in 2011, this report states that :`60 percent of GAS isolated in 2012 were resistant to erythromycin (which also predicts resistance to azithromycin and clarithromycin).’

While Penicillin and first generation cephalosporins are still effective, this is another example of a serious bacterial infection - once easily treated – evolving to evade our antibiotic arsenal.

 

The list of resistant bacteria continues to expand, with names like  MRSA, NDM-1, KPC, EHEC, Neisseria gonorrhoeae, and now Scarlet Fever making headlines around the world.

 

So while the end of the antibiotic era is not yet at hand, many experts fear we may be drawing closer to that day (see World Faces A `Post-Antibiotic Era’).

 

Short of seeing a hugely virulent pandemic – the problem of growing antimicrobial resistance may be the greatest threat to global public health that our species faces over the next couple of decades.

Unnecessary Antibiotic Use & C. Difficile Infections

C. difficile – Credit CDC PHIL 

# 6842

 

We’ve more evidence today on the perils of unnecessary antibiotic usage from a study that appears in the February 2013 edition of Infection Control and Hospital Epidemiology.

While the most publicized concern over the overuse of antibiotics is the creation of resistant bacteria, it is far from being the only danger.  

 

Two years ago in The Other Reason Not To Abuse Antibiotics, we looked at the what happens to our beneficial intestinal bacteria (gut flora or microbiota) after we take a course of antibiotics, and how that might affect our health.

 

In recent years the the NIH sponsored Human Microbiome Project has spurred new research into these ubiquitous micro-organisms that reside not only in our intestines, but on our skin, in our nasal passages, oral cavities, gastrointestinal tract, and urogenital tract.

 

For all the good they do, antibiotics can indiscriminately kill off good bacteria along with the bad, and that can upset the bacterial balance in our gut.

 

When this happens, we often see the blooming of a nasty Gram-Positive bacteria called Clostridium Difficile – or C. diff – an infection which claims tens of thousands of lives each year.

 

And as the name implies, C. diff is most difficult to treat (see Referral: Maryn McKenna On Regulatory Obstacles To Fecal Transplants).

 

Today’s study, looks at the antibiotic history of patients at the Minneapolis Veterans Affairs Medical Center and found that not only are antibiotics often prescribed unnecessarily, their use substantially increased the patient’s chances of developing a C. diff infection.

 

First a link to the study, then some excerpts from the Press Release.

 

Unnecessary Antimicrobial Use in Patients with Current or Recent Clostridium difficile Infection (pp. 109-116) 

Megan K. Shaughnessy, MD; William H. Amundson, MD; Michael A. Kuskowski, PhD; Douglas D. DeCarolis, PharmD; James R. Johnson, MD; Dimitri M. Drekonja, MD, MS

DOI: 10.1086/669089

 

While the bulk of this article is behind a pay-wall, we get more details from the SHEA press release.

 

Society for Healthcare Epidemiology of America

Unnecessary antimicrobial use increases risk of recurrent infectious diarrhea

The impact of antibiotic misuse has far-reaching consequences in healthcare, including reduced efficacy of the drugs, increased prevalence of drug-resistant organisms, and increased risk of deadly infections. A new study featured in the February issue of Infection Control and Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America, found that many patients with Clostridium difficile infection (C. difficile) are prescribed unnecessary antibiotics, increasing their risk of recurrence of the deadly infection. The retrospective report shows that unnecessary antibiotics use is alarmingly common in this vulnerable patient population.

 

C. difficile is a bacteria that usually affects people with recent antibiotic use or hospitalization. The symptoms of C. difficile range from mild diarrhea to severe illness and death, and it is now one of the most common healthcare-associated infections. Patients with C. difficile often experience recurrent episodes of the infection, especially if they receive antibiotics again in the future.

 

Researchers at the Minneapolis Veterans Affairs Medical Center reviewed patient cases with new-onset C. difficile infection. In total, 57 percent (141) of patients with new-onset C. difficile infection received additional antimicrobials during or within 30 days after their initial C. difficile treatment, raising their risk of recurrence substantially. From this group, 77 percent received at least one dose of unnecessary antibiotic, and 26 percent of patients received unnecessary antibiotics exclusively. Common reasons noted for unnecessary antibiotic use included urinary tract infections and pneumonia (despite little-to-no evidence of either being present), inappropriate surgical prophylaxis, and asymptomatic bacteriuria.

 

"Our findings serve as a reminder to both doctors and patients to use antibiotics only when absolutely necessary, particularly in patients with a history of C. difficile," said lead researcher Megan K. Shaughnessy, MD. "Patients with C. difficile are at high-risk for recurrence, especially with additional antibiotic use. Because of this heightened risk, clinicians should be exercising increased caution with antimicrobial therapy."

 

The researchers advise that providers contemplating antimicrobial therapy should be more aware of the risk of recurrent C. difficile with antimicrobial use, patients' previous C. difficile history, and which clinical conditions require antimicrobial therapy.

 

Obviously, when you are faced with a serious bacterial infection, antibiotics are a prudent, even lifesaving form of treatment.

 

But we should not fool ourselves into believing that antibiotics are always benign, or that there are not potential consequences from taking them.

 

There is a risk-reward ratio for every drug we take.

 

For more on the importance of proper antibiotic stewardship, you may wish to revisit these earlier blogs.

 

Chan: World Faces A `Post-Antibiotic Era’

Get Smart About Antibiotics Week

IDSA: Educational Guidelines Lower Antibiotic Use

 

And for a far more complete (and eye-opening) discussion of antimicrobial resistance issues, I can think of no better primer than Maryn McKenna’s book SUPERBUG: The Fatal Menace of MRSA.

 

And Maryn’s SUPERBUG Blog, part of Wired Science Blogs, continues to provide the best day-to-day coverage of these issues.