H5N1

Branswell: Drug-resistant gonorrhea prompts new treatment approach in Ontario

Via The Star, Helen Branswell of The Canadian Press writes: Drug-resistant gonorrhea prompts new treatment approach in Ontario. Excerpt:

Faced with evidence that drug-resistant gonorrhea is spreading in the province, Ontario is recommending a different treatment approach for the sexually transmitted infection. 

New treatment guidelines recommend that doctors no longer use the established therapy, a last oral antibiotic that could be used solo against the infection. Instead, Public Health Ontario is recommending that people who test positive for gonorrhea should be treated with a combination of an injectable antibiotic plus a second antibiotic, which comes in pill form. 

Dr. Vanessa Allen of the provincial public health agency co-chaired the committee that developed the new treatment guidelines. She said using a combination of antibiotics may help to slow gonorrhea’s relentless march through the antibiotics in medicine’s armamentarium. 

“It’s really too bad that we can no longer use the pill (alone),” Allen said in an interview. 

“If we could, obviously we would want to offer that. ... (But) we know it’s not as effective ... and it may in fact be promoting resistance in these organisms in the community.” 

In adopting the combination therapy — injectable ceftriaxone and oral azithromycin — Ontario is falling into line with the U.S. Centers for Disease Control, Public Health England and the European Centre for Disease Control, all of which recommend this regimen as the first-line treatment for gonorrhea. Those recommendations were made in the face of the spread of a resistant clone of gonorrhea which has been making its way around the globe. 

But it makes Ontario the first Canadian jurisdiction to go this route. Currently the first-line therapy for gonorrhea in the rest of the country remains a single dose of the oral drug cefixime. 

The Public Health Agency of Canada is in the process of revising the national treatment guidelines for gonorrhea and is expected to release its new recommendations sometime this year. In late 2012 the agency published interim recommendations that included urging doctors to double the dose of antibiotics used — either injected ceftriaxone or oral cefixime — to reduce the risk that the treatment would fail to cure the infection.

India "has lost" superbug war

Via India Real Time, a blog of the Wall Street Journal: India ‘Has Lost’ Superbug War. Excerpt:

India has lost the war against the toughest forms of antibiotic resistance, largely because of poor sanitation, unregulated use of antibiotics and an absence of drug resistance monitoring, according to the man who discovered a type of drug resistance in bacteria in New Delhi. 

“All these factors add to why it’s going to be so difficult to deal with or even tackle [resistance], you won’t solve it, it’s over,” said Tim Walsh, professor of medical microbiology at Cardiff University in Wales. 

In 2010, Mr. Walsh discovered an enzyme that made disease-causing bacteria resistant to antibiotics.  He named the enzyme “New Delhi Metallo 1” (NDM-1) and claims he was banned from working in India after the discovery. 

Bacteria carrying the NDM-1 enzyme are highly resistant to the most powerful group of antibiotics, known as carbopenems, making infections caused by them extremely difficult to treat. 

They can also transfer their resilience to other bacteria, including those that cause infections. “The rapidity and frequency of that transfer is something that we have never seen before in antibiotic resistance,” Mr. Walsh said. 

He estimates that up to 200 million Indians carry NDM-1 on the benign bacteria in their intestines. But a lack of research and scarcity of data make it difficult to gauge in terms of its transfer to disease causing bacteria. 

“We’ve failed to understand how NDM-1 spreads in the community,” Mr. Walsh said, adding that there is also very little understanding about the risks associated with being infected by a bacteria carrying NDM-1. 

“We’ve failed to understand what dominant clones are in hospital and we’ve failed to understand the risk post surgical infections,” he said. 

In almost three years since he published his research in the Lancet medical journal, Mr. Walsh says that India has failed to respond to the “urgent” need to regulate the sale and use of antibiotics, track the incidence of resistance or improve sanitation. 

Antibiotics are for sale without prescription in pharmacies in India and there are no national guidelines for clinicians on their use in hospitals. Bacterial diseases develop resistance to treatment with antibiotics when the drugs are wrongly used to treat viral infections or when a full course of drugs isn’t completed. 

Resistance makes infectious diseases more difficult or impossible to treat. Even simple urinary tract infections when caused by an NDM-1 carrying bacteria cannot be eradicated with antibiotics, Mr. Walsh said. 

When he published his findings in 2010 Walsh says his name “became mud” in political and scientific circles in India. 

“I named the gene after the capital of India which they [the government] weren’t too thrilled about,” he said. It is normal scientific practice to name genes after the cities in which they are found, he added. 

“We were banned from India and India had a massive clamp down on sending [biological] strains out,” Mr. Walsh said. “Indians were banned from working with me, or anybody in Europe the whole thing was a systematic campaign to control research into antibiotic resistance in India.” 

Neither the Ministry of Health nor the Central Drugs Standard Control Organization responded to requests for comment.

Australia: A new superbug

Via The Sydney Morning Herald: Superbug threat rises with proof of infection. Excerpt:

Researchers have confirmed long-held fears that a drug-resistant bug which is increasingly common in Australia can spread from person to person. 

In a finding which could carry implications for how hospitals control infections, British researchers have provided the first proof that the debilitating bug, called Mycobacterium abscessus, can be transmitted between patients. 

The bug, which causes an accelerated decline in lung function and can prevent safe lung transplantation, has become increasingly prevalent in Australia over the past decade, a previous study found. It must be treated with an extended course of a poorly-tolerated combination of antibiotics, and treatment often fails. 

The findings, published in The Lancet on Friday, come as a Senate committee examines Australia's response to the problem of drug-resistant infections. 

The researchers conducted DNA analysis of samples collected from 31 patients at a cystic fibrosis centre in Britain and concluded the bug had frequently been transmitted between patients, despite strict infection control measures. Previously, it had been thought people caught the bug from their environment. 

Uganda: Official blames drug resistant TB on negligent health workers

Via The Daily Monitor: Official blames drug resistant TB on negligent health workers. Excerpt:

A senior medical officer in the Ministry of Health has blamed the emergence of the deadly multi-drug resistant tuberculosis (MR-TB) in the country to negligent health workers. 

Dr Eldard Mabumba, a senior medical officer working with the TB and Leprosy Programme, said TB patients decline to take drugs and medical workers do not counsel them. 

“We still have high cases of TB patients not taking TB drugs which is contributing to the emergence of the deadly multi-drug resistant tuberculosis. But partly you medical workers are to blame because you don’t give the necessary counsel, information and time to these patients,” Dr Mabumba said. 

He was on Wednesday speaking during the southwestern region tuberculosis symposium organised by Makerere University HIV/Aids programme (MJAP) in Mbarara. 

Dr Mabumba added that despite the workload the medical workers have, they should give the necessary counselling and attention to patients. 

“Restore hope in these patients, counsel them then there will be limited cases of multi-drug resistant tuberculosis,” he added.

CIDRAP: News scan for March 28

Via CIDRAP: NEWS SCAN: Injection-related anthrax, drug-resistant gonorrhea, post-pandemic illness, imported rubella, polio vaccine deal. Excerpt:

A German analysis of patients hospitalized with 2009 H1N1 (pH1N1) flu during the pandemic year and the first post-pandemic year found that severe illnesses and deaths jumped dramatically the year after the pandemic. 

Researchers who conducted a retrospective study on patients hospitalized with lab-confirmed flu at University Hospital Heidelberg during the two seasons published their findings yesterday in Emerging Infectious Diseases. 

They identified 102 patients with pH1N1 infections during the 2009-10 season and 76 in the first post-pandemic season. The proportion of severe illnesses rose from 14% the first year to 46% the second year, and the mortality rate rose from 5% to 12%. Patients hospitalized during the post-pandemic season were older, at an average age of 38 compared with age 18 during the pandemic year. Those hospitalized during the second year were also more likely to have an underlying medical condition. 

Researchers noted that there weren't any virus changes that were known to account for the change in clinical pattern and that it's not unusual for trends to change from a pandemic season to the following one. They suggested that the increase in severity could reflect the effects of pH1N1 on remaining susceptible adults and risk groups.

Australia: XDR-TB on the doorstep

Via the Medical Journal of Australia: Extensively drug-resistant tuberculosis hovers threateningly at Australia’s door. Excerpt:

It was hoped that extensively drug-resistant tuberculosis (XDR-TB) might never arrive on Australia’s shores. But new cases raise the spectre of death for patients, transmission to others and large costs for Australian taxpayers. Papua New Guinea (PNG) national Catherina Abraham, aged 20 years, “made it” to Australia and hit the headlines in October 2012 because she had been diagnosed with XDR-TB. 

After almost a year in an isolation ward at Cairns Base Hospital, she died on 8 March 2013. Her treatment cost Queensland Health about $500 000 and would have cost $1 million had she lived to complete it. 

Now another PNG national has been diagnosed with XDR-TB in Australia. In the preceding 8 years, only two other XDR-TB cases were recorded in Australia. According to Queensland Health, the most recently diagnosed patient came through the Torres Strait, was referred to Cairns Base Hospital and was transferred to PNG health services before the laboratory diagnosis of XDR-TB was made. 

He or she is currently in Daru Hospital (in PNG’s Western Province, the closest to Cape York). Although TB treatment is meant to be free for patients in PNG, potential exposure to other patients, the cost of sourcing active drugs, and the complexity and length of XDR-TB treatment mean that this patient is at significant risk of dying. 

A recent television exposé of Daru Hospital showed numerous patients with XDR-TB and multi-drug resistant TB (MDR-TB) mixing together and leaving their isolation wards, resulting in the risk of drug-resistant TB spreading through the community. 

Experts believe Abraham would have died within 1 month had she not reached Cairns and also predict that Australia could see its own outbreak of XDR-TB within 5 years. In comparison, 24 patients have been diagnosed with XDR-TB in the United Kingdom since 1995, six of whom were diagnosed in 2011. 

Patients with XDR-TB and the still-challenging MDR-TB in the UK are largely migrants from Eastern Europe, Africa and Asia. Last year, the UK government began requiring new entrants from TB-prevalent nations to have a chest x-ray with them on arrival to be granted a visa to enter the UK. 

Yet, owing to the UK’s porous air and sea borders and its accessibility and proximity to Europe, it is much more vulnerable than Australia to receiving patients with MDR-TB and XDR-TB. According to the UK’s Health Protection Agency, screening new entrants for latent TB would also be desirable. 

However, Australia is unlikely to enact a similar policy since it would produce many positive results for latent infection without identifying which patients would progress to active or drug-resistant disease (Justin Waring, Chair of the National Tuberculosis Advisory Committee, personal communication). So apart from the Qld–PNG border, it is difficult to predict where other XDR-TB or MDR-TB cases may appear in Australia, since migrants with latent infection can reside in any Australian city or region. 

In Australia, significant resources can, at present, be directed at patients with XDR-TB. Yet in PNG, all forms of TB compete for resources with a catalogue of other health and social problems, including high rates of diarrhoeal illness, pneumonia, HIV (many patients with HIV are co-infected with TB), malaria, maternal mortality, and widespread and crippling poverty.

The famous epidemiologist Charles Dickens made the point in Bleak House, published in 1853: Let disease spread among the poor, and it will inevitably spread to the rich. We have been amazingly obtuse about this simple observation for 160 years.

The Lancet on World Tuberculosis Day

The Lancet has published a special issue today. The executive summary:

To commemorate World TB Day 2013, The Lancet Infectious Diseases publishes a Series of papers on tuberculosis, a disease that has long plagued human beings and was declared a global emergency in 1993 by WHO. 

Without concerted action from political leaders, health policy makers, funders, and others, health systems worldwide are at risk of being overwhelmed by increasing numbers of patients with treatment-resistant tuberculosis. 

As new diagnostic tests, drugs, and drug regimens become available that have the potential to radically improve the detection and management of tuberculosis, the papers in the Series explore the challenges for successful implementation of these interventions.

South Africa: New totally resistant TB identified

Just in time to ruin World Tuberculosis Day on Sunday, a report via allAfrica.com from Health-e: South Africa: Further Resistance to TB Drugs Identified in SA. Excerpt:

Researchers have identified a new strain of tuberculosis in 17 patients in the Eastern Cape which is totally resistant to the all current drug regimens. 

When an earlier study of extensively drug resistant (XDR) TB in the Eastern Cape showed that patients weren't responding to treatment - 58 percent of patients died within a year and only 8.4 percent became un-infectious after more than four months of treatment – epidemiologists at Stellenbosch University (SU) decided to investigate the bacteria that seemed to be more resistant against the available drugs. The Eastern Cape cases are the first to be identified in South Africa, and the fourth country in the world to report totally drug resistant (TDR) TB – it was discovered in India last year, and in Italy (2003) and Iran (2009). 

What they found was an emerging strain of TB even more resistant to drugs than XDR, which is already resistant to all first line drugs and some second line drugs. This new strain has shown resistance to at least 10 anti-TB drugs currently in use in the health sector. 

According to Prof Tommy Victor, from SU's Division of Molecular Biology and Human Genetics, the World Health Organisation and many experts in the field, including him, think the name "totally drug-resistant" (TDR), which is currently used in scientific literature, is not appropriate. They believe there may be a cure for TDR among some of the new drugs currently being developed, or old medication not in use anymore. 

"We really are facing bacteria that has become increasingly resistant, and there are now some bacteria that are hyper resistant, irrespective of the definition," said Victor who was one of the authors of the study. 

In the scientific paper, which was published in the Emerging Infectious Disease Journal in March this year, they used molecular techniques to study cultures of the tuberculosis bacterium of just under 400 Multi-drug resistant (MDR) TB patients in the Eastern Cape. Among these a large number were pre-XDR and XDR's, and 17 cases of TDR. 

There are approximately 18 000 new MDR cases diagnosed each year and "there may be be more TDR cases in South Africa ," says Victor, explaining that 17 cases emerged from only 400 MDR samples tested. 

A shortcoming of the study, which was acknowledged by the authors, is that they only studied the cultures from the infected patients, and don't have any data on patient outcomes – so they don't know how long they may have survived, or if any have been cured. Although a related study on the Eastern Cape cohort showed that patients responded quite badly to even the fiercest treatment.

50,000 Chinese die of TB annually: official

Via Xinhua: 50,000 Chinese die of TB annually: official.

As many as 50,000 people die of tuberculosis annually in China, with about 1 million new cases reported each year, a health official said on Thursday. 

That indicates that one person dies of the disease every ten minutes, according to Wang Yu, director with the Chinese Center for Disease Control and Prevention. 

Currently, there are 5 million Chinese people who suffer from active tuberculosis or TB, ranking China second following India among 22 countries that are most heavily plagued by the disease. 

About 120,000 new cases of multi-drug resistant TB (MDR-TB) are estimated to occur each year, ranking China first in the world and posing challenges to public health. 

The mortality rate of tuberculosis saw an 80 percent drop from 1990 to 2010 in China due to free diagnosis and treatment provided by the country's health departments, according to Wang. 

He noted that the prevalence rate was also halved during the same period. 

However, insufficient medical staff and funds cannot meet the needs of tuberculosis treatment in the country's rural areas, according to Wang. 

He said that health departments at all levels should mobilize social resources to accelerate the building of the country's tuberculosis prevention system. 

Even though tuberculosis is preventable and treatable, the disease kills 1.4 million people worldwide each year, according to Wang. 

The 18th World Tuberculosis Day falls on March 24.

CIDRAP: News scan for March 20

Via CIDRAP: NEWS SCAN: MRSA treatment, TB in the Americas, antibiotic resistance in Ontario, mumps on Virginia campus. Excerpt:

Vancomycin should remain the standard of care for most infections caused by methicillin-resistant Staphylococcus aureus (MRSA), as per 2011 treatment guidelines from the Infectious Diseases Society of America (IDSA), even though reports of treatment failure in cases with high but susceptible vancomycin minimum inhibitory concentrations (MICs) are not uncommon, say the authors of a review yesterday in Clinical Infectious Diseases. 

The authors point out that cases of persistant MRSA may not represent vancomycin failure at all but rather factors in the poorly understood natural history of MRSA bacteremia, the presence of a residual source of infection, altered pathogen virulence, and/or MIC "creep." 

Among the drawbacks of substituting other agents for vancomycin is the danger of developing resistance; vancomycin was in widespread use for 40 years before resistance emerged, the authors say, whereas resistance to the newer agents daptomycin and linezolid arose shortly after their introduction. 

Another drawback of the newer drugs is cost: Although there have been reports of shortened patient stays when treatment with the more expensive alternatives to vancomycin are used, this could be due to improved patient management more than to choice of antibiotic, the authors say.