CDC WARNS OF SPREAD OF MULTIDRUG-RESISTANT INTESTINAL ILLNESS IN U.S.

FROM:  CENTERS FOR DISEASE CONTROL AND PREVENTION
Multidrug-resistant Shigellosis Spreading in the United States
New infections emphasize the importance of using antibiotics wisely

International travelers are bringing a multidrug-resistant intestinal illness to the United States and spreading it to others who have not traveled, according to a report released today by the Centers for Disease Control and Prevention (CDC). Shigella sonnei bacteria resistant to the antibiotic ciprofloxacin sickened 243 people in 32 states and Puerto Rico between May 2014 and February 2015. Research by the CDC found that the drug-resistant illness was being repeatedly introduced as ill travelers returned and was then infecting other people in a series of outbreaks around the country.

CDC and public health partners investigated several recent clusters of shigellosis in Massachusetts, California and Pennsylvania and found that nearly 90 percent of the cases tested were resistant to ciprofloxacin (Cipro), the first choice to treat shigellosis among adults in the United States. Shigellosis can spread very quickly in groups like children in childcare facilities, homeless people and gay and bisexual men, as occurred in these outbreaks.

“These outbreaks show a troubling trend in Shigella infections in the United States,” said CDC Director Tom Frieden, M.D., M.P.H. “Drug-resistant infections are harder to treat and because Shigella spreads so easily between people, the potential for more – and larger – outbreaks is a real concern.  We’re moving quickly to implement a national strategy to curb antibiotic resistance because we can’t take for granted that we’ll always have the drugs we need to fight common infections.”

In the United States, most Shigella is already resistant to the antibiotics ampicillin and trimethoprim/sulfamethoxazole. Globally, Shigella resistance to Cipro is increasing. Cipro is often prescribed to people who travel internationally, in case they develop diarrhea while out of the United States. More study is needed to determine what role, if any, the use of antibiotics during travel may have in increasing the risk of antibiotic-resistant diarrhea infections among returned travelers.

“The increase in drug-resistant Shigella makes it even more critical to prevent shigellosis from spreading,” said Anna Bowen, M.D., M.P.H., a medical officer in CDC’s Waterborne Diseases Prevention Branch and lead author of the study. “Washing your hands with soap and water is important for everyone. Also, international travelers can protect themselves by choosing hot foods and drinking only from sealed containers.”

ANTIBIOTICS LINKED TO CHILDREN'S DIARRHEA

FROM:  CENTERS FOR DISEASE CONTROL AND PREVENTION 
Severe diarrheal illness in children linked to antibiotics prescribed in doctor’s offices

CDC urges physicians to improve prescribing practices to reduce harm
The majority of pediatric Clostridium difficile infections, which are bacterial infections that cause severe diarrhea and are potentially life-threatening, occur among children in the general community who recently took antibiotics prescribed in doctor’s offices for other conditions, according to a new study by the Centers for Disease Control and Prevention published this week in Pediatrics.
The study showed that 71 percent of the cases of C. difficile infection identified among children aged 1 through 17 years were community-associated—that is, not associated with an overnight stay in a healthcare facility.  By contrast, two-thirds of C. difficile infections in adults are associated with hospital stays.
Among the community-associated pediatric cases whose parents were interviewed, 73 percent were prescribed antibiotics during the 12 weeks prior to their illness, usually in an outpatient setting such as a doctor’s office.  Most of the children who received antibiotics were being treated for ear, sinus, or upper respiratory infections. Previous studies show that at least 50 percent of antibiotics prescribed in doctor’s offices for children are for respiratory infections, most of which do not require antibiotics.

Improved antibiotic prescribing is critical to protect the health of our nation’s children,” said CDC Director Tom Frieden, M.D., M.P.H.  “When antibiotics are prescribed incorrectly, our children are needlessly put at risk for health problems including C. difficile infection and dangerous antibiotic resistant infections.”
he FY 2015 President’s Budget requests funding for CDC to improve outpatient antibiotic prescribing practices and protect patients from infections, such as those caused by C. difficile.  The CDC initiative aims to reduce outpatient prescribing by up to 20 percent and healthcare-associated C. difficile infections by 50 percent in five years.  A 50 percent reduction in healthcare-associated C. difficile infections could save 20,000 lives, prevent 150,000 hospitalizations, and cut more than $2 billion in healthcare costs.

C. difficile, which causes at least 250,000 infections in hospitalized patients and 14,000 deaths every year among children and adults, remains at all-time high levels.  According to preliminary CDC data, an estimated 17,000 children aged 1 through 17 years get C. difficile infections every year.  The Pediatrics study found that there was no difference in the incidence of C. difficile infection among boys and girls, and that the highest numbers were seen in white children and those between the ages of 12 and 23 months.

Taking antibiotics is the most important risk factor for developing C. difficile infections for both adults and children.  When a person takes antibiotics, beneficial bacteria that protect against infection can be altered or even eliminated for several weeks to months. During this time, patients can get sick from C. difficile picked up from contaminated surfaces or spread from a health care provider’s hands.
Although there have been significant improvements in antibiotic prescribing for certain acute respiratory infections in children, further improvement is greatly needed.  In addition, it is critical that parents avoid asking doctors to prescribe antibiotics for their children and that doctors follow prescribing guidelines.
“As both a doctor and a mom, I know how difficult it is to see your child suffer with something like an ear infection,” said Lauri Hicks, DO, Adobe PDF file director of CDC’s Get Smart: Know When Antibiotics Work program. “Antibiotics aren’t always the answer. I urge parents to work with their child’s doctor to find the best treatment for the illness, which may just be providing symptom relief.”

NSF ON STUDYING "SOCIAL BACTERIA"

FROM:  NATIONAL SCIENCE FOUNDATION

"Social" bacteria that work together to hunt for food and survive under harsh conditions
Research into multi-cell bacterium could lead to new antibiotics or to development of new pest-resistant seeds
When considering the behavior of bacteria, the word "social" doesn't often come to mind.

Yet some bacteria are quite social, chief among them Myxococcus xanthus, a soil-dwelling bacterium that organizes itself into multi-cellular, three-dimensional structures made up of thousands of cells that work together to hunt for food and survive under harsh conditions.

"For the first 100 years of microbiology, researchers were trying to find model organisms to study bacteria, and most were selected because they had some medical or industrial significance influence, such as E. coli, and because they grow very well in the standard test tube," says Oleg Igoshin, an assistant professor of bioengineering at Rice University. "But when you base your choice on their behavior in a test tube, and not on social behavior or spatial structure, you lose some interesting species to study.

"The story is quite different for Myxococcus xanthus," he adds. "They are a very social bacteria that form really cool structures, and rely on each other for survival."

Myxococcus xanthus is "predatory," meaning it eats other microbes, although it is not harmful to humans. It is of great interest to researchers because of its self-made complex spatial formations, some even visible to the naked eye, and because it can kill efficiently and digest a wide range of microbial species.

"Their three-dimensional structures contain hundreds of thousands of bacteria, plus extra cellular material that holds the bacteria together like glue," says the National Science Foundation (NSF)-funded computational biologist, who is using both data-driven modeling and simulations to learn how M. xanthus behaves when there is sufficient food available, and when there is not. "We are trying to identify the mechanisms to understand how they achieve their multi-cellular behaviors."

Studying this organism addresses fundamental biological questions about how individual cells can break their symmetry to organize into these complicated many-celled compositions, teaching scientists about the evolution of multi-cellularity. "The most primitive form of life is single-cell life," Igoshin says. "The next step up would be going from single cells to multicellular organisms. These bacteria are somewhat in the middle."

When food is plentiful, these bacteria move in coordinated swarms, called ripples, often containing thousands of cells, which secrete enzymes into the environment to kill their prey and digest it outside their structure before taking in the resulting nutrients.

"M. xanthus has the ability to produce some powerful antibiotics that kill other species and enzymes that chew up the prey proteins into small segments," Igoshin says. "Single cells can't produce enough of these antibiotics or enzymes to effectively kill their prey, which is why they hunt together as a group."

But when food is scarce, M. xanthus takes another shape, forming itself into mounds of spores called fruiting bodies, where they can survive for a long time, sometimes for many years, until conditions improve and they can germinate again. "A single spore wouldn't survive," he says. "They need to be together."

The insights gained from a better understanding of how this bacterium functions potentially could help future researchers in designing new antibiotics, or possibly have a role in agricultural practices, such as developing new pest-resistant seeds. Moreover, deciphering the basic biology of multicellular organization can help to understand its more complex manifestations, such as embryonic development.

Igoshin is using M. xanthus as a model system for his computational tools, using approaches that involve both data analysis and simulation, both of which "have become a cornerstone of biological research in the modern era of biology," he says.

"I use reverse engineering approaches to look at these microscopic structures and try to figure out what these individual cells should do in order to produce this type of behavior," he adds. "I put in parameters such as size, velocity, flexibility, speed--some we can measure, some we can guess--and see whether the computer simulations will produce structures similar to those observed."

Igoshin is conducting his research under an NSF Faculty Early Career Development (CAREER) award, which he received in 2009. The award supports junior faculty who exemplify the role of teacher-scholars through outstanding research, excellent education, and the integration of education and research within the context of the mission of their organization. NSF is funding his work with $640,000 over five years.

He is collaborating with other experimental labs to study this organism, including Roy Welch, associate professor of biology at Syracuse University; Lawrence Shimkets, professor of biology at the University of Georgia; and Heidi Kaplan, associate professor of microbiology and genetics at the University of Texas-Houston Medical School.

As part of the grant's educational component, Igoshin and his colleagues created a new interdisciplinary graduate program at Rice offering doctoral degree in systems, synthetic, and physical biology, that began in the fall of 2013. Igoshin, who co-wrote the program proposal, serves on the program steering committee, and the admission and recruitment committee.

"Answering complex biological questions in the post-genomic era will require multidisciplinary approaches combining both experimental and computational methods" he says. "Our new program aims to educate a new generation of life-scientists that have truly interdisciplinary training and therefore can work together on these challenges."

-- Marlene Cimons, National Science Foundation
Investigators
Oleg Igoshin

FDA ANNOUNCES VOLUNTARY PLAN TO END USE OF SOME ANTIBIOTICS IN FARM ANIMALS

Photo From FDA Website.

FROM:  U.S. FOOD AND DRUG ADMINISTRATION 

Phasing Out Certain Antibiotic Use in Farm Animals

The Food and Drug Administration (FDA) is implementing a voluntary plan with industry to phase out the use of certain antibiotics for enhanced food production.
Antibiotics are added to the animal feed or drinking water of cattle, hogs, poultry and other food-producing animals to help them gain weight faster or use less food to gain weight.

Because all uses of antimicrobial drugs, in both humans and animals, contribute to the development of antimicrobial resistance, it is important to use these drugs only when medically necessary. Governments around the world consider antimicrobial-resistant bacteria a major threat to public health. Illnesses caused by drug-resistant strains of bacteria are more likely to be potentially fatal when the medicines used to treat them are rendered less effective.

FDA is working to address the use of “medically important” antibiotics in food-producing animals for production uses, such as to enhance growth or improve feed efficiency. These drugs are deemed important because they are also used to treat human disease and might not work if the bacteria they target become resistant to the drugs’ effects.

“We need to be selective about the drugs we use in animals and when we use them,” says William Flynn, DVM, MS, deputy director for science policy at FDA’s Center for Veterinary Medicine (CVM). “Antimicrobial resistance may not be completely preventable, but we need to do what we can to slow it down.”

FDA is issuing a final guidance document that explains how animal pharmaceutical companies can work with the agency to voluntarily remove growth enhancement and feed efficiency indications from the approved uses of their medically important antimicrobial drug products, and move the therapeutic uses of these products from over-the-counter (OTC) availability to marketing status requiring veterinary oversight.

Once manufacturers voluntarily make these changes, the affected products can then only be used in food-producing animals to treat, prevent or control disease under the order of or by prescription from a licensed veterinarian.

“This action promotes the judicious use of important antimicrobials, which protects public health and, at the same time, ensures that sick and at-risk animals receive the therapy they need,” says CVM Director Bernadette Dunham, DVM, Ph.D. “We realize that these steps represent changes for veterinarians and animal producers, and we have been working to make this transition as seamless as possible.”

Drugs Primarily in Feed

Flynn explains that all the drugs affected by this plan are antibacterial products. They have long been FDA-approved for production (e.g. growth enhancement) purposes as well as for the treatment, control or prevention of animal diseases. Even today, he says, it is not entirely understood how these drugs make animals grow faster. The drugs are primarily added to feed, although they are sometimes added to the animals’ drinking water.

Bacteria evolve to survive threats to their existence. In both humans and animals, even appropriate therapeutic uses of antibiotics can promote the development of drug resistant bacteria. When such bacteria enter the food supply, they can be transferred to the people who eat food from the treated animal.

In 2010, FDA called for a strategy to phase out production use of medically important antimicrobial products and to bring the remaining therapeutic uses under the oversight of a veterinarian. The guidance document that FDA is issuing on Dec. 11, 2013, which was previously issued in draft form in 2012, lays out such a strategy and marks the beginning of the formal implementation period.

The agency is asking animal pharmaceutical companies to notify FDA within the next three months of their intent to voluntarily make the changes recommended in the guidance. Based on timeframes set out in the guidance, these companies would then have three years to fully implement these changes.

To help veterinarians and producers of food-producing animals comply with the new terms of use for these products once the recommended changes are implemented, FDA is proposing changes to the Veterinary Feed Directives (VFD) process. This is an existing system that governs the distribution and use of certain drugs (VFD drugs) that can only be used in animal feed with the specific authorization of a licensed veterinarian. Flynn explains that feed-use antibiotics that are considered medically important and are currently available as OTC products will, as a result of implementation of the guidance document, come under the VFD process.

The proposed changes to the VFD process are intended to clarify the administrative requirements for the distribution and use of VFD drugs and improve the efficiency of the VFD program. Such updates to the VFD process will assist in the transition of OTC products to their new VFD status.

Why Voluntary?

Flynn explains that the final guidance document made participation voluntary because it is the fastest, most efficient way to make these changes. FDA has been working with associations that include those representing drug companies, the feed industry, producers of beef, pork and turkey, as well as veterinarians and consumer groups.

"Based on our outreach, we have every reason to believe that animal pharmaceutical companies will support us in this effort," says Michael R. Taylor, FDA's deputy commissioner for foods and veterinary medicine.

This article appears on FDA's Consumer Updates page, which features the latest on all FDA-regulated products.

CDC WANTS IMMEDIATE ACTION TO CURB DEADLY INFECTIONS IN HOSPITALS

FROM: CENTERS FOR DISEASE CONTROL
CDC: Action needed now to halt spread of deadly bacteria
Data show more inpatients suffering infections from bacteria resistant to all or nearly all antibiotics 


 A family of bacteria has become increasingly resistant to last-resort antibiotics during the past decade, and more hospitalized patients are getting lethal infections that, in some cases, are impossible to cure. The findings, published today in the Centers for Disease Control and Prevention’s
Vital Signs report, are a call to action for the entire health care community to work urgently – individually, regionally and nationally – to protect patients. During just the first half of 2012, almost 200 hospitals and long-term acute care facilities treated at least one patient infected with these bacteria.

The bacteria, Carbapenem-Resistant Enterobacteriaceae (CRE), kill up to half of patients who get bloodstream infections from them. In addition to spreading among patients, often on the hands of health care personnel, CRE bacteria can transfer their resistance to other bacteria within their family. This type of spread can create additional life-threatening infections for patients in hospitals and potentially for otherwise healthy people. Currently, almost all CRE infections occur in people receiving significant medical care in hospitals, long-term acute care facilities, or nursing homes.

"CRE are nightmare bacteria. Our strongest antibiotics don’t work and patients are left with potentially untreatable infections," said CDC Director Tom Frieden, M.D., M.P.H. "Doctors, hospital leaders, and public health, must work together now to implement CDC’s "detect and protect" strategy and stop these infections from spreading."

Enterobacteriaceae are a family of more than 70 bacteria including Klebsiella pneumoniae and E. coli that normally live in the digestive system. Over time, some of these bacteria have become resistant to a group of antibiotics known as carbapenems, often referred to as last-resort antibiotics. During the last decade, CDC has tracked one type of CRE from a single health care facility to health care facilities in at least 42 states. In some medical facilities, these bacteria already pose a routine challenge to health care professionals.

The Vital Signs report describes that although CRE bacteria are not yet common nationally, the percentage of Enterobacteriaceae that are CRE increased by fourfold in the past decade. One type of CRE, a resistant form of Klebsiella pneumoniae, has shown a sevenfold increase in the last decade. In the U.S., northeastern states report the most cases of CRE.

According to the report, during the first half of 2012, four percent of hospitals treated a patient with a CRE infection. About 18 percent of long-term acute care facilities treated a patient with a CRE infection during that time.

In 2012, CDC released a concise, practical CRE prevention toolkit with in-depth recommendations for hospitals, long-term acute care facilities, nursing homes and health departments. Key recommendations include:
enforcing use of infection control precautions (standard and contact precautions)
grouping patients with CRE together
dedicating staff, rooms and equipment to the care of patients with CRE, whenever possible
having facilities alert each other when patients with CRE transfer back and forth
asking patients whether they have recently received care somewhere else (including another country)
using antibiotics wisely
In addition, CDC recommends screening patients in certain scenarios to determine if they are carrying CRE. Because of the way CRE can be carried by patients from one health care setting to another, facilities are encouraged to work together regionally to implement CRE prevention programs.

These core prevention measures are critical and can significantly reduce the problem today and for the future. In addition, continued investment into research and technology, such as a testing approach called Advanced Molecular Detection (AMD), is critical to further prevent and more quickly identify CRE.

In some parts of the world, CRE appear to be more common, and evidence shows they can be controlled. Israel recently employed a coordinated effort in its 27 hospitals and dropped CRE rates by more than 70 percent. Several facilities and states in the U.S. have also seen similar reductions.

"We have seen in outbreak after outbreak that when facilities and regions follow CDC’s prevention guidelines, CRE can be controlled and even stopped," said Michael Bell, M.D., acting director of CDC’s Division of Healthcare Quality Promotion. "As trusted health care providers, it is our responsibility to prevent further spread of these deadly bacteria."