Antibiotic prescription in ambulatory care for COVID-19 patients: a cohort analysis in four European countries

OBJECTIVE

To analyse antibiotic prescription rates in ambulatory care for COVID-19 patients by general practitioners (GPs) in four European countries.

METHODS

A total of 4,513,955 anonymised electronic prescribing records of 3656 GPs in four European countries were analysed. Diagnosis and prescriptions were retrieved. Antibiotic prescription rates during COVID-19 consultations were analysed and compared between France, the UK, Belgium and Romania.

RESULTS

Overall prescription rate was in France and Belgium (6.66 and 7.46%). However, analysing median GP prescribing rates, we found that 33.9% of the GPs in Belgium prescribed antibiotics with a median of 16 prescriptions per 100 COVID-19 consultations, while 55.21% of the GPs in France prescribed a median of 8 antibiotic prescriptions per 100 COVID-19 consultations. Overall antibiotic prescription rates were less in Romania than in the UK (22% vs 32%); however, 73% of the Romanian GPs vs 57% of the British GPs prescribed antibiotics. Depending on the country, the proportion of each type of antibiotic was statistically different, with the proportion of azithromycin being more than 50% of all antibiotics in each country except for the UK where it was less than 1%.

CONCLUSION

Both individual GPs prescribing patterns in addition to overall consumption patterns should be analysed in order to implement a tailored antimicrobial stewardship programme. Furthermore, antibiotic prescribing rates in COVID-19 are lower than other respiratory tract infections.

S10.2d Fungal beta-glucans and mannan performances in HIV-associated histoplasmosis

 

S10.2 Fungal Infections in Transplant Patients, September 24, 2022, 10:30 AM - 12:00 PM

Objectives

Diagnosis of histoplasmosis in people living with HIV (PLWHIV) remains challenging despite developments in Histoplasma antigen and molecular detection tools. Fungal markers such as Beta-(1,3)-D-glucan (BDG) and galactomannan Aspergillus antigen (GM) are widely available, but the experience is limited during PLWHIV workup for suspicion of histoplasmosis. Our objective was to evaluate and compare BDG and GM performances for the diagnosis of HIV-associated histoplasmosis.

Methods

We performed a diagnostic accuracy study using primary serum samples stored frozen in a certified biorepository (CRB Amazonie-DC-2021-4649). Samples consisted of consecutive hospitalized PLWHIV unexposed to oral antifungals during the previous month (EDIRAPHIS study-NCT01884779). All patients gave consent for biobanking and ancillary studies on fungal markers.

Histoplasmosis cases, proven (EORTC/MSG criteria) and probable (polyclonal or monoclonal Histoplasma antigen detections in urines or serum), as well as negative controls, were randomly selected. Patients with a proven or suspected Pneumocystis jirovecii infection were excluded. Following manufacturers’ instructions, samples were blindly tested for BDG and GM using Fungitell® and PlateliaTM Aspergillus Ag assays, respectively.

Gold standard definition used three scenarios: EORTC scenario (cases and controls defined according to the EORTC/MSG 2020 criteria for endemic mycoses); strict scenario with proven cases restricted to those positives to all three previous Histoplasma antigen detections, and controls conversely negatives for all methods; and a large scenario with proven or probable cases and controls negatives for all methods.

Results

We included 121 samples, 92 HIV-associated histoplasmosis cases (34 proven and 58 probable), and 29 negative controls. Compared with controls, histoplasmosis cases were significantly younger and advanced in the course of HIV disease [median CD4 count level 33/mm3 (15-87) vs 116 (62-245)].

BDG and GM median detection levels were significantly higher among histoplasmosis cases compared with controls across all scenarios [368 (176-441) pg/ml vs 142 (89-211) for BDG and 2.5 (1.3-4.8) vs 0.19 (0.14-0.36) for GM, in cases vs controls of the strict scenario, respectively].

In the strict scenario, at 150 pg/ml and 0.5 for BDG and GM respectively, sensitivity, specificity, positive and negative likelihood ratios were respectively: 95% [95%confidence interval (CI), 85-100] vs 90% [77-100], 52% [34-70] vs 83% [69-97], 2 [1.4-3.0] vs 5.3 [2.4-12.0], and 0.1 [0.01-0.7] vs 0.12 [0.03-0.45]. ROC curves found AUCs of 0.82 [0.68-0.91] vs 0.92 [0.80-0.98], and optimal thresholds at 288 pg/ml and 1.29, for BDG and GM, respectively (Fig. 1). Post-test probabilities showed best performances at the lowest thresholds for negative testing of both BDG and GM, and at the 0.7 thresholds for a positive GM test (Fig. 2).

Conclusion

BDG and GM may not be used for the same objective when searching for HIV-associated histoplasmosis. Although a negative BDG test at the lowest thresholds should rule out histoplasmosis in a screening context, limitations of a positive BDG test, even at the highest thresholds, call for a consecutive positive GM test before starting patients on antifungal therapy targeting histoplasmosis. Still, when considering the highest costs of BDG testing, higher balanced diagnostic performances, and lower costs of GM testing alone, one may favor the use of GM, notably in resources-limited settings.

S2.2d Evaluation of new tools for the diagnosis of histoplasmosis

S2.2 Histoplasmosis and talaromycosis, September 21, 2022, 3:00 PM - 4:30 PM

In sub-Saharan Africa (SSA) and West African countries, histoplasmosis is rarely diagnosed probably due to lack of epidemiological information, insufficient training and awareness of frontline healthcare workers, and clinical features very similar to those of tuberculosis that can be misleading. This fungal infection mainly affects immunocompromised patients and particularly advanced HIV patients, with a high case-fatality rate in the absence of treatment (from <10% to >40%). The classical diagnostic methods are microscopic observation of yeasts with suggestive morphology and a positive culture from a biological sample. However, direct examination requires regular practice, and the yeasts can be confused with other pathogens and culture takes prolonged incubation (often 2-6 weeks) and involves, when positive, handling in a level 3 security laboratory.

Implementing non-invasive diagnostic tools will allow us to improve histoplasmosis diagnosis for the most exposed patients and also to evaluate the prevalence of this fungal infection in countries where data are still lacking. Rapid diagnostic tests (RDTs) such as the TB Lam for the diagnosis of tuberculosis or the Cryptococcal antigen (CrAg) lateral flow assay (LFA) for cryptococcosis have demonstrated their usefulness for the management of advanced HIV patients in similar contexts.

Recently, two RDTs have been made commercially available for the diagnosis of histoplasmosis, based on urinary monoclonal antigen detection: (1) Histoplasma Capsulatum Urinary Antigen Rapid Test from Optimium Imaging Diagnostics (OIDx) and (2) Histoplasma Urine Antigen Lateral Flow Assay from MiraVista Diagnostics (MV).

Objectives and Methods

Our objective was to evaluate these new tools, by experimenting with their feasibility in low-and middle-income countries (LMICs) and by studying their diagnostic performances using different sample collections recovered from patients with disseminated histoplasmosis (culture proven), other HIV-related infections, and proven negative urines (culture and other Histoplasma antigen detections).

Results

Preliminary results were obtained using the EDIRAPHIS study frozen samples from hospitalized patients diagnosed with proven positive and negative histoplasmosis from French Guiana and Suriname (n = 43) tested with OIDx and MV tests. We calculated a Se = 74.2% and a Sp = 83.3% for OIDx and a Se = 77.4% and a Sp = 91,7% for MV. A low number of false positives for both tests, <17% for OIDx and <9% for MV were observed. We have a perfect correlation between the observers with a Kappa coefficient of 100% for both tests. Overall, the probabilities that the patient had histoplasmosis with a positive test were 92% and 96% for OIDx and MV respectively.

Conclusion

These first results are very promising and will be completed with two other specimen collections to increase the total numbers of our sampling and get a whole picture of the performances of these two RDTs. The next step will be to implement these new tools at the bedside or in laboratories together with other tests in different settings across SSA.

Diffusion of RDTs together with appropriate training of clinical and laboratory teams and accessibility to treatment may help reduce the burden of histoplasmosis in endemic areas of SSA where the prevalence of the advanced-HIV disease is high.

She Has The Blues: An Unusual Case of Copper Sulphate Intoxication

BACKGROUND

Copper is an essential trace element of the human body. However, it is related to many diseases. Copper intoxication is not common in Western countries, but needs to be rapidly recognised because of its high lethality.

CASE PRESENTATION

We report the case of a 40-year-old woman who presented to the emergency department after performing intrarectal administration of a blue powder sent from Cameroon by her family, in the belief that this would help her to get pregnant. Her evolution was complicated by multiorgan failure and the unusual circumstances. The diagnosis was suspected on the basis of the clinical presentation and the colour of the powder, and confirmed by blood dosage and toxicological analysis of the powder. She underwent symptomatic treatment, and the outcome was progressively favourable, apart from persistent chronic renal failure with dependence on dialysis.

CONCLUSION

Copper intoxications are rare but severe. Laboratory diagnosis of the condition is not an issue; the difficulty is suspecting it and quickly initiating chelation treatment associated with symptomatic treatments.

LEARNING POINTS

Copper sulphate is a rare but severe condition that must be promptly diagnosed. Diagnosis may be based on clinical presentation, characterised by multiple organ failure, and suspected in the case of ingestion of a blue chemical product.In the presence of saturation gap on pulse oximetry, the clinician must consider the possibility of methemoglobinaemia, and look for toxic causes.Treatment of copper sulphate poisoning requires mainly symptomatic treatment and chelation of copper by oral or IV drugs.

Germs of thrones - spontaneous decolonization of Carbapenem-Resistant Enterobacteriaceae (CRE) and Vancomycin-Resistant Enterococci (VRE) in Western Europe: is this myth or reality?

Background

In France, Carbapenem-Resistant Enterobacteriaceae (CRE) and Vancomycin-Resistant Enterococci (VRE) are considered as Extensively Drug-Resistant (XDR) bacteria. Their management requires reinforcement of hospital’s hygiene policies, and currently there is few consistent data concerning the spontaneous decolonization in XDR colonized patients. Our aim is to study the natural history of decolonization of XDR carriers over time in a hospital setting in a low prevalence country.

Material and methods

Retrospective multicenter study over 2 years (2015–2016) in 2 different tertiary care hospital sites and units having an agreement for permanent cohorting of such XDR carriers. We gathered the type of microorganisms, risk factors for colonization and rectal swabs from patient’s follow-up. We also evaluated patient care considering isolation precautions.

Results

We included 125 patients, aged 63+/−19y, including 72.8% of CRE (n = 91), 24.8% of VRE (n = 31) and 2.4% (n = 3) co-colonized with CRE and VRE. CRE were mainly E. coli (n = 54), K. pneumoniae (n = 51) and E. cloacae (n = 6). Mechanisms of resistance were mainly OXA-48 (n = 69), NDM-1 (n = 11), OXA-232 (n = 8) and KPC (n = 3).

Prior antibiotic therapy was reported in 38.4% (n = 48) of cases. Conversely, 17.6% (n = 22) received antibiotics during follow-up.

Spontaneous decolonization occurred within the first 30 days in 16.4% (n = 19/116) of cases and up to 48.2% after day-90 with a median follow-up of 96 days (0–974).

We estimated that XDR carriage was associated with a larger care burden in 13.6% (n = 17) of cases, especially due to a prolongation of hospitalization of 32.5 days (15–300).

Conclusions

Our study shows that spontaneous decolonization is increasing over time (up to 48.2%). We can regret that only few patients underwent screening after 1 year, emphasizing the need for more monitoring and prospective studies.