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Highlights from the 25th ECCMID
Newsdesk
Highlights from the 25th ECCMID The European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) took place in Copenhagen on April 25–28. Raffaella Bosurgi, John McConnell, and Ammara Mushtaq report. Herpes zoster vaccine shows efficacy in reducing risk Thomas Heinemann (GSK Vaccines, King of Prussia, PA, USA) gave a presentation on a new vaccine, HZ/ su, for protection against herpes zoster. The vaccine showed efficacy in preventing disease in volunteers older than 50 years (stratified by age: 50–59, 60–69, ≥70 years), and efficacy persisted in older participants. This subunit vaccine was assessed in a placebo-controlled trial with 14 759 volunteers older than 50 years. Vaccine or placebo was given in two doses 2 months apart, and the participants were followed up after 3·2 years. Overall vaccine efficacy was 97% and did not differ significantly between any age group. Local and systemic reactions were more common in the vaccine group, but the incidence of serious adverse events, deaths, or potential immunemediated diseases was similar.
Treatment for uncomplicated urinary tract infection in women Andreas Kronenberg (University Hospital of Bern, Bern, Switzerland) gave a presentation on the treatment of uncomplicated urinary tract infection (UTI) in adult women. The aim of the study was to show the inferiority of the non-steroidal anti-inflammatory drug (NSAID) diclofenac to norfloxacin. 253 women (aged between 18 and 70 years) with UTI in Switzerland were randomly assigned, in a double-blind trial, to receive either diclofenac 2×75 mg for 3 days or the control antibiotic norfloxacin 2×400 mg for 3 days. The primary outcome was the proportion of patients in whom symptoms resolved after 3 days. Resolution was achieved in 53% of the NSAID group www.thelancet.com/infection Vol 15 June 2015
and 81% of the antibiotic group. Fosfomycin was given as rescue treatment if symptoms persisted after 3 days. The resolution of symptoms was lower with diclofenac and lasted longer with norfloxacin. One patient in the diclofenac group developed pyelonephritis and needed to be admitted to hospital.
Treating intra-abdominal infections J Solomkin (University of Cincinnati College of Medicine, Cincinnati, OH, USA) presented details of a new tetracycline derivative (eravacycline, a novel fluorocycline) that showed promise in treating intra-abdominal infections (IAI). In this randomised, double-blind, non-inferiority phase 3 trial, patients (541) with documented complicated IAI were assigned to receive either eravacycline or ertapenem. A range of pathogens was isolated including Escherichia coli, Pseudomonas aeruginosa, Klebsiella spp, Staphylococcus aureus, Bacteroides spp, streptococci, and enterococci. Results suggest that eravacycline was non-inferior to ertapenem and that side-effects were minimal and comparable.
the outbreak, and said that “cultural practices are adaptive and can be negotiated”. Marta Lada (Connaught Hospital, Freetown, Sierra Leone) described how an inadequate case definition led to cases of Ebola being missed early in the disease outbreak. She noted that symptoms at presentation have changed during the course of the outbreak, perhaps because early on patients tended to present later in the disease course and hence in a more severe condition. The most common signs of disease are fever, vomiting, and diarrhoea; however, fever is absent in 15% of confirmed cases. Lada said that days 0–5 of Ebola virus disease are characterised by extreme weakness and what she described as “pseudomalarial syndrome”; during days 5–10, patients have a gastrointestinal syndrome, with loss of appetite and joint pain; and on days 10–14 patients show a neurological syndrome with encephalitis and paralysis, a sign that often leads to death. For those patients that survive, recovery tends to happen from day 14. Lada stated that bleeding is not very common, and seen more often in children than adults. She noted that a national
Ammara Mushtaq co-authored the paper presented on environmental dissemination of MDRB carrying blaNDM and blaCTX-M-15 in a hospital environment, drinking water, birds, and insects
Ebola insight In accepting an excellence award on behalf of Medécins Sans Frontières for their work in response to the west Africa Ebola virus disease outbreak, Hilde De Clerk highlighted the role of “extended families, boyfriends, girlfriends, lovers, and taxi drivers” in spreading the disease. The vital importance of understanding cultural background was also emphasised by Sylvie Briand (WHO, Geneva, Switzerland). She noted the important role of anthropologists and social scientists in managing
The 25th ECCMID was held in Copenhagen
639
Newsdesk
effort to prepare for Ebola in Sierra Leone began in late March, 2014, with the construction of isolation facilities at seven locations. However, after the disease was first detected in the country on May 26 and the subsequent death of Sheik Umar Khan—the countries only expert on haemorrhagic fevers—the national response faced a major setback when health-care workers refused to work on Ebola. Despite such obstacles, Lada reported that two new cases per day are being detected in Sierra Leone, down substantially from the 60 per week she was seeing in her hospital alone at the height of the epidemic in October–November last year. Briand noted the complexity of coordinating the Ebola response: WHO counted 150 non-governmental organisations working on Ebola in Liberia alone. 72 emergency treatment centres were opened in the three affected countries, plus 88 community care centres, 27 mobile and three national diagnostic laboratories, 280 burial teams operated, and 58 foreign medical teams have been involved. Nancy Sullivan (National Institutes of Health, Bethesda, MD, USA) reported that a randomised controlled trial (RCT) of a vaccine against the Ebola virus has begun in Liberia, which is intended to recruit 27 000 participants. She stated that a RCT with a placebo group is “the only way to test efficacy”.
Maternal vaccines to prevent neonatal infections Ajoke Sobanjo-ter Meulen (Bill & Melinda Gates Foundation, Seattle, WA, USA) advocated that “maternal immunisations directly avert infection-related deaths in neonates” and in 2014, the Foundation expanded its maternal immunisation programme to five key pathogens: influenza, respiratory syncytial virus, tetanus, pertussis, and group B streptococcus (GBS); with the latter two receiving more recent attention from the Foundation. She pointed out 640
that although the currently available Tdap vaccination is safe and effective, it is cost-prohibitive in resourcelimited settings and therefore, pertussis toxoid is a promising costreductive target in the development of new pertussis vaccines. Sobanjo-ter Meulen went on to say that GBS is the major cause of neonatal infections and vaccines in the area are being researched but their safety, efficacy, and preventive effect in the neonates still needs to be shown, which would need future trials. She also remarked that there is substantial underreporting of GBS in middle-income and low-income countries because a substantial proportion of births are at home and the key challenges in establishing its burden are “active population-based surveillance in the first 24 h of life, availability of laboratory and healthcare facilities, and stillbirth autopsies”.
Dissemination of multidrugresistant bacteria into nonclinical settings in southeast Asia Brekhna Hassan (Cardiff University, UK) explored environmental niches for dissemination of bla NDM and blaCTX-M-15 in 729 samples from surfaces (ie, stairs, walls, switch boards, etc) and medical equipment in a hospital; as well as drinking water, bird droppings, and insects in Karachi, Pakistan. Results showed that 20% and 12% of the surface swabs from the hospital were positive for blaNDM and bla CTX-M-15, respectively. In the insects collected and tested, 3% were positive for blaNDM and 9% for blaCTX-M-15. In the samples from birds, 1% carried blaNDM and 24% carried blaCTX-M-15. Furthermore, 7% and 8% of the drinking water samples also tested positive for blaNDM and blaCTX-M-15, respectively. She also reported that amongst the blaNDM positive isolates, Enterobacteriaceae were the most commonly isolated organisms. The authors concluded that hospital equipment, surfaces, insects, birds,
and potable water might all be involved in widespread dissemination of antibiotic resistance.
Evidence on the efficacy of neuraminidase inhibitors in the treatment of influenza Xavier Duval (Bichat Claude Bernard University Hospital, Paris, France) reviewed randomised-controlled trials (RCTs) published on the efficacy of neuraminidase inhibitors (NIs). Based on the evidence from RCTs, Duval concluded that the efficacy of NIs is based on “modest reduction of duration of symptoms and also reduction of influenza complications when started within 48 h of symptom onset and when the circulating virus is sensitive to NI”. Duval also added that the benefit from treatment from NIs is “highly dependent on the proportion of the infected population which varies throughout the influenza epidemic”. He noted that there is very limited data on NIs other than oseltamivir. Jonathan Van-Tam (University of Nottingham, UK) presented evidence from observational studies on the efficacy of NIs. Their analysis involved data from 29 234 hospitalised patients who were diagnosed with pandemic influenza A H1N1pdm09 infection in 78 clinical centres globally. He reported that treatment with NIs (irrespective of timing) was associated with a reduction in mortality compared with no treatment (odds ratio 0·81, 95% CI 0·70–0·93; p=0·0024). Moreover, treatment within 2 days of symptom onset also had a mortality benefit compared with later treatment (0·48, 0·41–0·56; p<0·0001). These associations, however, were not significant for children. Van-Tam advocated early initiation of NIs in adults that are either hospitalised or are otherwise unwell with suspected or proven influenza.
Raffaella Bosurgi, John McConnell, Ammara Mushtaq www.thelancet.com/infection Vol 15 June 2015
Highlights from the 25th ECCMID The European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) took place in Copenhagen on April 25–28. Raffaella Bosurgi, John McConnell, and Ammara Mushtaq report. Herpes zoster vaccine shows efficacy in reducing risk Thomas Heinemann (GSK Vaccines, King of Prussia, PA, USA) gave a presentation on a new vaccine, HZ/ su, for protection against herpes zoster. The vaccine showed efficacy in preventing disease in volunteers older than 50 years (stratified by age: 50–59, 60–69, ≥70 years), and efficacy persisted in older participants. This subunit vaccine was assessed in a placebo-controlled trial with 14 759 volunteers older than 50 years. Vaccine or placebo was given in two doses 2 months apart, and the participants were followed up after 3·2 years. Overall vaccine efficacy was 97% and did not differ significantly between any age group. Local and systemic reactions were more common in the vaccine group, but the incidence of serious adverse events, deaths, or potential immunemediated diseases was similar.
Treatment for uncomplicated urinary tract infection in women Andreas Kronenberg (University Hospital of Bern, Bern, Switzerland) gave a presentation on the treatment of uncomplicated urinary tract infection (UTI) in adult women. The aim of the study was to show the inferiority of the non-steroidal anti-inflammatory drug (NSAID) diclofenac to norfloxacin. 253 women (aged between 18 and 70 years) with UTI in Switzerland were randomly assigned, in a double-blind trial, to receive either diclofenac 2×75 mg for 3 days or the control antibiotic norfloxacin 2×400 mg for 3 days. The primary outcome was the proportion of patients in whom symptoms resolved after 3 days. Resolution was achieved in 53% of the NSAID group www.thelancet.com/infection Vol 15 June 2015
and 81% of the antibiotic group. Fosfomycin was given as rescue treatment if symptoms persisted after 3 days. The resolution of symptoms was lower with diclofenac and lasted longer with norfloxacin. One patient in the diclofenac group developed pyelonephritis and needed to be admitted to hospital.
Treating intra-abdominal infections J Solomkin (University of Cincinnati College of Medicine, Cincinnati, OH, USA) presented details of a new tetracycline derivative (eravacycline, a novel fluorocycline) that showed promise in treating intra-abdominal infections (IAI). In this randomised, double-blind, non-inferiority phase 3 trial, patients (541) with documented complicated IAI were assigned to receive either eravacycline or ertapenem. A range of pathogens was isolated including Escherichia coli, Pseudomonas aeruginosa, Klebsiella spp, Staphylococcus aureus, Bacteroides spp, streptococci, and enterococci. Results suggest that eravacycline was non-inferior to ertapenem and that side-effects were minimal and comparable.
the outbreak, and said that “cultural practices are adaptive and can be negotiated”. Marta Lada (Connaught Hospital, Freetown, Sierra Leone) described how an inadequate case definition led to cases of Ebola being missed early in the disease outbreak. She noted that symptoms at presentation have changed during the course of the outbreak, perhaps because early on patients tended to present later in the disease course and hence in a more severe condition. The most common signs of disease are fever, vomiting, and diarrhoea; however, fever is absent in 15% of confirmed cases. Lada said that days 0–5 of Ebola virus disease are characterised by extreme weakness and what she described as “pseudomalarial syndrome”; during days 5–10, patients have a gastrointestinal syndrome, with loss of appetite and joint pain; and on days 10–14 patients show a neurological syndrome with encephalitis and paralysis, a sign that often leads to death. For those patients that survive, recovery tends to happen from day 14. Lada stated that bleeding is not very common, and seen more often in children than adults. She noted that a national
Ammara Mushtaq co-authored the paper presented on environmental dissemination of MDRB carrying blaNDM and blaCTX-M-15 in a hospital environment, drinking water, birds, and insects
Ebola insight In accepting an excellence award on behalf of Medécins Sans Frontières for their work in response to the west Africa Ebola virus disease outbreak, Hilde De Clerk highlighted the role of “extended families, boyfriends, girlfriends, lovers, and taxi drivers” in spreading the disease. The vital importance of understanding cultural background was also emphasised by Sylvie Briand (WHO, Geneva, Switzerland). She noted the important role of anthropologists and social scientists in managing
The 25th ECCMID was held in Copenhagen
639
Newsdesk
effort to prepare for Ebola in Sierra Leone began in late March, 2014, with the construction of isolation facilities at seven locations. However, after the disease was first detected in the country on May 26 and the subsequent death of Sheik Umar Khan—the countries only expert on haemorrhagic fevers—the national response faced a major setback when health-care workers refused to work on Ebola. Despite such obstacles, Lada reported that two new cases per day are being detected in Sierra Leone, down substantially from the 60 per week she was seeing in her hospital alone at the height of the epidemic in October–November last year. Briand noted the complexity of coordinating the Ebola response: WHO counted 150 non-governmental organisations working on Ebola in Liberia alone. 72 emergency treatment centres were opened in the three affected countries, plus 88 community care centres, 27 mobile and three national diagnostic laboratories, 280 burial teams operated, and 58 foreign medical teams have been involved. Nancy Sullivan (National Institutes of Health, Bethesda, MD, USA) reported that a randomised controlled trial (RCT) of a vaccine against the Ebola virus has begun in Liberia, which is intended to recruit 27 000 participants. She stated that a RCT with a placebo group is “the only way to test efficacy”.
Maternal vaccines to prevent neonatal infections Ajoke Sobanjo-ter Meulen (Bill & Melinda Gates Foundation, Seattle, WA, USA) advocated that “maternal immunisations directly avert infection-related deaths in neonates” and in 2014, the Foundation expanded its maternal immunisation programme to five key pathogens: influenza, respiratory syncytial virus, tetanus, pertussis, and group B streptococcus (GBS); with the latter two receiving more recent attention from the Foundation. She pointed out 640
that although the currently available Tdap vaccination is safe and effective, it is cost-prohibitive in resourcelimited settings and therefore, pertussis toxoid is a promising costreductive target in the development of new pertussis vaccines. Sobanjo-ter Meulen went on to say that GBS is the major cause of neonatal infections and vaccines in the area are being researched but their safety, efficacy, and preventive effect in the neonates still needs to be shown, which would need future trials. She also remarked that there is substantial underreporting of GBS in middle-income and low-income countries because a substantial proportion of births are at home and the key challenges in establishing its burden are “active population-based surveillance in the first 24 h of life, availability of laboratory and healthcare facilities, and stillbirth autopsies”.
Dissemination of multidrugresistant bacteria into nonclinical settings in southeast Asia Brekhna Hassan (Cardiff University, UK) explored environmental niches for dissemination of bla NDM and blaCTX-M-15 in 729 samples from surfaces (ie, stairs, walls, switch boards, etc) and medical equipment in a hospital; as well as drinking water, bird droppings, and insects in Karachi, Pakistan. Results showed that 20% and 12% of the surface swabs from the hospital were positive for blaNDM and bla CTX-M-15, respectively. In the insects collected and tested, 3% were positive for blaNDM and 9% for blaCTX-M-15. In the samples from birds, 1% carried blaNDM and 24% carried blaCTX-M-15. Furthermore, 7% and 8% of the drinking water samples also tested positive for blaNDM and blaCTX-M-15, respectively. She also reported that amongst the blaNDM positive isolates, Enterobacteriaceae were the most commonly isolated organisms. The authors concluded that hospital equipment, surfaces, insects, birds,
and potable water might all be involved in widespread dissemination of antibiotic resistance.
Evidence on the efficacy of neuraminidase inhibitors in the treatment of influenza Xavier Duval (Bichat Claude Bernard University Hospital, Paris, France) reviewed randomised-controlled trials (RCTs) published on the efficacy of neuraminidase inhibitors (NIs). Based on the evidence from RCTs, Duval concluded that the efficacy of NIs is based on “modest reduction of duration of symptoms and also reduction of influenza complications when started within 48 h of symptom onset and when the circulating virus is sensitive to NI”. Duval also added that the benefit from treatment from NIs is “highly dependent on the proportion of the infected population which varies throughout the influenza epidemic”. He noted that there is very limited data on NIs other than oseltamivir. Jonathan Van-Tam (University of Nottingham, UK) presented evidence from observational studies on the efficacy of NIs. Their analysis involved data from 29 234 hospitalised patients who were diagnosed with pandemic influenza A H1N1pdm09 infection in 78 clinical centres globally. He reported that treatment with NIs (irrespective of timing) was associated with a reduction in mortality compared with no treatment (odds ratio 0·81, 95% CI 0·70–0·93; p=0·0024). Moreover, treatment within 2 days of symptom onset also had a mortality benefit compared with later treatment (0·48, 0·41–0·56; p<0·0001). These associations, however, were not significant for children. Van-Tam advocated early initiation of NIs in adults that are either hospitalised or are otherwise unwell with suspected or proven influenza.
Raffaella Bosurgi, John McConnell, Ammara Mushtaq www.thelancet.com/infection Vol 15 June 2015