Risk factors for community-acquired urinary tract infections caused by ESBL-producing enterobacteriaceae--a case-control study in a low prevalence country

Risk Factors of Extended-Spectrum Beta-Lactamases-Producing Escherichia coli Community Acquired Urinary Tract Infections: A Systematic Review

Purpose

The prevalence of extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-EC) has been increasing worldwide since the early 2000s. E. coli is found in 70–90% of community-acquired urinary tract infections (CA-UTIs). We performed a systematic literature review to determine the risk factors for CA-UTI caused by ESBL-EC.

Methods

We searched the MEDLINE, Cochrane Library, Embase and Web of Science databases without language or date restriction up to March 2019. Two independent reviewers selected studies with quantified risk factors for CA-UTI due to ESBL-EC, and assessed their quality using the Newcastle-Ottawa Scale.

Results

Among the 5,597 studies identified, 16 observational studies (n=12,138 patients) met the eligibility criteria. The included studies were performed in various countries, and 14/16 were published after 2012. The most relevant risk factors for CA-UTI due to ESBL-EC identified were prior use of antibiotics (odds ratio (OR) from 2.2 to 21.4), previous hospitalization (OR: 1.7 to 3.9), and UTI history (OR: 1.3 to 3.8). Two risk factors were related to environmental contamination: travelling abroad, and swimming in freshwater.

Conclusion

Our findings could allow adapting empiric antibiotic treatments according to the patient profile. Further studies are needed to quantify the relationships between CA-UTI due to ESBL-EC and the environment.

Resistotyping and extended-spectrum beta-lactamase genes among Escherichia coli from wastewater treatment plants and recipient surface water for reuse in South Africa

The spread of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli has increased in different environments. This study aimed to evaluate the patterns of antibiotic resistance and ESBL genes among E. coli isolates collected from wastewater and recipient surface water in South Africa. Fifteen samples containing nine wastewater and six river water samples were collected from a local wastewater treatment plant. The E. coli isolates were detected using standard microbiology methods. Antibiotic susceptibility testing was performed using disc diffusion agar. The occurrence of bla_CTX-M, bla_SHV and bla_TEM ESBL genes was investigated by PCR. Exactly 140 isolates were selected from the primary enumeration plates with a log₁₀ CFU/mL count that ranged from 4.1 to 4.2 (influent), 4.2 to 4.5 (biofilter) and 2.5 to 3.3 (effluent). The wastewater effluent showed an impact on the receiving water environment, as the treatment efficiency was 92% and the downstream log₁₀ CFU/mL count (range, 3.6–3.8 log₁₀ CFU/mL) was higher than the upstream count (range, 3.3–3.6 log₁₀ CFU/mL). Antibiotic testing results showed that 40% to 100% of E. coli isolates were resistant to ampicillin, penicillin, tetracycline and cefotaxime but susceptible to imipenem, meropenem and ciprofloxacin. A total of 40 studied isolates (28.6%) had both the bla_TEM and bla_CTX-M genes, while no bla_SHV was detected. The wastewater treatment plants contributed multidrug-resistant ESBL-producing E. coli isolates that can be potential environmental health risks. Regular monitoring policies are recommended to prevent the spread of antibiotic resistance in the region.

Antibiotic Resistance in Recreational Waters: State of the Science

Ambient recreational waters can act as both recipients and natural reservoirs for antimicrobial resistant (AMR) bacteria and antimicrobial resistant genes (ARGs), where they may persist and replicate. Contact with AMR bacteria and ARGs potentially puts recreators at risk, which can thus decrease their ability to fight infections. A variety of point and nonpoint sources, including contaminated wastewater effluents, runoff from animal feeding operations, and sewer overflow events, can contribute to environmental loading of AMR bacteria and ARGs. The overall goal of this article is to provide the state of the science related to recreational exposure and AMR, which has been an area of increasing interest. Specific objectives of the review include (1) a description of potential sources of antibiotics, AMR bacteria, and ARGs in recreational waters, as documented in the available literature; (2) a discussion of what is known about human recreational exposures to AMR bacteria and ARGs, using findings from health studies and exposure assessments; and (3) identification of knowledge gaps and future research needs. To better understand the dynamics related to AMR and associated recreational water risks, future research should focus on source contribution, fate and transport-across treatment and in the environment; human health risk assessment; and standardized methods.

The Continuing Plague of Extended-Spectrum β-Lactamase Producing Enterbacterales Infections: An Update

Antimicrobial resistance is a common iatrogenic complication of modern life and medical care. One of the most demonstrative examples is the exponential increase in the incidence of extended-spectrum β-lactamases (ESBLs) production among Enterobacteriaceae, that is, the most common human pathogens outside of the hospital setting. Infections resulting from ESBL-producing bacteria are associated with devastating outcomes, now affecting even previously healthy individuals. This poses an enormous burden and threat to public health. This article aims to narrate the evolving epidemiology of ESBL infections and highlights current challenges in terms of management and prevention of these common infections.

Impact of the beta-lacta test on the management of urinary tract infections at the emergency department

INTRODUCTION

Rapid detection of extended-spectrum β-lactamases is essential. In this study, we evaluated the potential impact of β-lacta test on both the times to appropriate antibiotic therapy and to the implementation of patient isolation measures.

PATIENTS AND METHODS

We included prospectively all the patients admitted to the emergency department for clinical suspicion of urinary tract infection. Compared with physician's decision, we analysed the potential impact of β-lacta test on the initial antibiotic therapy and on the implementation of hygiene measures. This study has been registered under number NCT02897609.

RESULTS

We included 203 patients, 43% with acute pyelonephritis and 21% with acute prostatitis. The β-lacta test had a 95.2% sensitivity and a 99.5% specificity to detect extended-spectrum β-lactamases. Taking the β-lacta test results into account would have decreased significantly both the times to appropriate therapy and to isolation measures from 54 to 2.7 h and from 55.2 to 2.6 h, respectively.

CONCLUSION

The β-lacta test could reduce significantly the times to appropriate therapy and implementation of isolations measures.

Extended spectrum beta lactamase producing bacteria among outpatients with ear infection at FelegeHiwot Referral Hospital, North West Ethiopia

BACKGROUND

Antibiotic resistant bacteria particularly extended-spectrum beta lactamase (ESBL) producing are of major concern for management of outpatients. They can spread rapidly and are associated with poor patient outcome. However, there is scarcity of information on ear infection with ESBL producing bacteria in Ethiopia. Therefore, this study investigates the prevalence of ear infection with ESBL producing bacteria among outpatients attending Felegehiwot Referral Hospital, Northwest Ethiopia.

METHODS

A hospital based cross-sectional study was conducted from May, 2018 to January, 2019. Demographic and clinical data were collected with face to face interview and were complemented with patient card review. Ear discharge specimens were collected from study participants using swab technique. All ear swab specimens were cultured using standard microbiological techniques. The ESBL producing bacteria were detected by double disc synergy test and interpreted based on Clinical and laboratory Standards Institute Guidelines. Chi-square and fisher's exact tests were calculated to check association between variables.

RESULTS

A total of 236 patients (male = 138 and female = 98) with ear infection took part in the study. The median age of the participants was 20years. Overall, 10 (4.23%, 95%CI; 2.3-7.6%) of patients had ear infection with ESBL producing bacteria. Other chronic illnesses (p = 0.003), history of hospital visit and treatment (p = 0.006) and history of antibiotic use without physician's prescription (p<0.001) had significant association with prevalence of ESBL producing bacteria in ear infection. The proportion of ear infection with ESBL producing P.mirabilis, P.aeruginosa and K.pneumoniae were 4 (1.7%), 3 (1.3%) and 2 (0.8%), respectively. All ESBL producing isolates were MDR (100%). Overall, 58 (43%) species were MDR. P.aeruginosa was the leading MDR isolate 29 (53.7%).For all bacterial isolates of ear infection, ampicillin(93.3%) and amoxicillin-clavulanic acid (58.5%) revealed high level of resistance whereas low resistance rates were observed for ciprofloxacin (5.2%), third generation cephalosporin (11.9-20%) and aztreonam (16.3%).

CONCLUSIONS

Ear infection due to ESBL producing bacteria coupled with high levels of MDR is becoming a growing concern for outpatients in the study area. Regular detection of these bacteria and wise use of antibiotics are needed to stop the spread of this form of resistance.

Characterization of water treatment-resistant and multidrug-resistant urinary pathogenic Escherichia coli in treated wastewater

A growing body of evidence has demonstrated that extraintestinal pathogenic E. coli (ExPEC), such as the urinary pathogenic E. coli (UPEC), are common constituents of treated wastewater, and therefore represent a potential public health risk. However, no single virulence gene, or set of virulence genes, can be used to conclusively identify this genetically diverse pathotype. As such we sought to identify and characterize the public health relevance of potential UPEC found in treated sewage/wastewater using a comparative genomics approach. Presumptive wastewater UPEC (W-UPEC) were initially identified by virulence gene screening against 5 virulence genes, and for which isolates containing ≥3 virulence genes were whole genome sequenced (n = 24). Single nucleotide polymorphic (SNP) spanning tree analysis demonstrated that many of these wastewater UPEC (WUPEC) were virtually identical at the core genome (0.4 Mbp) when compared to clinical UPEC (C-UPEC) sequences obtained from NCBI, varying by as little as 1 SNP. Remarkably, at the whole genome level, W-UPEC isolates displayed >96% whole genome similarity to C-UPEC counterparts in NCBI, with one strain demonstrating 99.5% genome similarity to a particular C-UPEC strain. The W-UPEC populations were represented by sequence types (ST) known to be clinically important, including ST131, ST95, ST127 and ST640. Many of the W-UPEC carried the exact same complement of virulence genes as their most closely related C-UPEC strains. For example, O25b-ST131 W-UPEC strains possessed the same 80 virulence genes as their most closely related C-UPEC counterparts. Concerningly, W-UPEC strains also carried a plethora of antibiotic resistance genes, and O25b-ST131strains were designated as extended spectrum beta-lactamase (ESBL) producing E. coli by both genome profiling and phenotypic resistance testing. W-UPEC ST131 strains were found in the effluents of a single treatment plant at different times, as well as different wastewater treatment plants, suggesting a differentially ability to survive wastewater treatment. Indeed, in sewage samples treated with chlorine doses sufficient for inducing a ∼99.99% reduction in total E. coli levels, UPEC represented a significant proportion of the chlorine-resistant population. By contrast, no Shiga toxin-producing E. coli were observed in these chlorinated sewage libraries. Our results suggest that clinically-relevant UPEC exist in treated wastewater effluents and that they appear to be specifically adapted to survive wastewater treatment processes.

Risk factors of community-onset extended-spectrum β-lactamase Escherichia coli and Klebsiella pneumoniae bacteraemia: an 11-year population-based case-control-control study in Denmark

OBJECTIVES

To investigate and explore temporal changes in risk factors of community-onset extended-spectrum β-lactamase (ESBL) Escherichia coli and Klebsiella pneumoniae bacteraemia in a region with low antibiotic resistance.

METHODS

Population-based case-control study including 223 cases hospitalized with a first-time community-onset ESBL-producing E. coli and K. pneumoniae bacteraemia, 2214 non-ESBL E. coli and K. pneumoniae bacteraemia controls, and 2228 population controls in the North Denmark Region between 2007 and 2017. We used a conditional logistic regression to compute crude and adjusted (age, gender and co-morbidity) odds ratios (aORs) and 95% CIs of risk factors and compared selected risk factors between 2007-2011 and 2016-2017.

RESULTS

Several conventional risk factors of ESBL E. coli or K. pneumoniae were identified compared with the population controls. Compared with the non-ESBL controls, use of fluoroquinolones (aOR 3.56, 95% CI 2.52-5.05), three or more admissions within the recent year (aOR 2.18, 95% CI 1.45-3.28), three or more antibiotic prescriptions within 15-365 days before the admission (aOR 2.18, 95% CI 1.53-3.10), male sex (aOR 2.01, 95% CI 1.50-2.69), admission within 1-91 days (aOR 1.84, 95% CI 1.37-2.48) and antibiotic within 15-91 days (aOR 1.82, 95% CI 1.37-2.42) inferred the highest risk. Assessment of temporal dynamics between 2007-2011 and 2016-2017 revealed a slight reduction in risk factors associated with direct health-care contact (e.g. hospital admission).

CONCLUSIONS

Recent and frequent hospitalization, and exposure to antibiotics, especially use of fluoroquinolones, appeared to be associated specifically with ESBL production, and focus and interventions should be directed towards these areas. Our results indicated a dissemination of ESBLs into the community.

Whole Genome Sequencing and Characterization of Multidrug-Resistant (MDR) Bacterial Strains Isolated From a Norwegian University Campus Pond

The presence of extended-spectrum β-lactamase (ESBL)-producing bacteria in environmental sources has been reported worldwide and constitutes a serious risk of community-acquired infections with limited treatment options. The current study aimed to explore the presence of these worrisome bacteria in a pond located at the Norwegian University of Life Sciences in Ås, Norway. A total of 98 bacterial isolates survived growth on selective chromogenic media and were identified by 16S rRNA Sanger sequencing. All strains were evaluated for the presence of the most commonly found β-lactamases and ESBLs in clinical settings (bla_CTX–M groups 1, 2, and 9, bla_CMY, bla_SHV, and bla_TEM) and carbapenemases (bla_IMP, bla_KPC, bla_NDM, bla_OXA, bla_SFC1, bla_VIM) through multiplex PCR. A total of eight strains were determined to contain one or more genes of interest. Phenotypic resistance to 18 antimicrobial agents was assessed and isolates were subjected to whole genome sequencing through a combination of Oxford Nanopore’s MinION and Illumina’s MiSeq. Results revealed the presence of β-lactamase and ESBL-producing Escherichia coli, Klebsiella pneumoniae, Stenotrophomonas maltophilia, and a Paraburkholderia spp. Identified β-lactamases and ESBLs include bla_CTX–M, bla_TEM, bla_CMY, bla_SHV and a possible bla_KPC-like gene, with both documented and novel sequences established. In addition, two inducible β-lactamases were found, a class A β-lactamase (L1) and a cephalosporinase (L2). All strains were determined to be multidrug resistant and numerous resistance genes to non-β-lactams were observed. In conclusion, this study demonstrates that environmental sources are a potential reservoir of clinically relevant ESBL-producing bacteria that may pose a health risk to humans upon exposure.

Evaluating health risks associated with exposure to ambient surface waters during recreational activities: A systematic review and meta-analysis

Recreational water quality guidelines protect the public from health risks associated with water recreation by helping to prevent unacceptable concentrations of pathogenic organisms in ambient water. However, illness risk is associated with both the concentration of pathogens in the water and the degree of contact with those pathogens. Different recreational activities can result in different levels of contact with ambient water containing water-borne pathogens. We conducted a systematic literature review and meta-analysis to evaluate risks of illness associated with different recreational activities and different levels of contact to ambient surface waters. We screened 8,618 potentially relevant studies for quantitative measures of risk using inclusion/exclusion criteria established in advance. We categorized recreational activities as swimming, sports-related contact, minimal contact, and sand contact. We combined relative risks using a random effects meta-analysis for adverse health outcome categories representing gastrointestinal illness, respiratory illness, skin, eye, ear, nose, throat, and cold/flu illness. We identified 92 studies meeting our inclusion criteria. Pooled risk estimates indicate significant elevation of gastrointestinal illness with the recreational activity categories swimming (2.19, 95% CI: 1.82, 2.63) and sports-related contact (2.69, 95% CI: 1.04, 6.92), and nonsignificant elevation of gastrointestinal illness with minimal contact (1.27, 95% CI: 0.74, 2.16). We also found a significant elevation of respiratory illness with swimming (1.78, 95% CI: 1.38, 2.29) and sports-related contact (1.49, 95% CI: 1.00, 2.24), and no elevation of respiratory illness with minimal contact (0.90, 95% CI: 0.71, 1.14). This study suggests that exposures associated with different types of recreational activities are important characteristics of the exposure pathway when assessing illness risk associated with recreation in ambient surface waters.

Risk analysis of antimicrobial resistance in outpatient urinary tract infections of young healthy adults

Objectives

Most studies addressing community-acquired urinary tract infections (UTIs) pertain to mixed cohorts, in which young healthy adults are under-represented. We aimed to dissect the intricate interrelation between exposures and subsequent antimicrobial resistance (AMR) patterns in a unique setting of young healthy adults, allowing further guidance in this group.

Methods

We carried out a retrospective cross-sectional study of all Enterobacteriaceae-associated outpatient UTIs during 2014-16 in soldiers, representing the young fit population in Israel. Electronic medical records were reviewed for demographic and clinical data, antimicrobial exposures and prescriptions. Risk factors for AMR were analysed by multivariate logistic regression.

Results

Of 1207 cases, 1144 (94.8%) were females, with a median age of 20.2 years. Escherichia coli was the predominant species (83.2%). Only 686 (56.8%) isolates were fully susceptible. AMR rates were as follows: trimethoprim/sulfamethoxazole, 19.6%; oral cephalosporins, 9.7%-16.7%; amoxicillin/clavulanate, 12.1%; ciprofloxacin, 11.1%; and nitrofurantoin, 12.6%. Predictors of AMR were recurrent UTIs, past-year hospitalization, male gender and non E. coli strains. Antimicrobials prescribed >6 months preceding the culprit infection were not related to AMR. Fluoroquinolone and cephalosporin exposures were highly predictive of further AMR, yet nitrofurantoin and, to a lesser extent, amoxicillin/clavulanate had fewer associations with AMR induction and resistance to these antimicrobials was less associated with any exposure.

Conclusions

This nationwide study of community-related UTIs shows significant AMR rates for commonly used oral antimicrobials even in young fit adults. Nitrofurantoin proved once more to be an adequate empirical choice regardless of previous exposures, having a less detrimental effect on future AMR. Conversely, both resistance to fluoroquinolones following previous exposures and the associated heavy ecological burden should deter their common use as first-line agents for UTIs.

Guidelines of the Association of Anesthesiologists-Intensivists, the Interregional Non-Governmental Organization Alliance of Clinical Chemotherapists and Microbiologists, the Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy (IACMAC), and NGO Russian Sepsis Forum Diagnostics and antimicrobial therapy of the infections caused by multiresistant microorganisms

Introduction. Strains of microorganisms resistant to antimicrobial agents are commonly found in medical units throughout most regions of the world, including Russia. This leads to lower antimicrobial therapy efficacy when treating nosocomial infections. In this regard, the timely implementation of adequate antibiotic therapy is of great importance.

The objective of the guidelines: To provide summarized information on contemporary approaches to microbiological diagnostics and the assessment of results, as well as the principles of rational use of antimicrobial and antifungal agents, including treatment of infections caused by multiple drug-resistant strains of microorganisms.

Subjects and methods. These guidelines are based on published data obtained in the course of randomized trials, as well as information presented in the provisions of international guidelines supported by high-level evidence. The guidelines were prepared by a working group of Russian experts with extensive experience in research and practical work in this area. On October 11, 2019, the final version of the guidelines was reviewed and approved at a joint meeting of the working group and representatives of the public organizations which initiated the development of these guidelines (Association of Anesthesiologists-Intensivists, the Interregional Non-Governmental Organization Alliance of Clinical Chemotherapists and Microbiologists, the Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy (IACMAC), NGO Russian Sepsis Forum).

Conclusion. The guidelines reflect an interdisciplinary consensus of approaches to the diagnostics and antibiotic therapy of infections caused by multiresistant microorganisms. The provisions set forth should be used to decide on the strategy of empirical and etiotropic therapy of the most severe infections.

Risk factors for third-generation cephalosporin resistant Enterobacteriaceae in gestational urine cultures: A retrospective cohort study based on centralized electronic health records

Third-generation-cephalosporin resistant Enterobacteriaceae (3GCR-EB) carriage in pregnant women poses challenges for infection control and therapeutic decisions. The factors associated with multidrug resistant Enterobacteriaceae carriage in the gestational period are not well documented. The aim of our study was to identify risk factors associated with 3GCR-EB isolation in gestational urine cultures. The study was designed as retrospective cohort based on centralized electronic health records database. Women delivered in Clalit Health Services hospitals in Israel in 2009–2013 and provided urine culture(s) during pregnancy were included. Multivariable analysis using the Generalized Estimating Equations model was used to assess risk factors for 3GCR-EB isolation in gestational urine cultures. The study included 15,282 pregnant women with urine cultures yielding Enterobacteriaceae (EB). The proportion of 3GCR-EB in EB isolates was 3.9% (n = 603). The following risk factors were associated with 3GCR-EB isolation: multiple hospital admissions during the year before delivery (OR,1.47;95% CI,1.21–1.79), assisted fertilization procedure (OR,1.53; 95% CI,1.12–2.10), Arab ethnicity (OR,1.22; 95% CI,1.03–1.45), multiple antibiotic courses (OR,1.76; 95% CI,1.29–2.40), specifically, cephalosporins (OR,1.56; 95% CI,1.26–1.95), fluoroquinolones (OR,1.34; 95% CI,1.04–1.74), or nitrofurantoin (OR,1.29; 95% CI,1.02–1.64). The risk factors identified by this study for 3GCR-EB in gestation, can be easily generalized for pregnant women in the Israeli population. Moreover, these risk factors, other than ethnicity, are applicable to pregnant women worldwide. The information of previous antibiotic treatments, hospitalization in the last year and assisted fertilization procedure can be easily accessed and used for appropriate infection control practices and antimicrobial therapy.

A conceptual framework for the environmental surveillance of antibiotics and antibiotic resistance

Environmental surveillance of antibiotics and antibiotic resistance could contribute toward the protection of human, animal and ecosystem health. However, justification for the choice of markers and sampling sites that informs about different risk scenarios is often lacking. Here, we define five fundamentally different objectives for surveillance of antibiotics and antibiotic resistance in the environment. The first objective is (1) to address the risk of transmission of already antibiotic-resistant bacteria to humans via environmental routes. The second is (2) to address the risk for accelerating the evolution of antibiotic resistance in pathogens through pollution with selective agents and bacteria of human or animal origin. The third objective is (3) to address the risks antibiotics pose for aquatic and terrestrial ecosystem health, including the effects on ecosystem functions and services. The two final objectives overlap with those of traditional clinical surveillance, namely, to identify (4) the population-level resistance prevalence and (5) population-level antibiotic use. The latter two environmental surveillance objectives have particular potential in countries where traditional clinical surveillance data and antibiotic consumption data are scarce or absent. For each objective, the levels of evidence provided by different phenotypic and genotypic microbial surveillance markers, as well as antibiotic residues, are discussed and evaluated on a conceptual level. Furthermore, sites where monitoring would be particularly informative are identified. The proposed framework could be one of the starting points for guiding environmental monitoring and surveillance of antibiotics and antibiotic resistance on various spatiotemporal scales, as well as for harmonizing such activities with existing human and animal surveillance systems.

Antibiotic resistance of Escherichia coli isolated from uncomplicated UTI in general practice patients over a 10-year period

Recommendations of first choice antibiotic therapy need to be based on actual antibiotic susceptibility data. We determined the antibiotic susceptibility of E. coli in uncomplicated UTI among women and compared the results with 2004 and 2009. In 30 sentinel general practitioner practices of Nivel Primary Care database, urine samples were collected from women with symptoms of uncomplicated UTI. Patient characteristics, E. coli susceptibility, and ESBL production were analyzed. Six hundred eighty-nine urine samples were collected; E. coli was the most isolated uropathogen (83%). Antibiotic susceptibility was stable over time except for ciprofloxacin (96% in 2004, 97% in 2009, and 94% in 2014; P < 0.05). The susceptibility to co-amoxiclav was 88%, 87%, and 92% in 2004, 2009, and 2014, respectively. The prevalence of ESBL-producing E. coli increased from 0.1% in 2004 to 2.2% in 2014 (P < 0.05). Regional differences in antibiotic susceptibility for co-trimoxazole were found being the highest in the west (88%) and the lowest in the north (72%, P = 0.021). Ciprofloxacin susceptibility was related to antibiotic use in the past 3 months (97% no use versus 90% use, P = 0.002) and age > 70 years (P = 0.005). In 2014, prescription of fosfomycin increased compared to 2009 (14.3% versus 5.6%) at the expense of co-amoxiclav, co-trimoxazole, and fluoroquinolones (P < 0.05). The susceptibility percentages to most antimicrobial agents tested were stable over 10 years’ period although the prevalence of E. coli and ESBLs significantly increased. Performance of a survey with regular intervals is warranted.

Risk factors for community-onset urinary tract infections caused by extended-spectrum β-lactamase-producing Escherichia coli

Background/aim

Community-onset urinary tract infections(UTIs) caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli have increased in many parts of the world. This study aimed to determine the prevalence and risk factors for community-onset UTI caused by ESBL-producing E. coli.

Materials and methods

This prospective cohort study was conducted between January 2012 and March 2014 in cases of community-onset UTI caused by E. coli. Patients with UTI due to ESBL-producing E. coli and patients with UTI due to non-ESBL-producing E. coliwere compared to identify risk factors for ESBL-producing E. coli in the community.

Results

A total of 305 patients (116 males [46.4%]; mean age: 57.76 ± 18.06 years) were included in the study. Among these patients, 154 (50.5%) were infected with ESBL-producing E. coli. In multivariate analysis, the healthcare-associated UTI (odds ratio [OR]: 1.80; 95% confidence interval [CI]: 1.02–3.18; P = 0.041), upper urinary tract infection (OR: 3.05; 95% CI: 1.76–5.29; P < 0.0001), use of antibiotics in the preceding 6 months (OR: 2.28; 95% CI: 1.21–4.30; P = 0.011), and having two or more risk factors (OR: 4.03; 95% CI: 1.73–9.35; P = 0.001) were the significant factors associated with increased risk of community-onset UTIs due to ESBL-producing E. coli.

Conclusion

The increasing prevalence ofESBL-producing E. coli makes it difficult to decide the empirical therapy in UTIs, especially in patients with two or more of the risk factors. A better understanding of the epidemiology and risk factors associated with community-onset UTIs due to ESBL-producing E. coli may have significant implications in decision-making for empirical antimicrobial treatment.

Treatment of infections caused by multidrug-resistant Gram-negative bacteria: report of the British Society for Antimicrobial Chemotherapy/Healthcare Infection Society/British Infection Association Joint Working Party

The Working Party makes more than 100 tabulated recommendations in antimicrobial prescribing for the treatment of infections caused by multidrug-resistant (MDR) Gram-negative bacteria (GNB) and suggest further research, and algorithms for hospital and community antimicrobial usage in urinary infection. The international definition of MDR is complex, unsatisfactory and hinders the setting and monitoring of improvement programmes. We give a new definition of multiresistance. The background information on the mechanisms, global spread and UK prevalence of antibiotic prescribing and resistance has been systematically reviewed. The treatment options available in hospitals using intravenous antibiotics and in primary care using oral agents have been reviewed, ending with a consideration of antibiotic stewardship and recommendations. The guidance has been derived from current peer-reviewed publications and expert opinion with open consultation. Methods for systematic review were NICE compliant and in accordance with the SIGN 50 Handbook; critical appraisal was applied using AGREE II. Published guidelines were used as part of the evidence base and to support expert consensus. The guidance includes recommendations for stakeholders (including prescribers) and antibiotic-specific recommendations. The clinical efficacy of different agents is critically reviewed. We found there are very few good-quality comparative randomized clinical trials to support treatment regimens, particularly for licensed older agents. Susceptibility testing of MDR GNB causing infection to guide treatment needs critical enhancements. Meropenem- or imipenem-resistant Enterobacteriaceae should have their carbapenem MICs tested urgently, and any carbapenemase class should be identified: mandatory reporting of these isolates from all anatomical sites and specimens would improve risk assessments. Broth microdilution methods should be adopted for colistin susceptibility testing. Antimicrobial stewardship programmes should be instituted in all care settings, based on resistance rates and audit of compliance with guidelines, but should be augmented by improved surveillance of outcome in Gram-negative bacteraemia, and feedback to prescribers. Local and national surveillance of antibiotic use, resistance and outcomes should be supported and antibiotic prescribing guidelines should be informed by these data. The diagnosis and treatment of both presumptive and confirmed cases of infection by GNB should be improved. This guidance, with infection control to arrest increases in MDR, should be used to improve the outcome of infections with such strains. Anticipated users include medical, scientific, nursing, antimicrobial pharmacy and paramedical staff where they can be adapted for local use.

A coliform-targeted metagenomic method facilitating human exposure estimates to Escherichia coli-borne antibiotic resistance genes

Antimicrobial resistance and the spread of antibiotic resistance genes (ARGs) pose a threat to human health. Community-acquired infections resistant to treatment with first-line antibiotics are increasing, and there are few studies investigating environmental exposures and transmission. Our objective is to develop a novel targeted metagenomic method to quantify the abundance and diversity of ARGs in a faecal indicator bacterium, and to estimate human exposure to resistant bacteria in a natural environment. Sequence data from Escherichia coli metagenomes from 13 bathing waters in England were analysed using the ARGs Online Analysis Pipeline to estimate the abundance and diversity of resistance determinants borne by this indicator bacterium. These data were averaged over the 13 sites and used along with data on the levels of E. coli in English bathing waters in 2016 and estimates of the volume of water that water users typically ingest in an average session of their chosen activityto quantify the numbers of ARGs that water users ingest. Escherichia coli in coastal bathing waters were found to harbour on average 1.24 ARGs per cell. Approximately 2.5 million water sports sessions occurred in England in 2016 that resulted in water users ingesting at least 100 E. coli-borne ARGs.

Phenotypic and Genotypic Characterization of Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Asymptomatic Bacteriuria in Pregnancy

Asymptomatic bacteriuria (ASB) has been consistently observed in pregnancy. However, there is a paucity of data on the prevalence and characteristics of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in ASB in pregnant women. Therefore, we sought to investigate ESBL-producing and multidrug-resistant Enterobacteriaceae in antenatal women with ASB. Urine samples were collected from 310 asymptomatic pregnant women attending primary antenatal clinics and screened for significant bacteriuria. Isolates of Enterobacteriaceae were phenotypically tested for their ESBL production. ESBL genes (CTX-M, TEM, and SHV genes) were then amplified by polymerase chain reaction (PCR). Multiplex PCRs were used to perform phylogenetic typing of ESBL-producing Escherichia coli isolates and to examine the commonality of sequence type 131 (ST131)-O25b and ST131-O16. A total of 103 (33.2%) pregnant women were positive for significant bacteriuria (80 Enterobacteriaceae). Of these isolates, 32.5% (n = 26) were ESBL producers and had a higher rate of multidrug resistance than non-ESBL producers. Genotypic characterization of ESBL-producing isolates showed that 84.6% had the bla_CTX-M gene (bla_CTX-M-15 = 77.3%; bla_CTX-M-9 = 18.2%). None of the isolates were of the TEM or SHV type. Half of the ESBL-producing E. coli isolates were of the phylogroup B2, and 4 (20%) isolates were of the ST131-O16 clonal subgroup. This study is the first in Egypt to provide evidence for the high prevalence of ESBL-producing Enterobacteriaceae in pregnant women with ASB. It also represents an important step toward genotypic characterization of this resistant form of bacteria, which may be useful for future antimicrobial studies.

Investigation of risk factors for community-acquired urinary tract infections caused by extended-spectrum beta-lactamase Escherichia coli and Klebsiella species

Purpose

The aim of this study was to determine the prevalence and risk factors for community-acquired urinary tract infections (CA-UTIs) caused by extended-spectrum β-lactamase (ESBL) producing Escherichia coli and Klebsiella species.

Materials and Methods

The patients diagnosed with CA-UTIs caused by E. coli or Klebsiella spp. were included in the study. All of the patients were compared to demographic characteristics, underlying diseases, urinary tract pathology, history of hospitalization, use of antibiotics according to ESBL positivity.

Results

A total of 322 urine isolates were studied. Sixty-six patients (37.1%) of a total of 178 patients were ESBL positive E. coli and Klebsiella spp. Being over the age of sixty (odds ratio [OR], 1.90; p=0.03), history of renal stone (OR, 3.00; p=0.03), urinary tract anatomical of physiological disorder (OR, 2.17; p=0.01), urologic intervention (OR, 3.43; p<0.001), history of urinary tract surgery (OR, 3.10; p=0.01), history of urinary catheterization (OR, 3.43; p<0.001), and hospitalization for last 1 year (OR, 3.70; p=0.01) and antibiotic usage in the last 3 months (OR, 1.90; p=0.04) were found as significant risk factors for the producing of ESBL. However, gender and underlying disease were not related for ESBL production.

Conclusions

In present study, high rate of ESBL positivity was detected in CA-UTIs. The increasing of infections caused by ESBL positive E. coli and Klebsiella spp. are bringing together a lot of the problem, such as antibiotic resistance and reducing treatment options for outpatients. Identification of underlying risk factors would be important for the development of preventive strategies.

Bringing home unwelcome souvenirs: Travel and drug-resistant bacteria

Antimicrobial resistance poses a significant threat to public health globally and in Canada. Wide regional variability in antimicrobial resistance and ongoing increases in global travel present an important risk for the acquisition and transmission of drug-resistant organisms. Travel from high-income to low- and middle-income countries, particularly the Indian subcontinent, present the greatest risks for acquiring a drug-resistant Enterobacteriaceae. Risk factors for returning from travel with drug-resistant organisms include seeking medical care while abroad, travellers' diarrhea and antibiotic use. Health care professionals can play an important role in preventing harm for travellers by counselling patients on the risks of acquiring drug-resistant organisms, appropriate antibiotic prescribing for travellers' diarrhea and tailored empiric therapy for patients presenting with infection after travel.

Duration of travel-associated faecal colonisation with ESBL-producing Enterobacteriaceae - A one year follow-up study

Background

In a previous study, we found that 30% of individuals travelling outside Scandinavia acquired extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) in their faecal flora. The aim of this study was to determine the duration of travel-associated faecal colonisation with ESBL-PE, to assess risk factors for prolonged colonisation and to detect changes in antibiotic susceptibility during prolonged colonisation.

Methods

Individuals with travel-associated colonisation with ESBL-PE submitted faecal samples every 3rd month over a one-year period. A questionnaire was completed at the beginning and end of follow-up. All specimens were analysed for ESBL-PE, and all isolates underwent confirmatory phenotype testing as well as molecular characterisation of ESBL-genes. Minimum inhibitory concentrations (MIC) for beta-lactam and non-beta-lactam agents were determined using the Etest.

Results

Among 64 participants with travel-associated colonisation with ESBL-PE, sustained carriage was seen in 20/63 (32%), 16/63 (25%), 9/63 (14%) and 7/64 (11%) at 3, 6, 9 and 12 months after return from their journey, respectively. The majority, 44 (69%) of travellers were short-term carriers with ESBL-PE only detected in the initial post-travel stool sample. Evaluation of risk factors demonstrated a decreased risk of becoming a long-term carrier among travellers with diarrhoea while abroad and a history of a new journey during the follow-up period. High susceptible rates were demonstrated to carbapenems (97–100%), temocillin (95%), mecillinam (97%), amikacin (98%), fosfomycin (98%), nitrofurantoin (99%) and tigecycline (97%).

Conclusion

Travel-associated faecal colonisation with ESBL-PE appears to be transient and generally brief. Diarrhoea while abroad or a new trip abroad during the follow-up period decreased the risk of becoming a long-term carrier. Only 11% of travellers who acquired ESBL-PE during their travels had sustained colonisation 12 months after return.

Travel and the Spread of Drug-Resistant Bacteria

PURPOSE OF REVIEW

The rise in antimicrobial resistance is an urgent public health threat which, in the absence of intervention, may result in a post-antibiotic era limiting the effectiveness of antibiotics to treat both common and serious infections. Globalization and human migration have profoundly contributed to the spread of drug-resistant bacteria. In this review, we summarize the recent literature on the importance of travelers in the spread of drug-resistant bacterial organisms. Our goal was to describe the importance of travel on a variety of clinically relevant drug-resistant bacterial organisms including extended-spectrum β-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, methicillin-resistant Staphylococcus aureus, Salmonella species, as well as other enteric infections.

RECENT FINDINGS

Travelers from high income countries, visiting low and middle income countries, frequently acquire drug-resistant bacteria, particularly extended-spectrum β-lactamase-producing Enterobacteriaceae. The highest risk is associated with travel to the Indian subcontinent. Multidrug-resistant enteric infections in travelers from Salmonella spp., Campylobacter spp., and Shigella spp. are increasing. Refugees, pilgrimages, and medical tourists are associated with considerable risk of multiple forms of drug resistance. This review highlights the importance of antimicrobial stewardship, infection control, and surveillance; particularly in low and middle income countries. International leadership with global coordination is vital in the battle against antimicrobial resistance.

Exposure to and colonisation by antibiotic-resistant E. coli in UK coastal water users: Environmental surveillance, exposure assessment, and epidemiological study (Beach Bum Survey)

BACKGROUND

Antibiotic-resistant bacteria (ARB) present a global public health problem. With numbers of community-acquired resistant infections increasing, understanding the mechanisms by which people are exposed to and colonised by ARB can help inform effective strategies to prevent their spread. The role natural environments play in this is poorly understood. This is the first study to combine surveillance of ARB in bathing waters, human exposure estimates and association between exposure and colonisation by ARB in water users.

METHODS

97 bathing water samples from England and Wales were analysed for the proportion of E. coli harbouring bla_CTX-M. These data were used to estimate the likelihood of water users ingesting bla_CTX-M-bearing E. coli. Having identified surfers as being at risk of exposure to ARB, a cross-sectional study was conducted. Regular surfers and non-surfers were recruited to assess whether there is an association between surfing and gut colonisation by bla_CTX-M-bearing E. coli.

RESULTS

11 of 97 bathing waters sampled were found to contain bla_CTX-M-bearing E. coli. While the percentage of bla_CTX-M-bearing E. coli in bathing waters was low (0.07%), water users are at risk of ingesting these ARB. It is estimated that over 2.5 million water sports sessions occurred in 2015 resulting in the ingestion of at least one bla_CTX-M-bearing E. coli. In the epidemiological survey, 9/143 (6.3%) surfers were colonised by bla_CTX-M-bearing E. coli, as compared to 2/130 (1.5%) of non-surfers (risk ratio=4.09, 95% CI 1.02 to 16.4, p=0.046).

CONCLUSIONS

Surfers are at risk of exposure to and colonisation by clinically important antibiotic-resistant E. coli in coastal waters. Further research must be done on the role natural environments play in the transmission of ARB.

Prevalence and risk factors for Extended-Spectrum Beta-Lactamase-producing- Enterobacteriaceae in French military and civilian travelers: A cross-sectional analysis

BACKGROUND

International travel is a risk factor for colonization with Extended-Spectrum Beta-Lactamase-producing- Enterobacteriaceae (ESBL-E). We describe the prevalence of and risk-factors for ESBL-E colonization in civilian and military travelers.

METHODS

Patients hospitalized in the infectious diseases department of Bégin Military Hospital (France) from May 2012 to November 2015, who had traveled abroad over the past two months, were screened for intestinal colonization with ESBL-E.

RESULTS

Forty-one out of 166 travelers (24.7%) had ESBL-E colonization, predominantly Escherichia coli. The risk factors for ESBL-E colonization in the univariate analysis were a treatment with any antibiotic in the last two months (OR 4.19, 95% CI 1.91-9.16) or with a beta-lactam in the same period (OR 3.35, 95% CI 1.44-7.82), and an hospitalization in the last two months (OR 3.96, 95% CI 1.91-9.16). The military status, military mission or military accommodation were not associated with an increased risk of ESBL-E colonization. In the multivariate analysis, a treatment with any antibiotic in the last two months was significantly associated with ESBL-E colonization (OR 6.71, 95% CI 3.36-19.08).

CONCLUSION

Antibiotic treatment in the two previous months is strongly predictive of ESBL-E colonization in international travelers, while the military status and its specific living conditions are not.

Impact of cephalosporin restriction on incidence of infections with extended-spectrum beta-lactamase-producing Klebsiella pneumoniae in an endemic setting

Decreasing cephalosporin use was described as an effective intervention in decreasing the incidence of infections caused by Klebsiella pneumoniae harbouring extended-spectrum beta-lactamase (ESBLKP). Due to sustained increased levels of infections caused by ESBLKP, a multifaceted antibiotic stewardship intervention aimed to decrease cephalosporin use was carried out at a large medical unit of a teaching hospital. All cephalosporins except the first-generation were restricted and could only be prescribed after authorization by an infectious disease physician. The use of cephalosporins decreased significantly after intervention. The effect was most prominent for the third-generation cephalosporins (7.9-1.5 DDD/100 OBD). There was an increase in the consumption of piperacillin/tazobactam, carbapenems and fluoroquinolones. In contrast to our expectations the ESBLKP incidence increased, but the changes were not statistically significant. The intervention was successful in controlling the prescribing of cephalosporins, but had no impact on incidence of ESBLKP infections.

Antimicrobial resistance in women with urinary tract infection in primary care: No relation with type 2 diabetes mellitus

AIMS

To determine if type 2 diabetes mellitus (T2DM) is associated with the spectrum of uropathogens and antimicrobial resistance in urinary tract infections (UTI) in primary care.

METHODS

A cross-sectional study in female outpatients ≥30 years with positive urine cultures. T2DM patients were 1:1 matched to controls by age group and general practitioner (GP). GPs were sent questionnaires for additional data. Uropathogens and resistance patterns were compared between patients with and without T2DM. Multivariable regression analysis was performed to assess the independent association between T2DM and resistance to first line treatments, defined as resistance to nitrofurantoin, trimethoprim, fosfomycin, ciprofloxacin, amoxicillin/clavulanic acid and/or trimethoprim/sulfamethoxazole.

RESULTS

In 566 urine cultures, 680 uropathogens were found. Resistance to first line treatment antibiotics was present in 62.5% of patients. Frequencies and resistance rates of uropathogens did not differ between both groups of patients. Previous UTI and previous hospital admission were independent risk factors for resistance, but T2DM was not.

CONCLUSIONS

In this study T2DM was not an independent risk factor for antimicrobial resistance in UTI in primary care. Previous UTI and hospitalisation are drivers of resistance and should be included in the decision to perform a urine culture to target first line UTI treatment.

Fluoroquinolone-Resistant and Extended-Spectrum β-Lactamase-Producing Escherichia coli Infections in Patients with Pyelonephritis, United States(1)

For 2013-2014, we prospectively identified US adults with flank pain, temperature >38.0°C, and a diagnosis of acute pyelonephritis, confirmed by culture. Cultures from 453 (86.9%) of 521 patients grew Escherichia coli. Among E. coli isolates from 272 patients with uncomplicated pyelonephritis and 181 with complicated pyelonephritis, prevalence of fluoroquinolone resistance across study sites was 6.3% (range by site 0.0%-23.1%) and 19.9% (0.0%-50.0%), respectively; prevalence of extended-spectrum β-lactamase (ESBL) production was 2.6% (0.0%-8.3%) and 12.2% (0.0%-17.2%), respectively. Ten (34.5%) of 29 patients with ESBL infection reported no exposure to antimicrobial drugs, healthcare, or travel. Of the 29 patients with ESBL infection and 53 with fluoroquinolone-resistant infection, 22 (75.9%) and 24 (45.3%), respectively, were initially treated with in vitro inactive antimicrobial drugs. Prevalence of fluoroquinolone resistance exceeds treatment guideline thresholds for alternative antimicrobial drug strategies, and community-acquired ESBL-producing E. coli infection has emerged in some US communities.

Risk factors for acquisition of multidrug-resistant Escherichia coli and development of community-acquired urinary tract infections

We examined risk factors associated with the intestinal acquisition of antimicrobial-resistant extraintestinal pathogenic Escherichia coli (ExPEC) and development of community-acquired urinary tract infection (UTI) in a case-control study of young women across Canada. A total of 399 women were recruited; 164 women had a UTI caused by E. coli resistant to ⩾1 antimicrobial classes and 98 had a UTI caused by E. coli resistant to ⩾3 antimicrobial classes. After adjustment for age, student health service (region of Canada) and either prior antibiotic use or UTI history, consumption of processed or ground chicken, cooked or raw shellfish, street foods and any organic fruit; as well as, contact with chickens, dogs and pet treats; and travel to Asia, were associated with an increased risk of UTI caused by antimicrobial resistant E. coli. A decreased risk of antimicrobial resistant UTI was associated with consumption of apples, nectarines, peppers, fresh herbs, peanuts and cooked beef. Drug-resistant UTI linked to foodborne and environmental exposures may be a significant public health concern and understanding the risk factors for intestinal acquisition of existing or newly emerging lineages of drug-resistant ExPEC is important for epidemiology, antimicrobial stewardship and prevention efforts.

Alternative therapeutics for self-limiting infections-An indirect approach to the antibiotic resistance challenge

Alternative therapeutics for infectious diseases is a top priority, but what infections should be the primary targets? At present there is a focus on therapies for severe infections, for which effective treatment is most needed, but these infections are hard to manage, and progress has been limited. Here, we explore a different approach. Applying an evolutionary perspective to a review of antibiotic prescription studies, we identify infections that likely make a large contribution to resistance evolution across multiple taxa but are clinically mild and thus present easier targets for therapeutics development. Alternative therapeutics for these infections, we argue, would save lives indirectly by preserving the high efficacy of existing antibiotics for the patients who need them the most.

A comparison of extended spectrum β-lactamase producing Escherichia coli from clinical, recreational water and wastewater samples associated in time and location

Extended spectrum β-lactamase producing Escherichia coli (ESBL-EC) are excreted via effluents and sewage into the environment where they can re-contaminate humans and animals. The aim of this observational study was to detect and quantify ESBL-EC in recreational water and wastewater, and perform a genetic and phenotypic comparative analysis of the environmental strains with geographically associated human urinary ESBL-EC. Recreational fresh- and saltwater samples from four different beaches and wastewater samples from a nearby sewage plant were filtered and cultured on differential and ESBL-selective media. After antimicrobial susceptibility testing and multi-locus variable number of tandem repeats assay (MLVA), selected ESBL-EC strains from recreational water were characterized by whole genome sequencing (WGS) and compared to wastewater and human urine isolates from people living in the same area. We detected ESBL-EC in recreational water samples on 8/20 occasions (40%), representing all sites. The ratio of ESBL-EC to total number of E. coli colony forming units varied from 0 to 3.8%. ESBL-EC were present in all wastewater samples in ratios of 0.56-0.75%. ST131 was most prevalent in urine and wastewater samples, while ST10 dominated in water samples. Eight STs and identical ESBL-EC MLVA-types were detected in all compartments. Clinical ESBL-EC isolates were more likely to be multidrug-resistant (p<0.001). This study confirms that ESBL-EC, including those that are capable of causing human infection, are present in recreational waters where there is a potential for human exposure and subsequent gut colonisation and infection in bathers. Multidrug-resistant E. coli strains are present in urban aquatic environments even in countries where antibiotic consumption in both humans and animals is highly restricted.

Potential transmission opportunity of CTX-M-producing Escherichia coli on a large-scale chicken farm in Vietnam

OBJECTIVES

Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli have disseminated worldwide. This study investigated bla_CTX-M-positive E. coli on a large-scale Vietnamese chicken farm and analysed whether there was any difference in prevalence and molecular characteristics of bla_CTX-M-positive E. coli between the farm and the Vietnamese community.

METHODS

Faecal samples were collected from 24 human individuals and 38 chickens from the large-scale chicken farm as well as 51 humans and 36 chickens from the community. All samples were collected between June 2013 and June 2014 in Bavi Province in the Red River Delta region of Vietnam. Molecular characterisation of CTX-M-producing E. coli and genetic relatedness among the isolates were evaluated by conventional typing methods. Antimicrobial susceptibility of the isolates was evaluated by the disk diffusion method.

RESULTS

The prevalence of bla_CTX-M-positive E. coli was 83.3%, 71.1%, 54.9% and 13.9% in farm workers, farm chickens, community individuals and community backyard chickens, respectively. On average, bla_CTX-M-positive E. coli isolates from farm chickens were resistant to 8.3 different antibiotics. The average number of detected aminoglycoside-modifying enzyme genes (3.4 genes) and the detection rate of the plasmid-mediated colistin resistance gene mcr-1 (33.3%) were higher in bla_CTX-M-positive E. coli isolated from farm chickens compared with other sampling groups. In addition, two types of indistinguishable pulsed-field gel electrophoresis (PFGE) patterns were observed in six bla_CTX-M-65-positive E. coli and three bla_CTX-M-55-positive E. coli from farm chickens.

CONCLUSIONS

These results suggest a more frequent transmission opportunity of bla_CTX-M-positive E. coli on the large-scale Vietnamese chicken farm.

The Continuing Plague of Extended-spectrum β-lactamase-producing Enterobacteriaceae Infections

Antimicrobial resistance is a common iatrogenic complication of modern life and medical care. One of the most demonstrative examples is the exponential increase in the incidence of extended-spectrum β-lactamases (ESBLs) production among Enterobacteriaceae, which is the most common human pathogens outside of the hospital settings. Infections resulting from ESBL-producing bacteria are associated with devastating outcomes, now affecting even previously healthy individuals. This development poses an enormous burden and threat to public health. This paper aims to narrate the evolving epidemiology of ESBL infections, and highlight current challenges in terms of management and prevention of these common infections.

Guidelines for the prevention of travel-associated illness in older adults

International travel to the developing world is becoming more common in elderly patients (defined here as individuals greater than 65 years old). When providing pre-travel counseling, providers must appreciate the changing physiology, comorbidities, immunity and pharmacokinetics associated with the aging process to prepare elderly patients for the stressors of international travel. These guidelines present an evidence-based approach to pre-travel counseling, immunization, and pharmacology concerns unique to elderly patients seeking care in a travel clinic setting.

The global diabetes epidemic: what does it mean for infectious diseases in tropical countries?

Tropical countries are experiencing a substantial rise in type 2 diabetes, which is often undiagnosed or poorly controlled. Since diabetes is a risk factor for many infectious diseases, this increase probably adds to the large infectious disease burden in tropical countries. We reviewed the literature to investigate the interface between diabetes and infections in tropical countries, including the WHO-defined neglected tropical diseases. Although solid data are sparse, patients with diabetes living in tropical countries most likely face increased risks of common and health-care-associated infections, as well as infected foot ulcers, which often lead to amputation. There is strong evidence that diabetes increases the severity of some endemic infections such as tuberculosis, melioidosis, and dengue virus infection. Some HIV and antiparasitic drugs might induce diabetes, whereas helminth infections appear to afford some protection against future diabetes. But there are no or very scarce data for most tropical infections and for possible biological mechanisms underlying associations with diabetes. The rise in diabetes and other non-communicable diseases puts a heavy toll on health systems in tropical countries. On the other hand, complications common to both diabetes and some tropical infections might provide an opportunity for shared services-for example, for eye health (trachoma and onchocerciasis), ulcer care (leprosy), or renal support (schistosomiasis). More research about the interaction of diabetes and infections in tropical countries is needed, and the infectious disease burden in these countries is another reason to step up global efforts to improve prevention and care for diabetes.

Emerging extended-spectrum β-lactamase-producing Klebsiella pneumoniae causing community-onset urinary tract infections: a case-control-control study

The aim of this study was to determine the epidemiology and risk factors associated with community-onset urinary tract infections (CO-UTIs) due to extended-spectrum β-lactamase-producing Klebsiella pneumoniae (ESBL-Kp). A cohort study including all consecutive patients with K. pneumoniae CO-UTI identified from January 2010 to December 2014 was conducted. Patients with CO-UTI due to ESBL-Kp were then included as cases in a retrospective case-control-control study; controls were outpatients with CO-UTI caused by non-ESBL-producing Escherichia coli and K. pneumoniae (non-ESBL-Ec and non-ESBL-Kp, respectively). Each control was matched in a 2:1 ratio according to patient age, sex and year of isolation. Genotyping confirming ESBL was performed by multiplex PCR and sequencing. The prevalence of ESBL-Kp CO-UTIs, calculated among all K. pneumoniae CO-UTIs, increased from 2.4% in 2010 to 10.3% in 2014 (P = 0.01). Among cases, 63.8% were truly community-acquired, and CTX-M-15 was the predominant β-lactamase enzyme type (79.3%). A total of 83 cases and 319 controls were studied. Being a nursing home resident [odds ratio (OR) = 8.8, 95% confidence interval (CI) 2.6-29.4] and previous cephalosporin use (OR = 4.01, 95% CI 1.8-9.2) were risk factors independently associated with CO-UTI due to ESBL-Kp. In conclusion, the prevalence of CO-UTIs due to ESBL-Kp is increasing. In most cases, ESBL-Kp CO-UTIs are community-acquired and produce CTX-M-15 β-lactamase. Exposure to cephalosporins and being a nursing home resident were risk factors associated with ESBL-Kp CO-UTIs. CTX-M-15-producing K. pneumoniae isolates are emerging in the community.

Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report

BACKGROUND

: Travelers' diarrhea causes significant morbidity including some sequelae, lost travel time and opportunity cost to both travelers and countries receiving travelers. Effective prevention and treatment are needed to reduce these negative impacts.

METHODS

: This critical appraisal of the literature and expert consensus guideline development effort asked several key questions related to antibiotic and non-antibiotic prophylaxis and treatment, utility of available diagnostics, impact of multi-drug resistant (MDR) colonization associated with travel and travelers' diarrhea, and how our understanding of the gastrointestinal microbiome should influence current practice and future research. Studies related to these key clinical areas were assessed for relevance and quality. Based on this critical appraisal, guidelines were developed and voted on using current standards for clinical guideline development methodology.

RESULTS

: New definitions for severity of travelers' diarrhea were developed. A total of 20 graded recommendations on the topics of prophylaxis, diagnosis, therapy and follow-up were developed. In addition, three non-graded consensus-based statements were adopted.

CONCLUSIONS

: Prevention and treatment of travelers' diarrhea requires action at the provider, traveler and research community levels. Strong evidence supports the effectiveness of antimicrobial therapy in most cases of moderate to severe travelers' diarrhea, while either increasing intake of fluids only or loperamide or bismuth subsalicylate may suffice for most cases of mild diarrhea. Further studies are needed to address knowledge gaps regarding optimal therapies, the individual, community and global health risks of MDR acquisition, manipulation of the microbiome in prevention and treatment and the utility of laboratory testing in returning travelers with persistent diarrhea.

Travel-acquired ESBL-producing Enterobacteriaceae: impact of colonization at individual and community level

BACKGROUND

Antibiotic resistance is a rapidly increasing global emergency that calls for action from all of society. Intestinal multidrugresistant (MDR) bacteria have spread worldwide with extended-spectrum beta-lactamase (ESBL) -producing Enterobacteriaceae (ESBL-PE) as the most prevalent type. The millions of travelers annually visiting regions with poor hygiene contribute substantially to this spread. Our review explores the underlying data and discusses the consequences of the colonization.

METHODS

PubMed was searched for relevant literature between January 2010 and August 2016. We focused on articles reporting (1) the rate of ESBL-PE acquisition in a group of travelers recruited before/after international travel, (2) fecal carriage of ESBL-PE as explored by culture and, for part of the studies, (3) analysis of factors predisposing to colonization.

RESULTS

We reviewed a total of 16 studies focusing on travel-acquired ESBL-PE. The acquisition rates reveal that 2070% of visitors to (sub)tropical regions get colonized by ESBL-PE. The main risk factors predisposing to colonization during travel are destination, travelers diarrhea, and antibiotic use.

CONCLUSIONS

While most of those colonized remain asymptomatic, acquisition of ESBL-PE may have consequences both at individual and community level. We discuss current efforts to restrict the spread.

Fecal carriage of extended spectrum β-lactamase producing Escherichia coli and Klebsiella pneumoniae after urinary tract infection - A three year prospective cohort study

We have performed a prospective cohort study to investigate the duration of and risk factors for prolonged fecal carriage of ESBL-producing Escherichia coli or Klebsiella pneumoniae in patients with community acquired urinary tract infection caused by these bacteria. From 2009 to 2011, 101 Norwegian patients were recruited. Stool swabs and questionnaires were collected every three months for one year and at the end of the study in 2012. Information on antibiotic prescriptions was collected from the Norwegian Prescription Database. Stool samples were cultured directly on ChromID ESBL agar as well as in an enrichment broth, and culture positive isolates were examined by blaCTX-M multiplex PCR. Isolates without blaCTX-M were investigated for alternative ESBL-determinants with a commercial microarray system. Time to fecal clearance of ESBL producing Enterobacteriaceae was also analysed using Kaplan-Meier estimates. Uni- and multivariate logistic regression was used to compare groups according to previously described risk factors. The ESBL point prevalence of fecal carriage were 61% at 4 months, 56% at 7 months, 48% at 10 months, 39% at 13 months, 19% after two years, and 15% after three years or more. We found no correlation between duration of carriage, comorbidity, antibiotic use or travel to ESBL high-prevalence countries. Prolonged carriage was associated with E. coli isolates of phylogroup B2 or D. Importantly, comparative MLST and MLVA analyses of individual paired urine and fecal E. coli isolates revealed that ESBL production commonly occurred in diverse strains within the same host. When investigating cross-transmission of ESBL producing bacteria in health care institutions, this notion should be taken into account.

Intense pre-admission carriage and further acquisition of ESBL-producing Enterobacteriaceae among patients and their caregivers in a tertiary hospital in Rwanda

OBJECTIVES

To assess the presence and risk factors of intestinal carriage of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) among patients admitted to the University Teaching Hospital of Butare and among their attending caregivers, and to analyse the acquisition of ESBL-PE carriage during hospital stay and associated factors.

METHODS

We screened 392 patients and their attending caregivers at admission and discharge for ESBL-PE carriage. Bacterial species were determined using the API-20E system, and antimicrobial susceptibility testing was performed by agar disc diffusion. Data on socio-economic status, diet, behaviour, household assets, livestock and hospital procedures were collected.

RESULTS

At admission, 50% of the patients showed intestinal ESBL-PE carriage (Escherichia coli, 51%; Klebsiella pneumoniae, 39%; Enterobacter cloacae, 19%) as did 37% of their caregivers. Co-resistance was common but no carbapenem resistance was detected. At discharge, the proportion of ESBL-PE-colonised patients increased to 65% (caregivers, 47%) with almost complete carriage in paediatric patients (93%). The acquisition rate among initially non-colonised patients was 55% (or, 71/1000 patient days). Independent predictors of admission carriage included a colonised caregiver, prior antibiotic intake, egg consumption and neglecting to boil drinking water, whereas being a paediatric patient, undergoing surgery and male gender predicted acquisition during hospitalisation.

CONCLUSIONS

Abundant admission carriage of ESBL-PE and a high acquisition rate in a Rwandan university hospital point to potential intrahospital transmission and community dissemination. Caregivers are an additional source of possible spread. Risk factors of colonisation such as diet and water source need to be tackled to prevent the further emergence and spread of ESBL-PE.