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Ravensbergen SJ, Berends M, Stienstra Y, Ott A. High prevalence of MRSA and ESBL among asylum seekers in the Netherlands. PLoS One 2017; 12:e0176481. [PMID: 28441421 PMCID: PMC5404783 DOI: 10.1371/journal.pone.0176481] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 04/11/2017] [Indexed: 11/19/2022] Open
Abstract
Migration is one of the risk factors for the spread of multidrug-resistant organisms (MDRO). The increasing influx of migrants challenges local health care systems. To provide evidence for both hospital hygiene measure and empirical antibiotic therapy, we analysed all cultures performed in asylum seekers between January 1st 2014 and December 31st 2015 for methicillin resistant Staphylococcus aureus (MRSA) and for multidrug-resistant Enterobacteriaceae (MDRE). We compared these with cultures from the Dutch patient population with risk factors for carriage of MDRO. A total of 7181 patients were screened for MRSA. 7357 S. aureus were isolated in clinical cultures. Of 898 screened asylum seekers, almost 10% were MRSA positive. Of 118 asylum seekers with S. aureus in clinical cultures almost 19% were MRSA positive. The general patient population had a 1.3% rate of MRSA in S. aureus isolates. A higher rate of Panton-Valentine leukocidin (PVL) positive strains (RR: 2.4; 95% CI: 1.6-3.4) was found in asylum seekers compared to the general patient population. In 33475 patients one or more Enterobacteriaceae were obtained. More than 21% of the asylum seekers were carrier of MDRE, most of them producing extended spectrum beta-lactamases (20.3%). 5.1% of the general patient population was MDRE carrier. It can be concluded that asylum seekers present with higher rate of MDRO compared to the general patient population. These results justify continued screening of asylum seekers to anticipate multidrug-resistant organisms during hospital care of patients.
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Affiliation(s)
- Sofanne J. Ravensbergen
- Department of Internal Medicine/Infectious Diseases, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
- * E-mail:
| | - Matthijs Berends
- Department of Medical Microbiology, Certe, Groningen, the Netherlands
| | - Ymkje Stienstra
- Department of Internal Medicine/Infectious Diseases, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Alewijn Ott
- Department of Medical Microbiology, Certe, Groningen, the Netherlands
- Department of Medical Microbiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
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102
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Antipin RL, Beshnova DA, Petrov RA, Shiryaeva AS, Andreeva IP, Grigorenko VG, Rubtsova MY, Majouga AG, Lamzin VS, Egorov AM. Synthesis, SAR and molecular docking study of novel non-β-lactam inhibitors of TEM type β-lactamase. Bioorg Med Chem Lett 2017; 27:1588-1592. [DOI: 10.1016/j.bmcl.2017.02.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/10/2017] [Accepted: 02/13/2017] [Indexed: 10/20/2022]
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103
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Mushtaq S, Khan JA, Rabbani F, Latif U, Arfan M, Yameen MA. Biocompatible biodegradable polymeric antibacterial nanoparticles for enhancing the effects of a third-generation cephalosporin against resistant bacteria. J Med Microbiol 2017; 66:318-327. [DOI: 10.1099/jmm.0.000445] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Sana Mushtaq
- Department of Pharmacy, COMSATS Institute of Information Technology, Abbottabad, Pakistan
| | - Jawad Akbar Khan
- Department of Pharmacy, COMSATS Institute of Information Technology, Abbottabad, Pakistan
| | - Faiz Rabbani
- Department of Environmental Sciences, COMSATS Institute of Information Technology, Vehari, Pakistan
| | - Usman Latif
- Interdisciplinary Research Center in Biomedical Materials, COMSATS Institute of Information Technology, Lahore, Pakistan
| | - Muhammad Arfan
- Department of Chemistry, School of Natural Sciences, National University of Sciences and Technology, H-12, Islamabad, Pakistan
| | - Muhammad Arfat Yameen
- Department of Pharmacy, COMSATS Institute of Information Technology, Abbottabad, Pakistan
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Dholvitayakhun A, Trachoo N, Narkkong NA, Cushnie TT. Using scanning and transmission electron microscopy to investigate the antibacterial mechanism of action of the medicinal plant Annona squamosa Linn. J Herb Med 2017. [DOI: 10.1016/j.hermed.2016.10.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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105
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Popescu C, Popescu GA, Dorobăț O, Rafilă A, Tănase D, Mikula C, Weissensteiner G, Huhulescu S. OXA-48-Carbapenemase-Producing Klebsiella pneumoniae infections - the first cases diagnosed in Romanian National Institute of Infectious Diseases. REV ROMANA MED LAB 2017. [DOI: 10.1515/rrlm-2017-0006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
We report first description of clinical cases of OXA-48 carbapenemase-producing Klebsiella pneumoniae originating from patients hospitalized in the most important Infectious Diseases Hospital from Romania, between December 2012 and March 2013. All strains were isolated from patients who were previously admitted in surgical wards. None of the patients had been admitted in a hospital outside of Romania.
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Affiliation(s)
- Cristina Popescu
- „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- „Matei Balș” National Institute for Infectious Diseases, Bucharest, Romania
| | - Gabriel Adrian Popescu
- „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- „Matei Balș” National Institute for Infectious Diseases, Bucharest, Romania
| | - Olga Dorobăț
- „Matei Balș” National Institute for Infectious Diseases, Bucharest, Romania
| | - Alexandru Rafilă
- „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- „Matei Balș” National Institute for Infectious Diseases, Bucharest, Romania
| | - Diana Tănase
- „Matei Balș” National Institute for Infectious Diseases, Bucharest, Romania
| | - Claudia Mikula
- Austrian Agency for Health and Food Safety, Vienna, Austria
- Institute for Medical Microbiology and Hygiene, Graz, Austria
| | - Gudrun Weissensteiner
- Austrian Agency for Health and Food Safety, Vienna, Austria
- Institute for Medical Microbiology and Hygiene, Graz, Austria
| | - Steliana Huhulescu
- Austrian Agency for Health and Food Safety, Vienna, Austria
- Institute for Medical Microbiology and Hygiene, Vienna, Austria
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106
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Khawaja T, Kirveskari J, Johansson S, Väisänen J, Djupsjöbacka A, Nevalainen A, Kantele A. Patients hospitalized abroad as importers of multiresistant bacteria-a cross-sectional study. Clin Microbiol Infect 2017; 23:673.e1-673.e8. [PMID: 28196696 DOI: 10.1016/j.cmi.2017.02.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/30/2017] [Accepted: 02/04/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The pandemic spread of multidrug-resistant (MDR) bacteria poses a threat to healthcare worldwide, with highest prevalence in indigent regions of the (sub)tropics. As hospitalization constitutes a major risk factor for colonization, infection control management in low-prevalence countries urgently needs background data on patients hospitalized abroad. METHODS We collected data on 1122 patients who, after hospitalization abroad, were treated at the Helsinki University Hospital between 2010 and 2013. They were screened for methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE), vancomycin-resistant enterococci, carbapenemase-producing Enterobacteriaceae (CPE), multiresistant Pseudomonas aeruginosa and multiresistant Acinetobacter baumannii. Risk factors for colonization were explored by multivariate analysis. RESULTS MDR colonization rates were higher for those hospitalized in the (sub)tropics (55%; 208/377) compared with temperate zones (17%; 125/745). For ESBL-PE the percentages were 50% (190/377) versus 12% (92/745), CPE 3.2% (12/377) versus 0.4% (3/745) and MRSA 6.6% (25/377) versus 2.4% (18/745). Colonization rates proved highest in those returning from South Asia (77.6%; 38/49), followed by those having visited Latin America (60%; 9/16), Africa (60%; 15/25) and East and Southeast Asia (52.5%; 94/179). Destination, interhospital transfer, short time interval to hospitalization, young age, surgical intervention, residence abroad, visiting friends and relatives, and antimicrobial use proved independent risk factors for colonization. CONCLUSIONS Post-hospitalization colonization rates proved higher in the (sub)tropics than elsewhere; 11% (38/333) of carriers developed an MDR infection. We identified several independent risk factors for contracting MDR bacteria. The data provide a basis for infection control guidelines in low-prevalence countries.
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Affiliation(s)
- T Khawaja
- Inflammation Centre, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J Kirveskari
- Helsinki University Hospital Laboratory, Helsinki, Finland
| | - S Johansson
- Department of Medicine, Clinicum, University of Helsinki, Helsinki, Finland
| | - J Väisänen
- Department of Medicine, Clinicum, University of Helsinki, Helsinki, Finland
| | - A Djupsjöbacka
- Department of Medicine, Clinicum, University of Helsinki, Helsinki, Finland
| | - A Nevalainen
- Helsinki University Hospital Laboratory, Helsinki, Finland
| | - A Kantele
- Inflammation Centre, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Medicine, Clinicum, University of Helsinki, Helsinki, Finland; Karolinska Institutet, Solna, Stockholm, Sweden.
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107
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Affiliation(s)
- Guy E Thwaites
- From the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (G.E.T., N.P.J.D.); Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam (G.E.T.); and the Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (N.P.J.D.)
| | - Nicholas P J Day
- From the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (G.E.T., N.P.J.D.); Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam (G.E.T.); and the Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (N.P.J.D.)
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108
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Kantele A, Mero S, Kirveskari J, Lääveri T. Fluoroquinolone antibiotic users select fluoroquinolone-resistant ESBL-producing Enterobacteriaceae (ESBL-PE) - Data of a prospective traveller study. Travel Med Infect Dis 2017; 16:23-30. [PMID: 28153711 DOI: 10.1016/j.tmaid.2017.01.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 01/24/2017] [Accepted: 01/26/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND One third of travellers to the poor regions of the (sub)tropics become colonized by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE). Co-resistance to non-beta-lactam antibiotics complicates the treatment of potential ESBL-PE infections. METHODS We analysed co-resistance to non-beta-lactams among travel-acquired ESBL-PE isolates of 90 visitors to the (sub)tropics with respect to major risk factors of colonization: destination, age, travellers' diarrhoea (TD) and antibiotic (AB) use. RESULTS Of the ESBL-PE isolates, 53%, 52%, 73%, and 2% proved co-resistant to ciprofloxacin, tobramycin, co-trimoxazole, and nitrofurantoin, respectively. The rates were similar among those with (TD+) or without (TD-) travellers' diarrhoea. Among fluoroquinolone-users vs. AB non-users, the co-resistance rates for ciprofloxacin were 95% versus 37% (p = 0.001), for tobramycin 85% versus 43% (p = 0.005), co-trimoxazole 85% versus 68% (p = 0.146), and nitrofurantoin 5% versus 2% (p = 0.147). In multivariable analysis co-resistance to ciprofloxacin was associated with increasing age, fluoroquinolone use, and tobramycin resistance. CONLUSIONS While TD predisposes to ESBL-PE non-selectively, antimicrobial use favours strains resistant to drug taken and, simultaneously, any drug with resistance genetically linked to the drug used. Antibiotics taken during travel predispose to ESBL-PE with a high co-resistance rate.
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Affiliation(s)
- Anu Kantele
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, POB 348, FIN-00029 HUS, Helsinki, Finland; Aava Travel Clinic, Medical Centre Aava, Annankatu 32, FIN-00100 Helsinki, Finland; Unit of Infectious Diseases, Karolinska Institutet, Solna, SE-17176 Stockholm, Sweden.
| | - Sointu Mero
- Division of Clinical Microbiology, Helsinki University Hospital, HUSLAB, POB 400, FIN-00029 HUS, Helsinki, Finland.
| | - Juha Kirveskari
- Division of Clinical Microbiology, Helsinki University Hospital, HUSLAB, POB 400, FIN-00029 HUS, Helsinki, Finland.
| | - Tinja Lääveri
- Inflammation Center, Division of Infectious Diseases, University of Helsinki and Helsinki University Hospital, POB 348, FIN-00029 HUS, Helsinki, Finland.
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109
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Hsu LY, Apisarnthanarak A, Khan E, Suwantarat N, Ghafur A, Tambyah PA. Carbapenem-Resistant Acinetobacter baumannii and Enterobacteriaceae in South and Southeast Asia. Clin Microbiol Rev 2017; 30:1-22. [PMID: 27795305 PMCID: PMC5217790 DOI: 10.1128/cmr.masthead.30-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Carbapenem-resistant Gram-negative bacteria, in particular the Acinetobacter baumannii-calcoaceticus complex and Enterobacteriaceae, are escalating global public health threats. We review the epidemiology and prevalence of these carbapenem-resistant Gram-negative bacteria among countries in South and Southeast Asia, where the rates of resistance are some of the highest in the world. These countries house more than a third of the world's population, and several are also major medical tourism destinations. There are significant data gaps, and the almost universal lack of comprehensive surveillance programs that include molecular epidemiologic testing has made it difficult to understand the origins and extent of the problem in depth. A complex combination of factors such as inappropriate prescription of antibiotics, overstretched health systems, and international travel (including the phenomenon of medical tourism) probably led to the rapid rise and spread of these bacteria in hospitals in South and Southeast Asia. In India, Pakistan, and Vietnam, carbapenem-resistant Enterobacteriaceae have also been found in the environment and community, likely as a consequence of poor environmental hygiene and sanitation. Considerable political will and effort, including from countries outside these regions, are vital in order to reduce the prevalence of such bacteria in South and Southeast Asia and prevent their global spread.
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Affiliation(s)
- Li-Yang Hsu
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Tan Tock Seng Hospital, Singapore
| | | | - Erum Khan
- Aga Khan University, Karachi, Pakistan
| | - Nuntra Suwantarat
- Chulabhorn International College of Medicine, Thammasat University, Pathum Thani, Thailand
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110
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Hirai J, Yamagishi Y, Mikamo H. [Progress in Diagnostic Technology and Management of Infectious Diseases. Topics: I. Infection Diseases with Special Concern; 1. Carbapenem-resistant enterobacteriaceae]. ACTA ACUST UNITED AC 2016; 103:2657-65. [PMID: 27522804 DOI: 10.2169/naika.103.2657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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111
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Bassetti M, Carnelutti A, Peghin M. Patient specific risk stratification for antimicrobial resistance and possible treatment strategies in gram-negative bacterial infections. Expert Rev Anti Infect Ther 2016; 15:55-65. [PMID: 27766913 DOI: 10.1080/14787210.2017.1251840] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The isolation of multi-drug-resistant gram-negative (MDRGN) pathogens has progressively increased worldwide and has been associated with important delays in the prescription of an adequate antibiotic treatment, resulting in increased mortality rates. Patient's stratification for MDRGN infections to optimize the prescription of an adequate empiric antimicrobial regimen is crucial. Areas covered: This article covers MDRGN epidemiology, with a specific focus on risk factors for harbouring infections sustained by extended-spectrum-Beta-lactamase (ESBL), carbapenem resistant Enterobacteriacae (CRE), MDR Pseudomonas aeruginosa and MDR Acinetobacter baumanii. Moreover, we will propose an algorithm for the choice of empiric treatment when a MDRGN infection is suspected. Expert commentary: Although in clinical practice, a patient's stratification represents a challenge, whenever a MDRGN pathogen is suspected broad-spectrum, combination empiric treatment should be promptly started, looking for a balance between the prescription of an adequate empiric treatment and the risk of resistance selection.
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Affiliation(s)
- Matteo Bassetti
- a Infectious Diseases Division , Santa Maria Misericordia Hospital , Udine , Italy
| | - Alessia Carnelutti
- a Infectious Diseases Division , Santa Maria Misericordia Hospital , Udine , Italy
| | - Maddalena Peghin
- a Infectious Diseases Division , Santa Maria Misericordia Hospital , Udine , Italy
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112
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Clinical and economic impact of meropenem resistance in Pseudomonas aeruginosa-infected patients. Am J Infect Control 2016; 44:1275-1279. [PMID: 27320901 DOI: 10.1016/j.ajic.2016.04.218] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 04/20/2016] [Accepted: 04/20/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND The emergence of carbapenem resistance has had a significant impact on both clinical and economic outcomes. METHODS A retrospective, observational cohort study was performed in a 433-bed tertiary care medical center. The cohort was established from all inpatients with Pseudomonas aeruginosa-positive cultures over a 3-year period. Two multivariate models were developed: a logistic regression model to evaluate the primary outcome of in-hospital mortality and a linear regression model to evaluate the secondary outcome of total hospital cost. RESULTS The adjusted odds ratio for in-hospital mortality among patients with meropenem-resistant isolates was 2.89 (95% confidence interval [CI], 1.15-7.28). There were significantly more deaths in the meropenem-resistant group (28.1% vs 8.9%, P = .003). Patients with meropenem-resistant P aeruginosa experienced a 4-day increase in median length of stay versus those in the meropenem-susceptible group (14 vs 9 days, P = .004). Likewise, the percentage of patients who required intensive care unit (ICU) admission increased from 42% to 81.3% (P <.001). Meropenem resistance was also associated with a significant increase in total hospital cost by a factor of 1.42 among patients who were not admitted to the ICU (95% CI, 1.03-1.95). CONCLUSIONS Our results demonstrate that meropenem resistance was a significant predictor of in-hospital mortality. Carbapenem resistance also resulted in a significant increase in hospital cost, but only among patients who were not admitted to the ICU.
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113
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Carbapenem-Resistant Acinetobacter baumannii and Enterobacteriaceae in South and Southeast Asia. Clin Microbiol Rev 2016. [PMID: 27795305 DOI: 10.1128/cmr.00042-16] [Citation(s) in RCA: 183] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Carbapenem-resistant Gram-negative bacteria, in particular the Acinetobacter baumannii-calcoaceticus complex and Enterobacteriaceae, are escalating global public health threats. We review the epidemiology and prevalence of these carbapenem-resistant Gram-negative bacteria among countries in South and Southeast Asia, where the rates of resistance are some of the highest in the world. These countries house more than a third of the world's population, and several are also major medical tourism destinations. There are significant data gaps, and the almost universal lack of comprehensive surveillance programs that include molecular epidemiologic testing has made it difficult to understand the origins and extent of the problem in depth. A complex combination of factors such as inappropriate prescription of antibiotics, overstretched health systems, and international travel (including the phenomenon of medical tourism) probably led to the rapid rise and spread of these bacteria in hospitals in South and Southeast Asia. In India, Pakistan, and Vietnam, carbapenem-resistant Enterobacteriaceae have also been found in the environment and community, likely as a consequence of poor environmental hygiene and sanitation. Considerable political will and effort, including from countries outside these regions, are vital in order to reduce the prevalence of such bacteria in South and Southeast Asia and prevent their global spread.
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114
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Poulakou G, Plachouras D. Planet's population on the move, infections on the rise. Intensive Care Med 2016; 42:2055-2058. [PMID: 27730282 PMCID: PMC7080023 DOI: 10.1007/s00134-016-4580-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 09/26/2016] [Indexed: 01/16/2023]
Affiliation(s)
- Garyphallia Poulakou
- 4th Department of Internal Medicine, School of Medicine, Athens National and Kapodistrian University, Attikon University General Hospital, 1 Rimini st 12462, Athens, Greece
| | - Diamantis Plachouras
- European Centre for Disease Prevention and Control, Tomteboda 11 A, Solna, SE-171 83 Stockholm, Sweden
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115
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Kandil H, Cramp E, Vaghela T. Trends in Antibiotic Resistance in Urologic Practice. Eur Urol Focus 2016; 2:363-373. [PMID: 28723468 DOI: 10.1016/j.euf.2016.09.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022]
Abstract
CONTEXT The significant global upsurge in antimicrobial resistance, particularly among Enterobacteriaceae, represents a serious threat to health care systems. The implications for urologic practice are of particular concern. OBJECTIVE To review trends in antibiotic resistance in urologic practice. EVIDENCE ACQUISITION We report current European trends of resistance in Gram-negative uropathogens. EVIDENCE SYNTHESIS In addition to β-lactam resistance, Gram-negative pathogens are often resistant to multiple drug classes, including aminoglycosides, fluoroquinolones, and carbapenems, commonly used to treat urologic infections. Interest is renewed in old antibiotics, and several new antibiotics are in the pipeline to meet the challenge of treating these infections. In this review, we summarise emerging trends in antimicrobial resistance and its impact on urologic practice. We also review current guidelines on the treatment and prevention of urologic infections with these organisms, and some key antibiotics in the era of resistance. CONCLUSIONS Increasing antimicrobial resistance represents a challenge to urologic practice for both treatment and prophylaxis. Antibiotic choice should be determined according to risk factors for multidrug resistance. Good knowledge of the local microbial prevalence and resistance profile is required to guide antimicrobial therapy. PATIENT SUMMARY Antimicrobial resistance represents a challenge in urology. We summarise emerging trends in antimicrobial resistance and review current guidelines on the treatment and prevention of urologic infections, as well as some key antibiotics in the era of resistance.
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Affiliation(s)
- Hala Kandil
- Microbiology Department, West Hertfordshire Hospitals NHS Trust, Watford, UK
| | - Emma Cramp
- Pharmacy Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Tejal Vaghela
- Pharmacy Department, West Hertfordshire Hospitals NHS Trust, Watford, UK.
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116
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Baker KS, Dallman TJ, Behar A, Weill FX, Gouali M, Sobel J, Fookes M, Valinsky L, Gal-Mor O, Connor TR, Nissan I, Bertrand S, Parkhill J, Jenkins C, Cohen D, Thomson NR. Travel- and Community-Based Transmission of Multidrug-Resistant ShigellasonneiLineage among International Orthodox Jewish Communities. Emerg Infect Dis 2016. [DOI: 10.3201/eid2209.1511953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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117
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Abstract
Carbapenemase-producing Enterobacteriaceae (CPE) are an important and increasing threat to global health. Both clonal spread and plasmid-mediated transmission contribute to the ongoing rise in incidence of these bacteria. Among the 4 classes of β-lactamases defined by the Ambler classification system, the carbapenemases that confer carbapenem resistance in Enterobacteriaceae belong to 3 of them: Class A (K. pneumoniae carbapenemases, KPC), Class B (metallo-β-lactamases, MBL including New Delhi metallo-β-lactamases, NDM) and Class D (OXA-48-like carbapenemases). KPC-producing CPE are the most commonly occurring CPE in the United States. MBL-producing CPE have been most commonly associated with the Indian Subcontinent as well as with specific countries in Europe, including Romania, Denmark, Spain, and Hungary. The epicenter of OXA-48-like-producing is in Turkey and surrounding countries. Detailed knowledge of the epidemiology and molecular characteristics of CPE is essential to stem the spread of these pathogens.
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Affiliation(s)
- David van Duin
- a Division of Infectious Diseases , University of North Carolina , Chapel Hill , NC , USA
| | - Yohei Doi
- b Division of Infectious Diseases , University of Pittsburgh School of Medicine , Pittsburgh , PA , USA
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118
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Travel to Asia and traveller's diarrhoea with antibiotic treatment are independent risk factors for acquiring ciprofloxacin-resistant and extended spectrum β-lactamase-producing Enterobacteriaceae —a prospective cohort study. Clin Microbiol Infect 2016; 22:731.e1-7. [DOI: 10.1016/j.cmi.2016.05.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 04/29/2016] [Accepted: 05/03/2016] [Indexed: 01/16/2023]
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119
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Pires J, Kuenzli E, Kasraian S, Tinguely R, Furrer H, Hilty M, Hatz C, Endimiani A. Polyclonal Intestinal Colonization with Extended-Spectrum Cephalosporin-Resistant Enterobacteriaceae upon Traveling to India. Front Microbiol 2016; 7:1069. [PMID: 27462305 PMCID: PMC4940376 DOI: 10.3389/fmicb.2016.01069] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 06/27/2016] [Indexed: 12/18/2022] Open
Abstract
We aimed to assess the intestinal colonization dynamics by multiple extended-spectrum cephalosporin-resistant Enterobacteriaceae (ESC-R-Ent) clones in Swiss travelers to India, a country with high prevalence of these multidrug-resistant pathogens. Fifteen healthy volunteers (HVs) colonized with ESC-R-Ent after traveling to India who provided stools before, after, and at 3- and 6-month follow-up are presented in this study. Stools were enriched in a LB broth containing 3 mg/L cefuroxime and plated in standard selective media (BLSE, ChromID ESBL, Supercarba) to detect carbapenem- and/or ESC-R-Ent. At least 5 Enterobacteriaceae colonies were analyzed for each stool provided. All strains underwent phenotypic tests (MICs in microdilution) and molecular typing to define bla genes (microarray, PCR/sequencing), clonality (MLST, rep-PCR), and plasmid content. While only three HVs were colonized before the trip, all participants had positive stools after returning, but the colonization rate decreased during the follow-up period (i.e., six HVs were still colonized at both 3 and 6 months). More importantly, polyclonal acquisition (median of 2 clones, range 1–5) was identified at return in all HVs. The majority of the Escherichia coli isolates belonged to phylogenetic groups A and B1 and to high diverse non-epidemic sequence types (STs); however, 15% of them belonged to clonal complex 10 and mainly possessed blaCTX−M−15 genes. F family plasmids were constantly found (~80%) in the recovered ESC-R-Ent. Our results indicate a possible polyclonal acquisition of the ESC-R-Ent via food-chain and/or through an environmental exposure. For some HVs, prolonged colonization in the follow-up period was observed due to clonal persistence or presence of the same plasmid replicon types in a new bacterial host. Travel medicine practitioners, clinicians, and clinical microbiologists who are facing the returning travelers and their samples for different reasons should be aware of this important phenomenon, so that better infection control measures, treatment strategies, and diagnostic tests can be adopted.
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Affiliation(s)
- João Pires
- Institute for Infectious Diseases, University of BernBern, Switzerland; Graduate School of Cellular and Biomedical Sciences, University of BernBern, Switzerland
| | - Esther Kuenzli
- Division for Infectious Diseases and Hospital Epidemiology, University Hospital BaselBasel, Switzerland; Swiss Tropical and Public Health InstituteBasel, Switzerland; Epidemiology, Biostatistics and Prevention Institute, University of ZurichZurich, Switzerland
| | - Sara Kasraian
- Institute for Infectious Diseases, University of Bern Bern, Switzerland
| | - Regula Tinguely
- Institute for Infectious Diseases, University of Bern Bern, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital, University of Bern Bern, Switzerland
| | - Markus Hilty
- Institute for Infectious Diseases, University of BernBern, Switzerland; Department of Infectious Diseases, Bern University Hospital, University of BernBern, Switzerland
| | - Christoph Hatz
- Swiss Tropical and Public Health InstituteBasel, Switzerland; Epidemiology, Biostatistics and Prevention Institute, University of ZurichZurich, Switzerland
| | - Andrea Endimiani
- Institute for Infectious Diseases, University of Bern Bern, Switzerland
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Ravensbergen SJ, Lokate M, Cornish D, Kloeze E, Ott A, Friedrich AW, van Hest R, Akkerman OW, de Lange WC, van der Werf TS, Bathoorn E, Stienstra Y. High Prevalence of Infectious Diseases and Drug-Resistant Microorganisms in Asylum Seekers Admitted to Hospital; No Carbapenemase Producing Enterobacteriaceae until September 2015. PLoS One 2016; 11:e0154791. [PMID: 27144599 PMCID: PMC4856320 DOI: 10.1371/journal.pone.0154791] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 04/19/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction The current refugee crisis emphasizes the need for information on infectious diseases and resistant microorganisms in asylum seekers with possible consequences for public health and infection control. Methods We collected data from asylum seekers admitted to our university hospital or who presented at the Emergency Department (n = 273). We collected general and demographic characteristics including country of origin, the reason of presentation, and the screening results of multi-drug resistant organisms. Results 67% of the patients were male with a median age of the study group of 24 years (IQR 15–33); 48% of the patients had an infectious disease—predominantly malaria with P. vivax or tuberculosis. Patients also reported with diseases which are less common—e.g. leishmaniasis, or even conditions rarely diagnosed in Europe—e.g. louse borne relapsing fever. A carriage rate of 31% for multi-drug resistant microorganisms (MDRO) was observed, with ESBL-expressing E.coli (n = 20) being the most common MDRO. No carriage of Carbapenemase Producing Enterobacteriaceae was found. Conclusion The current refugee crisis in Europe challenges hospitals to quickly identify and respond to communicable diseases and the carriage of MDRO. A rapid response is necessary to optimize the treatment of infectious diseases amongst asylum seekers to maximize infection control.
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Affiliation(s)
- Sofanne J. Ravensbergen
- Department of Internal Medicine/Infectious Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Mariëtte Lokate
- Department of Medical Microbiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Darren Cornish
- Primary Health Care Centre for Asylum Seekers (Gezondheidscentrum Asielzoekers), Ter Apel, The Netherlands
| | - Eveline Kloeze
- Department of Internal Medicine/Infectious Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Alewijn Ott
- Department of Medical Microbiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Medical Microbiology, Certe, Groningen, The Netherlands
| | - Alex W. Friedrich
- Department of Medical Microbiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Rob van Hest
- Department of Tuberculosis Control, Regional Public Health Service Groningen, Groningen, The Netherlands
| | - Onno W. Akkerman
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Wiel C. de Lange
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Tjip S. van der Werf
- Department of Internal Medicine/Infectious Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Erik Bathoorn
- Department of Medical Microbiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Ymkje Stienstra
- Department of Internal Medicine/Infectious Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- * E-mail:
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Leblebicioglu H, Rodriguez-Morales AJ, Rossolini GM, López-Vélez R, Zahar JR, Rello J. Management of infections in critically ill returning travellers in the intensive care unit-I: considerations on infection control and transmission of resistance. Int J Infect Dis 2016; 48:113-7. [PMID: 27134158 PMCID: PMC7110831 DOI: 10.1016/j.ijid.2016.04.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 04/19/2016] [Accepted: 04/21/2016] [Indexed: 01/30/2023] Open
Abstract
Person-to-person transmission is the most important means of transmission. Malaria remains by far the most important cause of death. Surveillance strategies based on epidemiological data (country visited, duration of travel, and time elapsed since return) and clinical syndromes associated with a systematic search policy are usually mandatory to limit the risk of an outbreak. Hospitalization in a single-bed room and isolation according to symptoms should be the rule while awaiting laboratory test results.
Depending on their destinations and activities, international travellers are at a significant risk of contracting both communicable and non-communicable diseases. On return to their home countries, such travellers may require intensive care. The emergence of severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV), and more recently Ebola haemorrhagic fever, has highlighted the risks. Other well-known communicable pathogens such as methicillin-resistant Staphylococcus aureus and carbapenemase-producing Enterobacteriaceae have been described previously. However, malaria remains by far the most important cause of death. The issues related to imported antibiotic resistance and protection from highly contagious diseases are reviewed here. Surveillance strategies based on epidemiological data (country visited, duration of travel, and time elapsed since return) and clinical syndromes, together with systematic search policies, are usually mandatory to limit the risk of an outbreak. Single-bed hospital rooms and isolation according to symptoms should be the rule while awaiting laboratory test results. Because person-to-person contact is the main route of transmission, healthcare workers should implement specific prevention strategies.
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Affiliation(s)
- Hakan Leblebicioglu
- Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University Medical School, Samsun, Turkey
| | - Alfonso J Rodriguez-Morales
- Public Health and Infection Research Group, Faculty of Health Sciences, Universidad Tecnológica de Pereira, Pereira, Risaralda, Colombia
| | - Gian Maria Rossolini
- Department of Medical Biotechnologies, University of Siena, Siena, Italy; Department of Experimental and Clinical Medicine, University of Florence, and Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Rogelio López-Vélez
- National Referral Unit for Tropical Diseases, Infectious Diseases Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - Jean-Ralph Zahar
- Infection Control Unit, Université d'Angers, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Jordi Rello
- CIBERES, Vall Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Hassing RJ, Alsma J, Arcilla MS, van Genderen PJ, Stricker BH, Verbon A. International travel and acquisition of multidrug-resistant Enterobacteriaceae: a systematic review. ACTA ACUST UNITED AC 2016; 20:30074. [PMID: 26625301 DOI: 10.2807/1560-7917.es.2015.20.47.30074] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 09/23/2015] [Indexed: 12/18/2022]
Abstract
International travel is considered to be an important risk factor for acquisition of multidrug-resistant Enterobacteriaceae (MRE). The aim of this systematic review was to determine the effect of international travel on the risk of post-travel faecal carriage of MRE. Secondary outcomes were risk factors for acquisition of MRE. A systematic search for relevant literature in seven international databases was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles needed to report on (i) foreign travel, (ii) screening of asymptomatic participants, (iii) antimicrobial susceptibility data and (iv) faecal Enterobacteriaceae carriage. Two researchers independently screened the abstracts, assessed the full article texts for eligibility and selected or rejected them for inclusion in the systematic review. In case of disagreement, a third researcher decided on inclusion. Eleven studies were identified. In all studies, a high prevalence (>20%) of carriage of MRE after international travel was found. The highest prevalence was observed in travellers returning from southern Asia. Foreign travel was associated with an increased risk of carriage of MRE. Further research is needed to assess if this leads to an increase in the number of infections with MRE. Systematic review registration number: PROSPERO CRD42015024973.
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Affiliation(s)
- Robert Jan Hassing
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
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Baran I, Aksu N. Phenotypic and genotypic characteristics of carbapenem-resistant Enterobacteriaceae in a tertiary-level reference hospital in Turkey. Ann Clin Microbiol Antimicrob 2016; 15:20. [PMID: 27048322 PMCID: PMC4822248 DOI: 10.1186/s12941-016-0136-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 03/29/2016] [Indexed: 01/25/2023] Open
Abstract
Background Enterobacteriaceae are among the most common pathogens that are responsible for serious community-acquired, hospital-acquired, and health-care associated infections. The emergence and spread of carbapenem-resistant Enterobacteriaceae (CRE) have become an increasing concern for healthcare services worldwide. Infections caused by these bacteria have been associated with significant morbidity and mortality and treatment options have been limited. The rapid and accurate detection of carbapenem resistance in these bacteria is important for infection control. The aim of this study was to investigate the phenotypic and genotypic features of CRE strains isolated in a tertiary-level reference hospital in Turkey. Methods A total of 181 CRE strains were included in the study. Antimicrobial susceptibility rates were tested using Vitek 2 system. Modified Hodge test (MHT) was performed using meropenem and ertapenem discs. Metallo-β-lactamase antimicrobial gradient test (E-test MBL strips) were used for evaluation of metallo-β-lactamase production. A multiplex PCR was used for detection of carbapenems resistance genes (IMP, VIM, KPC, NDM-1 and OXA-48). Results The OXA-48 gene was detected in 86 strains, NDM-1 gene in six strains, VIM gene in one strain. IMP and KPC genes were not identified. Three strains produced both OXA-48 and NDM-1 and one strain produced both OXA-48 and VIM. In two patients more than one genus of OXA-48 positive CREs was isolated. Ninety-two of the isolates were multidrug-resistant. One hundred and ten isolates were MHT with meropenem (MEM-MHT) positive and 109 isolates were MHT with ertapenem (ERT-MHT) positive. Nine of the isolates were positive with E-test MBL strips. The sensitivity of MEM-MHT and ERT-MHT for detection of OXA-48 was 70.9 and 70.6 %, respectively. MEM-MHT was found highly discriminative for OXA-48 Escherichia coli (p < 0.001). The sensitivity of E-test MBL for NDM-1 was 66.7 %. A statistically significant correlation was observed between OXA-48 gene and MHT positivity and between NDM-1, VIM gene and E-test MBL positivity (p < 0.001). Conclusions OXA-48 gene is spreading rapidly to many different species of Enterobacteriaceae in the hospital environment. While OXA-48 is still the most common source of carbapenem resistance in Enterobacteriaceae in our country, NDM-1 is increasingly being isolated from patients without a history of foreign contact.
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Affiliation(s)
- Irmak Baran
- Department of Microbiology, Ankara Numune Training and Research Hospital, Talatpaşa Bulvarı No:5 Altındağ, 06100, Ankara, Turkey. .,, Esat Caddesi 101/3 Küçükesat, 06660, Ankara, Turkey.
| | - Neriman Aksu
- Department of Microbiology, Ankara Numune Training and Research Hospital, Talatpaşa Bulvarı No:5 Altındağ, 06100, Ankara, Turkey
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Ebrahimi F, Mózes J, Mészáros J, Juhász Á, Majoros L, Szarka K, Kardos G. Asymptomatic faecal carriage of ESBL producing enterobacteriaceae in Hungarian healthy individuals and in long-term care applicants: A shift towards CTX-M producers in the community. Infect Dis (Lond) 2016; 48:557-9. [PMID: 26982242 DOI: 10.3109/23744235.2016.1155734] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Faecal carriage of extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae in healthy individuals was examined and compared to previous results obtained in such individuals a few years earlier. Methods Faecal samples from 779 individuals screened for employment purposes and from 225 applicants to long-term care (LTC) were screened between November 2013 and May 2014. Results The overall rate of faecal carriage was 3.0% (30/1004). The carriage rate was significantly higher in applicants for LTC (5.3% vs 2.3%; p = 0.019). All isolates carried CTX-M ESBLs, with an overwhelming dominance of blaCTX-M-15 (84.4%) in both groups and in both E. coli and Klebsiella pneumoniae. Conclusions The prevalences were comparable to those in the earlier study, but a marked decrease of the diversity of ESBL genes in E. coli from the employment screening group was found, suggesting that the ESBL-producing isolates originating from diverse sources are being replaced by highly successful blaCTX-M-15 producing strains.
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Affiliation(s)
- Fatemeh Ebrahimi
- a Department of Medical Microbiology , University of Debrecen , Debrecen , Hungary
| | - Julianna Mózes
- a Department of Medical Microbiology , University of Debrecen , Debrecen , Hungary
| | - Júlia Mészáros
- b Synlab Ltd. , Microbiology Debrecen , Debrecen , Hungary
| | - Ágnes Juhász
- b Synlab Ltd. , Microbiology Debrecen , Debrecen , Hungary
| | - László Majoros
- a Department of Medical Microbiology , University of Debrecen , Debrecen , Hungary
| | - Krisztina Szarka
- a Department of Medical Microbiology , University of Debrecen , Debrecen , Hungary
| | - Gábor Kardos
- a Department of Medical Microbiology , University of Debrecen , Debrecen , Hungary
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Blyth DM, Mende K, Maranich AM, Beckius ML, Harnisch KA, Rosemann CA, Zera WC, Murray CK, Akers KS. Antimicrobial resistance acquisition after international travel in U.S. travelers. TROPICAL DISEASES TRAVEL MEDICINE AND VACCINES 2016; 2:4. [PMID: 28883948 PMCID: PMC5531010 DOI: 10.1186/s40794-016-0020-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 02/20/2016] [Indexed: 11/12/2022]
Abstract
Background Prior studies have shown an increase in multidrug-resistant (MDR) E. coli colonization from two percent in U.S.-based to 11 % in deployed, healthy military personnel. It is unclear if colonization with MDR organisms occurs through deployment exposures or risks related to routine overseas travel. This study prospectively evaluates rates and risk factors associated with MDR gram-negative bacterial and methicillin-resistant S. aureus (MRSA) colonization after international travel. Methods Participants traveled internationally for five or more days. Pre- and post-travel, colonizing bacteria from oropharyngeal, nares, groin, and peri-rectal (PR) areas were collected using BD CultureSwab™ MaxV(+). Identification and susceptibilities were done utilizing the BD Phoenix™ Automated Microbiology System. Non-MDR pre- and post-travel MDR bacteria within a subject were compared by pulsed-field gel electrophoresis (PFGE). A questionnaire solicited demographics and potential risk factors for MDR acquisition. Results Of 58 participants, 41 % were male and median age was 64 years. Pre- and post-travel swabs were obtained a median of ten and seven days before and after travel, respectively. Itineraries included 18 participants traveling to the Caribbean and Central America, 17 to Asia, 16 to Africa, 5 to Europe, 4 to South and North America. Seventeen of 22 travelers used atovaquone/proguanil for malaria prophylaxis. The only MDR organism isolated was extended-spectrum β-lactamase (ESBL)-producing E. coli in five (9 %) participants post-travel (all PR and unrelated by PFGE). There were no statistically significant associations between exposure risks and new ESBL-producing E.coli colonization. Of 36 participants colonized with E. coli pre- and post-travel, new resistance was detected: TMP/SMX in 42 % of isolates (p < 0.01), tetracycline in 44 % (p < 0.01), and ampicillin-sulbactam in 33 % (p = 0.09). No participants were colonized with MRSA pre- or post-travel. Conclusion Consistent with prior studies, new antimicrobial resistance was noted in colonizing E. coli after international travel. Nine percent of participants acquired new strains of ESBL-producing E.coli without identified risks.
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Affiliation(s)
- Dana M Blyth
- Infectious Disease Service, San Antonio Military Medical Center, JBSA Fort Sam Houston, 3551 Roger Brooke Drive, Houston, Texas 78234-4505 USA
| | - Katrin Mende
- Infectious Disease Service, San Antonio Military Medical Center, JBSA Fort Sam Houston, 3551 Roger Brooke Drive, Houston, Texas 78234-4505 USA.,Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland USA
| | - Ashley M Maranich
- Pediatric Infectious Disease Service, San Antonio Military Medical Center, JBSA Fort Sam Houston, Houston, Texas USA
| | - Miriam L Beckius
- Infectious Disease Service, San Antonio Military Medical Center, JBSA Fort Sam Houston, 3551 Roger Brooke Drive, Houston, Texas 78234-4505 USA
| | - Kristie A Harnisch
- Infectious Disease Service, San Antonio Military Medical Center, JBSA Fort Sam Houston, 3551 Roger Brooke Drive, Houston, Texas 78234-4505 USA
| | - Crystal A Rosemann
- Infectious Disease Service, San Antonio Military Medical Center, JBSA Fort Sam Houston, 3551 Roger Brooke Drive, Houston, Texas 78234-4505 USA
| | - Wendy C Zera
- Infectious Disease Service, San Antonio Military Medical Center, JBSA Fort Sam Houston, 3551 Roger Brooke Drive, Houston, Texas 78234-4505 USA.,Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland USA
| | - Clinton K Murray
- Infectious Disease Service, San Antonio Military Medical Center, JBSA Fort Sam Houston, 3551 Roger Brooke Drive, Houston, Texas 78234-4505 USA
| | - Kevin S Akers
- Infectious Disease Service, San Antonio Military Medical Center, JBSA Fort Sam Houston, 3551 Roger Brooke Drive, Houston, Texas 78234-4505 USA.,U.S. Army Institute for Surgical Research, JBSA Fort Sam Houston, Houston, Texas USA
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Haque M, Rahman NIA, Zulkifli Z, Ismail S. Antibiotic prescribing and resistance: knowledge level of medical students of clinical years of University Sultan Zainal Abidin, Malaysia. Ther Clin Risk Manag 2016; 12:413-26. [PMID: 27042083 PMCID: PMC4795448 DOI: 10.2147/tcrm.s102013] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The innovation of penicillin by Dr Alexander Fleming in 1928 and its use in clinical practice saved many lives, especially during the Second World War. Tuberculosis still carries a significant public health threat and has re-emerged over the past two decades, even in modern countries where tuberculosis was thought to be eliminated. The World Health Organization defines antimicrobial resistance as the resistance of a microorganism to an antimicrobial drug that was initially effective for treatment of infections caused by the microbe. Therefore, the findings of the current study will provide data to enable the design of a new educational program to better equip our students in confronting antimicrobial resistance. This study was a cross-sectional, questionnaire-based survey, which was undertaken in the Faculty of Medicine, Universiti Sultan Zainal Abidin, Kuala Terengganu, Malaysia. The study participants were students of the Bachelor of Medicine and Bachelor of Surgery program (MBBS) of Year III, IV, and V. A total of 142 out of 164 (86%) medical students returned the questionnaire. Specifically, the year-wise breakdown of responses was 29% (41), 39% (55), and 32% (45) for Year III, IV, and V, respectively. Among the study respondents, 28% (40) were male, and the remaining 72% (102) were female. In all, 67% of the participants felt more confident in "making an accurate diagnosis of infection/sepsis." The majority (88%) of the study participants stated that they would like more training on antibiotic selection. This research has found that there is a gap between theoretical input and clinical practice; the students are demanding more educational intervention to face the threat of antimicrobial resistance.
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Affiliation(s)
- Mainul Haque
- Faculty of Medicine, Universiti Sultan Zainal Abidin, Kuala Terengganu, Terengganu, Malaysia
| | - Nor Iza A Rahman
- Faculty of Medicine, Universiti Sultan Zainal Abidin, Kuala Terengganu, Terengganu, Malaysia
| | - Zainal Zulkifli
- Faculty of Medicine, Universiti Sultan Zainal Abidin, Kuala Terengganu, Terengganu, Malaysia
| | - Salwani Ismail
- Faculty of Medicine, Universiti Sultan Zainal Abidin, Kuala Terengganu, Terengganu, Malaysia
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Ribeiro TG, Novais Â, Peixe L, Machado E. Atypical epidemiology of CTX-M-15 among Enterobacteriaceae from a high diversity of non-clinical niches in Angola: Table 1. J Antimicrob Chemother 2016; 71:1169-73. [DOI: 10.1093/jac/dkv489] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 12/18/2015] [Indexed: 11/14/2022] Open
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Colistin-Nonsusceptible Pseudomonas aeruginosa Sequence Type 654 with blaNDM-1 Arrives in North America. Antimicrob Agents Chemother 2016; 60:1794-800. [PMID: 26824951 DOI: 10.1128/aac.02591-15] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 11/28/2015] [Indexed: 01/05/2023] Open
Abstract
This study describes 3 different blaNDM-1 genetic platforms in 3 different species obtained from the same patient who was directly transferred to an institution in Calgary, Alberta, Canada, following a prolonged hospital stay in India. The blaNDM-1 in the Escherichia coli isolate was located on a 176-kb IncA/C plasmid contained within an ISCR1 region. The blaNDM-1 in the Providencia rettgeri isolate was located on a 117-kb IncT plasmid contained within Tn3000, while the blaNDM-1 in the Pseudomonas aeruginosa isolate was located on the chromosome within an ISCR3 region. This report highlights the plasticity of the genetic regions and environments associated with blaNDM-1. To the best of our knowledge, this is the first report of P. aeruginosa with blaNDM-1 identified in North America and the first report of blaOXA-181 in P. rettgeri. The P. aeruginosa isolate belonged to the international high-risk sequence type 654 clone and was nonsusceptible to colistin. This case emphasizes the need for the use of appropriate infection prevention and control measures and vigilant screening for carbapenem-resistant Gram-negative bacteria in patients with a history of travel to areas of endemicity, such as the Indian subcontinent.
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Molecular Characterization by Using Next-Generation Sequencing of Plasmids Containing blaNDM-7 in Enterobacteriaceae from Calgary, Canada. Antimicrob Agents Chemother 2015; 60:1258-63. [PMID: 26643346 DOI: 10.1128/aac.02661-15] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 12/02/2015] [Indexed: 12/24/2022] Open
Abstract
Enterobacteriaceae with blaNDM-7 are relatively uncommon and had previously been described in Europe, India, the United States, and Japan. This study describes the characteristics of Enterobacteriaceae (Klebsiella pneumoniae [n = 2], Escherichia coli [n = 2], Serratia marcescens [n = 1], and Enterobacter hormaechei [n = 1] isolates) with blaNDM-7 obtained from 4 patients from Calgary, Canada, from 2013 to 2014. The 46,161-bp IncX3 plasmids with blaNDM-7 are highly similar to other blaNDM-harboring IncX3 plasmids and, interestingly, showed identical structures within the different isolates. This finding may indicate horizontal transmission within our health region, or it may indicate contact with individuals from areas of endemicity within the hospital setting. Patients infected or colonized with bacteria containing blaNDM-7 IncX3 plasmids generate infection control challenges. Epidemiological and molecular studies are required to better understand the dynamics of transmission, the risk factors, and the reservoirs for bacteria harboring blaNDM-7. To the best of our knowledge, this is the first report of S. marcescens and E. hormaechei with blaNDM-7.
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Johnning A, Kristiansson E, Angelin M, Marathe N, Shouche YS, Johansson A, Larsson DGJ. Quinolone resistance mutations in the faecal microbiota of Swedish travellers to India. BMC Microbiol 2015; 15:235. [PMID: 26498929 PMCID: PMC4619388 DOI: 10.1186/s12866-015-0574-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 10/16/2015] [Indexed: 01/03/2023] Open
Abstract
Background International travel contributes to the spread of antibiotic resistant bacteria over the world. Most studies addressing travel-related changes in the faecal flora have focused on specific mobile resistance genes, or depended on culturing of individual bacterial isolates. Antibiotic resistance can, however, also spread via travellers colonized by bacteria carrying chromosomal antibiotic resistance mutations, but this has received little attention so far. Here we aimed at exploring the abundance of chromosomal quinolone resistance mutations in Escherichia communities residing in the gut of Swedish travellers, and to determine potential changes after visiting India. Sweden is a country with a comparably low degree of quinolone use and quinolone resistance, whereas the opposite is true for India. Methods Massively parallel amplicon sequencing targeting the quinolone-resistance determining region of gyrA and parC was applied to total DNA extracted from faecal samples. Paired samples were collected from 12 Swedish medical students before and after a 4–15 week visit to India. Twelve Indian residents were included for additional comparisons. Methods known resistance mutations were common in Swedes before travel as well as in Indians, with a trend for all mutations to be more common in the Indian sub group. There was a significant increase in the abundance of the most common amino acid substitution in GyrA (S83L, from 44 to 72 %, p = 0.036) in the samples collected after return to Sweden. No other substitution, including others commonly associated with quinolone resistance (D87N in GyrA, S80I in ParC) changed significantly. The number of distinct genotypes encoded in each traveller was significantly reduced after their visit to India for both GyrA (p = 0.0020) and ParC (p = 0.0051), indicating a reduced genetic diversity, similar to that found in the Indians. Conclusions International travel can alter the composition of the Escherichia communities in the faecal flora, favouring bacteria carrying certain resistance mutations, and, thereby, contributes to the global spread of antibiotic resistance. A high abundance of specific mutations in Swedish travellers before visiting India is consistent with the hypothesis that these mutation have no fitness cost even in the absence of an antibiotic selection pressure. Electronic supplementary material The online version of this article (doi:10.1186/s12866-015-0574-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Johnning
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Guldhedsgatan 10, SE-413 46, Gothenburg, Sweden. .,Department of Mathematical Sciences, Chalmers University of Technology, SE-412 96, Gothenburg, Sweden.
| | - Erik Kristiansson
- Department of Mathematical Sciences, Chalmers University of Technology, SE-412 96, Gothenburg, Sweden.
| | - Martin Angelin
- Department of Clinical Microbiology, Infectious Diseases, Umeå University, SE-901 85, Umeå, Sweden.
| | - Nachiket Marathe
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Guldhedsgatan 10, SE-413 46, Gothenburg, Sweden. .,Microbial Culture Collection, National Centre for Cell Science, Ganeshkhind, Pune, 411 007, India.
| | - Yogesh S Shouche
- Microbial Culture Collection, National Centre for Cell Science, Ganeshkhind, Pune, 411 007, India.
| | - Anders Johansson
- Laboratory for Molecular Infection Medicine Sweden, Department of Clinical Microbiology, Bacteriology, Umeå University, SE- 901 87, Umeå, Sweden.
| | - D G Joakim Larsson
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Guldhedsgatan 10, SE-413 46, Gothenburg, Sweden.
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131
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van der Steen M, Leenstra T, Kluytmans JAJW, van der Bij AK. Trends in Expanded-Spectrum Cephalosporin-Resistant Escherichia coli and Klebsiella pneumoniae among Dutch Clinical Isolates, from 2008 to 2012. PLoS One 2015; 10:e0138088. [PMID: 26381746 PMCID: PMC4575062 DOI: 10.1371/journal.pone.0138088] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 08/26/2015] [Indexed: 11/25/2022] Open
Abstract
We investigated time trends in extended-spectrum cephalosporin-resistant Escherichia coli and Klebsiella pneumoniae isolates from different patient settings in The Netherlands from 2008–2012. E. coli and K. pneumoniae isolates from blood and urine samples of patients > = 18 years were selected from the Dutch Infectious Disease Surveillance System-Antimicrobial Resistance (ISIS-AR) database. We used multivariable Poisson regression to study the rate per year of blood stream infections by susceptible and resistant isolates, and generalized estimating equation (GEE) log-binomial regression for trends in the proportion of extended-spectrum cephalosporin-resistant isolates. Susceptibility data of 197,513 E. coli and 38,244 K. pneumoniae isolates were included. The proportion of extended-spectrum cephalosporin-resistant E. coli and K. pneumoniae isolates from urine and blood samples increased in all patient settings, except for K. pneumoniae isolates from patients admitted to intensive care units. For K. pneumoniae, there was a different time trend between various patient groups (p<0.01), with a significantly higher increase in extended-spectrum cephalosporin-resistant isolates from patients attending a general practitioner than in isolates from hospitalized patients. For E. coli, the increasing time trends did not differ among different patient groups. This nationwide study shows a general increase in extended-spectrum cephalosporin-resistant E. coli and K. pneumoniae isolates. However, differences in trends between E. coli en K. pneumoniae underline the importance of E. coli as a community-pathogen and its subsequent influence on hospital resistance level, while for K. pneumoniae the level of resistance within the hospital seems less influenced by the resistance trends in the community.
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Affiliation(s)
- Matthijs van der Steen
- Centre for Infectious disease control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
- Faculty of Earth and Life Sciences, VU University, Amsterdam, the Netherlands
| | - Tjalling Leenstra
- Centre for Infectious disease control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Jan A. J. W. Kluytmans
- Department of Medical Microbiology and Infection Control, VU Medical Center (VUmc), Amsterdam, the Netherlands
- Laboratory for Microbiology and Infection Control, Amphia Hospital, Breda, The Netherlands
| | - Akke K. van der Bij
- Centre for Infectious disease control (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
- Department of Medical Microbiology, Reinier de Graaf Groep, Delft, the Netherlands
- * E-mail:
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132
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Gillings MR, Paulsen IT, Tetu SG. Ecology and Evolution of the Human Microbiota: Fire, Farming and Antibiotics. Genes (Basel) 2015; 6:841-57. [PMID: 26371047 PMCID: PMC4584332 DOI: 10.3390/genes6030841] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 08/26/2015] [Accepted: 08/31/2015] [Indexed: 01/15/2023] Open
Abstract
Human activities significantly affect all ecosystems on the planet, including the assemblages that comprise our own microbiota. Over the last five million years, various evolutionary and ecological drivers have altered the composition of the human microbiota, including the use of fire, the invention of agriculture, and the increasing availability of processed foods after the Industrial Revolution. However, no factor has had a faster or more direct effect than antimicrobial agents. Biocides, disinfectants and antibiotics select for individual cells that carry resistance genes, immediately reducing both overall microbial diversity and within-species genetic diversity. Treated individuals may never recover their original diversity, and repeated treatments lead to a series of genetic bottlenecks. The sequential introduction of diverse antimicrobial agents has selected for increasingly complex DNA elements that carry multiple resistance genes, and has fostered their spread through the human microbiota. Practices that interfere with microbial colonization, such as sanitation, Caesarian births and bottle-feeding, exacerbate the effects of antimicrobials, generating species-poor and less resilient microbial assemblages in the developed world. More and more evidence is accumulating that these perturbations to our internal ecosystems lie at the heart of many diseases whose frequency has shown a dramatic increase over the last half century.
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Affiliation(s)
- Michael R Gillings
- Department of Biological Sciences, Macquarie University, Sydney, NSW 2109, Australia.
| | - Ian T Paulsen
- Department of Chemistry and Biomolecular Sciences, Macquarie University, Sydney, NSW 2109, Australia.
| | - Sasha G Tetu
- Department of Chemistry and Biomolecular Sciences, Macquarie University, Sydney, NSW 2109, Australia.
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Angue M, Allou N, Belmonte O, Lefort Y, Lugagne N, Vandroux D, Montravers P, Allyn J. Risk Factors for Colonization With Multidrug-Resistant Bacteria Among Patients Admitted to the Intensive Care Unit After Returning From Abroad. J Travel Med 2015; 22:300-5. [PMID: 26081076 DOI: 10.1111/jtm.12220] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/23/2015] [Accepted: 04/28/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Few national recommendations exist on management of patients returning from abroad and all focus on hospitalized patients. Our purpose was to compare, in an intensive care unit (ICU), the admission prevalence and acquisition of multidrug-resistant (MDR) bacteria carriage in patients with ("Abroad") or without ("Local") a recent stay abroad, and then identify the risk factors in "Abroad" patients. METHODS In this retrospective study, we reviewed charts of all the patients hospitalized in the ICU unit from January 2011 through July 2013 with hygiene samplings performed. We identified all patients who had stayed abroad ("Abroad") within 6 months prior to ICU admission. RESULTS Of 1,842 ICU patients, 129 (7%) "Abroad" patients were reported. In the "Abroad" group, the rate of MDR strain carriage was higher at admission (33% vs 6.7%, p < 0.001) and also more often diagnosed during the ICU stay (acquisition rate: 17% vs 5.2%, p < 0.001) than in "Local" patients. Risk factors associated with MDR bacteria carriage at admission in "Abroad" patients were diabetes mellitus [odds ratio (OR) 5.1 (1.7-14.8), p = 0.003] and "hospitalization abroad with antibiotic treatment" [OR 10.7 (4.2-27.3), p < 0.001]. Hospitalization abroad without antibiotic treatment was not identified as a risk factor. CONCLUSIONS The main factor associated with MDR bacteria carriage after a stay abroad seems to be a hospitalization abroad only in case of antibiotic treatment abroad. Screening and isolation of "Abroad" patients should be recommended, even in case of a first negative screening.
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Affiliation(s)
- Marion Angue
- Intensive Care Unit, CHU Félix Guyon, Saint-Denis, France
| | - Nicolas Allou
- Intensive Care Unit, CHU Félix Guyon, Saint-Denis, France
| | | | - Yannick Lefort
- Intensive Care Unit, CHU Félix Guyon, Saint-Denis, France
| | | | - David Vandroux
- Intensive Care Unit, CHU Félix Guyon, Saint-Denis, France
| | - Philippe Montravers
- Département Anesthésie Réanimation, AP-HP, Hop Bichat-Claude Bernard, Paris, France.,Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Jérôme Allyn
- Intensive Care Unit, CHU Félix Guyon, Saint-Denis, France
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134
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The Human Gut Microbiome as a Transporter of Antibiotic Resistance Genes between Continents. Antimicrob Agents Chemother 2015; 59:6551-60. [PMID: 26259788 DOI: 10.1128/aac.00933-15] [Citation(s) in RCA: 123] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/28/2015] [Indexed: 01/10/2023] Open
Abstract
Previous studies of antibiotic resistance dissemination by travel have, by targeting only a select number of cultivable bacterial species, omitted most of the human microbiome. Here, we used explorative shotgun metagenomic sequencing to address the abundance of >300 antibiotic resistance genes in fecal specimens from 35 Swedish students taken before and after exchange programs on the Indian peninsula or in Central Africa. All specimens were additionally cultured for extended-spectrum beta-lactamase (ESBL)-producing enterobacteria, and the isolates obtained were genome sequenced. The overall taxonomic diversity and composition of the gut microbiome remained stable before and after travel, but there was an increasing abundance of Proteobacteria in 25/35 students. The relative abundance of antibiotic resistance genes increased, most prominently for genes encoding resistance to sulfonamide (2.6-fold increase), trimethoprim (7.7-fold), and beta-lactams (2.6-fold). Importantly, the increase observed occurred without any antibiotic intake. Of 18 students visiting the Indian peninsula, 12 acquired ESBL-producing Escherichia coli, while none returning from Africa were positive. Despite deep sequencing efforts, the sensitivity of metagenomics was not sufficient to detect acquisition of the low-abundant genes responsible for the observed ESBL phenotype. In conclusion, metagenomic sequencing of the intestinal microbiome of Swedish students returning from exchange programs in Central Africa or the Indian peninsula showed increased abundance of genes encoding resistance to widely used antibiotics.
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135
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The role of epidemic resistance plasmids and international high-risk clones in the spread of multidrug-resistant Enterobacteriaceae. Clin Microbiol Rev 2015; 28:565-91. [PMID: 25926236 DOI: 10.1128/cmr.00116-14] [Citation(s) in RCA: 556] [Impact Index Per Article: 61.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Escherichia coli sequence type 131 (ST131) and Klebsiella pneumoniae ST258 emerged in the 2000s as important human pathogens, have spread extensively throughout the world, and are responsible for the rapid increase in antimicrobial resistance among E. coli and K. pneumoniae strains, respectively. E. coli ST131 causes extraintestinal infections and is often fluoroquinolone resistant and associated with extended-spectrum β-lactamase production, especially CTX-M-15. K. pneumoniae ST258 causes urinary and respiratory tract infections and is associated with carbapenemases, most often KPC-2 and KPC-3. The most prevalent lineage within ST131 is named fimH30 because it contains the H30 variant of the type 1 fimbrial adhesin gene, and recent molecular studies have demonstrated that this lineage emerged in the early 2000s and was then followed by the rapid expansion of its sublineages H30-R and H30-Rx. K. pneumoniae ST258 comprises 2 distinct lineages, namely clade I and clade II. Moreover, it seems that ST258 is a hybrid clone that was created by a large recombination event between ST11 and ST442. Epidemic plasmids with blaCTX-M and blaKPC belonging to incompatibility group F have contributed significantly to the success of these clones. E. coli ST131 and K. pneumoniae ST258 are the quintessential examples of international multidrug-resistant high-risk clones.
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136
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First Report and Molecular Characterization of a Campylobacter jejuni Isolate with Extensive Drug Resistance from a Travel-Associated Human Case. Antimicrob Agents Chemother 2015; 59:6670-2. [PMID: 26239988 DOI: 10.1128/aac.01395-15] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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137
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Hout B, Oum C, Men P, Vanny V, Supaprom C, Heang V, Rachmat A, Prouty M, Newell S, Harrison D, Noor S, Gollogly J, Tho L, Kim YJ, Ford G. Drug resistance in bacteria isolated from patients presenting with wounds at a non-profit Surgical Center in Phnom Penh, Cambodia from 2011-2013. TROPICAL DISEASES TRAVEL MEDICINE AND VACCINES 2015; 1:4. [PMID: 28883936 PMCID: PMC5526368 DOI: 10.1186/s40794-015-0006-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 06/29/2015] [Indexed: 12/23/2022]
Abstract
Background Emerging antibiotic resistance amongst clinically significant bacteria is a public health issue of increasing significance worldwide, but it is relatively uncharacterized in Cambodia. In this study we performed standard bacterial cultures on samples from wounds at a Non-Governmental-Organization (NGO) Hospital in Phnom Penh, Cambodia. Testing was performed to elucidate pathogenic bacteria causing wound infections and the antibiotic resistance profiles of bacterial isolates. All testing was performed at the Naval Medical Research Unit, No.2 (NAMRU-2) main laboratory in Phnom Penh, Cambodia. Methods Between 2011–2013, a total of 251 specimens were collected from patients at the NGO hospital and analyzed for bacterial infection by standard bacterial cultures techniques. Specimens were all from wounds and anonymous. No specific clinical information accompanied the submitted specimens. Antibiotic susceptibility testing, and phenotypic testing for extended-spectrum beta-lactamase (ESBL) were performed and reported based on CLSI guidelines. Further genetic testing for CTX-M, TEM and SHV ESBLs was accomplished using PCR. Results One-hundred and seventy-six specimens were positive following bacterial culture (70 %). Staphlycoccus aureus was the most frequently isolated bacteria. Antibiotic drug resistance testing revealed that 52.5 % of Staphlycoccus aureus isolates were oxacillin resistant. For Escherichia coli isolates, 63.9 % were ciprofloxacin and levofloxacin resistant and 96 % were ESBL producers. Resistance to meropenem and imipenem was observed in one of three Acinetobacter spp isolates. Conclusions This study is the first of its kind detailing the antibiotic resistance profiles of pathogenic bacteria causing wound infections at a single surgical hospital in Cambodia. The reported findings of this study demonstrate significant antibiotic resistance in bacteria from injured patients and should serve to guide treatment modalities in Cambodia.
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Affiliation(s)
- Boren Hout
- Naval Medical Research Unit - No.2, Phnom Penh, Cambodia
| | - Chamroeun Oum
- Naval Medical Research Unit - No.2, Phnom Penh, Cambodia
| | - Putheavy Men
- Naval Medical Research Unit - No.2, Phnom Penh, Cambodia
| | | | | | - Vireak Heang
- Naval Medical Research Unit - No.2, Phnom Penh, Cambodia
| | - Agus Rachmat
- Naval Medical Research Unit - No.2, Phnom Penh, Cambodia
| | - Michael Prouty
- Naval Medical Research Unit - No.2, Phnom Penh, Cambodia
| | - Steven Newell
- Naval Medical Research Unit - No.2, Phnom Penh, Cambodia
| | | | - Saqib Noor
- Children's Surgical Center, Phnom Penh, Cambodia
| | | | - Ly Tho
- Children's Surgical Center, Phnom Penh, Cambodia
| | | | - Gavin Ford
- Naval Medical Research Unit - No.2, Phnom Penh, Cambodia.,Department of Infectious Diseases, Walter Reed National Military Medical Center, Bethesda, MD USA
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Costa Ramos JM, Stein C, Pfeifer Y, Brandt C, Pletz MW, Makarewicz O. Mutagenesis of the CTX-M-type ESBL-is MIC-guided treatment according to the new EUCAST recommendations a safe approach? J Antimicrob Chemother 2015; 70:2528-35. [PMID: 26071519 DOI: 10.1093/jac/dkv153] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 05/15/2015] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Spurred by the latest EUCAST and CLSI recommendation to adjust antibiotic therapy on the basis of MICs instead of resistance mechanisms, we aimed to investigate the ability of CTX-M-1 and CTX-M-14 to achieve ceftazidime resistance under selective conditions. METHODS We exposed Escherichia coli transconjugants bearing natural plasmids that express CTX-M-1, CTX-M-14 or CTX-M-15 to various selective culture conditions and tracked their growth and mutational frequencies. For selected mutants we analysed the sequences of the bla CTX-M genes, determined the altered MICs of cefotaxime, cefepime, ceftazidime and meropenem, and measured the efflux properties and the changes in transcriptional levels of bla CTX-M genes. RESULTS The CTX-M-1- and CTX-M-14-bearing clones switched from ceftazidime-susceptible to ceftazidime-resistant phenotypes under selective conditions within 24 h. However, no mutations within the bla CTX-M genes were found, and the efflux was unlikely to be involved in the increased ceftazidime MICs. In CTX-M-1-bearing clones bla CTX-M-1 expression was 19-fold increased under ceftazidime-selective conditions but there was a high variance within the clones. Reasons for increased ceftazidime MICs of CTX-M-bearing clones remain unclear but might be the increased enzymatic activity or other intrachromosomal mutations. CONCLUSIONS It can be speculated that different strategies to survive under selective conditions can be adopted by E. coli, thereby establishing an optimal mechanism with the lowest energy demand for each transconjugant. Based on our in vitro findings, we cannot fully recommend the use of ceftazidime, particularly in critically ill patients with infections due to ESBL producers, regardless of susceptibility to ceftazidime.
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Affiliation(s)
- João M Costa Ramos
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Erlanger Allee 101, D-07747 Jena, Germany
| | - Claudia Stein
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Erlanger Allee 101, D-07747 Jena, Germany
| | - Yvonne Pfeifer
- Nosocomial Pathogens and Antibiotic Resistance, Robert Koch Institute, Burgstrasse 37, D-8855 Wernigerode, Germany
| | - Christian Brandt
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Erlanger Allee 101, D-07747 Jena, Germany
| | - Mathias W Pletz
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Erlanger Allee 101, D-07747 Jena, Germany
| | - Oliwia Makarewicz
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Erlanger Allee 101, D-07747 Jena, Germany
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139
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Population-based epidemiology and microbiology of community-onset bloodstream infections. Clin Microbiol Rev 2015; 27:647-64. [PMID: 25278570 DOI: 10.1128/cmr.00002-14] [Citation(s) in RCA: 189] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Bloodstream infection (BSI) is a major cause of infectious disease morbidity and mortality worldwide. While a positive blood culture is mandatory for establishment of the presence of a BSI, there are a number of determinants that must be considered for establishment of this entity. Community-onset BSIs are those that occur in outpatients or are first identified <48 h after admission to hospital, and they may be subclassified further as health care associated, when they occur in patients with significant prior health care exposure, or community associated, in other cases. The most common causes of community-onset BSI include Escherichia coli, Staphylococcus aureus, and Streptococcus pneumoniae. Antimicrobial-resistant organisms, including methicillin-resistant Staphylococcus aureus and extended-spectrum β-lactamase/metallo-β-lactamase/carbapenemase-producing Enterobacteriaceae, have emerged as important etiologies of community-onset BSI.
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140
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Jans B, D Huang TD, Bauraing C, Berhin C, Bogaerts P, Deplano A, Denis O, Catry B, Glupczynski Y. Infection due to travel-related carbapenemase-producing Enterobacteriaceae, a largely underestimated phenomenon in Belgium. Acta Clin Belg 2015; 70:181-7. [PMID: 25825036 DOI: 10.1179/2295333715y.0000000001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Carbapenemase-producing Enterobacteriaceae (CPE) are emerging worldwide, representing a major threat for public health. Early CPE detection is crucial in order to prevent infections and the development of reservoirs/outbreaks in hospitals. In 2008, most of the CPE strains reported in Belgium were imported from patients repatriated from abroad. Actually, this is no longer the case. OBJECTIVES AND METHODS A surveillance was set up in Belgian hospitals (2012) in order to explore the epidemiology and determinants of CPE, including the link with international travel/hospitalization. The present article describes travel-related CPE reported in Belgium. Different other potential sources for importation of CPE are discussed. RESULTS Only 12% of all CPE cases reported in Belgium (2012-2013) were travel related (with/without hospitalization). This is undoubtedly an underestimation (missing travel data: 36%), considering the increasing tourism, the immigration from endemic countries, the growing number of foreign patients using scheduled medical care in Belgium, and the medical repatriations from foreign hospitals. The free movement of persons and services (European Union) contributes to an increase in foreign healthcare workers (HCW) in Belgian hospitals. Residents from nursing homes located at the country borders can be another potential source of dissemination of CPE between countries. Moreover, the high population density in Belgium can increase the risk for CPE-dissemination. Urban areas in Belgium may cumulate these potential risk factors for import/dissemination of CPE. CONCLUSIONS Ideally, travel history data should be obtained from hospital hygiene teams, not from the microbiological laboratory. Patients who received medical care abroad (whatever the country) should be screened for CPE at admission.
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141
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Downing T. Tackling Drug Resistant Infection Outbreaks of Global Pandemic Escherichia coli ST131 Using Evolutionary and Epidemiological Genomics. Microorganisms 2015; 3:236-67. [PMID: 27682088 PMCID: PMC5023239 DOI: 10.3390/microorganisms3020236] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 04/28/2015] [Accepted: 04/30/2015] [Indexed: 11/16/2022] Open
Abstract
High-throughput molecular screening is required to investigate the origin and diffusion of antimicrobial resistance in pathogen outbreaks. The most frequent cause of human infection is Escherichia coli, which is dominated by sequence type 131 (ST131)-a set of rapidly radiating pandemic clones. The highly infectious clades of ST131 originated firstly by a mutation enhancing conjugation and adhesion. Secondly, single-nucleotide polymorphisms occurred enabling fluoroquinolone-resistance, which is near-fixed in all ST131. Thirdly, broader resistance through beta-lactamases has been gained and lost frequently, symptomatic of conflicting environmental selective effects. This flexible approach to gene exchange is worrying and supports the proposition that ST131 will develop an even wider range of plasmid and chromosomal elements promoting antimicrobial resistance. To stop ST131, deep genome sequencing is required to understand the origin, evolution and spread of antimicrobial resistance genes. Phylogenetic methods that decipher past events can predict future patterns of virulence and transmission based on genetic signatures of adaptation and gene exchange. Both the effect of partial antimicrobial exposure and cell dormancy caused by variation in gene expression may accelerate the development of resistance. High-throughput sequencing can decode measurable evolution of cell populations within patients associated with systems-wide changes in gene expression during treatments. A multi-faceted approach can enhance assessment of antimicrobial resistance in E. coli ST131 by examining transmission dynamics between hosts to achieve a goal of pre-empting resistance before it emerges by optimising antimicrobial treatment protocols.
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Affiliation(s)
- Tim Downing
- School of Biotechnology, Faculty of Science and Health, Dublin City University, Dublin 9, Ireland.
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142
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Morrison BJ, Rubin JE. Carbapenemase producing bacteria in the food supply escaping detection. PLoS One 2015; 10:e0126717. [PMID: 25966303 PMCID: PMC4429064 DOI: 10.1371/journal.pone.0126717] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 04/07/2015] [Indexed: 11/18/2022] Open
Abstract
Carbapenem antimicrobials are critically important to human health and they are often the only remaining effective antibiotics for treating serious infections. Resistance to these drugs mediated by acquired carbapenemase enzymes is increasingly encountered in gram-negative bacteria and is considered a public health emergency. Animal origin food products are recognized as a potential source of resistant organisms, although carbapenem resistance has only recently been reported. In western countries there are active resistance surveillance programs targeting food animals and retail meat products. These programs primarily target beef, pork and poultry and focus exclusively on E. coli, Salmonella, Campylobacter spp. and Enterococcus spp. This global surveillance strategy does not capture the diversity of foods available nor does it address the presence of resistance gene-bearing mobile genetic elements in non-pathogenic bacterial taxa. To address this gap, a total of 121 seafood products originating in Asia purchased from retail groceries in Canada were tested. Samples were processed using a taxa-independent method for the selective isolation of carbapenem resistant organisms. Isolates were characterized by phenotypic antimicrobial susceptibility testing, PCR and DNA sequencing. Carbapenemase producing bacteria, all blaOXA-48, were isolated from 4 (3.3%) of the samples tested. Positive samples originated from China (n=2) and Korea (n=2) and included squid, sea squirt, clams and seafood medley. Carbapenemase producing organisms found include Pseudomonas, Stenotrophomonas and Myroides species. These findings suggest that non-pathogenic bacteria, excluded from resistance surveillance programs, in niche market meats may serve as a reservoir of carbapenemase genes in the food supply.
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Affiliation(s)
- Beverly J. Morrison
- Department of Veterinary Microbiology, University of Saskatchewan, Saskatoon, Saskatchewan Canada
| | - Joseph E. Rubin
- Department of Veterinary Microbiology, University of Saskatchewan, Saskatoon, Saskatchewan Canada
- * E-mail:
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Angelin M, Forsell J, Granlund M, Evengård B, Palmgren H, Johansson A. Risk factors for colonization with extended-spectrum beta-lactamase producing Enterobacteriaceae in healthcare students on clinical assignment abroad: A prospective study. Travel Med Infect Dis 2015; 13:223-9. [PMID: 25982453 DOI: 10.1016/j.tmaid.2015.04.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 04/24/2015] [Accepted: 04/25/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND The increase of antibiotic resistance in clinically important bacteria is a worldwide threat, especially in healthcare environments. International travel is a risk factor for gut colonization with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE). The risk for healthcare students of being colonized with ESBL-PE when participating in patient-related work abroad has not been previously investigated. METHODS Swedish healthcare students travelling for pre-clinical and clinical courses outside Scandinavia submitted faecal samples and survey data before and after travel. The faecal samples were screened for ESBL-PE and carbapenemase-producing Enterobacteriaceae (CPE). Screening results and survey data were analysed to identify risk factors for colonization. RESULTS In the 99 subjects who submitted a full set of samples, 35% were colonized with a new ESBL-PE strain during travel. No CPE was found. The most important risk factor for ESBL-PE colonization was travel destination, and the highest colonization rate was found in the South-East Asia region. Antibiotic treatment during travel was an independent risk factor for ESBL-PE colonization but patient-related work was not significantly associated with an increased risk. CONCLUSIONS Patient-related work abroad was not a risk factor for ESBL-PE suggesting that transmission from patients is uncommon. Pre-travel advice on avoiding unnecessary antibiotic treatment during travel is recommended.
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Affiliation(s)
- Martin Angelin
- Department of Clinical Microbiology, Infectious Diseases, Umeå University, SE-901 85 Umeå, Sweden.
| | - Joakim Forsell
- Department of Clinical Microbiology, Bacteriology, Umeå University, SE-901 85 Umeå, Sweden.
| | - Margareta Granlund
- Department of Clinical Microbiology, Bacteriology, Umeå University, SE-901 85 Umeå, Sweden.
| | - Birgitta Evengård
- Department of Clinical Microbiology, Infectious Diseases, Umeå University, SE-901 85 Umeå, Sweden.
| | - Helena Palmgren
- Department of Clinical Microbiology, Infectious Diseases, Umeå University, SE-901 85 Umeå, Sweden.
| | - Anders Johansson
- Laboratory for Molecular Infection Medicine Sweden, Department of Clinical Microbiology, Bacteriology, Umeå University, SE-901 85 Umeå, Sweden.
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Allyn J, Angue M, Belmonte O, Lugagne N, Traversier N, Vandroux D, Lefort Y, Allou N. Delayed diagnosis of high drug-resistant microorganisms carriage in repatriated patients: three cases in a French intensive care unit. J Travel Med 2015; 22:215-7. [PMID: 25728976 DOI: 10.1111/jtm.12194] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/07/2015] [Accepted: 01/12/2015] [Indexed: 12/27/2022]
Abstract
We report three cases of high drug-resistant microorganisms (HDRMO) carriage by patients repatriated from a foreign country. National recommendations suggest systematic screening and contact isolation pending results of admission screening of all patients recently hospitalized abroad. HDRMO carriage (carbapenem-resistant Acinetobacter baumanii and carbapenemase-producing Enterobacteriaceae) was not isolated on admission screening swabs, but later between 3 and 8 days after admission. In absence of cross-transmission, two hypotheses seem possible: a false-negative test on admission, or a late onset favored by antibiotic pressure. Prolonged isolation may be discussed even in case of negative screening on admission from high-risk patients.
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145
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Rodríguez-Baño J, Cisneros JM, Cobos-Trigueros N, Fresco G, Navarro-San Francisco C, Gudiol C, Horcajada JP, López-Cerero L, Martínez JA, Molina J, Montero M, Paño-Pardo JR, Pascual A, Peña C, Pintado V, Retamar P, Tomás M, Borges-Sa M, Garnacho-Montero J, Bou G. Diagnosis and antimicrobial treatment of invasive infections due to multidrug-resistant Enterobacteriaceae. Guidelines of the Spanish Society of Infectious Diseases and Clinical Microbiology. Enferm Infecc Microbiol Clin 2015; 33:337.e1-337.e21. [DOI: 10.1016/j.eimc.2014.11.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 11/21/2014] [Indexed: 12/21/2022]
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146
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Ebrahimi F, M�zes J, M�sz�ros J, Juh�sz �, Kardos G. Carriage Rates and Characteristics of Enterobacteriaceae Producing Extended-Spectrum Beta-Lactamases in Healthy Individuals: Comparison of Applicants for Long-Term Care and Individuals Screened for Employment Purposes. Chemotherapy 2015; 60:239-49. [DOI: 10.1159/000375407] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 01/19/2015] [Indexed: 11/19/2022]
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147
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Nilholm H, Holmstrand L, Ahl J, Månsson F, Odenholt I, Tham J, Melander E, Resman F. An Audit-Based, Infectious Disease Specialist-Guided Antimicrobial Stewardship Program Profoundly Reduced Antibiotic Use Without Negatively Affecting Patient Outcomes. Open Forum Infect Dis 2015; 2:ofv042. [PMID: 26380341 PMCID: PMC4567088 DOI: 10.1093/ofid/ofv042] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 03/19/2015] [Indexed: 11/14/2022] Open
Abstract
Background. Antimicrobial stewardship programs are increasingly implemented in hospital care. They aim to simultaneously optimize outcomes for individual patients with infections and reduce financial and health-associated costs of overuse of antibiotics. Few studies have examined the effects of antimicrobial stewardship programs in settings with low proportions of antimicrobial resistance, such as in Sweden. Methods. An antimicrobial stewardship program was introduced during 5 months of 2013 in a department of internal medicine in southern Sweden. The intervention consisted of audits twice weekly on all patients given antibiotic treatment. The intervention period was compared with a historical control consisting of patients treated with antibiotics in the same wards in 2012. Studied outcome variables included 28-day mortality and readmission, length of hospital stay, and use of antibiotics. Results. A reduction of 27% in total antibiotic use (2387 days of any antibiotic) was observed in the intervention period compared with the control period. The reduction was due to fewer patients started on antibiotics as well as to significantly shorter durations of antibiotic courses (P < .001). An earlier switch to oral therapy and a specific reduction in use of third-generation cephalosporins and fluoroquinolones was also evident. Mortality, total readmissions, and lengths of stay in hospital were unchanged compared with the control period, whereas readmissions due to a nonresolved infection were fewer during the intervention of 2013. Conclusions. This study demonstrates that an infectious disease specialist-guided antimicrobial stewardship program can profoundly reduce antibiotic use in a low-resistance setting with no negative effect on patient outcome.
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Affiliation(s)
- Hannah Nilholm
- Infectious Diseases Research Unit, Department of Clinical Sciences , Lund University , Malmö
| | - Linnea Holmstrand
- Infectious Diseases Research Unit, Department of Clinical Sciences , Lund University , Malmö
| | - Jonas Ahl
- Infectious Diseases Research Unit, Department of Clinical Sciences , Lund University , Malmö
| | - Fredrik Månsson
- Infectious Diseases Research Unit, Department of Clinical Sciences , Lund University , Malmö
| | - Inga Odenholt
- Infectious Diseases Research Unit, Department of Clinical Sciences , Lund University , Malmö
| | - Johan Tham
- Infectious Diseases Research Unit, Department of Clinical Sciences , Lund University , Malmö
| | - Eva Melander
- Department of Infection Control, Skåne County , Sweden
| | - Fredrik Resman
- Infectious Diseases Research Unit, Department of Clinical Sciences , Lund University , Malmö
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148
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Affiliation(s)
- Jonathan Statham
- Bishopton Veterinary Group/RAFT Solutions Ltd; The Surgery, Mill Farm, Studley Road Ripon North Yorkshire HG4 2QR
| | - Martin Green
- School of Veterinary Medicine and Science; Sutton Bonington Campus Sutton Bonington Leicestershire LE12 5RD
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149
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150
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Connor BA, Keystone JS. Editorial commentary: Antibiotic self-treatment of travelers' diarrhea: helpful or harmful? Clin Infect Dis 2015; 60:847-8. [PMID: 25613288 DOI: 10.1093/cid/ciu961] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Bradley A Connor
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Jay S Keystone
- Tropical Disease Unit, Toronto General Hospital, University of Toronto, Ontario, Canada
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