Management of multidrug-resistant organisms in health care settings, 2006

Population-based bloodstream infection surveillance in rural Thailand, 2007-2014

Background

Bloodstream infection (BSI) surveillance is essential to characterize the public health threat of bacteremia. We summarize BSI epidemiology in rural Thailand over an eight year period.

Methods

Population-based surveillance captured clinically indicated blood cultures and associated antimicrobial susceptibility results performed in all 20 hospitals in Nakhon Phanom (NP) and Sa Kaeo (SK) provinces. BSIs were classified as community-onset (CO) when positive cultures were obtained ≤2 days after hospital admission and hospital-onset (HO) thereafter. Hospitalization denominator data were available for incidence estimates for 2009–2014.

Results

From 2007 to 2014 a total of 11,166 BSIs were identified from 134,441 blood cultures. Annual CO BSI incidence ranged between 89.2 and 123.5 cases per 100,000 persons in SK and NP until 2011. Afterwards, CO incidence remained stable in SK and increased in NP, reaching 155.7 in 2013. Increases in CO BSI incidence over time were limited to persons aged ≥50 years. Ten pathogens, in rank order, accounted for > 65% of CO BSIs in both provinces, all age-groups, and all years: Escherichia coli, Klebsiella pneumoniae, Burkholderia pseudomallei, Staphylococcus aureus, Salmonella non-typhi spp., Streptococcus pneumoniae, Acinetobacter spp., Streptococcus agalactiae, Streptococcus pyogenes, Pseudomonas aeruginosa. HO BSI incidence increased in NP from 0.58 cases per 1000 hospitalizations in 2009 to 0.91 in 2014, but were higher (ranging from 1.9 to 2.3) in SK throughout the study period. Extended-spectrum beta-lactamase production among E. coli isolates and multi-drug resistance among Acinetobacter spp. isolates was common (> 25% of isolates), especially among HO cases (> 50% of isolates), and became more common over time, while methicillin-resistance among S. aureus isolates (10%) showed no clear trend. Carbapenem-resistant Enterobacteriaceae were documented in 2011–2014.

Conclusions

Population-based surveillance documented CO BSI incidence estimates higher than previously reported from Thailand and the region, with temporal increases seen in older populations. The most commonly observed pathogens including resistance profiles were similar to leading pathogens and resistance profiles worldwide, thus; prevention strategies with demonstrated success elsewhere may prove effective in Thailand.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6775-4) contains supplementary material, which is available to authorized users.

Current status of postoperative infections after digestive surgery in Japan: The Japan Postoperative Infectious Complications Survey in 2015

AIM

To survey postoperative infections (PI) after digestive surgery.

METHODS

This survey, conducted by the Japan Society of Surgical Infection, included patients undergoing digestive surgery at 28 centers between September 2015 and March 2016. Data collected included patient background characteristics, type of surgery, contamination status, and type of PI, including surgical site infection (SSI), remote infection (RI), and antimicrobial-resistant (AMR) bacterial infections and colonization.

RESULTS

Postoperative infections occurred in 10.7% of 6582 patients who underwent digestive surgery (6.8% for endoscopic surgery and 18.7% for open surgery). SSI and RI, including respiratory tract infection, urinary tract infection, antibiotic-associated diarrhea, drain infection, and catheter-related bloodstream infection, occurred in 8.9% and 3.7% of patients, respectively. Among all PI, 13.2% were overlapping infections. The most common overlapping infections were incisional and organ/space SSI, which occurred in 4.2% of patients. AMR bacterial infections occurred in 1.2% of patients after digestive surgery and comprised 11.5% of all PI. Rate of AMR bacterial colonization after digestive surgery was only 0.3%.

CONCLUSION

Periodic surveillance of PI, including AMR bacteria, is necessary for a detailed evaluation of nosocomial infections.

Ethics of Infection Control Measures for Carriers of Antimicrobial Drug-Resistant Organisms

Many countries have implemented infection control measures directed at carriers of multidrug-resistant organisms. To explore the ethical implications of these measures, we analyzed 227 consultations about multidrug resistance and compared them with the literature on communicable disease in general. We found that control measures aimed at carriers have a range of negative implications. Although moral dilemmas seem similar to those encountered while implementing control measures for other infectious diseases, 4 distinct features stand out for carriage of multidrug-resistant organisms: carriage presents itself as a state of being; carriage has limited relevance for the health of the carrier; carriage has little relevance outside healthcare settings; and antimicrobial resistance is a slowly evolving threat on which individual carriers have limited effect. These features are of ethical relevance because they influence the way we traditionally think about infectious disease control and urge us to pay more attention to the personal experience of the individual carrier.

Ability of serum procalcitonin to distinguish focus of infection and pathogen types in patients with bloodstream infection

Background

Serum procalcitonin (PCT) is a widely recognized inflammatory marker which can distinguish systemic bacterial infection from other types of infections. The ability of PCT levels to distinguish different pathogens from different focus of infection is contradictory.

Methods

This study included 551 patients with bloodstream infection (BSI) diagnosed with positive blood culture (BC) during Jan 2013 and May 2018. The patients were divided into two groups with or without definite focus of infection. In this study, we analyzed PCT levels induced by Gram-positive bacteria, Gram-negative bacteria and fungal infection. Relationship of time between PCT peak and BC collection, and the impact of antibiotics usage on PCT peak distribution were examined.

Results

For patients without definite focus of infection, the serum PCT values of Gram-negative bacteria were higher than that of Gram-positive bacteria (P<0.05). A cut-off value of 7.54 ng/mL for PCT showed a sensitivity of 88.3%. For patients with definite focus of infection, the serum PCT values of Gram-negative bacteria were significantly higher than Gram-positive bacteria in patients with lower respiratory tract (P=0.003), abdominal (P=0.039), urinary tract infection (P=0.025), but not in patients with upper respiratory tract infection (P=0.664). The PCT values between multidrug-resistant organism (MDRO) and sensitive bacteria were not statistically significant (P>0.05) among all patients. Moreover, among patients who use antibiotics before BC collection, the longer antibiotics used, the higher trend of the proportion for PCT peak distribution after BC collection. The higher proportion of antibiotics combined before BC collection, the lower proportion of PCT peak distribution appeared before BC collection, and the higher the proportion of PCT peak distribution appeared after BC collection.

Conclusions

PCT value is determined by many factors. PCT value is related to not only Gram-positive bacteria or Gram-negative bacteria, but also related to specific pathogens, and specific of infection sites etc. The use of Antibiotics is also an important factor of PCT value.

Impact of an Antimicrobial Stewardship Intervention on Within- and Between-Patient Daptomycin Resistance Evolution in Vancomycin-Resistant Enterococcus faecium

Vancomycin-resistant Enterococcus (VRE) is a leading cause of hospital-acquired infection, with limited treatment options. Resistance to one of the few remaining drugs, daptomycin, is a growing clinical problem and has previously been described in this hospital. In response to increasing resistance, an antimicrobial stewardship intervention was implemented to reduce hospital-wide use of daptomycin. To assess the impact of the intervention, daptomycin prescribing patterns and clinically reported culture results from vancomycin-resistant Enterococcus faecium (VREfm) bloodstream infections (BSIs) from 2011 through 2017 were retrospectively extracted and the impact of the intervention was estimated using interrupted time series analysis (ITS). We corrected for a change in MIC determination methodology by retesting 262 isolates using Etest and broth microdilution. Hospital-wide and within-patient resistance patterns of corrected daptomycin MICs are reported. Our data show that daptomycin prescriptions decreased from an average of 287 days of therapy/month preintervention to 151 days of therapy/month postintervention. Concurrently, the proportion of patients experiencing an increase in daptomycin MIC during an infection declined from 14.6% (7/48 patients) in 2014 to 1.9% (1/54 patients) in 2017. Hospital-wide resistance to daptomycin also decreased in the postintervention period, but this was not maintained. This study shows that an antimicrobial stewardship-guided intervention reduced daptomycin use and improved individual level outcomes but had only transient impact on the hospital-level trend.

Surface colonization and subsequent development of infections with multi drug resistant organisms in a neonatal intensive care unit

BACKGROUND

This study analyzes colonization of the neonates in a NICU and incidence of these colonized infants developing infections due to the colonizers.

METHODS

Over a 12 month period, samples (surface swabs and rectal swabs) were obtained from all the infants admitted to NICU. The samples were cultured and examined for the presence of colonizers and especially for multi-drug resistant organisms.

RESULTS

From the total 533 patients, 473 (89%) neonates acquired colonizers and 60 (11%) did not. Of the 473 (89%) colonized infants, 57 (12%) developed infections of whom 33 (58%) were infected from the same organism as the colonizer and 24 (42%) neonates developed an infection that was different from the colonizer. 416 (88%) infants did not develop any infection inspite of being colonized.

CONCLUSIONS

The total numbers of babies contracting infection were more in the colonized group than the non-colonized. Other factors like gestational age and preterm may have played a role in development of infection in addition to colonization in these babies. Screening for the presence of MDRO colonization may be of limited use in predicting infections in the colonized individual. However, knowledge of their presence results in implementation of strict infection control practices. This along with judicious uses of antimicrobials effectively reduces infections from colonized bacteria and more importantly prevent their spread.

Consideration of sex and gender in Cochrane reviews of interventions for preventing healthcare-associated infections: a methodology study

BACKGROUND

Healthcare-associated infections (HAIs) are common and increase morbidity, mortality, and healthcare costs. Their control continues to be an unresolved issue worldwide. HAIs epidemiology shows sex/gender differences. Thus the lack of consideration of sex/gender in Cochrane reviews will limit their applicability and capacity to support informed decisions. This study aims to describe the extent to which Cochrane reviews of interventions for preventing HAIs consider sex and gender.

METHODS

Methodology study appraising Cochrane reviews of interventions to prevent HAIs.

SEARCH METHODS

Cochrane Database of Systematic Reviews from 1995 (launch of the journal) to 31 December 2016. Two authors independently extracted data with EPPI-Reviewer 4 software, and independently appraised the sex/gender content of the reviews with the Sex and Gender Appraisal Tool for Systematic Reviews (SGAT-SR).

RESULTS

This study included 113 reviews assessing the effects of interventions for preventing HAIs. 100 reviews (88%) used at least one sex or gender-related term. The terminology used was heterogeneous, being "sex" the term used in more reviews (51%). No review defined neither sex nor gender. Thus we could not assess the definitions provided. Consideration of sex and gender was practically absent in the included reviews; in fact, no review met all the applicable items of the SGAT-SR, and 51 reviews (50%) fulfilled no item. No review provided a complete description of the sex and the gender of the samples of the included studies. Only ten reviews (10%) planned to perform sex- and gender-based analysis and only three (3%) could complete the analysis. The method chosen was always the subgroup analysis based on sex (one review) or gender (two reviews). Three reviews (3%) considered sex or gender-related findings in the conclusions.

CONCLUSION

Consideration of sex and gender in Cochrane reviews of interventions for preventing HAIs was practically absent. This lack of attention to sex and gender reduces the quality of Cochrane reviews, and their applicability for all people: women and men, boys and girls, and people of diverse gender identities. Cochrane should attempt to address the shortfalls detected.

Neonatal sepsis due to glycopeptide resistant Enterococcus faecium from colonized maternal gut- rare case evidence

Background

Vancomycin-resistant enterococcal infections in the neonatal ICU are growing global problems. We report a case of neonatal septicemia by multidrug-resistant vancomycin-resistant Enterococcus faecium (VRE), the source of infection being the mother's gut.

Case presentation

A newborn male child admitted to the neonatal intensive care unit (NICU) was diagnosed to have mild meconium aspiration syndrome, early onset neonatal septicemia, and bacteremia by multidrug and vancomycin-resistant Enterococcus faecium. Screening of gut flora of the baby and the mother were carried out to trace the source of infection. Stool cultures of the mother and the baby yielded Vancomycin-Resistant Enterococcus faecium. All three isolates of Enterococcus faecium had similar antibiogram, harbored the vanA gene and similar pulsed-field gel electrophoresis pattern. Baby responded to the 1 week therapy with oral linezolid suspension 20 mg/kg/day, 1 ml/t.d.s. No VRE was isolated from baby on a repeat stool culture 1 week after the linezolid therapy. He was discharged with the advice for the continuance of linezolid for seven more days.

Conclusion

Isolation of MDR-VRE from the blood culture of the baby and stool specimens of the mother and the baby with the same antibiogram profile and clonal similarities reveals that maternal gut colonization was responsible for neonatal sepsis. Optimal infection control measures and the development of guidelines for monitoring VRE colonization in pregnant women might be useful in reducing the occurrence of neonatal sepsis.

A retrospective cohort study of antibiotic exposure and vancomycin-resistant Enterococcus recolonization

OBJECTIVE

In the National Institutes of Health (NIH) Clinical Center, patients colonized or infected with vancomycin-resistant Enterococcus (VRE) are placed in contact isolation until they are deemed "decolonized," defined as having 3 consecutive perirectal swabs negative for VRE. Some decolonized patients later develop recurrent growth of VRE from surveillance or clinical cultures (ie, "recolonized"), although that finding may represent recrudescence or new acquisition of VRE. We describe the dynamics of VRE colonization and infection and their relationship to receipt of antibiotics.

METHODS

In this retrospective cohort study of patients at the National Institutes of Health Clinical Center, baseline characteristics were collected via chart review. Antibiotic exposure and hospital days were calculated as proportions of VRE decolonized days. Using survival analysis, we assessed the relationship between antibiotic exposure and time to VRE recolonization in a subcohort analysis of 72 decolonized patients.

RESULTS

In total, 350 patients were either colonized or infected with VRE. Among polymerase chain reaction (PCR)-positive, culture (Cx)-negative (PCR+/Cx-) patients, PCR had a 39% positive predictive value for colonization. Colonization with VRE was significantly associated with VRE infection. Among 72 patients who met decolonization criteria, 21 (29%) subsequently became recolonized. VRE recolonization was 4.3 (P = .001) and 2.0 (P = .22) times higher in patients with proportions of antibiotic days and antianaerobic antibiotic days above the median, respectively.

CONCLUSION

Colonization is associated with clinical VRE infection and increased mortality. Despite negative perirectal cultures, re-exposure to antibiotics increases the risk of VRE recolonization.

Exploring bacterial resistome and resistance dessemination: an approach of whole genome sequencing

For several decades antibiotics are used to combat against pathogenic bacteria, but their misuse and overuse have caused the emergence of resistant bacteria. The scarcities of effective antibiotics along with unavailability of alternative solutions have exacerbated bacterial infections and mortality rate. This review provides the concept of bacterial resistome and mechanisms of resistance. It has also described the utility of whole genome sequencing in identifying resistance and its dissemination in association with available bioinformatics tools and databases. Moreover, the whole genome sequencing methodology described in this review will help to select effective antibiotics, maintain unparalleled surveillance of resistance and provide early diagnosis during resistance outbreaks. The provided information could be used to control infection caused by resistant microorganisms.

Postmortem microbiology sampling following death in hospital: an ESGFOR task force consensus statement

Postmortem microbiology (PMM) is a valuable tool in the identification of the cause of death and of factors contributory to death where death has been caused by infection. The value of PMM is dependent on careful autopsy planning, appropriate sampling, minimisation of postmortem bacterial translocation and avoidance of sample contamination. Interpretation of PMM results requires careful consideration in light of the clinical history, macroscopic findings and the histological appearances of the tissues. This consensus statement aims to highlight the importance of PMM in the hospital setting and to give microbiological and pathological advice on sampling in deaths occurring in hospital.

Aerosol transmission of severe fever with thrombocytopenia syndrome virus during resuscitation

We investigated potential nosocomial aerosol transmission of severe fever with thrombocytopenia syndrome virus (SFTSV) with droplet precautions. During aerosol generating procedures, SFTSV was be transmitted from person to person through aerosols. Thus, airborne precautions should be added to standard precautions to avoid direct contact and droplet transmission.

Best tigecycline dosing for treatment of infections caused by multidrug-resistant pathogens in critically ill patients with different body weights

Background

The intensive care unit (ICU) is a center of multidrug-resistant (MDR) pathogens. This is due to overuse of antibiotics in the treatment of critically ill patients. Tigecycline is a broad-spectrum antibiotic that belongs to the glycylcycline group. Tigecycline has been indicated in treatment of complicated intra-abdominal infections (cIAIs) and complicated skin and soft-tissue infections (cSSTIs).

Objective

This study was done to discover the best dose regimen of tigecycline in treatment of cSSTIs and cIAIs, especially in patients who are critically ill and obese, for clinical outcomes and safety.

Setting

The study was conducted in an adult ICU that consists of 25 beds in a general hospital and was conducted within 2 years. A total of 954 patients were screened in this study.

Methods

This was a retrospective cohort study that compared the clinical outcomes of patients: mortality, ICU stay, and safety of using two different dose regimens of tigecycline between patients with different body weight who were treated for infections caused by MDR pathogens in the ICU. The study was conducted within 2 years. All results were collected from patients’ files and were analyzed with SPSS version 20.

Main outcome

The study was implemented to figure out the best dose regimen of tigecycline to achieve a reduction in mortality, ICU stay, treatment duration, and secondary septic-shock incidence with minimum side effects in treatment of cSSTIs and cIAIs in patients with different body weight.

Results

There was a significant improvement in mortality, ICU stay, recurrent infection by the same organism, duration of tigecycline treatment, number of patients who had first negative culture after starting treatment, secondary bacteremia, and secondary septic shock with patients who used high-dose regimens of tigecycline in different subgroups of body weight, with no significant difference in side effects.

Conclusion

The use of high-dose tigecycline resulted in a significant enhancement in all clinical outcomes, especially mortality and ICU stay when used in treatment of overweight and obese patients with cSSTIs and cIAIs.

ASID/ACIPC position statement - Infection control for patients with Clostridium difficile infection in healthcare facilities

BACKGROUND

In 2011, the Australasian Society for Infectious Diseases (ASID) and the Australian Infection Control Association (AICA), now known as the Australasian College of Infection Prevention and Control (ACIPC), produced a position statement on infection control requirements for preventing and controlling Clostridium difficile infection (CDI) in healthcare settings.

METHODS

The statement updated in 2017 to reflect new literature available .The authors reviewed the 2011 position statement and critically appraised new literature published between 2011 and 2017 and relevant current infection control guidelines to identify where new evidence had become available or best practice had changed.

RESULTS

The position statement was updated incorporating the new findings. A draft version of the updated position statement was circulated for consultation to members of ASID and ACIPC. The authors responded to all comments received and updated the position statement.

CONCLUSIONS

This updated position statement emphasizes the importance of health service organizations having evidence-based infection prevention and control programs and comprehensive antimicrobial stewardship programs, to ensure the risk of C. difficile acquisition, transmission and infection is minimised.

Intensive Care Unit Relocation and Its Effect on Multidrug-Resistant Respiratory Microorganisms

Background

Infection by multidrug-resistant (MDR) pathogens leads to poor patient outcomes in intensive care units (ICUs). Contact precautions are necessary to reduce the transmission of MDR pathogens. However, the importance of the surrounding environment is not well known. We studied the effects of ICU relocation on MDR respiratory pathogen detection rates and patient outcomes.

Methods

Patients admitted to the ICU before and after the relocation were retrospectively analyzed. Baseline patient characteristics, types of respiratory pathogens detected, antibiotics used, and patient outcomes were measured.

Results

A total of 463 adult patients admitted to the ICU, 4 months before and after the relocation, were included. Of them, 234 were admitted to the ICU before the relocation and 229 afterward. Baseline characteristics, including age, sex, and underlying comorbidities, did not differ between the two groups. After the relocation, the incidence rate of MDR respiratory pathogen detection decreased from 90.0 to 68.8 cases per 1,000 patient-days, but that difference was statistically insignificant. The use of colistin was significantly reduced from 53.5 days (95% confidence interval [CI], 20.3 to 86.7 days) to 18.7 days (95% CI, 5.6 to 31.7 days). Furthermore, the duration of hospital stay was significantly reduced from a median of 29 days (interquartile range [IQR], 14 to 50 days) to 21 days (IQR, 11 to 39 days).

Conclusions

Incidence rates of MDR respiratory pathogen detection were not significantly different before and after ICU relocation. However, ICU relocation could be helpful in reducing the use of antibiotics against MDR pathogens and improving patient outcomes.

High rates of meticillin-resistant Staphylococcus aureus among asylum seekers and refugees admitted to Helsinki University Hospital, 2010 to 2017

IntroductionAntimicrobial resistance is increasing rapidly in countries with low hygiene levels and poorly controlled antimicrobial use. The spread of resistant bacteria poses a threat to healthcare worldwide. Refugees and migrants from high-prevalence countries may add to a rise in multidrug-resistant (MDR) bacteria in low-prevalence countries. However, respective data are scarce.MethodsWe retrospectively collected microbiological and clinical data from asylum seekers and refugees treated at Helsinki University Hospital between January 2010 and August 2017.ResultsOf 447 asylum seekers and refugees (Iraq: 46.5%; Afghanistan: 10.3%; Syria: 9.6%, Somalia: 6.9%); 45.0% were colonised by MDR bacteria: 32.9% had extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE), 21.3% meticillin-resistant Staphylococcus aureus (MRSA), 0.7% carbapenemase-producing Enterobacteriaceae (CPE), 0.4% multiresistant Pseudomonas aeruginosa (MRPA), 0.4% multiresistant Acinetobacter baumannii (MRAB); no vancomycin-resistant Enterococcus (VRE) were found. Two or more MDR bacteria strains were recorded for 12.5% of patients. Multivariable analysis revealed geographical region and prior surgery outside Nordic countries as risk factors of MRSA colonisation. Young age (< 6 years old), short time from arrival to first sample, and prior hospitalisation outside Nordic countries were risk factors of ESBL-PE colonisation.ConclusionWe found MDR bacterial colonisation to be common among asylum seekers and refugees arriving from current conflict zones. In particular we found a high prevalence of MRSA. Refugees and migrants should, therefore, be included among risk populations requiring MDR screening and infection control measures at hospitals.

Confronting barriers to improve healthcare literacy and cultural competency in disparate populations

Positive patient outcomes depend on clear communication. Understanding healthcare literacy, cultural competency, and health disparities/inequalities is essential for providing empathetic care to patients and their family members. Guidelines to provide culturally competent care may enhance the patient experience and improve healthcare provider communication.

Experiences of carriers of multidrug-resistant organisms: a systematic review

OBJECTIVES

A comprehensive overview of the ways control measures directed at carriers of multidrug-resistant organisms (MDRO) affect daily life of carriers is lacking. In this systematic literature review, we sought to explore how carriers experience being a carrier and how they experience being subjected to control measures by looking at the impact on basic capabilities.

METHODS

We searched Medline, Embase and PsychINFO until 26 May 2016 for studies addressing experiences of MDRO carriers. Twenty-seven studies were included, addressing experiences with methicillin-resistant Staphylococcus aureus (n = 21), ESBL (n = 1), multiple MDRO (n = 4) and other (n = 1, not specified). We categorized reported experiences according to Nussbaum's capability approach.

RESULTS

Carriage and control measures were found to interfere with quality of care, cause negative emotions, limit interactions with loved ones, cause stigmatization, limit recreational activities and create financial and professional insecurity. Further, carriers have difficulties with full comprehension of the problem of antimicrobial resistance, thus affecting six out of ten basic capabilities.

CONCLUSIONS

Applying Nussbaum's capability approach visualizes an array of unintended consequences of control measures. Carriers experience stigmatization, especially in healthcare settings, and have limited understanding of their situation and the complexities of antimicrobial resistance.

Reassessing the need for active surveillance of extended-spectrum beta-lactamase-producing Enterobacteriaceae in the neonatal intensive care population

OBJECTIVE

To determine the continued need for active surveillance to prevent extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) transmission in a neonatal intensive care unit (NICU).

DESIGN

This retrospective observational study included patients with ESBL-E colonization or infection identified during their NICU stay at our institution between 1999 and March 2018. Active surveillance was conducted between 1999 and March 2017 by testing rectal swab specimens collected upon admission and weekly thereafter. The overall incidence rates, of ESBL-E colonization or infection (including hospital acquired) before and after active surveillance were calculated. The cost associated with active surveillance was then estimated.

RESULTS

Overall, 171 NICU patients were found to have ESBL-E colonization or infection, and 150 of those patients (87.7%) were detected by active surveillance. The overall incidence rate was 1.4 per 100 patient admissions. The hospital-acquired incidence rate was 0.41 per 1,000 patient days, and this rate had decreased since 2002, with an average of 6 cases detected annually. A significant decrease was observed in 2009 when the unit moved to a new single-bed unit featuring private rooms. Active surveillance was discontinued with no increase in the number of infections. Of the 150 ESBL-E colonized patients, 14 (9.3%) subsequently developed an infection. Active surveillance resulted in a total of 50,950 specimen collections and a cost of $127,187 for processing, an average of $848 to detect 1 ESBL-E colonized patient.

CONCLUSION

ESBL-E transmission and infection in our NICU remains uncommon. Active surveillance may have contributed to the decline of ESBL-E transmission when used in conjunction with contact precautions and private rooms, but its relatively high cost could be prohibitive.

Mathematical modelling of vancomycin-resistant enterococci transmission during passive surveillance and active surveillance with contact isolation highlights the need to identify and address the source of acquisition

Background

Clinical studies and mathematical simulation suggest that active surveillance with contact isolation is associated with reduced vancomycin-resistant enterococci (VRE) prevalence compared to passive surveillance. Models using pre- and post-intervention data that account for the imperfect observation and serial dependence of VRE transmission events can better estimate the effectiveness of active surveillance and subsequent contact isolation; however, such analyses have not been performed.

Methods

A mathematical model was fitted to surveillance data collected pre- and post-implementation of active surveillance with contact isolation in the haematology-oncology ward. We developed a Hidden Markov Model to describe undetected and observed VRE colonisation/infection status based on the detection activities in the ward. Bayesian inference was used to estimate transmission rates. The effectiveness of active surveillance was assumed to be via increased detection and subsequent contact isolation of VRE positive patients.

Results

We estimated that 31% (95% credible interval: 0.33–85%) of the VRE transmissions were due to cross-transmission between patients. The ratio of transmission rates from patients with contact isolation versus those without contact isolation was 0.33 (95% credible interval: 0.050–1.22).

Conclusions

The majority of the VRE acquisitions in the haematology-oncology ward was estimated to be due to background rates of VRE, rather than within ward patient to patient acquisition. The credible interval for cross-transmission was wide which results in a large degree of uncertainty in the estimates. Factors that could account for background VRE acquisition include endogenous acquisition from antibiotic selection pressure and VRE in the environment. Contact isolation was not significantly associated with reduced VRE transmission in settings where the majority of VRE acquisition was due to background acquisition, emphasising the need to identify and address the source of acquisition. As the credible interval for the ratio of VRE transmission in contact isolated versus non-contact isolated patients crossed 1, there is a probability that the transmission rate in contact isolation was not lower. Our finding highlights the need to optimise infection control measures other than active surveillance for VRE and subsequent contact isolation to reduce VRE transmission. Such measures could include antimicrobial stewardship, environmental cleaning, and hand hygiene.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3388-y) contains supplementary material, which is available to authorized users.

The Impact of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Infections on Postdischarge Health Care Costs and Utilization across Multiple Health Care Systems

OBJECTIVE

To measure how much of the postdischarge cost and utilization attributable to methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections (HAIs) occur within the US Department of Veterans Affairs (VA) system and how much occurs outside.

DATA SOURCES/STUDY SETTING

Health care encounters from 3 different settings and payment models: (1) within the VA; (2) outside the VA but paid for by the VA (purchased care); and (3) outside the VA and paid for by Medicare.

STUDY DESIGN

Historical cohort study using data from admissions to VA hospitals between 2007 and 2012.

METHODS

We assessed the impact of a positive MRSA test result on costs and utilization during the 365 days following discharge using inverse probability of treatment weights to balance covariates.

PRINCIPAL FINDINGS

Among a cohort of 152,687 hospitalized Veterans, a positive MRSA test result was associated with an overall increase of 6.6 (95 percent CI: 5.7-7.5) inpatient days and $9,237 (95 percent CI: $8,211-$10,262) during the postdischarge period. VA inpatient admissions, Medicare reimbursements, and purchased care payments accounted for 60.6 percent, 22.5 percent, and 16.9 percent of these inpatient costs.

CONCLUSIONS

While most of the excess postdischarge health care costs associated with MRSA HAIs occurred in the VA, non-VA costs make up an important subset of the overall burden.

Impact of antimicrobial wipes compared with hypochlorite solution on environmental surface contamination in a health care setting: A double-crossover study

OBJECTIVE

Antimicrobial wipes are increasingly used in health care settings. This study evaluates, in a clinical setting, the efficacy of sporicidal wipes versus a cloth soaked in a 1,000 ppm chlorine solution.

INTERVENTION

A double-crossover study was performed on 2 different surgical and cardiovascular wards in a 1,000-bed teaching hospital over 29 weeks. The intervention period that consisted of surface decontamination with the preimpregnated wipe or cloth soaked in chlorine followed a 5-week baseline assessment of microbial bioburden on surfaces. Environmental samples from 11 surfaces were analyzed weekly for their microbial content.

RESULTS

A total of 1,566 environmental samples and 1,591 ATP swabs were analyzed during the trial. Overall, there were significant differences in the recovery of total aerobic bacteria (P < .001), total anaerobic bacteria (P < .001), and ATP measurement (P < .001) between wards and between the different parts of the crossover study. Generally, the use of wipes produced the largest reduction in the total aerobic and anaerobic counts when compared with the baseline data or the use of 1,000 ppm chlorine. Collectively, the introduction of training plus daily wipe disinfection significantly reduced multidrug-resistant organisms recovered from surfaces. Reversion to using 1,000 ppm chlorine resulted in the number of sites positive for multidrug-resistant organisms rising again.

CONCLUSIONS

This double-crossover study is the first controlled field trial comparison of using preimpregnated wipes versus cotton cloth dipped into a bucket of hypochlorite to decrease surface microbial bioburden. The results demonstrate the superiority of the preimpregnated wipes in significantly decreasing microbial bioburden from high-touch surfaces.

Chlorhexidine-based body washing for colonization and infection of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: an updated meta-analysis

Background

The effects of chlorhexidine-based body washing (CHW) on health care-associated infections have been reported in numerous studies, while their findings remain conflicting. This study aims to update the evidence for the effects of CHW on the risk of colonization or infection with hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE).

Methods

Two independent authors searched PubMed, Embase, and Cochrane Library from inception through February 2018. We selected all observational studies or clinical trials for the effect of CHW on the risk of colonization and infection with hospital-acquired MRSA or VRE. Random-effects models were applied to calculate summary incidence rate ratios (IRRs) for the related associations.

Results

Of 140 records identified, we obtained data from 17 relevant articles for meta-analysis. Compared with patients without antiseptic bathing, patients with CHW had a significantly lower risk of MRSA colonization (IRR 0.61, 95% CI 0.48–0.77) and VRE colonization (IRR 0.58, 95% CI 0.42–0.80). Similarly, we also noted that patients with CHW had a significantly lower risk of MRSA infection (IRR 0.65, 95% CI 0.52–0.81). However, no significantly lower risk of VRE infection (IRR 0.61, 95% CI 0.30–1.25) was noted in patients with CHW. Sensitivity analyses or trim-and-fill method confirmed the robustness of the findings.

Conclusion

Current evidence supports that patients with CHW had a significantly lower risk of MRSA or VRE colonization and a lower risk of MRSA infection. More evidence should be accumulated to reinforce these findings, especially on the effect of CHW on the risk of VRE infection.

Bioactive nano-metal-organic frameworks as antimicrobials against Gram-positive and Gram-negative bacteria

More effective antibiotics are needed to overcome the problem of multidrug resistance. The antibacterial efficacies of three Zn-based nano metal-organic frameworks (nMOFs) - IRMOF-3, MOF-5, and Zn-BTC - were explored, both alone and as mixtures with ampicillin and kanamycin. When tested against Escherichia coli, Staphylococcus aureus, Staphylococcus lentus, and Listeria monocytogenes, the nMOF/drug mixtures demonstrated synergistic (IRMOF-3/kanamycin) or additive (other nMOF/drug combinations) effects compared with the nMOFs or antibiotics alone. Zn-Based nMOFs can reduce the burden of the new discovery of antimicrobial pharmaceuticals by increasing the potency of existing antibiotics.

Effectiveness of topical green tea against multidrug-resistant Staphylococcus aureus in cases of primary pyoderma: An open controlled trial

Background

Antimicrobial activity of green tea against Staphylococcus aureus both in vitro and in vivo has been reported recently. Studies on clinical efficacy and safety of green tea as antibacterial agent against S. aureus in human cases are rare.

Objectives

To evaluate the clinical effectiveness and safety of topical green tea on primary pyoderma caused by S. aureus. We also attempted to determine the minimum inhibitory concentration of green tea against S. aureus and methicillin-resistant S. aureus.

Methods

Open label, prospective, placebo-controlled study included community-acquired primary pyoderma cases caused by S. aureus. Severity grading was done on a scale of 1-5. Green tea ointment 3% and placebo ointment were used. Cure was defined on the basis of negative culture and assessment of clinical improvement. Minimum inhibitory concentration was determined by agar dilution method. Data were analyzed using Statistical Package for Social Sciences (SPSS) software version 16.

Results

Of the 372 patients, 250 received green tea and 122 received placebo. Multidrug-resistant S. aureus was isolated in 89.1% in green tea group and 81.1% in placebo group, respectively. Methicillin-resistant S. aureus was isolated in 24 patients. Cure was seen in 86% in green tea group and 6.6% in placebo group which was statistically very significant. The number of days for comprehensive cure in green tea group was 9.2 ± 6.4 days. All patients with methicillin-resistant S. aureus infection in the green tea group were cured. Minimum inhibitory concentration of green tea against S. aureus was 0.0265 ± 0.008 μg/ml and against methicillin-resistant S. aureus was 0.0205 ± 0.003 μg/ml.

Limitations of the Study

Comparative trial was not conducted in the same patient with different lesions; children less than seven years were not considered as the school authorities did not permit for younger children to be included in the study and true randomization and blinding of investigators were not done.

Conclusions

Green tea has a significant antibacterial effect against multidrug-resistant S. aureus. Minimum inhibitory concentration of green tea is established and is promising in methicillin-resistant S. aureus infections.

Amphipathic sulfonamidobenzamides mimicking small antimicrobial marine natural products; investigation of antibacterial and anti-biofilm activity against antibiotic resistant clinical isolates

There is an urgent need for novel antimicrobial agents to address the threat of bacterial resistance to modern society. We have used a structural motif found in antimicrobial marine hit compounds as a basis for synthesizing a library of antimicrobial sulfonamidobenzamide lead compounds. Potent in vitro antimicrobial activity against clinically relevant bacterial strains was demonstrated for two compounds, G6 and J18, with minimal inhibitory concentrations (MIC) of 4-16 μg/ml against clinical methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus faecium (VRE). The two compounds G6 and J18, together with several other compounds of this library, also caused ≥90% eradication of pre-established biofilm of methicillin-resistant S. epidermidis (MRSE) at 40 μg/ml. Using a luciferase assay, the mechanism of action of G6 was shown to resemble the biocide chlorhexidine by targeting the bacterial cell membrane.

Course of colonization by multidrug-resistant organisms after allogeneic hematopoietic cell transplantation

Multidrug-resistant organisms (MDRO) have been developing as an emerging problem in allogeneic hematopoietic cell transplantation (HCT). Since no data are available on the course of MDRO colonization after HCT, we investigated in this retrospective, single-center study, persistence and clearance of MDRO after HCT. From June 2010 to December 2015, 121 consecutive HCT patients were included. Patients received a MDRO screening before conditioning as well as surveillance cultures after HCT. In MDRO-colonized patients, surveillance specimens were taken until MDRO were no longer detectable. Thirty-three patients (27%) were found to be colonized by at least one MDRO at any time point until day 100 post HCT. Day 100 (2-year) non-relapse mortality (NRM) and overall survival (OS) of MDRO-colonized (MDRO⁺) versus non-colonized (MDRO^-) patients were essentially the same. NRM is 15% (21%) versus 15% (24%). Two-year OS is 60 versus 55% for MDRO⁺ versus MDRO^- patients. Out of the 33 MDRO⁺ patients, 21 cleared the MDRO. Median time to non-detectability of MDRO was 6 months. In 12 patients, the MDRO persisted. There was a significant (p < 0.0001) survival difference between patients who cleared the MDRO versus those with MDRO persistence (2-year OS 80 vs 40%). Except for the length of antibiotic therapy as a potential risk factor for MDRO persistence after HCT, no other conventional factors could be identified. (a) colonization by MDRO per se had no negative impact on the outcome, (b) MDRO can be cleared by the majority of patients after allogeneic HCT, and (c) to increase the probability to clear MDRO, the use of antibiotics in MDRO⁺ patients should be reviewed critically.

Infection Prevention and Control Core Practices: A Roadmap for Nursing Practice

In 2017, the CDC released a set of Core Practices focusing on infection prevention and control relevant for care delivered in all settings. These eight Core Practices address foundational elements of practice and should be embedded into every aspect of nursing care and part of every nurse's professional development plan.

Methicillin-Resistant Staphylococcus aureus: The Effects Are More Than Skin Deep

OBJECTIVES

To assess the psychosocial effects of a methicillin-resistant Staphylococcus aureus (MRSA) diagnosis on the households of children with MRSA skin and soft tissue infection (SSTI).

STUDY DESIGN

We constructed and administered an interview to the primary caregiver within the home of a child with a history of MRSA SSTI.

RESULTS

Seventy-six households were enrolled. Survey responses were analyzed and grouped into 4 themes: health behavior changes, disclosure, social interactions, and knowledge/awareness. The most common theme was disclosure; 91% of participants reported sharing their child's MRSA diagnosis with someone outside of the household. Forty-two percent of respondents reported a change in the manner in which household contacts interacted as a result of the index patient's MRSA diagnosis, including isolating the index patient from other children in the household. Many households reported adopting enhanced personal hygiene behaviors and environmental cleaning routines. Thirty-eight percent of participating households reported altering how they interact with people outside of their home, largely to avoid spreading MRSA to vulnerable individuals. In addition, many participants perceived that others regarded them with caution, especially at daycare, whereas other affected households were excluded from family gatherings.

CONCLUSION

Primary caregivers of children with MRSA SSTI reported changing their health behaviors, altering their interactions with people outside of their home, and feeling isolated by others in response to their child's MRSA diagnosis. The findings of our study highlight a need for community interventions and education to prevent the negative psychosocial repercussions associated with MRSA.

Bacterial Infections After Burn Injuries: Impact of Multidrug Resistance

Patients who are admitted to the hospital after sustaining a large burn injury are at high risk for developing hospital-associated infections. If patients survive the initial 72 hours after a burn injury, infections are the most common cause of death. Ventilator-associated pneumonia is the most important infection in this patient population. The risk of infections caused by multidrug-resistant bacterial pathogens increases with hospital length of stay in burn patients. In the first days of the postburn hospitalization, more susceptible, Gram-positive organisms predominate, whereas later more resistant Gram-negative organisms are found. These findings impact the choice of empiric antibiotics in critically ill burn patients. A proactive infection control approach is essential in burn units. Furthermore, a multidisciplinary approach to burn patients with a team that includes an infectious disease specialist and a pharmacist in addition to the burn surgeon is highly recommended.

Risk for subsequent infection and mortality after hospitalization among patients with multidrug-resistant gram-negative bacteria colonization or infection

Background

Risks for subsequent multidrug-resistant gram-negative bacteria (MDRGNB) infection and long-term outcome after hospitalization among patients with MDRGNB colonization remain unknown.

Methods

This observational study enrolled 817 patients who were hospitalized in the study hospital in 2009. We defined MDRGNB as a GNB resistant to at least three different antimicrobial classes. Patients were classified into MDRGNB culture-positive (MDRGNB-CP; 125 patients) and culture-negative (MDRGNB-CN; 692 patients) groups based on the presence or absence of any MDRGNB identified from either active surveillance or clinical cultures during index hospitalization. Subsequent MDRGNB infection and mortality within 12 months after index hospitalization were recorded. We determined the frequency and risk factors for subsequent MDRGNB infection and mortality associated with previous MDRGNB culture status.

Results

In total, 129 patients had at least one subsequent MDRGNB infection (MDRGNB-CP, 48.0%; MDRGNB-CN, 10.0%), and 148 patients died (MDRGNB-CP, 31.2%; MDRGNB-CN, 15.9%) during the follow-up period. MDR Escherichia coli and Acinetobacter baumannii were the predominant colonization microorganisms; patients with Proteus mirabilis and Pseudomonas aeruginosa had the highest hazard risk for developing subsequent infection. After controlling for other confounders, MDRGNB-CP during hospitalization independently predicted subsequent MDRGNB infection (hazard ratio [HR], 5.35; 95% confidence interval [CI], 3.72–7.71), all-cause mortality (HR, 2.42; 95% CI, 1.67–3.50), and subsequent MDRGNB infection-associated mortality (HR, 4.88; 95% CI, 2.79–8.52) after hospitalization.

Conclusions

Harboring MDRGNB significantly increases patients’ risk for subsequent MDRGNB infection and mortality after hospitalization, justifying the urgent need for developing effective strategies to prevent and eradicate MDRGNB colonization.

Efficient processing of MRSA screening specimens by a modified inoculation protocol

Methicillin-resistant Staphylococcus aureus (MRSA) is a major cause of healthcare-associated infections and mortality, and therefore constitutes a serious cost factor in public health. Culture-based MRSA screening is a crucial part of MRSA-infection prevention and control strategies in the hospital setting. Manual inoculation of screening swabs onto culture plates still constitutes the major part of the technicians' workload in laboratories. We present a modified inoculation protocol that comprises direct inoculation of specimen onto a chromogenic MRSA-selective agar plate without further streaking for isolation. This study aims to evaluate the impact of this inoculation protocol on technicians' workload and the downstream workflow in our laboratory. Batches of 50 specimens were processed by different technicians and the hands-on time was compared between the standard and modified inoculation protocol. To assess the impact on downstream processing, a retrospective analysis of the rate of subcultures and turnaround time (TAT) of specimens yielding putative MRSA colonies from 9 months before (n = 1548) and after (n = 1267) the protocol change was carried out based on laboratory information system (LIS) data. The implementation of the modified protocol significantly reduced technicians' hands-on time needed for inoculation by 26.5% without altering the overall turnaround time of surveillance cultures or causing higher costs for extra plates needed for subcultures. Our modified inoculation protocol offers a cost-effective and easy to implement procedure for MRSA surveillance cultures which significantly decreases technicians' workload and does not impede the downstream workflow. It therefore increases the capacity of laboratory technicians' to execute more demanding tasks.

Safe removal of gloves from contact precautions: The role of hand hygiene

BACKGROUND

Routine hand hygiene effectively removes methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin resistant Enterococcus (VRE) from the ungloved hands of healthcare workers (HCWs) who are caring for patients under contact precautions, when exposure to bodily fluids is not expected.

METHODS

HCWs' ungloved hands were cultured after hand hygiene with alcohol-based hand rub (ABHR) or soap-and-water wash after routine clinical care of patients known to be colonized or infected with MRSA or VRE.

RESULTS

Two hundred forty samples from 40 HCWs were tested and found to be culture negative for either MRSA or VRE after contact with patients when 3 pumps of ABHR (0/80) or plain soap-and-water wash (0/80) were used. No VRE was observed in any of the 120 samples collected. Two plates (2/40) grew 1 colony-forming unit of MRSA after 2 pumps of ABHR. Two HCWs with positive plates were cultured negative on retesting.

CONCLUSION

We showed that appropriate hand hygiene was effective in removing MRSA and VRE even when gloves were not used for routine clinical care, despite contact with patients known to be colonized with MRSA or VRE. A modified approach to glove use for dry contact with patients on contact precautions might improve patient safety within healthcare settings.

Emergency surgeons' perceptions and attitudes towards antibiotic prescribing and resistance: a worldwide cross-sectional survey

Background

Antibiotic resistance (AMR) is a growing public health problem worldwide, in part related to inadequate antibiotic use. A better knowledge of physicians' motivations, attitudes and practice about AMR and prescribing should enable the design and implementation of effective antibiotic stewardship programs (ASPs). The objective of the study was to assess attitudes and perceptions concerning AMR and use of antibiotics among surgeons who regularly perform emergency or trauma surgery.

Methods

A cross-sectional web-based survey was conducted contacting 4904 individuals belonging to a mailing list provided by the World Society of Emergency Surgery. Participation was voluntary and anonymous. The survey was open for 5 weeks (from May 3, 2017, to June 6, 2017), within which two reminders were sent. The self-administered questionnaire was developed by a multidisciplinary team; reliability and validity were assessed.

Results

The overall response rate was 12.5%. Almost all participants considered AMR an important worldwide problem, but 45.6% of them underrated the problem in their own hospitals. Surgeons provided with periodic reports on local AMR demonstrated a lower underrating in their hospital. Only 66.3% of the surgeons stated to receive periodic reports on local AMR data, and among them, 56.2% had consulted them to select an antibiotic in the previous month. Availability of systematic reports about AMR, availability of guidelines for therapy of infections, and advice from an infectious diseases specialist were considered very helpful measures to improve antibiotic prescribing by 68.0, 65.7, and 64.9%, respectively. Persuasive and restrictive ASPs were both considered helpful measures by 64.5%. Moreover, 86.3% considered locally developed guidelines more useful than national ones. Only 21.9% received formal training in antibiotic prescribing in the previous year; among them, 86.6% declared to be interested in receiving more training.

Conclusions

Availability of periodic reports on local AMR data was considered an important tool to guide surgeons in choosing the correct antibiotic and to increase awareness of the problem of AMR. Local guidelines for therapy of infections should be implemented in every emergency surgery setting, and developed by a multidisciplinary team directly involving surgeons, infectious diseases specialists, and microbiologists, and formally established in an ASP.

A comparative study for detection of extended spectrum β-lactamase (ESBL) production by Enteroaggregative Escherichia coli (EAEC) strains using double disc, nitrocefin and PCR assays

We explored and evaluated for the first time colorimetric nitrocefin assay in conjunction with the double disc test and PCR assay. We suggested the use of nitrocefin assay for rapid screening of ESBL-production by Enteroaggregative Escherichia coli.

Towards a Definition for Health Care-Associated Infection

BACKGROUND

Health care-associated infection (HcAI) is a term frequently used to describe community-onset infections likely to be caused by multidrug-resistant organisms (MDROs). The most frequently used definition was developed at Duke University Medical Center in 2002 (Duke-2002). Although some professional societies have based management recommendations on Duke-2002 (or modifications thereof), neither Duke-2002 nor other variations have had their performance measured.

METHODS

A case-control study was conducted at Assaf Harofeh Medical Center (AHMC) of consecutive adult bloodstream infections (BSIs). A multivariable model was used to develop a prediction score for HcAI, measured by the presence of MDRO infection on admission. The performances of this new score and previously developed definitions at predicting MDRO infection on admission were measured.

RESULTS

Of the 504 BSI patients enrolled, 315 had a BSI on admission and 189 had a nosocomial BSI. Patients with MDRO-BSI on admission (n = 100) resembled patients with nosocomial infections (n = 189) in terms of epidemiological characteristics, illness acuity, and outcomes more than patients with non-MDRO-BSI on admission (n = 215). The performances of both the newly developed score and the Duke-2002 definition to predict MDRO infection on admission were suboptimal (area under the receiver operating characteric curve, 0.76 and 0.68, respectively).

CONCLUSIONS

Although the term HcAI is frequently used, its definition does not perform well at predicting MDRO infection present on admission to the hospital. A validated score that calculates the risk of MDRO infection on admission is still needed to guide daily practice and improve patient outcomes.

Biosafety in beauty centers: knowledge and practices in a state capital in Northeast Brazil

OBJECTIVE To evaluate the knowledge and biosafety practices adopted by professionals of the beauty segment. METHODS Descriptive study, of survey type. 238 professionals of the beauty segment were interviewed between August 2014 and 2015. The variables were expressed by means of absolute and relative frequencies, as well as average and standard deviation. RESULTS 62.6% of the interviwed professionals reported having had contact with blood from customers when they were not wearing gloves; 74.4% said they washed their hands before and after each service, and only 16.8% of the respondents reported reusing nonsterilizable materials. None of them was able to inform the correct number of sets of tools needed , and 32.8% of the respondents did not use Personal Protective Equipment during their work activities. CONCLUSIONS The most frequently reported diseases associated with the risk of infection and transmission in the work activities were viral hepatitis, HIV and fungi. Regarding the biosafety procedures adopted, autoclave is the least used method for sterilizing devices.

Regional Epidemiology of Methicillin-Resistant Staphylococcus aureus Among Adult Intensive Care Unit Patients Following State-Mandated Active Surveillance

Background

In 2007, Illinois became the first state in the United States to mandate active surveillance of methicillin-resistant Staphylococcus aureus (MRSA). The Illinois law applies to intensive care unit (ICU) patients; contact precautions are required for patients found to be MRSA colonized. However, the effectiveness of a legislated "search and isolate" approach to reduce MRSA burden among critically ill patients is uncertain. We evaluated whether the prevalence of MRSA colonization declined in the 5 years after the start of mandatory active surveillance.

Methods

All hospitals with an ICU having ≥10 beds in Chicago, Illinois, were eligible to participate in single-day serial point prevalence surveys. We assessed MRSA colonization among adult ICU patients present at time of survey using nasal and inguinal swab cultures. The primary outcome was region-wide MRSA colonization prevalence over time.

Results

All 25 eligible hospitals (51 ICUs) participated in serial point prevalence surveys over 8 survey periods (2008-2013). A total of 3909 adult ICU patients participated in the point prevalence surveys, with 432 (11.1%) found to be colonized with MRSA (95% confidence interval [CI], 10.1%-12.0%). The MRSA colonization prevalence among patients was unchanged during the study period; year-over-year relative risk for MRSA colonization was 0.97 (95% CI, .89-1.05; P = .48).

Conclusions

MRSA colonization prevalence among critically ill adult patients did not decline during the time period following legislatively mandated MRSA active surveillance. Our findings highlight the limits of legislated MRSA active surveillance as a strategy to reduce MRSA colonization burden among ICU patients.

The Impact of Isolation on Healthcare Worker Contact and Compliance With Infection Control Practices in Nursing Homes

OBJECTIVETo directly observe healthcare workers in a nursing home setting to measure frequency and duration of resident contact and infection prevention behavior as a factor of isolation practiceDESIGNObservational studySETTING AND PARTICIPANTSHealthcare workers in 8 VA nursing homes in Florida, Maryland, Massachusetts, Michigan, Washington, and TexasMETHODSOver a 15-month period, trained research staff without clinical responsibilities on the units observed nursing home resident room activity for 15-30-minute intervals. Observers recorded time of entry and exit, isolation status, visitor type (staff, visitor, etc), hand hygiene, use of gloves and gowns, and activities performed in the room when visible.RESULTSA total of 999 hours of observation were conducted across 8 VA nursing homes during which 4,325 visits were observed. Residents in isolation received an average of 4.73 visits per hour of observation compared with 4.21 for nonisolation residents (P<.01), a 12.4% increase in visits for residents in isolation. Residents in isolation received an average of 3.53 resident care activities per hour of observation, compared with 2.46 for residents not in isolation (P<.01). For residents in isolation, compliance was 34% for gowns and 58% for gloves. Healthcare worker hand hygiene compliance was 45% versus 44% (P=.79) on entry and 66% versus 55% (P<.01) on exit for isolation and nonisolation rooms, respectively.CONCLUSIONSHealthcare workers visited residents in isolation more frequently, likely because they required greater assistance. Compliance with gowns and gloves for isolation was limited in the nursing home setting. Adherence to hand hygiene also was less than optimal, regardless of isolation status of residents.Infect Control Hosp Epidemiol 2018;39:683-687.

Strategies against methicillin-resistant Staphylococcus aureus persisters

Chronic Staphylococcus aureus infections are complicated by frequent relapses not only from the development of drug resistance to conventional antibiotics, but also through the formation of persister bacterial cells. Bacterial persisters are in a transient, metabolically inactive state, making conventional antibiotics that target essential cellular growth processes ineffective, resulting in high clinical failure rates of antibiotic chemotherapy. The development of new antibiotics against persistent S. aureus is an urgent issue. Over the last decade, new strategies to identify S. aureus persister-active compounds have been proposed. This review summarizes the proposed targets, antipersister compounds and innovative methods that may augment conventional antibiotics against S. aureus persisters. The reviewed antipersister strategies can be summarized as two broad categories; directly targeting growth-independent targets and potentiating existing, ineffective antibiotics by aiding uptake or accessibility.

Impact of Discontinuing Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: An Interrupted Time Series Analysis

OBJECTIVETo investigate the impact of discontinuing contact precautions among patients infected or colonized with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) on rates of healthcare-associated infection (HAI).

DESIGN

Single-center, quasi-experimental study conducted between 2011 and 2016.METHODSWe employed an interrupted time series design to evaluate the impact of 7 horizontal infection prevention interventions across intensive care units (ICUs) and hospital wards at an 865-bed urban, academic medical center. These interventions included (1) implementation of a urinary catheter bundle in January 2011, (2) chlorhexidine gluconate (CHG) perineal care outside ICUs in June 2011, (3) hospital-wide CHG bathing outside of ICUs in March 2012, (4) discontinuation of contact precautions in April 2013 for MRSA and VRE, (5) assessments and feedback with bare below the elbows (BBE) and contact precautions in August 2014, (6) implementation of an ultraviolet-C disinfection robot in March 2015, and (7) 72-hour automatic urinary catheter discontinuation orders in March 2016. Segmented regression modeling was performed to assess the changes in the infection rates attributable to the interventions.RESULTSThe rate of HAI declined throughout the study period. Infection rates for MRSA and VRE decreased by 1.31 (P=.76) and 6.25 (P=.21) per 100,000 patient days, respectively, and the infection rate decreased by 2.44 per 10,000 patient days (P=.23) for device-associated HAI following discontinuation of contact precautions.CONCLUSIONThe discontinuation of contact precautions for patients infected or colonized with MRSA or VRE, when combined with horizontal infection prevention measures was not associated with an increased incidence of MRSA and VRE device-associated infections. This approach may represent a safe and cost-effective strategy for managing these patients.Infect Control Hosp Epidemiol 2018;39:676-682.

Methicillin-resistant Staphylococcus aureus (MRSA) screening of hospital dental clinic surfaces

We assessed the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) strains on surfaces of hospital dental clinics. Specimens were obtained from 5 clinically symptoms-free patients of five different specialties clinics (Implantology, Pediatric Dentistry, Prosthetics, Restorative Dentistry, and Oral Medicine) of the Dental Clinic Hospital of King Saud University before and after each patient. A Q-tip swabs were used from 10 surfaces in each clinic (Arm rest of dental chair, floor beneath dental chair, sink/faucet, towel dispenser, instrument table handle, light handle, X-ray viewer, paper dental records, head rest, and bench). Specimens were cultured in CHROMagar MRSA medium. Prevalence of MRSA colonization was compared between periods before and after patients visited each clinic for treatment. The results showed that the prevalence of MRSA was remarkably increased after patients visited the area. The results indicate that dental clinics should be considered as possible reservoirs of MRSA in the hospital setting.

Infection Control Following an Outbreak of Extended-Spectrum Beta-Lactamase-Producing Klebsiella pneumoniae Isolated from Catheter-Associated Urinary Tract Infection

We present our experience with controlling an outbreak of extended-spectrum beta-lactamase (ESBL)-producing bacteria in catheter-associated urinary tract infection and the measures taken to prevent future outbreaks. In June 2015, 9 out of 44 hospitalized patients in the same ward tested positive for antibiotic-resistant bacteria in urine cultures, including ESBL-producing Klebsiella pneumoniae. Since these bacteria belonged to the same cluster, we concluded this was a localized outbreak. Seven out of 10 environmental tests detected resistant strains at 1,000 colony forming units/cm² or more. After an outbreak, we undertook periodic monitoring by active surveillance culture (ASC) every 2 months, along with environmental wipe testing. Cleaning regimen was performed through alcohol disinfection 5 or 7 times a day, then changed to complex-type chlorine-based disinfectant cleaner once a day that includes potassium peroxymonosulfate. ASC revealed only one positive case of antibiotic-resistant strain after incorporating new infection controls. Only a few environmental tests were positive for the bacteria after the new cleaning regimen, suggesting this cleaner might be effective for inhibiting outbreaks. Our control measures successfully prevented further outbreak and inhibited the recurrence.

Epidemiologic Factors, Clinical Presentation, Causes, and Outcomes of Liver Abscess: A 35-Year Olmsted County Study

Objective

To report the changing incidence, clinical presentation, microbiologic spectrum, and outcomes of pyogenic liver abscess (PLA) in Olmsted County, Minnesota, over the past 35 years.

Patients and Methods

The Rochester Epidemiology Project was used to identify residents with PLA from January 1, 1980, through December 31, 2014. The study included all patients older than 18 years, with the diagnosis of PLA confirmed through radiographic review and microbiologic cultures.

Results

In total, 72 patients received a diagnosis of PLA from 1980 through 2014. The age-adjusted incidence for men was 3.92 cases per 100,000 person-years (95% CI, 2.76-5.09 cases per 100,000 person-years) compared with 1.87 cases per 100,000 person-years (95% CI, 1.15-2.59 cases per 100,000 person-years) for women. Incidence was higher in the period from January 1, 2001, through December 31, 2014, than in the period from January 1, 1980, through December 31, 2000, for women (incidence rate ratio [IRR], 3.8; 95% CI, 1.43-10.09; P=.007) but not for men (IRR, 0.99; 95% CI, 0.55-1.76; P=.96). Fifteen additional patients had postintervention PLA (1980-2000: n=3 of 29 [10.3%] vs 2001-2015: n=12 of 58 [20.6%]). A significant association was seen between age- and sex-adjusted incidence rates of PLA and year of diagnosis (per year since 1980: IRR, 1.04; 95% CI, 1.02-1.07; P<.001) after including postintervention PLA. Streptococcus milleri was the most common organism identified (52.5%). Organisms with multidrug resistance were more common in the period from 2001 through 2014 than in the period from 1980 through 2000 (51% vs 14%; P=.005). The overall mortality rate of PLA was 16.8% (95% CI, 7.6%-25.0%) at 6 months.

Conclusion

The incidence of PLA is increasing, probably because of increase in frequency of hepatobiliary interventions and organisms with multidrug resistance.

Distribution of the Most Prevalent Spa Types among Clinical Isolates of Methicillin-Resistant and -Susceptible Staphylococcus aureus around the World: A Review

Background:Staphylococcus aureus, a leading cause of community-acquired and nosocomial infections, remains a major health problem worldwide. Molecular typing methods, such as spa typing, are vital for the control and, when typing can be made more timely, prevention of S. aureus spread around healthcare settings. The current study aims to review the literature to report the most common clinical spa types around the world, which is important for epidemiological surveys and nosocomial infection control policies.

Methods: A search via PubMed, Google Scholar, Web of Science, Embase, the Cochrane library, and Scopus was conducted for original articles reporting the most prevalent spa types among S. aureus isolates. The search terms were “Staphylococcus aureus, spa typing.”

Results: The most prevalent spa types were t032, t008 and t002 in Europe; t037 and t002 in Asia; t008, t002, and t242 in America; t037, t084, and t064 in Africa; and t020 in Australia. In Europe, all the isolates related to spa type t032 were MRSA. In addition, spa type t037 in Africa and t037and t437 in Australia also consisted exclusively of MRSA isolates. Given the fact that more than 95% of the papers we studied originated in the past decade there was no option to study the dynamics of regional clone emergence.

Conclusion: This review documents the presence of the most prevalent spa types in countries, continents and worldwide and shows big local differences in clonal distribution.

Prevention and Control of Multidrug-Resistant Gram-Negative Bacteria in Adult Intensive Care Units: A Systematic Review and Network Meta-analysis

Background

This study evaluated the relative efficacy of strategies for the prevention of multidrug-resistant gram-negative bacteria (MDR-GNB) in adult intensive care units (ICUs).

Methods

A systematic review and network meta-analysis was performed; searches of the Cochrane Library, PubMed, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) included all randomized controlled trials and observational studies conducted in adult patients hospitalized in ICUs and evaluating standard care (STD), antimicrobial stewardship program (ASP), environmental cleaning (ENV), decolonization methods (DCL), or source control (SCT), simultaneously. The primary outcomes were MDR-GNB acquisition, colonization, and infection; secondary outcome was ICU mortality.

Results

Of 3805 publications retrieved, 42 met inclusion criteria (5 randomized controlled trials and 37 observational studies), involving 62068 patients (median age, 58.8 years; median APACHE [Acute Physiology and Chronic Health Evaluation] II score, 18.9). The majority of studies reported extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae and MDR Acinetobacter baumannii. Compared with STD, a 4-component strategy composed of STD, ASP, ENV, and SCT was the most effective intervention (rate ratio [RR], 0.05 [95% confidence interval {CI}, .01-.38]). When ENV was added to STD+ASP or SCT was added to STD+ENV, there was a significant reduction in the acquisition of MDR A. baumannii (RR, 0.28 [95% CI, .18-.43] and 0.48 [95% CI, .35-.66], respectively). Strategies with ASP as a core component showed a statistically significant reduction the acquisition of ESBL-producing Enterobacteriaceae (RR, 0.28 [95% CI, .11-.69] for STD+ASP+ENV and 0.23 [95% CI, .07-.80] for STD+ASP+DCL).

Conclusions

A 4-component strategy was the most effective intervention to prevent MDR-GNB acquisition. As some strategies were differential for certain bacteria, our study highlighted the need for further evaluation of the most effective prevention strategies.

The Hospital Water Environment as a Reservoir for Carbapenem-Resistant Organisms Causing Hospital-Acquired Infections-A Systematic Review of the Literature

Over the last 20 years there have been 32 reports of carbapenem-resistant organisms in the hospital water environment, with half of these occurring since 2010. The majority of these reports have described associated clinical outbreaks in the intensive care setting, affecting the critically ill and the immunocompromised. Drains, sinks, and faucets were most frequently colonized, and Pseudomonas aeruginosa the predominant organism. Imipenemase (IMP), Klebsiella pneumoniae carbapenemase (KPC), and Verona integron-encoded metallo-β-lactamase (VIM) were the most common carbapenemases found. Molecular typing was performed in almost all studies, with pulse field gel electrophoresis being most commonly used. Seventy-two percent of studies reported controlling outbreaks, of which just more than one-third eliminated the organism from the water environment. A combination of interventions seems to be most successful, including reinforcement of general infection control measures, alongside chemical disinfection. The most appropriate disinfection method remains unclear, however, and it is likely that replacement of colonized water reservoirs may be required for long-term clearance.