Prevalence of carbapenem-resistant organisms and other Gram-negative MDRO in German ICUs: first results from the national nosocomial infection surveillance system (KISS)

Quality indicators in intensive care medicine for Germany - fourth edition 2022

The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 10 indicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.

Burden of severe infections due to carbapenem-resistant pathogens in intensive care unit

Intensive care units (ICU) for various reasons, including the increasing age of admitted patients, comorbidities, and increasingly complex surgical procedures (e.g., transplants), have become "the epicenter" of nosocomial infections, these are characterized by the presence of multidrug-resistant organisms (MDROs) as the cause of infection. Therefore, the perfect match of fragile patients and MDROs, as the cause of infection, makes ICU mortality very high. Furthermore, carbapenems were considered for years as last-resort antibiotics for the treatment of infections caused by MDROs; unfortunately, nowadays carbapenem resistance, mainly among Gram-negative pathogens, is a matter of the highest concern for worldwide public health. This comprehensive review aims to outline the problem from the intensivist's perspective, focusing on the new definition and epidemiology of the most common carbapenem-resistant MDROs (Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacterales) to emphasize the importance of the problem that must be permeating clinicians dealing with these diseases.

Deceased donors with multidrug-resistant organisms: implications and future directions

PURPOSE OF REVIEW

Organ utilization from donors infected or colonized with multidrug-resistant organisms (MDROs) remains inconsistent, and hesitancy to accept organs from these donors may relate to poor outcomes among solid organ transplant recipients with MDRO donor-derived infections (DDIs). An improved understanding of the risk factors for donor MDRO colonization or infection and the risk of MDRO DDI is needed to safely expand the donor pool while minimizing unnecessary organ discard.

RECENT FINDINGS

Recent studies have begun to delineate risk factors for MDRO acquisition among deceased donors and the epidemiology of MDRO DDIs, but additional efforts are warranted to inform optimal approaches to donor evaluation, risk stratification, management, interfacility and interagency data sharing, and approaches to recipient management.

SUMMARY

This review summaries recent data regarding risk factors for MDRO colonization and infection in deceased donors, epidemiology of MDRO DDIs, and current approaches to donors harboring MDROs and provides a framework for future research and collaboration.

Epidemiological characteristics of carbapenem-resistant Enterobacteriaceae and carbapenem-resistant Acinetobacter baumannii in a tertiary referral hospital in Korea

Objectives

This study aimed to identify the epidemiological characteristics of patients with carbapenem-resistant Enterobacteriaceae and Acinetobacter baumannii (CRE/CRAB) isolates in a tertiary referral hospital in Korea.

Methods

We collected and analyzed data from 528 adults admitted to a tertiary referral hospital from August 1, 2018 to February 29, 2020. The CRE/CRAB isolates were confirmed as being present at the time of patients’ admission or acquired during hospitalization based on their medical records. The t-test, chi-square test, or Fisher exact test and stepwise multiple logistic regression were performed.

Results

While the proportion of community-acquired CRE/CRAB was low (6%), 20% of CRE/CRAB isolates were identified in patients at the time of hospitalization. The risk of CRAB isolation was positively associated with mechanical ventilator use (odds ratio [OR], 3.52; 95% confidence interval [CI], 1.96−6.33) and total parenteral nutrition use (OR, 3.64; 95% CI, 1.87−7.08).

Conclusion

Over 20% of CRE/CRAB isolates in a tertiary referral hospital in Korea were found at the time of patients’ admission. Furthermore, patients with mechanical ventilation and/or total parenteral nutrition tended to acquire CRAB more frequently. Thus, active surveillance for CRE/CRAB at the time of hospitalization is strongly required, particularly for patients who are expected to require mechanical ventilation or total parenteral nutrition.

Geographical differences of carbapenem non-susceptible Enterobacterales and Acinetobacter spp. in Germany from 2017 to 2019

BACKGROUND

Since May 2016, infection and colonisation with carbapenem non-susceptible Acinetobacter spp. (CRA) and Enterobacterales (CRE) have to be notified to health authorities in Germany. The aim of our study was to assess the epidemiology of CRA and CRE from 2017 to 2019 in Germany, to identify risk groups and to determine geographical differences of CRA and CRE notifications.

METHODS

Cases were notified from laboratories to local public health authorities and forwarded to state and national level. Non-susceptibility was defined as intermediate or resistant to ertapenem, imipenem, or meropenem excluding intrinsic bacterial resistance or the detection of a carbapenemase gene. We analysed CRA and CRE notifications from 2017, 2018 and 2019 per 100,000 inhabitants (notification incidence), regarding their demographic, clinical and laboratory information. The effect of regional hospital-density on CRA and CRE notification incidence was estimated using negative binomial regression.

RESULTS

From 2017 to 2019, 2278 CRA and 12,282 CRE cases were notified in Germany. CRA and CRE cases did not differ regarding demographic and clinical information, e.g. proportion infected. The notification incidence of CRA declined slightly from 0.95 in 2017 to 0.86 in 2019, whereas CRE increased from 4.23 in 2017 to 5.72 in 2019. The highest CRA and CRE notification incidences were found in the age groups above 70 years. Infants below 1 year showed a high CRE notification incidence, too. Notification incidences varied between 0.10 and 2.86 for CRA and between 1.49 and 9.99 for CRE by federal state. The notification incidence of CRA and CRE cases increased with each additional hospital per district.

CONCLUSION

The notification incidence of CRA and CRE varied geographically and was correlated with the number of hospitals.The results support the assumption that hospitals are the main driver for higher CRE and CRA incidence. Preventive strategies and early control measures should target older age groups and newborns and areas with a high incidence.

Impact of donor multidrug-resistant organisms on solid organ transplant recipient outcomes

BACKGROUND

The impact of donor colonization or infection with multidrug-resistant organisms (MDROs) on solid organ transplant (SOT) recipient outcomes remains uncertain. We thus evaluated the association between donor MDROs and risk of posttransplant infection, graft failure, and mortality.

METHODS

A multicenter retrospective cohort study was performed. All SOT recipients with a local deceased donor were included. The cohort was divided into three exposure groups: recipients whose donors had (1) an MDRO, (2) a non-MDRO bacterial or candidal organism, or (3) no growth on cultures. The primary outcomes were (1) bacterial or invasive candidal infection within 3 months and (2) graft failure or death within 12 months posttransplant. Mixed effect multivariable frailty models were developed to evaluate each association.

RESULTS

Of 658 total SOT recipients, 93 (14%) had a donor with an MDRO, 477 (73%) had a donor with a non-MDRO organism, and 88 (13%) had a donor with no organisms on culture. On multivariable analyses, donor MDROs were associated with a significantly increased hazard of infection compared to those with negative donor cultures (adjust hazard ratio [aHR] 1.63, 95% CI 1.01-2.62, p = .04) but were not associated with graft failure or death (aHR 0.45, 95% CI 0.15-1.36, p = .16).

CONCLUSIONS

MDROs on donor culture increase the risk of early posttransplant infection but do not appear to affect long-term graft or recipient survival, suggesting organ donors with MDROs on culture may be safely utilized. Future studies aimed at reducing early posttransplant infections associated with donor MDROs are needed.

Detection of Multidrug-Resistant Enterobacterales-From ESBLs to Carbapenemases

Multidrug-resistant Enterobacterales (MDRE) are an emerging threat to global health, leading to rising health care costs, morbidity and mortality. Multidrug-resistance is commonly caused by different β-lactamases (e.g., ESBLs and carbapenemases), sometimes in combination with other resistance mechanisms (e.g., porin loss, efflux). The continuous spread of MDRE among patients in hospital settings and the healthy population require adjustments in healthcare management and routine diagnostics. Rapid and reliable detection of MDRE infections as well as gastrointestinal colonization is key to guide therapy and infection control measures. However, proper implementation of these strategies requires diagnostic methods with short time-to-result, high sensitivity and specificity. Therefore, research on new techniques and improvement of already established protocols is inevitable. In this review, current methods for detection of MDRE are summarized with focus on culture based and molecular techniques, which are useful for the clinical microbiology laboratory.

Antimicrobial effects of nitric oxide in murine models of Klebsiella pneumonia

RATIONALE

Inhalation of nitric oxide (NO) exerts selective pulmonary vasodilation. Nitric oxide also has an antimicrobial effect on a broad spectrum of pathogenic viruses, bacteria and fungi.

OBJECTIVES

The aim of this study was to investigate the effect of inhaled NO on bacterial burden and disease outcome in a murine model of Klebsiella pneumonia.

METHODS

Mice were infected with Klebsiella pneumoniae and inhaled either air alone, air mixed with constant levels of NO (at 80, 160, or 200 parts per million (ppm)) or air intermittently mixed with high dose NO (300 ppm). Forty-eight hours after airway inoculation, the number of viable bacteria in lung, spleen and blood was determined. The extent of infiltration of the lungs by inflammatory cells and the level of myeloperoxidase activity in the lungs were measured. Atomic force microscopy was used to investigate a possible mechanism by which nitric oxide exerts a bactericidal effect.

MEASUREMENTS AND MAIN RESULTS

Compared to control animals infected with K. pneumoniae and breathed air alone, intermittent breathing of NO (300 ppm) reduced viable bacterial counts in lung and spleen tissue. Inhaled NO reduced infection-induced lung inflammation and improved overall survival of mice. NO destroyed the cell wall of K. pneumoniae and killed multiple-drug resistant K. pneumoniae in-vitro.

CONCLUSIONS

Intermittent administration of high dose NO may be an effective approach to the treatment of pneumonia caused by K. pneumoniae.

Low colonization rates with Multidrug-resistant Gram-negative bacteria in a German hospital-affiliated hemodialysis center

Background

Multidrug-resistant Gram-negative bacteria (MDRGN) are found with rising prevalence in non-hemodialysis risk populations as well as hemodialysis (HD) cohorts in Asia, Europe and North America. At the same time, colonization and consecutive infections with such pathogens may increase mortality and morbidity of affected individuals. We aimed to monitor intestinal MDRGN colonization in a yet not investigated German HD population.

Methods

We performed cross-sectional point-prevalence testing with 12 months follow-up and selected testing of relatives in an out-patient HD cohort of n = 77 patients by using microbiological cultures from fresh stool samples, combined with Matrix Assisted Laser Desorption Ionization—Time of Flight Mass Spectrometry (MALDI-TOF-MS) and antimicrobial susceptibility testing.

Results

We detected MDRGN in 8 out of 77 patients (10.4%) and 1 out of 22 relatives (4.5%), indicating only colonization and no infections. At follow-up, 2 patients showed phenotypic persistence of MDRGN colonization, and in 6 other patients de-novo MDRGN colonization could be demonstrated. Pathogens included Escherichia coli and Klebsiella pneumoniae (with extended-spectrum beta-lactamase [ESBL]-production as well as fluoroquinolone resistance), Stenotrophomonas maltophilia and Enterobacter cloacae.

Conclusions

In a single-center study, MDRGN colonization rates were below those found in non-HD high-risk populations and HD units in the US, respectively. Reasons for this could be high hygiene standards and a strict antibiotic stewardship policy with evidence of low consumption of fluoroquinolones and carbapenems in our HD unit and the affiliated hospital.

[Infections due to multidrug-resistant pathogens : Pathogens, resistance mechanisms and established treatment options]

The increase in resistant pathogens has long been a global problem. Complicated life-threatening infections due to multidrug-resistant pathogens (MRD) meanwhile occur regularly in intensive care medicine. An important and also potentially modifiable factor of the rapid spread of resistance is the irrational use of broad spectrum antibiotics in human medicine. In addition to many other resistance mechanisms, beta-lactamases play an important role in Gram-negative pathogens. They are not uncommonly the leading reason of difficult to treat infections and the failure of known routinely used broad spectrum antibiotics, such as cephalosporins, (acylamino)penicillins and carbapenems. Strategies for containment of MRDs primaríly target the rational use of antibiotics. In this respect interdisciplinary treatment teams, e.g. antibiotic stewardship (ABS) and infectious diseases stewardship (IDS) play a major role.

Prevalence of Common Nosocomial Infections and Evaluation of Antibiotic Resistance Patterns in Patients with Secondary Infections in Hamadan, Iran

Introduction

The prevalence of nosocomial infections in patients hospitalized to three hospitals of Shahid Beheshti, Farshchian, and Be’ saat in Hamadan was investigated for 2 years (2018 to 2020).

Materials and Methods

The samples were cultured and characterized using morphological and diagnostic biochemical tests. The analysis of the frequency of the isolates and their antibiotic resistance were calculated using SPSS (version 22) at a significant level of P-value < 0.05.

Results

Bacterial isolates were collected from the 1194 clinical specimens, of which 1394 were isolated from urine, 16 from CSF, and 588 from tracheal aspiration. Also, 654 (54.8%) isolates were obtained from females and 540 (45.2%) from males with the age range 15–73 years (P> 0.05). The results showed that 22.1% were gram-positive and 77.9% were gram-negative. In our study, the frequency of Klebsiella pneumoniae bacteria was higher than in some studies, and this indicates the genetic changes and resistance of this bacterium to many antibiotics.

Conclusion

To prevent further spread of resistance, increase the effectiveness of antibiotics and prevent multidrug resistance, it is essential to establish a precise schedule for the use of antibiotics and assess the resistance pattern periodically in each region based on the antibiotic resistance pattern.

Management of patients with multidrug-resistant organisms in rehabilitation facilities. Results of a survey in the Rhine-Main region, Germany, 2019

Introduction: Multidrug-resistant organisms (MDRO) are a problem in medical facilities, including rehabilitation facilities in Germany. The national recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) for prevention of and dealing with patients affected by MDRO are obligatory in rehabilitation facilities. A survey on the management of patients with MDRO in rehabilitation facilities in the Rhine-Main area is presented below. Materials and methods: The questions from a recently published survey in 45 rehabilitation facilities in 26 European countries (Doherty et al., 2019) were largely adopted unchanged: the type, size, and organization of the facility, availability of guidelines on MDRO, screening and (estimated) prevalence of MDRO, as well as special hygiene measures or restrictions for patients with MDRO. Results: 22 of the 43 institutions contacted participated (58%). All facilities had specific recommendations on how to deal with MDRO and more than 95% had adequate hygiene staff. The facilities encompassed 4,369 beds, with 3,909 (89%) of them in single-bed rooms, and only a few offered 3-bed rooms. About 20% of patients in general rehabilitation and 100% in early neurological rehabilitation are screened on admission. Six (27%) facilities refused to accept patients with MDRO. 40% of the facilities treated these patients in their own room and/or in a separate area. 27% of the facilities prohibited eating in the dining room and participating in hydrotherapy. Only 6 (27%) of the rehabilitation centers indicated that patients with MDRO are allowed to participate in full rehabilitation programs. Discussion: In accordance with the results of Doherty et al. (2019), there were many restrictions for rehabilitation patients with MDRO, indicating considerable need for improvement. Necessary hygiene recommendations to avoid the transmission of MDRO must not lead to rejection of inpatient rehabilitation or to less intensive rehabilitation.

Acquired Genetic Elements that Contribute to Antimicrobial Resistance in Frequent Gram-Negative Causative Agents of Healthcare-Associated Infections

Antimicrobial resistance (AMR) is a worldwide public health problem that reduces therapeutic options and increases the risk of death. The causative agents of healthcare-associated infections (HAIs) are drug-resistant microorganisms of the nosocomial environment, which have developed different mechanisms of AMR. The hospital-associated microbiota has been proposed to be a reservoir of genes associated with AMR and an environment where the transfer of genetic material among organisms may occur. The ESKAPE group (Enterococcus faecalis and Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter aerogenes and Escherichia coli) is a frequent causative agents of HAIs. In this review, we address the issue of acquired genetic elements that contribute to AMR in the most frequent Gram-negative of ESKAPE, with a focus on last resort antimicrobial agents and the role of transference of genetic elements for the development of AMR.

Dissemination of VIM-producing Pseudomonas aeruginosa associated with high-risk clone ST654 in a tertiary and quaternary hospital in Makkah, Saudi Arabia

To the best of our knowledge, no molecular surveillance that has been conducted to identify the most common clones of carbapenem-resistant Pseudomonas aeruginosa (CRPA) in western Saudi Arabia. Therefore, this study aimed to identify genetic diversity and the most common CRPA clones in this region. Thirty-five CRPA isolates were collected from a tertiary and quaternary hospital in Makkah. bla _VIM was the most common carbapenemase-encoding gene (11 CRPA isolates), while bla_GES was reported in only three isolates. CRPA isolates were subjected to multi- locus sequence typing and showed relatively high genetic diversity with 20 sequence types. Approximately one-third (31.4%) of the CRPA isolates belonged to two high-risk clones (ST235 and ST654). This troublesome finding raises serious concerns about the emergence and further dissemination of CRPA high-risk clones in local hospitals and suggest that surveillance programs should be established in this region to monitor and control clonal dissemination of all multidrug resistant bacteria, including CRPA.

Determining the ideal prevention strategy for multidrug-resistance organisms in resource-limited countries: a cost-effectiveness analysis study

The aim of this study was to determine the most cost-effective strategy for the prevention and control of multidrug-resistant organisms (MDROs) in intensive care units (ICUs) in areas with limited health resources. The study was conducted in 12 ICUs of four hospitals. The total cost for the prevention of MDROs and the secondary attack rate (SAR) of MDROs for each strategy were collected retrospectively from 2046 subjects from January to December 2017. The average cost-effectiveness ratio (CER), incremental cost-effectiveness ratio (ICER) and cost-effectiveness acceptability curve were calculated. Hand hygiene (HH) had the lowest total cost (2149.6 RMB) and SAR of MDROs (8.8%) while single-room isolation showed the highest cost (33 700.2 RMB) and contact isolation had the highest SAR of MDROs (31.8%). The average cost per unit infection prevention was 24 427.8 RMB, with the HH strategy followed by the environment disinfection strategy (CER = 21 314.67). HH had the highest iterative cost effect under willingness to pay less than 2000 RMB. Due to the low cost for repeatability and obvious effectiveness, we conclude that HH is the optimal strategy for MDROs infections in ICUs in developing countries. The cost-effectiveness of the four prevention strategies provides some reference for developing countries but multiple strategies remain to be examined.

Healthcare Associated Infections: An Interoperable Infrastructure for Multidrug Resistant Organism Surveillance

Prevention and surveillance of healthcare associated infections caused by multidrug resistant organisms (MDROs) has been given increasing attention in recent years and is nowadays a major priority for health care systems. The creation of automated regional, national and international surveillance networks plays a key role in this respect. A surveillance system has been designed for the Abruzzo region in Italy, focusing on the monitoring of the MDROs prevalence in patients, on the appropriateness of antibiotic prescription in hospitalized patients and on foreseeable interactions with other networks at national and international level. The system has been designed according to the Service Oriented Architecture (SOA) principles, and Healthcare Service Specification (HSSP) standards and Clinical Document Architecture Release 2 (CDAR2) have been adopted. A description is given with special reference to implementation state, specific design and implementation choices and next foreseeable steps. The first release will be delivered at the Complex Operating Unit of Infectious Diseases of the Local Health Authority of Pescara (Italy).

Effects of sub-inhibitory concentrations of antibiotics and oxidative stress on the expression of type II toxin-antitoxin system genes in Klebsiella pneumoniae

OBJECTIVES

Sub-inhibitory concentrations (sub-MICs) of antibiotics reflect the conditions that bacteria encounter in tissues and the natural environment. Sub-MICs of antibiotics can induce stress and alter the expression of different bacterial genes. Bacteria react to stress conditions using different mechanisms, one of which is the toxin-antitoxin (TA) system. This study investigated the expression of the TA system genes under oxidative and antibiotic stresses in Klebsiella pneumoniae (K. pneumoniae).

METHODS

To determine the effects of sub-MICs of gentamicin, nalidixic acid, ceftazidime, and certain concentrations of H₂O₂ on bacterial survival and growth, colony forming units were quantitated and turbidity was assessed following the treatment of K. pneumoniae with ½ MICs of antibiotics and 5 mM H₂O₂ at different time intervals. The expression of TA system genes in K. pneumoniae was evaluated 1 h after treatment using the quantitative real-time PCR (qRT-PCR) method.

RESULTS

The results revealed reduced K. pneumoniae growth in the presence of sub-MICs of antibiotics and 5 mM H₂O₂ compared to the control. Furthermore, according to the results of the qRT-PCR assay, only the presence of gentamicin could increase the expression of TA system genes.

CONCLUSION

Although the exact role of the TA systems in response to stress is still unclear, this study provided information on the effect of the type II TA systems under oxidative and antibiotic stress conditions.

Risk factors for multidrug-resistant organisms among deceased organ donors

Donor infection or colonization with a multidrug-resistant organism (MDRO) affects organ utilization and recipient antibiotic management. Approaches to identifying donors at risk of carrying MDROs are unknown. We sought to determine the risk factors for MDROs among transplant donors. A multicenter retrospective cohort study was conducted at four transplant centers between 2015 and 2016. All deceased donors who donated at least one organ were included. Cultures obtained during the donor's terminal hospitalization and organ procurement were evaluated. The primary outcome was isolation of an MDRO on culture. Multivariable Cox regression was used to determine risk factors associated with time to donor MDRO. Of 440 total donors, 64 (15%) donors grew an MDRO on culture. Predictors of an MDRO on donor culture included hepatitis C viremia (hazard ratio [HR] 4.09, 95% confidence interval [CI] 1.71-9.78, P = .002), need for dialysis (HR 4.59, 95% CI 1.09-19.21, P = .037), prior hematopoietic cell transplant (HR 7.57, 95% CI 1.03-55.75, P = .047), and exposure to antibiotics with a narrow gram-negative spectrum (HR 1.13, 95% CI 1.00-1.27, P = .045). This is the first study to determine risk factors for MDROs among deceased donors and will be important for risk stratifying potential donors and informing transplant recipient prophylaxis.

Rate and impact of multidrug-resistant organisms in patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

Multidrug-resistant organisms (MDRO) are an increasing problem in critical care medicine. This study describes for the first time the rate and impact of MDRO in patients suffering from aneurysmal subarachnoid hemorrhage (SAH).

METHODS

Anonymized data of SAH patients admitted to our institution from November 2010 to August 2017 were retrospectively reviewed. Patients with microbiological tests positive for MDRO were identified. Screening of MDRO was in consensus with national recommendations.

RESULTS

449 SAH patients were reviewed with 18 patients (prevalence: four MDRO-positive patients per 100 SAH patients) having positive tests for MDRO during their hospital stay. The prevalence upon admission was 1.3 MDRO-positive patients per 100 patients. The acquisition rate was 1.1 MDRO-positive patients per 1000 hospital days. Patients positive for an MDRO had a significantly extended length of stay in intensive care (mean ± SD 26.7 ± 13.0 versus 18.4 ± 11.7 days, p = 0.004) and in hospital (mean ± SD 33.9 ± 12.4 versus 24.4 ± 12.6 days, p = 0.002). MDRO detection was associated with a significant prolonged duration of mechanical ventilation (median (IQR) 254.0 (14.9-632.8) versus 37.5 (3.3-277.0) hours, p = 0.02). There was no statistically significant effect on the Glasgow Outcome Scale (GOS) at discharge and at follow-up after 164.4 ± 113.0 days.

CONCLUSIONS

MDRO positivity is present in 4% of aneurysmal SAH patients. It seems to be associated with a prolonged length of stay and prolonged duration of mechanical ventilation. The importance of infection control standards in neurointensive care units is emphasized.

Role of the Clinical Microbiology Laboratory in Antimicrobial Stewardship

For adequate antimicrobial stewardship, microbiology needs to move from the laboratory to become physically and verbally amenable to the caregivers of an institution. Herein, we describe the contributions of our microbiology department to the antimicrobial stewardship program of a large teaching hospital as 10 main points ranging from the selection of patients deemed likely to benefit from a fast track approach, to their clinical samples, or the rapid reporting of results via a microbiology hotline, to rapid searches for pathogens and susceptibility testing. These points should serve as guidelines for similar programs designed to decrease the unnecessary use of antimicrobials.

Knowledge and practice of Chinese physicians toward carbapenem-resistant enterobacteriaceae: a nationwide cross-sectional survey in top 100 hospitals

Background

Carbapenem-resistant enterobacteriaceae (CRE) has been one of the greatest threats to population health over the past decade. Few reports have focused on the knowledge and practice of Chinese physicians toward CRE.

Methods

A cross-sectional survey of CRE-related knowledge and practice was conducted in top 100 tertiary comprehensive hospitals between June and July 2017.

Results

A total of 53 designed hospitals responded, including 217 intensive care unit physicians, 142 respiratory physicians, 112 hematology physicians, and 58 infectious disease physicians. The percentage of correct answers to each questions ranged from 25.7% to 89%, and the physicians' knowledge score ranged from 1 to 9 (median =6; interquartile range, 5-7). A significant relationship was found between CRE knowledge level and demographics of city level, work department, and CRE treated in the last 6 months. In terms of practice, physicians with a high knowledge level were more likely to treat CRE infection with combined medication, considering undesirable infection control practice as the main risk factor.

Conclusions

Overall, majority of physicians were concerned about CRE infections and indicated that they would take measures to prevent this gram-negative resistant bacteria. The findings will help focus and target on teaching and awareness-raising strategies.

Epidemiology of sepsis in intensive care units in Turkey: a multicenter, point-prevalence study

BACKGROUND

The prevalence and mortality of sepsis are largely unknown in Turkey, a country with high antibiotic resistance. A national, multicenter, point-prevalence study was conducted to determine the prevalence, causative microorganisms, and outcome of sepsis in intensive care units (ICUs) in Turkey.

METHODS

A total of 132 ICUs from 94 hospitals participated. All patients (aged > 18 years) present at the participating ICUs or admitted for any duration within a 24-h period (08:00 on January 27, 2016 to 08:00 on January 28, 2016) were included. The presence of systemic inflammatory response syndrome (SIRS), severe sepsis, and septic shock were assessed and documented based on the consensus criteria of the American College of Chest Physicians and Society of Critical Care Medicine (SEPSIS-I) in infected patients. Patients with septic shock were also assessed using the SEPSIS-III definitions. Data regarding demographics, illness severity, comorbidities, microbiology, therapies, length of stay, and outcomes (dead/alive during 30 days) were recorded.

RESULTS

Of the 1499 patients included in the analysis, 237 (15.8%) had infection without SIRS, 163 (10.8%) had infection with SIRS, 260 (17.3%) had severe sepsis without shock, and 203 (13.5%) had septic shock. The mortality rates were higher in patients with severe sepsis (55.7%) and septic shock (70.4%) than those with infection alone (24.8%) and infection + SIRS (31.2%) (p < 0.001). According to SEPSIS-III, 104 (6.9%) patients had septic shock (mortality rate, 75.9%). The respiratory system (71.6%) was the most common site of infection, and Acinetobacter spp. (33.7%) were the most common isolated pathogen. Approximately, 74.9%, 39.1%, and 26.5% of Acinetobacter, Klebsiella, and Pseudomonas spp. isolates, respectively, were carbapenem-resistant, which was not associated with a higher mortality risk. Age, acute physiology and chronic health evaluation II score at ICU admission, sequential organ failure assessment score on study day, solid organ malignancy, presence of severe sepsis or shock, Candida spp. infection, renal replacement treatment, and a nurse-to-patient ratio of 1:4 (compared with a nurse-to-patient ratio of 1:2) were independent predictors of mortality in infected patients.

CONCLUSIONS

A high prevalence of sepsis and an unacceptably high mortality rate were observed in Turkish ICUs. Although the prevalence of carbapenem resistance was high in Turkish ICUs, it was not associated with a higher risk for mortality.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT03249246 . Date: August 15, 2017. Retrospectively registered.

Carbapenem-resistant Gram-negative pathogens in a German university medical center: Prevalence, clinical implications and the role of novel β-lactam/β-lactamase inhibitor combinations

Objectives

To determine the spectrum of infections with multidrug-resistant Gram-negative bacteria (MDR-GNB) and the clinical impact of the newly available betalactam/betalactamase inhibitor combinations ceftolozane/tazobactam and ceftazidime/avibactam in a German academic tertiary care center.

Methods

Retrospective analysis.

Results

Between September 1, 2015 and August 31, 2016, 119 individual patients (0.22% of all hospital admissions) were colonized or infected with carbapenem-resistant MDR-GNB. The species distribution was Pseudomonas aeruginosa, n = 66; Enterobacteriaceae spp., n = 44; and Acinetobacter baumannii, n = 18. In 9 patients, carbapenem-resistant isolates belonging to more than one species were detected. Infection was diagnosed in 50 patients (total: 42.0%; nosocomial pneumonia: n = 23, 19.3%; bloodstream infection: n = 11, 9.2%). Antimicrobial treatment with broad-spectrum antibiotics prior to detection of a carbapenem-resistant isolate was documented in 105 patients (88.2%, prior administration of carbapenems: 62.2%). Nosocomial transmission was documented in 29 patients (24.4%). In 26 patients (21.8%), at least one carbapenem-susceptible, third-generation cephalosporin non-susceptible isolate was documented prior to detection of a carbapenem-resistant isolate belonging to the same species (median 38 days, IQR 23–78). 12 patients (10.1%) had documented previous contact to the healthcare system in a country with high burden of carbapenemase-producing strains. Genes encoding carbapenemases were detected in 60/102 patient isolates (58.8%; VIM-2, n = 25; OXA-48, n = 21; OXA-23-like, n = 10). Susceptibility to colistin was 94.3%. Ceftolozane/tazobactam and ceftazidime/avibactam were administered to 3 and 5 patients, respectively (in-hospital mortality: 66% and 100%). Development of drug-resistance under therapy was observed for both antimicrobials.

Conclusions

i) The major predisposing factors for acquisition of carbapenem-resistant MDR-GNB were selective pressure due to preceding antimicrobial therapy and nosocomial transmission. ii) Colistin remains the backbone of antimicrobial chemotherapy for infections caused by carbapenem-resistant MDR-GNB. iii) Novel β-lactam/β-lactamase inhibitor combinations are of limited usefulness in our setting because of the high prevalence of Ambler class B carbapenemases and the emergence of nonsusceptibility under therapy.

Incidence of Multidrug-Resistant Organism Among Children Admitted to Pediatric Intensive Care Unit in a Developing Country

AIM

Multidrug-resistant infections are an increasingly common condition particularly in critical care units. This study aimed to determine the incidence and types of resistant bacteria acquired in a pediatric intensive care unit (PICU) of a university hospital.

SUBJECT AND METHODS

A prospective study was conducted during the year 2016. All children aged below 16 years were studied for infection development and pattern of susceptibility to various groups of antibiotics.

RESULTS

A total of 264 patients were admitted to the PICU: 16 patients had community-acquired infection (CAI), 23 had hospital-acquired infection, and 24 patients had PICU-acquired infection (with 36 episodes) which is equivalent to 14.75 case/1,000 patient days. The study revealed high incidence of resistant organisms in the PICU but more important is the appearance of multi- and extreme drug-resistant bacteria in CAI. The study revealed that gram-negative bacteria were more prevalent in PICU, especially Klebsiella (30.5%), Acinetobacter baumanii (22.22%), and Pseudomonas (16.67%). Infection with resistant organisms in the PICU caused initial treatment failure and increased fourfold risk of mortality.

CONCLUSION

The incidence of resistant bacteria especially gram-negative pathogens was very high in the PICU. The top three resistant organisms of concern were Klebsiella, Acinetobacter, and Pseudomonas. This is a global concern that necessitates new strategies.

Anesthesia in patients with infectious disease caused by multi-drug resistant bacteria

PURPOSE OF REVIEW

Up to 50% of specific bacterial strains in healthcare admission facilities are multi-drug resistant organisms (MDROs). Involvement of anesthesiologists in management of patients carrying/at risk of carrying MDROs may decrease transmission in the Operating Room (OR).

RECENT FINDINGS

Anesthesiologists, their work area and tools have all been implicated in MDRO outbreaks. Causes include contamination of external ventilation circuits and noncontribution of filters to prevention, inappropriate decontamination procedures for nondisposable equipment (e.g. laryngoscopes, bronchoscopes and stethoscopes) and the anesthesia workplace (e.g. external surfaces of cart and anesthesia machine, telephones and computer keyboards) during OR cleaning and lack of training in sterile drug management.

SUMMARY

Discussions regarding the management of potential MDRO carriers must include anesthesia providers to optimize infection control interventions as well as the anesthesia method, the location of surgery and recovery and the details of patient transport. Anesthesia staff must learn to identify patients at risk for MDRO infection. Antibiotic prophylaxis, although not evidence based, should adhere to known best practices. Adjuvant therapies (e.g. intranasal Mupirocin and bathing with antiseptics) should be considered. Addition of nonmanual OR cleaning methods such as ultraviolet irradiation or gaseous decontamination is encouraged. Anesthesiologists must undergo formal training in sterile drug preparation and administration.

Screening and contact precautions - A survey on infection control measures for multidrug-resistant bacteria in German university hospitals

To assess the scope of infection control measures for multidrug-resistant bacteria in high-risk settings, a survey among university hospitals was conducted. Fourteen professionals from 8 sites participated. Reported policies varied largely with respect to the types of wards conducting screening, sample types used for screening and implementation of contact precautions. This variability among sites highlights the need for an evidence-based consensus of current infection control policies.

Antibiotic resistance: What is so special about multidrug-resistant Gram-negative bacteria?

In the past years infections caused by multidrug-resistant Gram-negative bacteria have dramatically increased in all parts of the world. This consensus paper is based on presentations, subsequent discussions and an appraisal of current literature by a panel of international experts invited by the Rudolf Schülke Stiftung, Hamburg. It deals with the epidemiology and the inherent properties of Gram-negative bacteria, elucidating the patterns of the spread of antibiotic resistance, highlighting reservoirs as well as transmission pathways and risk factors for infection, mortality, treatment and prevention options as well as the consequences of their prevalence in livestock. Following a global, One Health approach and based on the evaluation of the existing knowledge about these pathogens, this paper gives recommendations for prevention and infection control measures as well as proposals for various target groups to tackle the threats posed by Gram-negative bacteria and prevent the spread and emergence of new antibiotic resistances.

[Multidrug-resistant bacteria in Germany. The impact of sources outside healthcare facilities]

BACKGROUND

Currently, there is an ongoing discussion about the question whether the emergence of multidrug-resistant microorganisms (MDRO) among humans is due to transfer of these bacteria from animals.

OBJECTIVES

This review summarizes data on the occurrence of methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase (ESBL) producing enterobacteria in animals and humans, and describes knowledge about transmission pathways.

MATERIAL AND METHODS

After a scientific literature analysis, relevant articles were identified by screening of titles and abstracts, amended by publications of infection control authorities and the respective reference lists.

RESULTS

MDRO are both transmitted in the nosocomial setting and are increasingly detected as sources of infection outside healthcare facilities.

CONCLUSIONS

Due to new transmission pathways of MDRO an inter-disciplinary approach towards prevention is necessary, involving medical, pharmaceutical and veterinary expertise.

Carbapenem-Resistant Pseudomonas aeruginosa Bacteremia: Risk Factors for Mortality and Microbiologic Treatment Failure

We reviewed 37 patients treated for bacteremia due to carbapenem-resistant (CR) Pseudomonas aeruginosa Although 65% of isolates were multiple-drug resistant, therapeutic options were available, as all were susceptible to ≥1 antibiotic. A total of 92% of patients received active antimicrobial therapy, but only 57% received early active therapy (within 48 h). Fourteen-day mortality was 19%. Microbiologic failure occurred in 29%. The Pitt bacteremia score (P = 0.046) and delayed active therapy (P = 0.027) were predictive of death and microbiologic failure, respectively.

Prolonged outbreak of clonal MDR Pseudomonas aeruginosa on an intensive care unit: contaminated sinks and contamination of ultra-filtrate bags as possible route of transmission?

BACKGROUND

We report on an outbreak in a surgical, interdisciplinary intensive care unit (ICU) of a tertiary care hospital. We detected a cluster of ICU patients colonized or infected with multidrug-resistant Pseudomonas aeruginosa. We established an outbreak investigation team, performed an exploratory epidemiological analysis and initiated an epidemiology-based intervention.

METHODS

As part of the outbreak investigation, we performed microbiological examinations of the sinks in the patient rooms and a retrospective case-control study. All patients admitted to the outbreak ICU between January 2012 and February 2014 were included. Cases were patients colonized with the outbreak strain. Controls were patients with a different Pseudomonas aeruginosa strain. Risk factors were evaluated using multivariable conditional logistic regression analysis. Strain typing was performed using the repetitive element-based polymerase chain reaction (rep-PCR) DiversiLab system.

RESULTS

The outbreak strain was found in the sinks of five (of 16) patient rooms. Altogether 21 cases and 21 (randomly selected) controls were included. In the univariate analysis, there was no significant difference in baseline data of the patients. In the multivariate analysis, stay in a room with a colonized sink (Odds Ratio[OR] 11.2, p = 0.007) and hemofiltration (OR 21.9, p = 0.020) were independently associated with an elevated risk for colonization or infection by the outbreak strain. In a subsequent evaluation of the work procedures associated with hemofiltration, we found that the ultra-filtrate bags had been on average five times per day emptied in the sinks of the patient rooms and were used multiple for the same patient. We exchanged the traps of the contaminated sinks and eliminated work procedures involving sinks in patient rooms by implementation of single use bags, which are emptied outside patient rooms to reduce splash water at the sinks. In the 20 month follow-up period, the outbreak strain was detected only once, which indicated that the outbreak had been ceased (incidence 0.75% vs. 0.04%, p < 0.001) Furthermore, the incidence of Pseudonomas aeruginosa overall was significantly decreased (2.5% vs. 1.5%, p < 0.001).

CONCLUSION

In ICUs, limiting work processes involving sinks results in reduced multidrug-resistant Pseudomonas aeruginosa rates. ICUs with high rates of Pseudomonas aeruginosa should consider eliminating work processes that involve sinks and potentially splash water in close proximity to patients.

TRIAL REGISTRATION

All data were surveillance based data which were obtained within the German Law on Protection against Infection ("Infektionsschutzgesetz"). Therefore a trial registration was not required.

Carriage of multidrug-resistant organisms in a tertiary university hospital in Albania-a point prevalence survey

BACKGROUND

Antimicrobial resistance has been recognised as a serious global Public Health problem. Prevalence of Multiple-Drug-Resistant (MDR) organism carriage in Albania is largely unknown since no national surveillance system is in place and few publications are accessible in the literature.

METHODS

A 1-day point-prevalence-survey (PPS) screening for nasal methicillin-resistant Staphylococcus aureus (MRSA) and rectal MDR Gram-negative carriage was carried out at the high-dependency wards in the country's only tertiary care hospital, in Tirana.

RESULTS

A total of 106 nasal and 104 rectal swabs were collected. 14.2 % of patients (95 % Confidence Interval [95 CI]: 8.1-22.3 %) were MRSA nasal carriers. Resistance to aminoglycosides and fluoroquinolones was common in these isolates (≥80 %) but no resistance was identified against glycopeptides, nitrofurantoin and the relatively newer agents, tigecycline and linezolid. Fifty Enterobacteriaceae isolates were cultivated from 33 of 104 screened patients (31.7 % [95 CI: 22.9-41.6 % 95 CI]). The prevalence of Extended Spectrum Beta-Lactamase (ESBL) production in Enterobacteriaceae was 41.3 % (95 CI: 31.8-51.4 %). The two more commonly isolated Enterobacteriaceae were E. coli ([n = 28], 24 ESBL positive; 1 AmpC positive and 3 without an identified mechanism of resistance) and Klebsiella pneumoniae ([n = 13], all ESBL positive; 1 also AmpC and metallo-β-lactamase (MBL) positive). Susceptibility to carbapenems (≥98 %), fosfomycin (90 %) and amikacin (70 + 20 % intermediate) was high but a high level of resistance to all other agents tested was noted. Non-fermenting Gram-negative bacilli were less commonly isolated {22 isolates: Acinetobacter baumannii (9); Pseudomonas aeruginosa (8) and Stenotrophomonas maltophilia (5)}.

CONCLUSION

Although a significant rate of MRSA carriage was identified, the main resistance challenge in Albania appears to be linked with Gram-negative organisms, particularly ESBL in Enterobacteriaceae.