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Chelaru EC, Muntean AA, Hogea MO, Muntean MM, Popa MI, Popa GL. The Importance of Carbapenemase-Producing Enterobacterales in African Countries: Evolution and Current Burden. Antibiotics (Basel) 2024; 13:295. [PMID: 38666971 PMCID: PMC11047529 DOI: 10.3390/antibiotics13040295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/19/2024] [Accepted: 03/20/2024] [Indexed: 04/29/2024] Open
Abstract
Antimicrobial resistance (AMR) is a worldwide healthcare problem. Multidrug-resistant organisms (MDROs) can spread quickly owing to their resistance mechanisms. Although colonized individuals are crucial for MDRO dissemination, colonizing microbes can lead to symptomatic infections in carriers. Carbapenemase-producing Enterobacterales (CPE) are among the most important MDROs involved in colonizations and infections with severe outcomes. This review aimed to track down the first reports of CPE in Africa, describe their dissemination throughout African countries and summarize the current status of CRE and CPE data, highlighting current knowledge and limitations of reported data. Two database queries were undertaken using Medical Subject Headings (MeSH), employing relevant keywords to identify articles that had as their topics beta-lactamases, carbapenemases and carbapenem resistance pertaining to Africa or African regions and countries. The first information on CPE could be traced back to the mid-2000s, but data for many African countries were established after 2015-2018. Information is presented chronologically for each country. Although no clear conclusions could be drawn for some countries, it was observed that CPE infections and colonizations are present in most African countries and that carbapenem-resistance levels are rising. The most common CPE involved are Klebsiella pneumoniae and Escherichia coli, and the most prevalent carbapenemases are NDM-type and OXA-48-type enzymes. Prophylactic measures, such as screening, are required to combat this phenomenon.
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Affiliation(s)
- Edgar-Costin Chelaru
- Department of Microbiology II, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (E.-C.C.); (A.-A.M.); (M.-O.H.); (M.-M.M.)
| | - Andrei-Alexandru Muntean
- Department of Microbiology II, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (E.-C.C.); (A.-A.M.); (M.-O.H.); (M.-M.M.)
- Department of Microbiology, Cantacuzino National Military Medical Institute for Research and Development, 050096 Bucharest, Romania
| | - Mihai-Octav Hogea
- Department of Microbiology II, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (E.-C.C.); (A.-A.M.); (M.-O.H.); (M.-M.M.)
| | - Mădălina-Maria Muntean
- Department of Microbiology II, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (E.-C.C.); (A.-A.M.); (M.-O.H.); (M.-M.M.)
| | - Mircea-Ioan Popa
- Department of Microbiology II, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (E.-C.C.); (A.-A.M.); (M.-O.H.); (M.-M.M.)
- Department of Microbiology, Cantacuzino National Military Medical Institute for Research and Development, 050096 Bucharest, Romania
| | - Gabriela-Loredana Popa
- Department of Microbiology, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Parasitic Disease Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
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Kedišaletše M, Phumuzile D, Angela D, Andrew W, Mae NF. Epidemiology, risk factors, and clinical outcomes of carbapenem-resistant Enterobacterales in Africa: A systematic review. J Glob Antimicrob Resist 2023; 35:297-306. [PMID: 37879456 DOI: 10.1016/j.jgar.2023.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 10/27/2023] Open
Abstract
OBJECTIVES Carbapenem-resistant Enterobacterales (CRE) commonly cause hospital-acquired infections and hospital outbreaks worldwide, with an alarming increase in Africa, necessitating review of regional CRE epidemiological trends. METHODS A systematic review was conducted using PRISMA guidelines, searching PubMed, Scopus and Web of Science databases for studies describing CRE distribution, risk factors for CRE acquisition and clinical outcome of CRE infections in Africa. RESULTS One-hundred and sixty-nine studies were included, with the majority from North Africa (92/169, 54.4%). Most studies (136/169; 80.4%) focused only on infection, with a total of 15666 CRE isolates (97.4% clinical infection, 2.6% colonisation). The leading bacterial species included Klebsiella (72.2%), Escherichia coli (13.5%), and Enterobacter (8.3%). The most frequently detected carbapenemases were NDM (43.1%) and OXA-48-like (42.9%). Sequence types were reported in 44 studies, with ST101 and ST147 most commonly reported in K. pneumoniae, and ST410, ST167 and ST38 in E. coli. Previous antibiotic use, prior hospitalisation, surgical procedures, indwelling devices, intensive care unit admission and prolonged hospital stay, were the most frequent factors associated with CRE infection/colonisation. Crude mortality for CRE infection was 37%. CONCLUSION Although K. pneumoniae and E. coli remain the most frequent CRE in Africa, observed sequence types are not the commonly reported global 'high-risk' clones. The distribution of species and carbapenemases differs across African regions, while risk factors for CRE colonisation/infection, and patient outcomes are similar to those reported globally. There are limited data on CREs from parts of Africa, highlighting the need to strengthen epidemiologic surveillance programmes in the region.
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Affiliation(s)
- Moloto Kedišaletše
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Dube Phumuzile
- Synthetic Biology Center, NextGeneration Health, Council for Scientific and Industrial Research, Pretoria, South Africa
| | - Dramowski Angela
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Whitelaw Andrew
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Newton-Foot Mae
- Division of Medical Microbiology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
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Fadlallah M, Salman A, Salem-Sokhn E. Updates on the Status of Carbapenem-Resistant Enterobacterales in Lebanon. Int J Microbiol 2023; 2023:8831804. [PMID: 37283804 PMCID: PMC10241595 DOI: 10.1155/2023/8831804] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/10/2023] [Accepted: 05/15/2023] [Indexed: 06/08/2023] Open
Abstract
Carbapenem-resistant Enterobacterales (CRE) pathogens have been increasingly isolated and reported in Lebanon. Several studies have been published over the last two decades about the CRE situation in the country. However, compared to the worldwide data, those studies are scarce and mostly restricted to single center studies. In this review, we aim to present a comprehensive and reliable report illustrating the current situation regarding CRE in Lebanon. Variable studies have shown an increasing pattern of carbapenem resistance in Enterobacterales since the first reports of CRE isolates in 2007 and 2008. Escherichia coli and Klebsiella pneumoniae were the most detected ones. The OXA-48 class D carbapenemases were the most prevalent carbapenemases among CRE isolates. Moreover, the emergence of other carbapenemases like the NDM class B carbapenemase has been noticed. Strict infection control measures in hospitals, including the identification of CRE carriers, are needed in Lebanese hospitals since carriage is a potential risk for the spread of CRE in healthcare settings. The dissemination of CRE in the community is noticed and attributed to multiple causes, such as the refugee crisis, water contamination, and antimicrobial misuse. In conclusion, strict infection control measures in healthcare settings, in addition to accurate antimicrobial stewardship program implementation, are urgently needed.
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Affiliation(s)
- Mahdi Fadlallah
- Laboratory Medicine, Lebanese University, Faculty of Medical Sciences, Beirut, Lebanon
| | - Ahmad Salman
- Infectious Diseases, Lebanese University, Faculty of Medical Sciences, Beirut, Lebanon
| | - Elie Salem-Sokhn
- Department of Medical Laboratory Technology, Faculty of Health Sciences, Beirut Arab University, P.O. Box 11-5020, Beirut, Lebanon
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Venne DM, Hartley DM, Malchione MD, Koch M, Britto AY, Goodman JL. Review and analysis of the overlapping threats of carbapenem and polymyxin resistant E. coli and Klebsiella in Africa. Antimicrob Resist Infect Control 2023; 12:29. [PMID: 37013626 PMCID: PMC10071777 DOI: 10.1186/s13756-023-01220-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/18/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Carbapenem-resistant Enterobacterales are among the most serious antimicrobial resistance (AMR) threats. Emerging resistance to polymyxins raises the specter of untreatable infections. These resistant organisms have spread globally but, as indicated in WHO reports, the surveillance needed to identify and track them is insufficient, particularly in less resourced countries. This study employs comprehensive search strategies with data extraction, meta-analysis and mapping to help address gaps in the understanding of the risks of carbapenem and polymyxin resistance in the nations of Africa. METHODS Three comprehensive Boolean searches were constructed and utilized to query scientific and medical databases as well as grey literature sources through the end of 2019. Search results were screened to exclude irrelevant results and remaining studies were examined for relevant information regarding carbapenem and/or polymyxin(s) susceptibility and/or resistance amongst E. coli and Klebsiella isolates from humans. Such data and study characteristics were extracted and coded, and the resulting data was analyzed and geographically mapped. RESULTS Our analysis yielded 1341 reports documenting carbapenem resistance in 40 of 54 nations. Resistance among E. coli was estimated as high (> 5%) in 3, moderate (1-5%) in 8 and low (< 1%) in 14 nations with at least 100 representative isolates from 2010 to 2019, while present in 9 others with insufficient isolates to support estimates. Carbapenem resistance was generally higher among Klebsiella: high in 10 nations, moderate in 6, low in 6, and present in 11 with insufficient isolates for estimates. While much less information was available concerning polymyxins, we found 341 reports from 33 of 54 nations, documenting resistance in 23. Resistance among E. coli was high in 2 nations, moderate in 1 and low in 6, while present in 10 with insufficient isolates for estimates. Among Klebsiella, resistance was low in 8 nations and present in 8 with insufficient isolates for estimates. The most widespread associated genotypes were, for carbapenems, blaOXA-48, blaNDM-1 and blaOXA-181 and, for polymyxins, mcr-1, mgrB, and phoPQ/pmrAB. Overlapping carbapenem and polymyxin resistance was documented in 23 nations. CONCLUSIONS While numerous data gaps remain, these data show that significant carbapenem resistance is widespread in Africa and polymyxin resistance is also widely distributed, indicating the need to support robust AMR surveillance, antimicrobial stewardship and infection control in a manner that also addresses broader animal and environmental health dimensions.
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Affiliation(s)
- Danielle M Venne
- Center on Medical Product Access, Safety and Stewardship, Georgetown University, 3900 Reservoir Road, Washington, DC, 20057, USA
| | - David M Hartley
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, 45229, USA
| | - Marissa D Malchione
- Center on Medical Product Access, Safety and Stewardship, Georgetown University, 3900 Reservoir Road, Washington, DC, 20057, USA
- Sabin Vaccine Institute, Influenza Vaccine Innovation, 2175 K St NW, Washington, DC, 20037, USA
| | - Michala Koch
- Center on Medical Product Access, Safety and Stewardship, Georgetown University, 3900 Reservoir Road, Washington, DC, 20057, USA
| | - Anjali Y Britto
- Center on Medical Product Access, Safety and Stewardship, Georgetown University, 3900 Reservoir Road, Washington, DC, 20057, USA
| | - Jesse L Goodman
- Center on Medical Product Access, Safety and Stewardship, Georgetown University, 3900 Reservoir Road, Washington, DC, 20057, USA.
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Estimation, Evaluation and Characterization of Carbapenem Resistance Burden from a Tertiary Care Hospital, Pakistan. Antibiotics (Basel) 2023; 12:antibiotics12030525. [PMID: 36978392 PMCID: PMC10044297 DOI: 10.3390/antibiotics12030525] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023] Open
Abstract
Carbapenem resistance has become major concern in healthcare settings globally; therefore, its monitoring is crucial for intervention efforts to halt resistance spread. During May 2019–April 2022, 2170 clinical strains were characterized for antimicrobial susceptibility, resistance genes, replicon and sequence types. Overall, 42.1% isolates were carbapenem-resistant, and significantly associated with Klebsiella pneumoniae (K. pneumoniae) (p = 0.008) and Proteus species (p = 0.043). Carbapenemases were detected in 82.2% of isolates, with blaNDM-1 (41.1%) associated with the ICU (p < 0.001), cardiology (p = 0.042), pediatric medicine (p = 0.013) and wound samples (p = 0.041); blaOXA-48 (32.6%) was associated with the ICU (p < 0.001), cardiology (p = 0.008), pediatric medicine (p < 0.001), general surgery (p = 0.001), general medicine (p = 0.005) and nephrology (p = 0.020); blaKPC-2 (5.5%) was associated with general surgery (p = 0.029); blaNDM-1/blaOXA-48 (11.4%) was associated with general surgery (p < 0.001), and wound (p = 0.002), urine (p = 0.003) and blood (p = 0.012) samples; blaOXA-48/blaVIM (3.1%) was associated with nephrology (p < 0.001) and urine samples (p < 0.001). Other detected carbapenemases were blaVIM (3.0%), blaIMP (2.7%), blaOXA-48/blaIMP (0.1%) and blaVIM/blaIMP (0.3%). Sequence type (ST)147 (39.7%) represented the most common sequence type identified among K. pneumoniae, along with ST11 (23.0%), ST14 (15.4%), ST258 (10.9%) and ST340 (9.6%) while ST405 comprised 34.5% of Escherichia coli (E. coli) isolates followed by ST131 (21.2%), ST101 (19.7%), ST10 (16.0%) and ST69 (7.4%). Plasmid replicon types IncFII, IncA/C, IncN, IncL/M, IncFIIA and IncFIIK were observed. This is first report describing the carbapenem-resistance burden and emergence of blaKPC-2-ST147, blaNDM-1-ST340 and blaNDM-1-ST14 in K. pneumoniae isolates and blaNDM-1-ST69 and blaNDM-1/blaOXA-48-ST69 in E. coli isolates coharboring extended-spectrum beta-lactamases (ESBLs) from Pakistan.
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Fu P, Luo X, Shen J, He L, Rong H, Li C, Chen S, Zhang L, Wang A, Wang C. The molecular and epidemiological characteristics of carbapenemase-producing Enterobacteriaceae isolated from children in Shanghai, China, 2016-2021. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:48-56. [PMID: 35987725 DOI: 10.1016/j.jmii.2022.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/02/2022] [Accepted: 07/30/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND We isolated the carbapenemase-producing Enterobacteriaceae (CPE) strains from children during 2016-2021 in Shanghai, China and investigated the antimicrobial resistance, molecular and epidemiological features of these isolates. METHODS Antimicrobial susceptibility tests were performed to confirm the carbapenem resistance. Carbapenemase production was assessed by the rapid phenotypic identification of five major carbapenemases (KPC, NDM, VIM, IMP, and OXA-48), which were further confirmed by PCR amplification and sequencing. Multilocus sequence typing (MLST) was conducted for phylogenetic analyses. RESULTS A total of 320 CPE strains were collected from 2016 to 2021, consisting of carbapenemase-producing Klebsiella pneumoniae (CP-Kpn, 55.0%), Escherichia coli (CP-Eco, 24.5%) and Enterobacter cloacae (CP-Ecl, 20.4%) and others (2, 0.1%). NDM was the primary carbapenemase (67.6%) in children, followed by KPC(26.4%), IMP(5.3%) and OXA-48 (0.6%). The minimum inhibitory concentration (MIC) for imipenem has been increasing from 2016 to 2021. NDM and KPC isolates are high resistant while IMP strains show the lower resistant to imipenem. Invasive infection accounted for 10.7% of CPE-related infections and was mainly caused by CP-Kpn (70.6%). NDM-Kpn was detected in 51.8% of infants (70.8% of neonates), while KPC-Kpn was mainly isolated from non-infants (56.3%∼64.3%). ST11 was the primary clone (64.6%) of KPC-Kpn and presented an increasing trend from 2016 to 2021. CONCLUSION NDM is widely prevalent and transfers among CPE strains in children. NDM-Kpn shows the most serious threat to infants, especially to neonates. High-risk clone of ST11 KPC-Kpn should be paid more attention and monitored continuously in children.
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Affiliation(s)
- Pan Fu
- Department of Clinical Microbiology Laboratory, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China; Nosocomial Infection Control Department, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China.
| | - Xinpeng Luo
- Department of Clinical Microbiology Laboratory, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Jun Shen
- Department of Infectious Diseases, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Leiyan He
- Department of Clinical Microbiology Laboratory, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Hua Rong
- Department of Clinical Laboratory, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Chunling Li
- Department of Clinical Microbiology Laboratory, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Saige Chen
- Department of Clinical Microbiology Laboratory, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Lei Zhang
- Department of Clinical Microbiology Laboratory, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Aimin Wang
- Department of Clinical Microbiology Laboratory, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Chuanqing Wang
- Department of Clinical Microbiology Laboratory, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China; Nosocomial Infection Control Department, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China.
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Sharma RK, Dey G, Banerjee P, Maity JP, Lu CM, Siddique JA, Wang SC, Chatterjee N, Das K, Chen CY. New aspects of lipopeptide-incorporated nanoparticle synthesis and recent advancements in biomedical and environmental sciences: a review. J Mater Chem B 2022; 11:10-32. [PMID: 36484467 DOI: 10.1039/d2tb01564a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The toxicity of metal nanoparticles has introduced promising research in the current scenario since an enormous number of people have been potentially facing this problem in the world. The extensive attention on green nanoparticle synthesis has been focussed on as a vital step in bio-nanotechnology to improve biocompatibility, biodegradability, eco-friendliness, and huge potential utilization in various environmental and clinical assessments. Inherent influence on the study of green nanoparticles plays a key role to synthesize the controlled and surface-influenced molecule by altering the physical, chemical, and biological assets with the provision of various precursors, templating/co-templating agents, and supporting solvents. However, in this article, the dominant characteristics of several kinds of lipopeptide biosurfactants are discussed to execute a critical study of factors affecting synthesis procedure and applications. The recent approaches of metal, metal oxide, and composite nanomaterial synthesis have been deliberated as well as the elucidation of the reaction mechanism. Furthermore, this approach shows remarkable boosts in the production of nanoparticles with the very less employed harsh and hazardous processes as compared to chemical or physical method-based nanoparticle synthesis. This study also shows that the advances in strain selection for green nanoparticle production could be a worthwhile and strong economical approach in futuristic medical science research.
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Affiliation(s)
- Raju Kumar Sharma
- Department of Chemistry and Biochemistry, National Chung Cheng University, 168 University Road, Min-Hsiung, Chiayi County 62102, Taiwan.,Department of Earth and Environmental Sciences, National Chung Cheng University, 168 University Road, Min-Hsiung, Chiayi County 62102, Taiwan.
| | - Gobinda Dey
- Department of Earth and Environmental Sciences, National Chung Cheng University, 168 University Road, Min-Hsiung, Chiayi County 62102, Taiwan. .,Department of Biomedical Sciences, Graduate Institute of Molecular Biology, National Chung Cheng University, 168 University Road, Min-Hsiung, Chiayi County 62102, Taiwan
| | - Pritam Banerjee
- Department of Earth and Environmental Sciences, National Chung Cheng University, 168 University Road, Min-Hsiung, Chiayi County 62102, Taiwan. .,Department of Biomedical Sciences, Graduate Institute of Molecular Biology, National Chung Cheng University, 168 University Road, Min-Hsiung, Chiayi County 62102, Taiwan
| | - Jyoti Prakash Maity
- Department of Earth and Environmental Sciences, National Chung Cheng University, 168 University Road, Min-Hsiung, Chiayi County 62102, Taiwan. .,Department of Chemistry, School of Applied Sciences, KIIT Deemed to be University, Bhubaneswar, Odisha 751024, India
| | - Chung-Ming Lu
- Department of Earth and Environmental Sciences, National Chung Cheng University, 168 University Road, Min-Hsiung, Chiayi County 62102, Taiwan. .,Department of Chemical Engineering, National Chung Cheng University, 168 University Road, Min-Hsiung, Chiayi County 62102, Taiwan
| | | | - Shau-Chun Wang
- Department of Chemistry and Biochemistry, National Chung Cheng University, 168 University Road, Min-Hsiung, Chiayi County 62102, Taiwan
| | - Nalonda Chatterjee
- Department of Earth and Environmental Sciences, National Chung Cheng University, 168 University Road, Min-Hsiung, Chiayi County 62102, Taiwan.
| | - Koyeli Das
- Department of Earth and Environmental Sciences, National Chung Cheng University, 168 University Road, Min-Hsiung, Chiayi County 62102, Taiwan. .,Department of Biomedical Sciences, Graduate Institute of Molecular Biology, National Chung Cheng University, 168 University Road, Min-Hsiung, Chiayi County 62102, Taiwan
| | - Chien-Yen Chen
- Department of Earth and Environmental Sciences, National Chung Cheng University, 168 University Road, Min-Hsiung, Chiayi County 62102, Taiwan.
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Tesfa T, Mitiku H, Edae M, Assefa N. Prevalence and incidence of carbapenem-resistant K. pneumoniae colonization: systematic review and meta-analysis. Syst Rev 2022; 11:240. [PMID: 36380387 PMCID: PMC9667607 DOI: 10.1186/s13643-022-02110-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 10/30/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Klebsiella pneumoniae is a gram-negative rod belonging to the order Enterobacterales and having a wide distribution in the environment, including the human colon. Recently, the bacterium is one of the known problems in the healthcare setting as it has become resistant to last-resort drugs like carbapenems. The colonized person can serve as a reservoir for his/herself and others, especially in the healthcare setting leading to nosocomial and opportunistic infections. Therefore, we aimed to quantitatively estimate the rate of prevalence and incidence of colonization with carbapenem-resistant K. pneumoniae. METHODS A literature search was conducted on PubMed/MEDLINE, Google Scholar, Science Direct, Cochrane Library, WHO Index Medicus, and university databases. The study includes all published and unpublished papers that addressed the prevalence or incidence of K. pneumoniae colonization. Data were extracted onto format in Microsoft Excel and pooled estimates with a 95% confidence interval calculated using Der-Simonian-Laird random-effects model. With the use of I2 statistics and prediction intervals, the level of heterogeneity was displayed. Egger's tests and funnel plots of standard error were used to demonstrate the publication bias. RESULTS A total of 35 studies were included in the review and 32 records with 37,661 patients for assessment of prevalence, while ten studies with 3643 patients for incidence of colonization. The prevalence of carbapenem-resistant K. pneumoniae colonization varies by location and ranges from 0.13 to 22%, with a pooled prevalence of 5.43%. (3.73-7.42). Whereas the incidence of colonization ranges from 2 to 73% with a pooled incidence of 22.3% (CI 12.74-31.87), both prevalence and incidence reports are majorly from developed countries. There was a variation in the distribution of carbapenem resistance genes among colonizing isolates with KPC as a prominent gene reported from many studies and NDM being reported mainly by studies from Asian countries. A univariate meta-regression analysis indicated continent, patient type, study design, and admission ward do not affect the heterogeneity (p value>0.05). CONCLUSION The review revealed that colonization with K. pneumoniae is higher in a healthcare setting with variable distribution in different localities, and resistance genes for carbapenem drugs also have unstable distribution in different geographic areas.
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Affiliation(s)
- Tewodros Tesfa
- Department of Medical Laboratory Sciences, College of Health and Medical Sciences, Haramaya University, P.O.Box 235, Harar, Ethiopia.
| | - Habtamu Mitiku
- Department of Medical Laboratory Sciences, College of Health and Medical Sciences, Haramaya University, P.O.Box 235, Harar, Ethiopia
| | - Mekuria Edae
- Hiwot Fana Specialized University Hospital, College of Health and Medical Sciences, Haramaya University, P.O.Box 235, Harar, Ethiopia
| | - Nega Assefa
- School of Nursing Midwifery, College of Health and Medical Sciences, Haramaya University, P.O.Box 235, Harar, Ethiopia
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Abdelhalim MM, Saafan GS, El-Sayed HS, Ghaith DM. In vitro antibacterial effect of probiotics against Carbapenamase-producing multidrug-resistant Klebsiella pneumoniae clinical isolates, Cairo, Egypt. J Egypt Public Health Assoc 2022; 97:19. [PMID: 36210390 PMCID: PMC9548457 DOI: 10.1186/s42506-022-00114-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 09/01/2022] [Indexed: 11/25/2022]
Abstract
Background Searching for a non-antibiotic therapeutic option such as probiotics is gaining momentum nowadays. We aimed to evaluate the in vitro antibacterial ability of cell-free supernatant (CFS) of selected Lactobacillus strains (with probiotic properties) against clinical isolates of OXA-48-producing multidrug-resistant (MDR) Klebsiella pneumoniae separately and in combination with cefoperazone antibiotic. Methods Over a period of 8 months, a cross-sectional experimental study involving 590 Klebsiella pneumoniae isolates was done. Our study took place at The Specialized Pediatric Teaching Hospital of Cairo University. Of the 590 Klebsiella pneumoniae isolates collected from blood cultures, pus, endotracheal aspirates, and pleural fluid, only 50 unrepeated clinical isolates of MDR Klebsiella pneumoniae-producing OXA-48-like detected by CHROMID® OXA-48 (bioMérieux, France) were selected for our study. After determining the minimal inhibitory concentration of CFS of ten Lactobacillus strains and cefoperazone each, the synergistic effect of both was tested. Results Among ten tested Lactobacillus spp., a significant increase in the mean value of inhibition zone diameter with CFS of L. helveticus (14.32 mm) and L. rhamnosus (13.3 mm) was detected separately. On the contrary, an antagonistic activity against all tested isolates was detected upon combination of Lactobacilli with cefoperazone (512 μg/ml). The mean value of inhibition zone diameter of L. helveticus CFS+ cefoperazone was (11.0 mm) and for L. rhamnosus CFS+ cefoperazone was (10.88 mm) (p value <0.001). Conclusion The antimicrobial efficiency of using CFS of Lactobacillus species separately indicates that these therapies may be a substitute treatment strategy against MDR Klebsiella pneumoniae.
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Wassef M, Yousef RHA, Hussein MM, El-Shazly MA, Ghaith DM. Surgical Site Infections in Post-Living Donor Liver Transplantation: Surveillance and Evaluation of Care Bundle Approach. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.10155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background and Aim: Although implantation of a care bundle approach is well established in intensive care units (ICUs), yet its impact on reducing surgical site infections (SSI) among post living-donor-liver transplantation (LDLT) patients has not been established. Our aim is to evaluate the impact of a care bundle in reducing SSI and to detect the pattern of antibiotic resistance in LDLT. Materials and Methods: This before and after comparative study was conducted at Elmanial specialized tertiary hospital, Cairo University over a period of 3 years (January 2016 - December 2018) including 57 LDLT patients. We introduced a care bundle comprised of a group of evidence-based practices implemented together. The study was divided into three phases. All bacterial identification and antibiotic sensitivity testing were done by a Vitek 2 compact system. Results: SSIs rates were reduced significantly by 30.4% from the pre-implementation to the post implementation phase (from 13/24, 54.2% to 5/21, 23.8%, OR 0.21, CI 95%: 1.137- 0.039). This reduction went hand in hand with increase in the hand hygiene compliance from 57.3 % to 78 %, then remained sustained with a median rate of 78% in the last 6 months. Klebsiella pneumoniae 11\25 (44% of SSIs), Acinetobacter baumannii 8\25 (32% of SSIs), Escherichia coli 5\25 (20%), Pseudomonas aeruginosa 5\25 (20%) and MRSA 4\25 (16%). With predominance of XDR phenotype 14/25 (56%), followed by ESBL of gram-negative bacteria 6/25 (24%), then MRSA 4/25 (16%). Conclusion: SSIs in LDLT mandates strict implementation of comprehensive evidence-based care bundles for better patent outcome.
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El-Defrawy I, Gamal D, El-Gharbawy R, El-Seidi E, El-Dabaa E, Eissa S. Detection of intestinal colonization by carbapenem-resistant Enterobacteriaceae (CRE) among patients admitted to a tertiary care hospital in Egypt. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2022. [DOI: 10.1186/s43042-022-00295-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The irrational use of carbapenems in the last years lead to the emergence of carbapenem-resistant Enterobacteriaceae (CRE). This study aimed at determining the prevalence of CRE intestinal carriage among admitted patients in a tertiary care hospital in Egypt, to characterize carbapenemase-producing genes and to identify possible risk factors of CRE colonization. One hundred rectal swabs were collected from patients within 48 h of hospital admission. Culture was done on chromogenic media and then identification and antibiotic susceptibility testing were done using Vitek 2 compact system. Carbapenemase production was confirmed by Rapidec Carba NP test and by multiplex PCR for blaOXA-48-like, blaNDM-like, blaVIM-like, blaIMP-like and blaKPC-like.
Results
A total number of 36 CRE isolates were recovered from 28 patients. Thus, the prevalence of CRE colonization was 28%. Escherichia coli (83%), followed by Klebsiella pneumoniae (17%) were the main species. History of recent hospitalization and prior antibiotic intake were statistically significant risk factors predisposing to CRE colonization. Rapidec Carba NP gave positive results in 29/36 CRE isolates, whereas seven isolates gave negative results; six of them harbored blaOXA-48-like. Overall, the blaOXA-48-like was detected in 24/36 (66.7%), followed by blaNDM-like in 11/36 (30.6%) and lastly blaVIM-like in 1/36 (2.8%).
Conclusions
Our findings confirm that CRE colonization is disseminating in our healthcare facility, a fact that should be considered as possible pathogens causing infections in high risk patients. Strict infection control measures should be applied to all CRE carriers at hospital admission and a proper antimicrobial stewardship program should be followed in clinical settings.
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Klebsiella oxytoca Complex: Update on Taxonomy, Antimicrobial Resistance, and Virulence. Clin Microbiol Rev 2021; 35:e0000621. [PMID: 34851134 DOI: 10.1128/cmr.00006-21] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Klebsiella oxytoca is actually a complex of nine species-Klebsiella grimontii, Klebsiella huaxiensis, Klebsiella michiganensis, K. oxytoca, Klebsiella pasteurii, Klebsiella spallanzanii, and three unnamed novel species. Phenotypic tests can assign isolates to the complex, but precise species identification requires genome-based analysis. The K. oxytoca complex is a human commensal but also an opportunistic pathogen causing various infections, such as antibiotic-associated hemorrhagic colitis (AAHC), urinary tract infection, and bacteremia, and has caused outbreaks. Production of the cytotoxins tilivalline and tilimycin lead to AAHC, while many virulence factors seen in Klebsiella pneumoniae, such as capsular polysaccharides and fimbriae, have been found in the complex; however, their association with pathogenicity remains unclear. Among the 5,724 K. oxytoca clinical isolates in the SENTRY surveillance system, the rates of nonsusceptibility to carbapenems, ceftriaxone, ciprofloxacin, colistin, and tigecycline were 1.8%, 12.5%, 7.1%, 0.8%, and 0.1%, respectively. Resistance to carbapenems is increasing alarmingly. In addition to the intrinsic blaOXY, many genes encoding β-lactamases with varying spectra of hydrolysis, including extended-spectrum β-lactamases, such as a few CTX-M variants and several TEM and SHV variants, have been found. blaKPC-2 is the most common carbapenemase gene found in the complex and is mainly seen on IncN or IncF plasmids. Due to the ability to acquire antimicrobial resistance and the carriage of multiple virulence genes, the K. oxytoca complex has the potential to become a major threat to human health.
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Zhang W, Feng Y, Zhao H, Yan C, Feng J, Gan L, Cui J, Liu S, Zhang R, Du S, Li N, Xu W, Han J, Li R, Xue G, Yuan J. A Recombinase Aided Amplification Assay for Rapid Detection of the Klebsiella pneumoniae Carbapenemase Gene and Its Characteristics in Klebsiella pneumoniae. Front Cell Infect Microbiol 2021; 11:746325. [PMID: 34616692 PMCID: PMC8488121 DOI: 10.3389/fcimb.2021.746325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/24/2021] [Indexed: 11/20/2022] Open
Abstract
Klebsiella pneumoniae carbapenemase genes (blaKPC) play an important role in carbapenem-resistant Enterobacteriaceae in China. A rapid detection method for blaKPC genes and investigations into the molecular characteristics of blaKPC positive Klebsiella pneumoniae were necessary. In this study, an easy and rapid recombinase aided amplification assay (RAA) for blaKPC was established. This protocol could be completed at 39°C in 15–20 min. The sensitivity of this assay was determined as 48 copies per reaction, and the specificity was 100%. The blaKPC RAA method could be used for clinical diagnosis and epidemiological investigation. Among 801 fecal samples from inpatients, 34 blaKPC positive isolates were identified from each sample, of which 23 isolates were K. pneumoniae. ST11 with blaKPC-2 was the most prevalent type. All these strains were multidrug resistant and carried various virulence genes. Fecal carriage of blaKPC positive carbapenem-resistant K.pneumoniae poses significant challenges for public health control.
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Affiliation(s)
- Weiwei Zhang
- The Second Affiliated Hospital of Dalian Medical University, Liaoning, China.,Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Yanling Feng
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Hanqing Zhao
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Chao Yan
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Junxia Feng
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Lin Gan
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Jinghua Cui
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Shiyu Liu
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Rui Zhang
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Shuheng Du
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Nannan Li
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Wenjian Xu
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Juqiang Han
- Department of Daily Clinic, Seventh Medical Center of People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Rongkuan Li
- The Second Affiliated Hospital of Dalian Medical University, Liaoning, China
| | - Guanhua Xue
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
| | - Jing Yuan
- Department of Bacteriology, Capital Institute of Pediatrics, Beijing, China
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Sleiman A, Fayad AGA, Banna H, Matar GM. Prevalence and molecular epidemiology of carbapenem-resistant Gram-negative bacilli and their resistance determinants in the Eastern Mediterranean Region over the last decade. J Glob Antimicrob Resist 2021; 25:209-221. [PMID: 33812049 DOI: 10.1016/j.jgar.2021.02.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 01/05/2021] [Accepted: 02/28/2021] [Indexed: 12/14/2022] Open
Abstract
Carbapenem resistance in Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa is increasing worldwide, which has led the World Health Organization (WHO) to list these bacteria in the critical priority pathogens group. Infections by such pathogens pose a serious threat to hospitalised patients and are associated with clinical and economic consequences. What worsens the case is the weak pipeline of available antimicrobial agents to treat such infections and the absence of new drugs. The aim of this review was to shed light on all studies tackling carbapenem resistance in Enterobacteriaceae, A. baumannii and P. aeruginosa in the Eastern Mediterranean region, with indication for each country, description of studies timeline, prevalence of carbapenem resistance, and carbapenem resistance-encoding genes detected in these countries.
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Affiliation(s)
- Ahmad Sleiman
- Department of Experimental Pathology, Immunology and Microbiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon; World Health Organization (WHO) Collaborating Center for Reference and Research on Bacterial Pathogens, Beirut, Lebanon
| | - Antoine G Abou Fayad
- Department of Experimental Pathology, Immunology and Microbiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon; World Health Organization (WHO) Collaborating Center for Reference and Research on Bacterial Pathogens, Beirut, Lebanon.
| | - Hanin Banna
- Department of Experimental Pathology, Immunology and Microbiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon; World Health Organization (WHO) Collaborating Center for Reference and Research on Bacterial Pathogens, Beirut, Lebanon
| | - Ghassan M Matar
- Department of Experimental Pathology, Immunology and Microbiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon; World Health Organization (WHO) Collaborating Center for Reference and Research on Bacterial Pathogens, Beirut, Lebanon.
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Al-Sa'ady AT, Mohammad GJ, Hussen BM. Genetic relation and virulence factors of carbapenemase-producing Uropathogenic Escherichia coli from urinary tract infections in Iraq. GENE REPORTS 2020. [DOI: 10.1016/j.genrep.2020.100911] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Flores C, Bianco K, de Filippis I, Clementino MM, Romão CMC. Genetic Relatedness of NDM-Producing Klebsiella pneumoniae Co-Occurring VIM, KPC, and OXA-48 Enzymes from Surveillance Cultures from an Intensive Care Unit. Microb Drug Resist 2020; 26:1219-1226. [DOI: 10.1089/mdr.2019.0483] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Claudia Flores
- Fundação Oswaldo Cruz, Instituto Nacional de Controle de Qualidade em Saúde, Rio de Janeiro, Brazil
| | - Kayo Bianco
- Fundação Oswaldo Cruz, Instituto Nacional de Controle de Qualidade em Saúde, Rio de Janeiro, Brazil
| | - Ivano de Filippis
- Fundação Oswaldo Cruz, Instituto Nacional de Controle de Qualidade em Saúde, Rio de Janeiro, Brazil
| | | | - Célia Maria C.P.A. Romão
- Fundação Oswaldo Cruz, Instituto Nacional de Controle de Qualidade em Saúde, Rio de Janeiro, Brazil
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Touati A, Mairi A. Epidemiology of carbapenemase-producing Enterobacterales in the Middle East: a systematic review. Expert Rev Anti Infect Ther 2020; 18:241-250. [PMID: 32043905 DOI: 10.1080/14787210.2020.1729126] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction: The Middle East is actually recognized as endemic for carbapenemases-producing Enterobacterales (CPE) including at least OXA-48-like and NDM-like.Areas covered: We performed a search of PubMed and Scopus using relevant keywords. We included peer-reviewed articles published only in English reporting any data on carbapenemase-producing bacteria from Middle East countries. The last literature search was performed on 26 October 2019. All studies describing carbapenemase-producing Enterobacterales isolated from humans, animals or environmental samples from the Middle East were included.Expert opinion: The Middle-East is considered an endemic region for CPE strains and the extensive international exchange could facilitate the spread of CPE from these countries to other parts of the Globe in which the prevalence of the CPE is low. The expansion of the Middle East conflict has been associated with the rapid collapse of the existing health care system of the concerned countries. Considering that Millions of refugees have fled their country, they could introduce these CPE strains in countries with low endemicity. In conclusion, the health care system actors should take in a count the endemicity of CPE in these countries and develop local surveillance programs to limit the spread of these MDR bacteria.
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Affiliation(s)
- Abdelaziz Touati
- Laboratoire d'Ecologie Microbienne, FSNV, Université de Bejaia, Bejaia, Algérie
| | - Assia Mairi
- Laboratoire d'Ecologie Microbienne, FSNV, Université de Bejaia, Bejaia, Algérie
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Wassef M, Mukhtar A, Nabil A, Ezzelarab M, Ghaith D. Care Bundle Approach to Reduce Surgical Site Infections in Acute Surgical Intensive Care Unit, Cairo, Egypt. Infect Drug Resist 2020; 13:229-236. [PMID: 32095080 PMCID: PMC6995287 DOI: 10.2147/idr.s236814] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/14/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Surgical site infections (SSIs) are one of the most frequently reported hospital acquired infections associated with significant spread of antibiotic resistance. Purpose We aimed to evaluate a bundle-based approach in reducing SSI at acute surgical intensive care unit of the Emergency Hospital of Cairo University. Patients and Methods Our prospective study ran from March 2018 to February 2019 and used risk assessment. The study was divided into three phases. Phase I: (pre-bundle phase) for 5 months; data collection, active surveillance of the SSIs, screening for OXA-48 producing Enterobacteriaceae and multidrug resistant Acinetobacter baumannii colonizers using Chrom agars were carried out. Phase II: (bundle-implementation) a 6-S bundle approach included education, training and postoperative bathing with Chlorhexidine Gluconate in collaboration with the infection control team. Finally, Phase III: (post-implementation) for estimation of compliance, rates of colonization, and infection. Results Phase I encompassed 177 patients, while Phase III included 93 patients. A significant reduction of colonization from 24% to 15% (p<0.001) was observed. Similarly, a decrease of SSI from 27% to 15% (p=0.02) was noticed. A logistic regression was performed to adjust for confounding in the implementation of the bundle and we found a 70% reduction of SSI odd's ratio (OR's ratio = 0.3) confidence interval (95% CI 0.14-0.6) with significant Apache II (p=0.04), type of wound; type II (p=0.002), type III (p=0.001) and duration of surgery (p=0.04) as independent risk factors for SSI. Klebsiella pneumoniae was the most prevalent organism during phase I (34.7%). On the other hand, A. baumannii was the commonest organism to be isolated during phase III with (38.5%) preceding K. pneumoniae (30%). Conclusion Our study demonstrated that the implementation of a multidisciplinary bundle containing evidence-based interventions was associated with a significant reduction of colonization and SSIs and was met with staff approval and acceptable compliance.
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Affiliation(s)
- Mona Wassef
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Mukhtar
- Department of Anesthesia and Critical Care, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Nabil
- Department of General Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Moushira Ezzelarab
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Doaa Ghaith
- Department of Clinical and Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
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