Influx of multidrug resistant, Gram-negative bacteria (MDRGNB) in a public hospital among elderly patients from long-term care facilities: a single-center pilot study

Antibiogram of Multidrug-Resistant Bacteria Based on Sepsis Onset Location in Korea: A Multicenter Cohort Study

BACKGROUND

Administration of adequate antibiotics is crucial for better outcomes in sepsis. Because no uniform tool can accurately assess the risk of multidrug-resistant (MDR) pathogens, a local antibiogram is necessary. We aimed to describe the antibiogram of MDR bacteria based on locations of sepsis onset in South Korea.

METHODS

We performed a prospective observational study of adult patients diagnosed with sepsis according to Sepsis-3 from 19 institutions (13 tertiary referral and 6 university-affiliated general hospitals) in South Korea. Patients were divided into four groups based on the respective location of sepsis onset: community, nursing home, long-term-care hospital, and hospital. Along with the antibiogram, risk factors of MDR bacteria and drug-bug match of empirical antibiotics were analyzed.

RESULTS

MDR bacteria were detected in 1,596 (22.7%) of 7,024 patients with gram-negative predominance. MDR gram-negative bacteria were more commonly detected in long-term-care hospital- (30.4%) and nursing home-acquired (26.3%) sepsis, whereas MDR gram-positive bacteria were more prevalent in hospital-acquired (10.9%) sepsis. Such findings were consistent regardless of the location and tier of hospitals throughout South Korea. Patients with long-term-care hospital-acquired sepsis had the highest risk of MDR pathogen, which was even higher than those with hospital-acquired sepsis (adjusted odds ratio, 1.42; 95% confidence interval, 1.15-1.75) after adjustment of risk factors. The drug-bug match was lowest in patients with long-term-care hospital-acquired sepsis (66.8%).

CONCLUSION

Gram-negative MDR bacteria were more common in nursing home- and long-term-care hospital-acquired sepsis, whereas gram-positive MDR bacteria were more common in hospital-acquired settings in South Korea. Patients with long-term-care hospital-acquired sepsis had the highest the risk of MDR bacteria but lowest drug-bug match of initial antibiotics. We suggest that initial antibiotics be carefully selected according to the onset location in each patient.

Mortality in Thai Nursing Homes Based on Antimicrobial-Resistant Enterobacterales Carriage and COVID-19 Lockdown Timing: A Prospective Cohort Study

Antimicrobial-resistant Enterobacterales carriage and the coronavirus disease 2019 (COVID-19) lockdown measures may impact the incidence all-cause mortality rate among nursing home residents. To determine the all-cause mortality rate in the presence/absence of antimicrobial-resistant Enterobacterales carriage and the incidence all-cause mortality rate before and during COVID-19 pandemic lockdown, this prospective closed-cohort study was conducted at various types of nursing homes in Bangkok, Thailand, from June 2020 to December 2021. The elderly residents included 142 participants (aged ≥60 years) living in nursing homes ≥3 months, who did not have terminal illnesses. Time-to-event analyses with Cox proportional hazards models and stratified log-rank tests were used. The all-cause mortality rate was 18%, and the incidence all-cause mortality rate was 0.59/1000 person-days in residents who had antimicrobial-resistant Enterobacterales carriage at baseline. Meanwhile, the incidence all-cause mortality rate among noncarriage was 0.17/1000 person-days. The mortality incidence rate of carriage was three times higher than residents who were noncarriage without statistical significance (HR 3.2; 95% CI 0.74, 13.83). Residents in nonprofit nursing homes had a higher mortality rate than those in for-profit nursing homes (OR 9.24; 95% CI 2.14, 39.86). The incidence mortality rate during and before lockdown were 0.62 and 0.30, respectively. Effective infection-control policies akin to hospital-based systems should be endorsed in all types of nursing homes. To limit the interruption of long-term chronic care, COVID-19 prevention should be individualized to nursing homes.

Risk Factors for Extended-Spectrum-β-Lactamase-Producing Escherichia coli in Community-Onset Bloodstream Infection: Impact on Long-Term Care Hospitals in Korea

Background

The prevalence of extended-spectrum β-lactamase-producing Escherichia coli (ESBL-EC) in the community has increased worldwide due to multifactorial reasons. ESBL-EC bloodstream infection (BSI) complicates the decision for proper antimicrobial administration. In this multicenter study, we investigated the prevalence, risk factors, and molecular background of community-onset (CO) ESBL-EC BSI.

Methods

We included data for all episodes of ESBL-EC BSI of community origin from May 2016 to April 2017 obtained from the Korean national antimicrobial resistance surveillance system, which comprises six sentinel hospitals. Data, including previous history of admission and use of antimicrobials and medical devices before BSI, were collected, along with microbiological analysis results.

Results

Among 1,189 patients with CO BSI caused by E. coli, 316 (27%) were identified as ESBL producers. History of admission, especially to a long-term care hospital (LTCH), and previous use of β-lactams/β-lactamase inhibitors, carbapenem, lincosamide, aminoglycoside, and extended-spectrum cephalosporin were independent risk factors for CO ESBL-EC BSI; admission to an LTCH showed the highest odds ratio (3.8, 95% confidence interval 2.3-6.1). The most common genotype was CTX-M-15 (N=131, 41%), followed by CTX-M-14 (N=86, 27%). ST131 was the most common sequence type among ESBL-EC groups (57%).

Conclusions

In Korea, 27% of CO E. coli BSI were caused by ESBL producers. From perspectives of empirical treatment and infection control, history of admission to an LTCH and antimicrobial use should be noted.

Antibacterial properties of Ag/TiO2/PDA nanofilm on anodized 316L stainless steel substrate under illumination by a normal flashlight

The demand of medical materials for rapid and efficient elimination of bacteria has seen a dramatic surge over the past few years. In this study, antibacterial nanofilms with reactive oxygen species were generated by photocatalysis. To prepare these nanofilms, Ag and amorphous TiO₂ nanoparticles decorated on polydopamine (PDA) were coated on three-dimensional (3D) nanopore arrays, which was fabricated on a substrate of anodized stainless steel. All the antibacterial tests were conducted with a household flashlight, which may be considered as a practical approach for antibacterial materials. The photoelectrochemical property of the 3D Ag/TiO₂/PDA nanofilm on 316L stainless steel (Ag/TiO₂/PDA SS) was about 15 times higher than that of the annealed Ag/TiO₂/PDA SS, and consequently, it exhibited higher antibacterial activity. The enhanced photoelectrochemical property is attributed to the successful separation of electrons (amorphous TiO₂) and holes (Ag nanoparticles). Further, when a plate containing 3D Ag/TiO₂/PDA SS was irradiated with visible light just for 10 min, it immediately destroyed the bacteria in 10⁶ CFU/mL without any bacterial colony. After five weeks, there were still no bacterial colonies in the plate corresponding to Ag/TiO₂/PDA SS under visible light, while Ag/TiO₂/PDA SS in dark had a negligible effect on the bacteria, i.e., the antibacterial mechanism through direct contact and ion dissolution was not efficient. The excellent antibacterial properties of 3D Ag/TiO₂/PDA SS illuminated by flashlight provides an efficient, facile, and cost-effective technique for the development of antibacterial medical materials to meet the increasing demand of eliminating bacterial infections.

An overview of carbapenemase producing enterobacteriaceae (CPE) in trauma and orthopaedics

Carbapenemase resistant enterobacteriae (CPE) may be found in asymptomatic carriers. Its incidence is increasing worldwide. Surgical patients are at increased risk of immunocompromise and of carriage progressing to active infection. Active infection with CPE caries a high mortality rate, with the bacteria being resistant to many antibiotics. This article provides details on the epidemiology, screening and management of the orthopaedic patient with CPE. The guidelines advise orthopaedic staff on ways to avoid the spread of CPE amongst inpatients.

Active surveillance at the time of hospital admission for multidrug-resistant microorganisms among patients who had recently been hospitalized at health care facilities

BACKGROUND

This study aimed to investigate the epidemiology of multidrug-resistant microorganism (MDRO) carriage at hospital admission and to identify risk factors for MDRO influx into hospital settings.

METHODS

This cohort study was conducted at a 1,051-bed university-affiliated hospital in the Republic of Korea between July 1 and December 31, 2017. Active surveillance for MDRO carriage was performed within 48 hours of hospitalization in all adult patients who had prior hospitalization within the preceding 3 months.

RESULTS

During the study, 575 patients were admitted with a hospitalization history within 3 months. Active surveillance at hospital admission was performed in 192 eligible patients. Thirty-three (17.2%) patients with MDRO carriage were identified from active surveillance. In the multivariate logistic regression analysis, prior exposure to antibiotics within 90 days, hospitalization for ≥60 days before admission, cognitive dysfunction, percutaneous drainage, and underlying pulmonary diseases were identified as independent risk factors for MDRO influx.

CONCLUSIONS

Our findings suggest a significant prevalence of MDRO acquisition at acute care hospital admission in patients who had been recently hospitalized. To control the spread of MDRO, collaborations among health care institutions and targeted screening at hospital admission according to patient risk factors are warranted.

Prevalence of multidrug-resistant gram-negative bacteria among nursing home residents: A systematic review and meta-analysis

BACKGROUND

Multidrug-resistant gram-negative bacteria (MDR-GNB) are associated with an increasing proportion of infections among nursing home (NH) residents. The objective of this systematic review and meta-analysis was to critically review evidence of the prevalence of MDR-GNB among NH residents.

METHODS

Following Meta-Analysis of Observational Studies in Epidemiology guidelines, a systematic review of literature for the years 2005-2016 using multiple databases was conducted. Study quality, appraised by 2 reviewers, used Downs and Black risk of bias criteria. Studies reporting prevalence of MDR-GNB colonization were pooled using a random effects meta-analysis model. Heterogeneity was assessed using Cochran Q and I² statistics.

RESULTS

Of 327 articles, 12 met the criteria for review; of these, 8 met the criteria for meta-analysis. Escherichia coli accounted for the largest proportion of isolates. Reported MDR-GNB colonization prevalence ranged from 11.2%-59.1%. Pooled prevalence for MDR-GNB colonization, representing data from 2,720 NH residents, was 27% (95% confidence interval, 15.2%-44.1%) with heterogeneity (Q = 405.6; P = .01; I² = 98.3). Two studies reported MDR-GNB infection rates of 10.9% and 62.7%.

CONCLUSION

Our findings suggest a high prevalence of MDR-GNB colonization among NH residents, emphasizing the need to enhance policies for infection control and prevention (ICP) in NHs.

Safety and feasibility of antibiotic de-escalation in bacteremic pneumonia

Background

Antibiotic de-escalation is a potential strategy advocated to conserve the effectiveness of broad-spectrum antibiotics. The aim of this study was to examine the safety and feasibility of antibiotic de-escalation in patients admitted with bacteremic pneumonia.

Methods

A retrospective chart review was done for patients with bacteremic pneumonia admitted to Northwest Texas Hospital in Amarillo, TX, USA, during 2008. Antibiotic de-escalation was defined as changing the empiric antibiotic regimen to a culture-directed single agent with a narrower spectrum than the original regimen.

Results

Sixty-eight patients were admitted with bacteremic pneumonia. Eight patients were not eligible for de-escalation. Among the 60 patients who were eligible for de-escalation, the treating physicians failed to de-escalate antibiotics in 27 cases (45.0%). Discharge to a long-term care facility predicted failure to de-escalate antibiotics, while an infectious diseases consultation was significantly associated with antibiotic de-escalation. The average daily cost of antibacterial therapy in the de-escalation group was $25.7 compared with $61.6 in the group where de-escalation was not implemented. The difference in mean length of hospital stay and mortality between the two groups was not statistically significant.

Conclusion

Antibiotic de-escalation is a safe management strategy but unfortunately is not widely adopted. Although bacterial resistance poses a significant threat and is rising, antimicrobial de-escalation has emerged as a potential intervention that can conserve the effectiveness of broad-spectrum antibiotics without compromising the patient’s outcome. This practice is becoming important in the face of slow development of new anti-infective agents.

Multidrug-resistant gram-negative bloodstream infections among residents of long-term care facilities

OBJECTIVE

Prevalence of multidrug-resistant (MDR) gram-negative (GN) bacteria is increasing globally and is complicated by patient movement between acute and long-term care facilities (LTCFs). In Asia, the contribution of LTCFs as a source of MDR GN infections is poorly described. We aimed to define the association between residence in LTCFs and MDR GN bloodstream infections (BSIs).

DESIGN

Secondary analysis of data from an observational cohort.

SETTING

Two tertiary referral hospitals in Singapore, including the 1,400-bed Tan Tock Seng Hospital and the 1,600-bed Singapore General Hospital.

PARTICIPANTS

Adult patients with healthcare-onset (HCO) or hospital-onset (HO) GN BSI.

METHODS

Patients were identified from hospital databases using standard definitions. Risk factors for both MDR GN HCO and HO BSI were analyzed using a multivariable logistic regression model.

RESULTS

A total of 675 episodes of GN BSI occurred over a 31-month period. Residence in a LTCF was an independent risk factor for developing MDR GN BSI (odds ratio [OR], 5.1 [95% confidence interval (CI), 2.2-11.9]; P < .01) when antibiotics were not used within the preceding 30 days. This risk persisted beyond the first 48 hours of hospitalization (OR, 3.4 [95% CI, 1.3-9.0]; P = .01). Previous culture growing an MDR organism (OR, 1.8 [95% CI, 1.3-2.7]; P < .01), previous antibiotic use (OR, 1.8 [95% CI, 1.2-2.6]; P < .01), and intensive care unit stay (OR, 2.2 [95% CI, 1.2-3.9]; P = .01), increased the risk of MDR GN BSI.

CONCLUSIONS

Residence in a LTCF is an independent risk factor for MDR GN BSI. Attempts to contain MDR GN bacteria in large Asian cities, where the proportion of the population that is elderly is projected to increase, should include infection prevention strategies that engage LTCFs.

A call for action: managing the emergence of multidrug-resistant Enterobacteriaceae in the acute care settings

PURPOSE OF REVIEW

Multidrug-resistant (MDR) Enterobacteriaceae are an emerging and a major concern for the medical community. Reported rates of MDR Enterobacteriaceae are increasing, and infections with these organisms are no longer limited to those associated with healthcare in the severely ill or infirm. Community-acquired infections are now described. The purpose of this review is to provide the readers with an up to date picture of MDR Enterobacteriaceae and to highlight the infection prevention practices that will impede the spread of this public health threat.

RECENT FINDINGS

The epidemiology of MDR Enterobacteriaceae is rapidly evolving. Among the various MDR Gram-negatives, carbapenemase-producing organisms have been some of the most concerning. Descriptions of the global spread of carbapenemase-producing Enterobacteriaceae, and emerging epidemiology including the findings of the New Delhi metallo beta-lactamase (NDM) in water and other environmental sources, have forced reconsideration of prevention strategies. Similarly, food-borne outbreaks of extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae have also caused public health experts to rethink approaches to control their spread. Finally, several articles published in the past year address the challenges and contemporary strategies to combat the MDR Enterobacteriaceae.

SUMMARY

The speed with which the newest resistance genes have disseminated among the different Gram-negative species and around the world is such that it is now considered a global public health crisis. Proposed infection prevention and control practices related to MDR Enterobacteriaceae are primarily 'bundled' and based on clinical case reports derived from outbreak-like situations, on expert opinion and understanding about other Gram-negatives.