Trends in bacterial resistance in a tertiary university hospital over one decade

Prediction of multidrug-resistant bacteria (MDR) hospital-acquired infection (HAI) and colonisation: A systematic review

BACKGROUND

Hospital-Acquired Infections (HAI) represent a public health priority in most countries worldwide. Our main objective was to systematically review the quality of the predictive modeling literature regarding multidrug-resistant gram-negative bacteria in Intensive Care Units (ICUs).

METHODS

We conducted and reported a Systematic Literature Review according to the recommendations of the PRISMA statement. We analysed the quality of the articles in terms of adherence to the TRIPOD checklist.

RESULTS

The initial search identified 1935 papers and 15 final articles were included in the review. Most studies analysed used traditional prediction models (logistic regression), and only three developed machine-learning techniques. We noted poor adherence to the main methodological issues recommended in the TRIPOD checklist to develop prediction models, such as handling missing data (20% adherence), model-building procedures (20% adherence), assessing model performance (47% adherence), and reporting performance measures (33% adherence).

CONCLUSIONS

Our review found few studies that use efficient alternatives to predict the acquisition of multidrug-resistant gram-negative bacteria in ICUs. Furthermore, we noted a lack of strategies for dealing with missing data, feature selection, and imbalanced datasets, a common problem in HAI studies.

Prevalence of health care-associated infections and antimicrobial resistance of the responsible pathogens in Ukraine: Results of a multicenter study (2014-2016)

BACKGROUND

The aim of this study was to obtain the first national estimates of the current prevalence and incidence and death of health care-associated infections (HAIs) of all types in acute care hospitals in Ukraine.

METHODS

Prospective surveillance was conducted from January 2014 to December 2016 in 17 hospitals. Surveillance case definitions were derived from the Centers for Disease Control and Prevention's National Healthcare Safety Network HAI case definitions. The identification and antimicrobial susceptibility of cultures were determined using a automated microbiology analyzer. Some antimicrobial susceptibility tests used Kirby-Bauer antibiotic testing.

RESULTS

Of 97,340 patients, 10,986 (11.3%) HAIs were observed. The most frequently reported HAI types were surgical site infections (60%), respiratory tract infections (pneumonia and lower respiratory tract, 18.4%), bloodstream infections (10.2%), and urinary tract infections (9.5%). Death during hospitalization was reported in 9.7% of HAI cases. The most common organism reported was Escherichia coli, accounting for 21.8% of all organisms, followed by Staphylococcus aureus (18.4%), Enterococcus spp (15.7%), and Pseudomonas aeruginosa (12.4%). Antimicrobial resistance among the isolates associated with HAIs showed that 42.1% and 3.6% of coagulase-negative Staphylococcus spp isolates were β-lactam (oxacillin)- and glycopeptide (teicoplanin)-resistant, respectively. Meticillin resistance was reported in 39.2% of S aureus isolates.

CONCLUSIONS

HAIs and increasing antimicrobial resistance present a significant burden to the Ukraine hospital system. Infection control priorities in hospitals should include preventing surgical site infections, respiratory tract infections (which also include PNEU and LRTI), bloodstream infections, and urinary tract infections, as well preventing infections due to antimicrobial-resistant pathogens.

Prevalence of healthcare-associated infections and antimicrobial resistance in acute care hospitals in Kyiv, Ukraine

BACKGROUND

Healthcare-associated infections (HAIs) are among the most common adverse events in patient care, and account for substantial morbidity and mortality.

AIM

To obtain the first estimates of the current prevalence of HAIs and antimicrobial resistance in acute care hospitals in Kyiv, Ukraine.

METHODS

Prospective surveillance was conducted from January 2014 to December 2016 in five acute care hospitals in Kyiv. Definitions of HAIs were adapted from the Centers for Disease Control and Prevention's National Healthcare Safety Network.

FINDINGS

Among 53,884 patients, 3753 (7%) HAIs were observed. The most frequently reported HAIs were respiratory tract infections (pneumonia 19.4%, lower respiratory tract infections 4.1%), surgical site infections (19.6%), urinary tract infections (17.5%) and bloodstream infections (10.6%). Death during hospitalization was reported in 7.2% cases of HAI. The micro-organisms most frequently isolated from HAIs were Escherichia coli (15.9%), Staphylococcus aureus (14.8%), Enterococcus spp. (10.2%), Pseudomonas aeruginosa (8.9%) and Klebsiella spp. (8.9%). Meticillin resistance was reported in 28.2% of S. aureus, and 14.2% of enterococci were resistant to vancomycin. Overall, 35.1% of all Enterobacteriaceae were resistant to third-generation cephalosporins, with the highest resistance rates seen in K. pneumoniae (53.8%) and E. coli (32.1%).

CONCLUSIONS

Infection control priorities in hospitals should include prevention of surgical site infections, pneumonia, bloodstream infections and urinary tract infections. These results may help to delineate the requirements for infection prevention and control in acute care hospitals.

PATTERN OF MULTIDRUG RESISTANT BACTERIA ASSOCIATED WITH INTENSIVE CARE UNIT INFECTIONS IN IBADAN, NIGERIA

BACKGROUND

Patients admitted into the intensive care unit (ICU) usually have impaired immunity and are therefore at high risk of acquiring hospital associated infections. Infections caused by multidrug resistant organisms now constitute a major problem, limiting the choice of antimicrobial therapy.

OBJECTIVES

This study was aimed at determining the antimicrobial resistance pattern of pathogens causing ICU infections in University College Hospital (UCH), Ibadan, Nigeria. The aetiological agents, prevalence and types ICU infections were also determined.

METHODS

One year hospital associated infections surveillance was conducted in the ICU of UCH, Ibadan. Blood, urine, tracheal aspirate and wound biopsies specimens were collected under strict asepsis and sent to the Medical Microbiology laboratory of the same institution for immediate processing. All pathogens were isolated and identified by standard microbiological methods. Disk diffusion antibiotic susceptibility testing was performed and interpreted according to Clinical and Laboratory Standards Institute (CLSI) guidelines.

RESULTS

The overall prevalence of ICU infections was 30.9% out of which 12.9% were bloodstream infections, 31.5% urinary tract infections, 38.9% pneumonia, and 16.7% skin and soft tissue infections. Klebsiella species andEscherichia coli were the predominant pathogens. Multidrug resistant organisms constituted 59.3% of the pathogens, MDR Klebsiella spp and MDR E. coli were 70.8% and 71.4% respectively. Resistance to Cefuroxime was the highest (92.9%) while Meropenem had the least resistance (21.4%).

CONCLUSION

There is a high prevalence of multidrug resistant bacteria causing ICU infections. Application of more stringent infection control procedures and institution of functional antimicrobial stewardship are recommended to combat this problem.

An update on technical, interpretative and clinical relevance of antimicrobial synergy testing methodologies

Testing for antimicrobial interactions has gained popularity in the last decade due to the increasing prevalence of drug-resistant organisms and limited options for the treatment of these infections. In vitro combination testing provides information, on which two or more antimicrobials can be combined for a good clinical outcome. Amongst the various in vitro methods of drug interactions, time-kill assay (TKA), checkerboard (CB) assay and E-test-based methods are most commonly used. Comparative performance of these methods reveals the TKA as the most promising method to detect synergistic combinations followed by CB assay and E-test. Various combinations of antimicrobials have been tested to demonstrate synergistic activity. Promising results were obtained for the combinations of meropenem plus colistin and rifampicin plus colistin against Acinetobacter baumannii, colistin plus carbapenem and carbapenem plus fluoroquinolones against Pseudomonas aeruginosa and colistin/polymyxin B plus rifampicin/meropenem against Klebsiella pneumoniae. Antagonism was detected in only few instances. The presence of synergy or antagonism with a combination seems to correlate with minimum inhibitory concentration of the agent and molecular mechanism involved in the resistance. Further studies need to be conducted to assess the utility of in vitro testing to predict clinical outcome and direct therapy for drug-resistant organisms.

Carbapenem-resistant Gram-negative bacteria associated with catheter-related bloodstream infections in three intensive care units in Egypt

We aimed to identify the carbapenem-resistant Gram-negative bacteria (GNB) causing catheter-related bloodstream infections (CRBSI) in intensive care units (ICU) in a tertiary care Egyptian hospital, to study their resistance mechanisms by phenotypic and genetic tests, and to use ERIC-PCR for assessing their relatedness. The study was conducted over 2 years in three ICUs in a tertiary care hospital in Egypt during 2015-2016. We identified 194 bloodstream infections (BSIs); 130 (67.01%) were caused by GNB, of which 57 were isolated from CRBSI patients (73.84%). Identification of isolates was performed using conventional methods and MALDI-TOF MS. Antimicrobial susceptibility testing (AST) was done by disc diffusion following CLSI guidelines. Phenotypic detection of carbapenemases enzymes activity was by modified Hodge test and the Carba-NP method. Isolates were investigated for the most common carbapenemases encoding genes bla_KPC, bla_NDM, and bla_OXA-48 using multiplex PCR. Molecular typing of carbapenem-resistant isolates was done by ERIC-PCR followed by sequencing of common resistance genes. The overall rate of CRBSI in our study was 3.6 per 1000 central venous catheter (CVC) days. Among 57 Gram-negative CRBSI isolates, Klebsiella pneumoniae (K. pneumoniae) was the most frequently isolated (27/57; 47.4%), of which more than 70% were resistant to Meropenem. Phenotypic tests for carbapenemases showed that 37.9% of isolates were positive by modified Hodge test and 63.8% by Carba-NP detection. Multiplex PCR assay detected the bla_NDM in 28.6% of the isolates and bla_KPC in 26.8%, bla_NDM and bla_KPC were detected together in the same isolate in 5.6%, while bla_OXA-48-like were not detected. ERIC-PCR detected limited genetic relatedness between K. pneumoniae isolates. Elevated resistance rates were observed to all antibiotics including carbapenems among K. pneumoniae isolates causing CRBSI. ERIC-PCR showed that the resistant isolates were mainly polyclonal. Our results call for reinforcement of antimicrobial stewardship and measures to prevent CRBSI.

Prospective surveillance of healthcare-associated infections and patterns of antimicrobial resistance of pathogens in an Italian intensive care unit

Background

The study aimed to evaluate the distribution of healthcare-associated infections (HAIs), the incidence rates and device utilization ratio (DUR) of device-associated infections (DAIs), as well as the distribution and patterns of antimicrobial resistance of the responsible pathogens.

Methods

Eligible patients who were admitted to an adult Intensive Care Unit (ICU) from May 1, 2013 to December 31, 2016 were included in the surveillance. Demographics, intrinsic and extrinsic risk factors, information regarding infection and isolated pathogens with antibiogram results were collected.

Results

One thousand two hundred eighty-three patients were included in the surveillance. One hundred forty-seven HAIs were detected with a cumulative incidence of 9.2 per 100 patients 4-year period and an incidence rate of 17.4 per 1000 patient days. Fifty-six out of 1283 patients were affected by at least one episode of ICU-acquired pneumonia, and 72.7% of these were associated with intubation. ICU-acquired bloodstream infections (BSIs) occurred in 4.4% of patients and 89.5% were catheter-related. ICU-acquired urinary tract infections (UTIs) occurred in 1% of patients, with 84.6% of the episodes being associated with the use of an urinary catheter. The pattern of antimicrobial-resistance in the isolates showed, among the Gram-positive bacteria, that 66.6% and 16.6% of Staphylococcus epidermidis were oxacillin and teicoplanin resistant, respectively. Among the Gram-negative bacteria, carbapenem resistance was found in 91.6% of Acinetobacter baumannii and 28.5% of Klebsiella pneumoniae isolates.

Conclusions

The majority of HAIs in the ICU studied were associated with the use of invasive devices. Since a significant proportion of these HAIs are considered preventable, reinforcement of the evidence-based preventive procedures are needed.

Electronic supplementary material

The online version of this article (10.1186/s13756-018-0337-x) contains supplementary material, which is available to authorized users.

Antimicrobial consumption, costs and resistance patterns: a two year prospective study in a Romanian intensive care unit

Background

Due to the vulnerable nature of its patients, the wide use of invasive devices and broad-spectrum antimicrobials used, the intensive care unit (ICU) is often called the epicentre of infections. In the present study, we quantified the burden of hospital acquired pathology in a Romanian university hospital ICU, represented by antimicrobial agents consumption, costs and local resistance patterns, in order to identify multimodal interventional strategies.

Methods

Between 1^st January 2012 and 31^st December 2013, a prospective study was conducted in the largest ICU of Western Romania. The study group was divided into four sub-samples: patients who only received prophylactic antibiotherapy, those with community-acquired infections, patients who developed hospital acquired infections and patients with community acquired infections complicated by hospital-acquired infections. The statistical analysis was performed using the EpiInfo version 3.5.4 and SPSS version 20.

Results

A total of 1596 subjects were enrolled in the study and the recorded consumption of antimicrobial agents was 1172.40 DDD/ 1000 patient-days.

The presence of hospital acquired infections doubled the length of stay (6.70 days for patients with community-acquired infections versus 16.06/14.08 days for those with hospital-acquired infections), the number of antimicrobial treatment days (5.47 in sub-sample II versus 11.18/12.13 in sub-samples III/IV) and they increased by 4 times compared to uninfected patients. The perioperative prophylactic antibiotic treatment had an average length duration of 2.78 while the empirical antimicrobial therapy was 3.96 days in sample II and 4.75/4.85 days for the patients with hospital-acquired infections. The incidence density of resistant strains was 8.27/1000 patient-days for methicilin resistant Staphylococcus aureus, 7.88 for extended spectrum β-lactamase producing Klebsiella pneumoniae and 4.68/1000 patient-days for multidrug resistant Acinetobacter baumannii.

Conclusions

Some of the most important circumstances collectively contributing to increasing the consumption of antimicrobials and high incidence densities of multidrug-resistant bacteria in the studied ICU, are represented by prolonged chemoprophylaxis and empirical treatment and also by not applying the definitive antimicrobial therapy, especially in patients with favourable evolution under empirical antibiotic treatment. The present data should represent convincing evidence for policy changes in the antibiotic therapy.

National surveillance of health care-associated infections in Egypt: Developing a sustainable program in a resource-limited country

BACKGROUND

Health care-associated infections (HAIs) are a major global public health concern. The lack of surveillance systems in developing countries leads to an underestimation of the global burden of HAI. We describe the process of developing a national HAI surveillance program and the magnitude of HAI rates in Egypt.

METHODS

The detailed process of implementation of a national HAI surveillance program is described. A 3-phase surveillance approach was implemented in intensive care units (ICUs). This article focuses on results from the phase 2 surveillance. Standard surveillance definitions were used, clinical samples were processed by the hospital laboratories, and results were confirmed by a reference laboratory.

RESULTS

Ninety-one ICUs in 28 hospitals contributed to 474,544 patient days and 2,688 HAIs. Of these, 30% were bloodstream infections, 29% were surgical site infections, 26% were pneumonia, and 15% were urinary tract infections. Ventilator-associated pneumonia had the highest incidence of device-associated infections (4.3/1,000 ventilator days). The most common pathogens reported were Klebsiella spp (28.7%) and Acinetobacter spp (13.7%). Of the Acinetobacter spp, 92.8% (157/169) were multidrug resistant, whereas 42.5% (151/355) of the Klebsiella spp and 54% (47/87) of Escherichia coli were extended-spectrum β-lactamase producers.

CONCLUSIONS

Implementation of a sustainable surveillance system in a resource-limited country was possible following a stepwise approach with continuous evaluation. Enhancing infection prevention and control programs should be an infection control priority in Egypt.

The Resistance Mechanism and Clonal Distribution of Tigecycline-Nonsusceptible Klebsiella pneumoniae Isolates in Korea

PURPOSE

Tigecycline is one of the drugs used to treat multi-drug resistant Klebsiella pneumoniae (K. pneumoniae) infections, including complicated skin and soft tissue infections, complicated intra-abdominal infection, and community-acquired pneumonia in the Republic of Korea. However, since its commercial release, K. pneumoniae resistance against tigecycline has been reported, and there is a serious concern about the spread of tigecycline resistant bacteria.

MATERIALS AND METHODS

In this study, we collected and analyzed 342 isolates from 23 hospitals in the Republic of Korea to determine the mechanisms of tigecycline susceptibility and their clonal types. The hospitals include several from each province in the Republic of Korea, except Jeju, an island province, and nonsusceptibility among the isolates was tested by the disk diffusion method. In our lab, susceptibility was checked again using the broth dilution method, and clonal types were determined using the multilocus sequence typing protocol. Real-time PCR was performed to measure the ramR mutation in the isolates nonsusceptible to tigecycline, which would suggest an increased expression of the AcrAB multidrug pump.

RESULTS

Fifty-six K. pneumoniae isolates were found to be nonsusceptible, 16% of the 342 collected. Twenty-seven and nine isolates of the tigecycline nonsusceptible isolates had mutations in the ramR and rpsJ genes, respectively; while 18 nonsusceptible isolates harbored the tetA gene. Comparison of isolates with and without ramR mutation showed a significant statistical difference (p<0.05) for expression of AcrAB. Moreover, the most common clonal types, as observed in our study, appear to be ST11 and ST789.

CONCLUSION

Several dominate clonal types infer tigecycline resistance to K. pneumoniae, including ST11, ST768, ST15, ST23, ST48, and ST307. There does not seem to be a transferrable medium, such as plasmid, for the resistance yet, although mutation of the ramR gene may be a common event, accounting for 48% of the nonsusceptibility in this study.

Gram-negative infections in adult intensive care units of latin america and the Caribbean

This review summarizes recent epidemiology of Gram-negative infections in selected countries from Latin American and Caribbean adult intensive care units (ICUs). A systematic search of the biomedical literature (PubMed) was performed to identify articles published over the last decade. Where appropriate, data also were collected from the reference list of published articles, health departments of specific countries, and registries. Independent cohort data from all countries (Argentina, Brazil, Chile, Colombia, Cuba, Mexico, Trinidad and Tobago, and Venezuela) signified a high rate of ICU infections (prevalence: Argentina, 24%; Brazil, 57%). Gram-negative pathogens, predominantly Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli, accounted for >50% of ICU infections, which were often complicated by the presence of multidrug-resistant strains and clonal outbreaks. Empirical use of antimicrobial agents was identified as a strong risk factor for resistance development and excessive mortality. Infection control strategies utilizing hygiene measures and antimicrobial stewardship programs reduced the rate of device-associated infections. To mitigate the poor health outcomes associated with infections by multidrug-resistant Gram-negative bacteria, urgent focus must be placed on infection control strategies and local surveillance programs.

Prevalence of extensively drug-resistant gram negative bacilli in surgical intensive care in Egypt

Introduction

The prevalence of extensively drug resistant gram negative bacilli (XDR-GNB) is rapidly progressing; however in Egypt data are sparse. We conducted the present study to quantify the incidence, risk factors and outcome of patients harboring XDR-GNB.

Methods

A one year prospective study was done by collecting all the bacteriological reports for cultures sent from the surgical intensive care unit, Cairo university teaching hospital. XDR-GNB were defined as any gram negative bacilli resistant to three or more classes of antimicrobial agents. Patients with XDR-GNB compared with those sustaining non extensively drug-resistant infection. A multivariate logistic regression model was created to identify independent predictors of multi-resistance.

Results

During one-year study period, a total of 152 samples (65%) out of 234 gram negative bacilli samples developed extensively drug resistant infection. XDR strains were significantly higher in Acinetobacterspp (86%), followed by Pseudomonas (63%), then Proteus (61%), Klebsiella (52%), and E coli (47%). Fourth generation cephalosporine (Cefipime) had the lowest susceptibility (10%) followed by third generation cephalosporines (11%), Quinolones (31%), Amikacin (42%), Tazobactam (52%), Carbapinems (52%), and colistin (90%). Relaparotomy was the only significant risk factor for acquisition of XDR infection.

Conclusion

Extensively drug-resistant gram negative infections are frequent in our ICU. This is an alarming health care issue in Egypt which emphasizes the need to rigorously implement infection control practices.