Regional distribution of nosocomial infections due to ESBL-positive Enterobacteriaceae in Germany: data from the German National Reference Center for the Surveillance of Nosocomial Infections (KISS)

Monitoring of antimicrobial resistance in respiratory tract pathogens during the COVID-19 pandemic: A retrospective study

To understand the distribution and antimicrobial resistance (AMR) of pathogens in respiratory samples in Changle District People's Hospital in Fujian Province in recent years, and provide empirical guidance for infection control and clinical treatment in the region. A retrospective analysis was conducted on 5137 isolates of pathogens from respiratory samples collected from 2019 to 2022. The AMR patterns were systematically analyzed. For research purposes, the data was accessed on October 12, 2023. A total of 3517 isolates were included in the study, including 811 (23.06%) gram-positive bacteria and 2706 (76.94%) gram-negative bacteria. The top 3 gram-positive bacteria were Staphylococcus aureus with 455 isolates (12.94%), Streptococcus pneumoniae with 99 isolates (2.81%), and Staphylococcus hemolytic with 99 isolates (2.81%). The top 3 gram-negative bacteria were Klebsiella pneumoniae with 815 isolates (23.17%), Pseudomonas aeruginosa with 589 isolates (16.75%), and Acinetobacter baumannii with 328 isolates (9.33%). The proportion of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and K pneumoniae fluctuated between 41.9% and 70.5%, and 18.6% and 20.9%, respectively. The resistance rates of E coli, K pneumoniae, P aeruginosa, and A baumannii to carbapenems were 2.36%, 8.9%, 18.5%, and 19.6%, respectively. The prevalence of methicillin-resistant S aureus (MRSA) was 48.55%, but it decreased to 38.4% by 2022. The resistance rate of Staphylococcus haemolyticus to methicillin was 100%, and 1 case of vancomycin-resistant strain was detected. K pneumoniae, P aeruginosa, A baumannii, and S aureus are the main pathogens in respiratory samples. Although the resistance rates of some multidrug-resistant strains have decreased, ESBL-producing Enterobacteriaceae, carbapenem-resistant bacteria have still increased. Therefore, it is necessary to strengthen the monitoring of pathogen resistance, promote rational use of antibiotics, and promptly report findings.

Assessing bacterial prevalence and resistance in paediatric meningitis: safeguarding the central nervous system

Introduction

Paediatric bacterial meningitis (PBM) represents a major contributor to childhood morbidity and mortality globally, with heightened susceptibility in low- and middle-income nations where antimicrobial resistance (AMR) is highly prevalent. Pakistan exemplifies this setting, with widespread antibiotic overuse driving AMR expansion. Thus, expediting PBM diagnosis and targeted antibiotic therapy is imperative yet challenged by the dynamic local epidemiology. This study aimed to delineate the recent bacterial etiologies and AMR profiles of PBM from a major Pakistani diagnostics laboratory to inform empirical treatment.

Materials and methods

This prospective observational investigation evaluated PBM epidemiology in patients under 18 years old admitted to the study hospital. Standard cerebrospinal fluid analysis identified bacterial pathogens and antibiotic susceptibility patterns.

Results

Among 171 PBM cases, 152 (88.9%) had bacterial isolates confirmed via culture. The cohort was 42.7% male with a mean age of 3 months. The most prevalent pathogens among infants younger than 3 months were Escherichia coli, Enterococcus faecium, and Staphylococcus epidermidis, contrasting with S. epidermidis, Streptococcus pneumoniae, and Staphylococcus hominis predominating in older children. Staphylococcal isolates exhibited considerable penicillin and erythromycin resistance but maintained vancomycin and linezolid susceptibility. Other resistance patterns varied.

Conclusion

These findings highlight the pressing threat of paediatric AMR in Pakistan, underscoring the need for vigilant AMR surveillance and judicious antimicrobial use. This study provides a reference to current PBM epidemiology to guide context-specific empirical therapy.

Molecular epidemiology of antimicrobial resistance in central africa: A systematic review

Background

In Central Africa, it is difficult to tackle antibiotic resistance, because of a lack of data and information on bacterial resistance, due to the low number of studies carried out in the field. To fill this gap, we carried out a systematic review of the various studies, and devised a molecular epidemiology of antimicrobial resistance from humans, animals and the environmental samples.

Method

A systematic search of all publications from 2005 to 2020 on bacterial resistance in Central Africa (Gabon, Cameroon, Democratic Republic of Congo, Central African Republic, Chad, Republic of Congo, Equatorial Guinea, São Tomé and Príncipe, Angola) was performed on Pubmed, Google scholar and African Journals Online (AJOL). All circulating resistance genes, prevalence and genetic carriers of these resistances were collected. The study area was limited to the nine countries of Central Africa.

Results

A total of 517 studies were identified through a literature search, and 60 studies carried out in eight countries were included. Among all articles included, 43 articles were from humans. Our study revealed not only the circulation of beta-lactamase and carbapenemase genes, but also several other types of resistance genes. To finish, we noticed that some studies reported mobile genetic elements such as integrons, transposons, and plasmids.

Conclusion

The scarcity of data poses difficulties in the implementation of effective strategies against antibiotic resistance, which requires a health policy in a 'One Health' approach.

Impact of antimicrobial stewardship on antibiogram, consumption and incidence of multi drug resistance

INTRODUCTION

Antimicrobial stewardship programs are intended to improve patient outcomes, reduce side effects, bacterial resistance, and costs. Thus, it is important to assess their impact on an ongoing basis. We aimed to assess the impact of the antimicrobial stewardship program in two different hospitals which used different program approaches.

METHODOLOGY

This is a retrospective observational study in two private hospitals [4088 patient records] in Amman- Jordan. Antibiotic susceptibility using antibiogram results, consumption of antibiotics using Defined Daily Dose, and the incidence of Multi-Drug Resistance were recorded using patients' records during 2018, 2019, and 2020.

RESULTS

Antimicrobial stewardship program outcomes varied between the two hospitals. Bacterial susceptibility to antibiotics were improved in both hospitals. Moreover, the defined daily dose in Hospital "A" showed no significant change in Fluoroquinolones, Carbapenems, and Piperacillin- Tazobactam, Cephalosporins, and Colistin, while a significant change was observed among Anti-MRSA antibiotics. Finally, the incidence of Extended Spectrum Beta-lactamase [ESBL] E. coli, ESBL Klebsiella, and Vancomycin Resistant Enterococci [VRE] have decreased numerically over the study period, while Methicillin-Resistant Staphylococcus aureus [MRSA] showed an increase in incidence during the second year of the study.

CONCLUSION

The study emphasizes the positive impact of the AMS program throughout the three years of the study. Plus, the need to enhance the program through recruiting extra staff and applying extra regulations like implementing educational programs for the hospital staff, designing local guidelines for common ID diseases, and monitoring the program's outcomes which would eventually be more efficient, cost-effective, and safe.

Prevalence of Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Ethiopia: A Systematic Review and Meta-Analysis

Background

Antimicrobial resistance especially caused by extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) has become a global public health concern. Globally, these isolates have remained the most important causes of several infections and associated mortality. Their rapid spread in Ethiopia is associated with a lack of regular surveillance and antibiotic stewardship programs. Isolates of ESBL-PE from different regions of Ethiopia were searched exhaustively. However, published data regarding the pooled estimate of ESBL-PE are not conducted in Ethiopia. For this reason, we systematically reviewed laboratory-based studies to summarize the overall pooled prevalence of the isolates recovered from various human specimens.

Methods

An exhaustive literature search was carried out using the major electronic databases including PubMed, Web of Science, MEDLINE, EMBASE, CINAHL, Google Scholar, Cochrane Library, Scopus, and Wiley Online Library to identify potentially relevant studies without date restriction. Original articles which address the research question were identified, screened, and included using the PRISMA follow diagram. Data extraction form was prepared in Microsoft Excel, and data quality was assessed by using 9-point Joanna Briggs Institute critical appraisal tools. Then, data were exported to STATA 16.0 software for analyses of pooled estimation of outcome measures. Estimation of outcome measures at 95% confidence interval was performed using Der-Simonian-Laird's random-effects model. Finally, results were presented via text, figures, and tables.

Results

A comprehensive electronic database literature search has yielded a total of 86 articles. Among the total, 68 original articles were excluded after the review process. A total of 18 studies with 1191 bacterial isolates recovered from 7919 various clinical samples sizes were included for systematic review and meta-analysis. In this study, the pooled prevalence of ESBL-PE was 18% (95% CI: 9–26). Nine out of the total (50%) reviewed articles were studied using the combination disk test. Likewise, E. coli and K. pneumoniae (50% both) were the predominant isolates of ESBL-PE in addition to other isolates such as Salmonella spp. and Shigella spp.

Conclusion

This meta-analysis has shown a low pooled estimate of ESBL-PE in Ethiopia.

Prevalence and antimicrobial resistance patterns of bacteria isolated from cerebrospinal fluid among children with bacterial meningitis in China from 2016 to 2018: a multicenter retrospective study

Background

Pediatric bacterial meningitis (PBM) remains a devastating disease that causes substantial neurological morbidity and mortality worldwide. However, there are few large-scale studies on the pathogens causing PBM and their antimicrobial resistance (AMR) patterns in China. The present multicenter survey summarized the features of the etiological agents of PBM and characterized their AMR patterns.

Methods

Patients diagnosed with PBM were enrolled retrospectively at 13 children’s hospitals in China from 2016 to 2018 and were screened based on a review of cerebrospinal fluid (CSF) microbiology results. Demographic characteristics, the causative organisms and their AMR patterns were systematically analyzed.

Results

Overall, 1193 CSF bacterial isolates from 1142 patients with PBM were obtained. The three leading pathogens causing PBM were Staphylococcus epidermidis (16.5%), Escherichia coli (12.4%) and Streptococcus pneumoniae (10.6%). In infants under 3 months of age, the top 3 pathogens were E. coli (116/523; 22.2%), Enterococcus faecium (75/523; 14.3%), and S. epidermidis (57/523; 10.9%). However, in children more than 3 months of age, the top 3 pathogens were S. epidermidis (140/670; 20.9%), S. pneumoniae (117/670; 17.5%), and Staphylococcus hominis (57/670; 8.5%). More than 93.0% of E. coli isolates were sensitive to cefoxitin, piperacillin/tazobactam, cefoperazone/sulbactam, amikacin and carbapenems, and the resistance rates to ceftriaxone, cefotaxime and ceftazidime were 49.4%, 49.2% and 26.4%, respectively. From 2016 to 2018, the proportion of methicillin-resistant coagulase-negative Staphylococcus isolates (MRCoNS) declined from 80.5 to 72.3%, and the frequency of penicillin-resistant S. pneumoniae isolates increased from 75.0 to 87.5%. The proportion of extended-spectrum β-lactamase (ESBL)-producing E. coli fluctuated between 44.4 and 49.2%, and the detection rate of ESBL production in Klebsiella pneumoniae ranged from 55.6 to 88.9%. The resistance of E. coli strains to carbapenems was 5.0%, but the overall prevalence of carbapenem-resistant K. pneumoniae (CRKP) was high (54.5%).

Conclusions

S. epidermidis, E. coli and S. pneumoniae were the predominant pathogens causing PBM in Chinese patients. The distribution of PBM causative organisms varied by age. The resistance of CoNS to methicillin and the high incidence of ESBL production among E. coli and K. pneumoniae isolates were concerning. CRKP poses a critical challenge for the treatment of PBM.

Does inappropriate initial antibiotic therapy affect in-hospital mortality of patients in the emergency department with Escherichia coli and Klebsiella pneumoniae bloodstream infections?

Extended-spectrum β-lactamase (ESBL)-positive bloodstream infection (BSI) is on the rise worldwide. The purpose of this study is to evaluate the impact of inappropriate initial antibiotic therapy (IIAT) on in-hospital mortality of patients in the emergency department (ED) with Escherichia coli and Klebsiella pneumoniae BSIs. This retrospective single-center cohort study included all adult patients with E. coli and K. pneumoniae BSIs between January 2007 and December 2013, who had undergone a blood culture test and initiation of antibiotics within 6 h of ED registration time. Multiple logistic regression was used to adjust for bacterial species, IIAT, time to antibiotics, age, sex, quick Sepsis Related Organ Failure Assessment (qSOFA) score ⩾ 2, and comorbidities. A total of 3533 patients were enrolled (2967 alive and 566 deceased, in-hospital mortality rate 16%). The patients with K. pneumoniae ESBL-positive BSI had the highest mortality rate. Non-survivors had qSOFA scores ⩾ 2 (33.6% vs 9.5%, P < 0.001), more IIAT (15.0% vs 10.7%, P = 0.004), but shorter mean time to antibiotics (1.70 vs 1.84 h, P < 0.001). A qSOFA score ⩾ 2 is the most significant predictor for in-hospital mortality; however, IIAT and time to antibiotics were not significant predictors in multiple logistic regression analysis. In subgroup analysis divided by qSOFA scores, IIAT was still not a significant predictor. Severity of the disease (qSOFA score ⩾ 2) is the key factor influencing in-hospital mortality of patients with E. coli and K. pneumoniae BSIs. The time to antibiotics and IIAT were not significant predictors because they in turn were affected by disease severity.

The burden of extended-spectrum β-lactamase-producing Enterobacteriaceae in Nigeria: a systematic review and meta-analysis

Antibiotic resistance on account of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) has become a major public health concern in developing countries. The presence of ESBL-PE is associated with increased morbidity, mortality and healthcare costs. There is no active antimicrobial surveillance mechanism in Nigeria. The aim of this study is to determine a precise estimate of the burden of ESBL-PE in Nigeria. We employed Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and searched electronic databases for suitable studies. We derived pooled prevalence estimates using random effects models and assessed trends with meta-regression. We found 208 studies, with 38 satisfying our inclusion criteria. The overall pooled prevalence of ESBL-PE in Nigeria was 34.6% (95% CI 26.8 to 42.3%) and increased at a rate of 0.22% per year (p for trend=0.837). In summary, we found the prevalence of ESBL-PE in Nigeria to be high and recommend a robust national survey to provide a more detailed picture of the epidemiology of ESBL-PE in Nigeria.

Current status of post-operative infections due to antimicrobial-resistant bacteria after digestive tract surgery in Japan: Japan Postoperative Infectious Complications Survey in 2015 (JPICS'15)

PURPOSE

We herein report the findings of the Japan Postoperative Infectious Complication Survey in 2015 (JPICS'15), which evaluated the rate of post-operative infections and colonization due to antimicrobial-resistant (AMR) bacteria after digestive tract surgery.

METHODS

This survey by the Japan Society of Surgical Infection included patients undergoing digestive tract surgery at 28 centers between September 2015 and March 2016. Data included patient background characteristics, type of surgery, contamination status, and type of post-operative infections, including surgical site infections (SSIs), remote infections (RIs), and colonization.

RESULTS

During the study period, 7,565 surgeries (of 896 types) were performed; among them, 905 cases demonstrated bacteria after digestive tract surgery. The survey revealed that post-operative infections or colonization by AMR bacteria occurred in 0.9% of the patient cohort, constituting 7.5% of post-operative infections, including 5.6% of SSIs and 1.8% of RIs. Extended-spectrum β-lactamase-producing Enterobacteriaceae and methicillin-resistant Staphylococcus aureus were the predominant AMR bacteria isolated from patients after digestive tract surgery. Patients infected with AMR bacteria had a poor prognosis.

CONCLUSION

Our results reveal that 7.5% of the post-operative infections were due to AMR bacteria, indicating the need for antibacterial coverage against AMR bacteria in patients with critical post-operative infections.

Recent Advances in Investigation, Prevention, and Management of Healthcare-Associated Infections (HAIs): Resistant Multidrug Strain Colonization and Its Risk Factors in an Intensive Care Unit of a University Hospital

Active screening for resistant multidrug strain carriers remains an important component of infection control policy in any healthcare setting indifferent of financial and logistical costs. The objective of our study was to determine the spectrum of bacterial colonization individually among intensive care unit patients. A retrospective observational study was performed in the Intensive Care Unit of Emergency Clinical County Hospital of Oradea during 2017. Medical records of the patients were used for evaluation of source of ICU admission, previous antibiotic therapy, comorbidities, and length of hospital stay. Nasal and groin swabs for MRSA detection and rectal swabs for ESBL, VRE, and CRE detection were collected upon ICU admission of all patients in the first 24 hours and after 7 days. Swab samples were processed for isolation and identification of these resistant multidrug strains. Bacterial colonization on admission was detected in a quarter of patients included in the study. Carbapenemase-producing bacteria were the most common colonizers (21.16%). On admission, 12.06% of patients have been colonized by ESBL-producing members of the family Enterobacterales. Risk factors for colonization on admission to the ICU were chronic liver diseases and chronic renal failure for ESBL infection and chronic liver disease for CRE in male patients. Evaluation of Carmeli's score for male patients showed association only with CRE colonization. Chronic renal failure was found as risk factor for ESBL colonization in female patients. The prevalence of MRSA was 5.23% and less than 1% for VRE. There was no association between any risk factors studied and the presence of S. aureus or VRE upon admission. The 7-day ICU stay also proved to be an increased risk for ESBL and CRE infection.

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

AIM

To survey postoperative infections (PI) after digestive surgery.

METHODS

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

RESULTS

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

CONCLUSION

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

Trend in Antibiotic Resistance of Extended-Spectrum Beta-Lactamase-Producing Escherichia Coli and Klebsiella Pneumoniae Bloodstream Infections

Objectives:

Extended-spectrum beta-lactamases (ESBLs) have been detected more frequently in members of the Enterobacteriaceae family, particularly Escherichia coli and Klebsiella pneumoniae. Infections caused by ESBL-producing bacteria are often resistant to treatment with various antibiotic classes and accompanied by increased complication risks, mortality, and costs. In this study, blood culture results were analyzed to determine the change in the ESBL production rate and antibiotic susceptibilities in E. coli and K. pneumoniae isolates over a period of 3 years.

Methods:

The results of blood cultures sent to our laboratory between February 2014 and August 2016 were examined retrospectively. Repeat isolates from the same patient were not included when antibiotic susceptibility rates and clinical distributions were calculated. BD Bactec FX automated blood culture system (Becton Dickinson, Sparks, MD, USA) was used to examine the blood cultures. Matrix-assisted laser desorption ionization-time of flight mass spectrometry (Bruker Daltonics, Bremen, Germany) was used to identify microorganisms. For antibiotic susceptibility tests (AST) and ESBL detection Kirby Bauer disk diffusion method or Phoenix automated system (Becton Dickinson, Sparks, MA, USA) was used. When the AST results were evaluated, Clinical and Laboratory Standards Institute breakpoints were used for 2014 and 2015, and European Committee on Antimicrobial Susceptibility Testing breakpoints were used for 2016.

Results:

During the 3-year period, 224 (35%) of 632 E. coli and 137 (31%) of 439 K. pneumoniae isolates were determined to be ES BL-producers. The ESBL-positive isolate percentage for E. coli and K. pneumoniae for 2014, 2015, and 2016 was 23%, 36%, 48% and 23%, 32%, 37%, respectively. The increase in ESBL was statistically significant for both E. coli (p<0.001) and K. pneumoniae (p=0.011). ESBL-positive E. coli and K. pneumoniae strains were most sensitive to carbapenem-class antibiotics, amikacin, and colistin. While there was no meropenem-resistant strain, 5 (3.3%) ertapenem-resistant and 1 (0.7%) imipenem-resistant ESBL E. coli strains were detected. The ESBL K. pneumoniae strain resistance rate to ertapenem, imipenem, and meropenem was 12%, 11.2%, and 11.1%, respectively. The resistance rates of K. pneumonia strains to ertapenem, imipenem, meropenem, and piperacillin-tazobactam increased significantly over the study period (p<0.001).

Conclusion:

Monitoring ESBL rates and the antibiotic susceptibility of E. coli and K. pneumoniae strains of bloodstream infections is of the utmost importance in guiding empiric antibiotic therapies and patient management.

Incidence of infections due to third generation cephalosporin-resistant Enterobacteriaceae - a prospective multicentre cohort study in six German university hospitals

Background

Infections caused by third generation cephalosporin-resistant Enterobacteriaceae (3GCREB) are an increasing healthcare problem. We aim to describe the 3GCREB infection incidence and compare it to prevalence upon admission. In addition, we aim to describe infections caused by 3GCREB, which are also carbapenem resistant (CRE).

Methods

In 2014-2015, we performed prospective 3GCREB surveillance in clinically relevant patient specimens (screening specimens excluded). Infections counted as hospital-acquired (HAI) when the 3GCREB was detected after the third day following admission, otherwise as community-acquired infection (CAI).

Results

Of 578,420 hospitalized patients under surveillance, 3367 had a 3GCREB infection (0.58%). We observed a similar 3GCREB CAI and HAI incidence (0.28 and 0.31 per 100 patients, respectively). The most frequent pathogen was 3GCR E. coli, in CAI and HAI (0.15 and 0.12 per 100 patients). We observed a CRE CAI incidence of 0.006 and a HAI incidence of 0.008 per 100 patients (0.014 per 1000 patient days).

Conclusions

Comparing the known 3GCREB admission prevalence of the participating hospitals (9.5%) with the percentage of patients with a 3GCREB infection (0.58%), we conclude the prevalence of 3GCREB in university hospitals to be about 16 times higher than suggested when only patients with 3GCREB infections are considered. Moreover, we find the HAI and CAI incidence caused by CRE in Germany to be relatively low.

Post-appendectomy pelvic abscess with extended-spectrum beta-lactamase producing Escherichia coli: A case report and review of literature

BACKGROUND

Appendicitis, the inflammation of the appendix, is the most common abdominal surgical emergency requiring expedient surgical intervention. Extended-spectrum beta-lactamases (ESBLs) are bacterial enzymes that catalyse the degradation of the beta-lactam ring of penicillins and cephalosporins (but without carbapenemase activity), leading to resistance of these bacteria to beta-lactam antibiotics. Recent increases in incidence of ESBL-producing bacteria have caused alarm worldwide. Proportion estimates of ESBL-Enterobacteriaceae hover around 46% in China, 42% in East Africa, 12% in Germany, and 8% in the United States.

CASE SUMMARY

The impact of ESBL-producing bacteria on appendiceal abscesses and consequent pelvic abscesses are yet to be examined in depth. A literature review using the search words “appendiceal abscesses” and “ESBL Escherichia coli (E. coli)” revealed very few cases involving ESBL E. coli in any capacity in the context of appendiceal abscesses. This report describes the clinical aspects of a patient with appendicitis who developed a postoperative pelvic abscess infected with ESBL-producing E. coli. In this report, we discuss the risk factors for contracting ESBL E. coli infection in appendicitis and post-appendectomy pelvis abscesses. We also discuss our management approach for post-appendectomy ESBL E. coli pelvic abscesses, including drainage, pathogen identification, and pathogen characterisation. When ESBL E. coli is confirmed, carbapenem antibiotics should be promptly administered, as was done efficaciously with this patient. Our report is the first one in a developed country involving ESBL E. coli related surgical complications in association with a routine laparoscopic appendectomy.

CONCLUSION

Our report is the first involving ESBL E. coli and appendiceal abscesses, and that too consequent to laparoscopic appendectomy.

A Probabilistic Transmission Model for the Spread of Extended-Spectrum-β-Lactamase and AmpC-β-Lactamase-Producing Escherichia Coli in the Broiler Production Chain

Direct contact between humans and live broilers, as well as the consumption of chicken meat, have been suggested as pathways for transmission of extended-spectrum-β-lactamase (ESBL) and AmpC-β-lactamase (AmpC)-producing Escherichia coli. One approach to design intervention strategies to control the transmission of such bacteria between animals and humans is to study the transmission pathways of such bacteria between the animals themselves. The rationale is that controlling the process of the underlying source, here transmission between animals, can provide hints on how to control a higher-level process, here the transmission between animals and humans. The focus of this article is the transmission of the above-mentioned bacteria between broilers and broiler flocks in meat production with regards to the establishment of possible intervention strategies to reduce the transfer of these bacteria between animals. The objective of this work is to design a mathematical transmission model describing the effects of vertical and horizontal bacterial transmission in the broiler production chain, from the parent generation to the slaughterhouse level. To achieve this objective, an existing transmission model for Campylobacter was adapted for the case of E. coli. The model keeps track of prevalence among flocks (flock prevalence) and of prevalence among animals within one flock (animal prevalence). Flock and animal prevalences show different dynamics in the model. While flock prevalence increases mainly through horizontal transmission in hatcheries, animal prevalence increases mainly at the broiler-fattening farm. Transports have rather small effects just as the vertical transmission from parents to chicks.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prevalence of extended-spectrum-β-lactamase-producing Enterobacteriaceae: first systematic meta-analysis report from Pakistan

Background

South-Asia is known as a hub for multidrug-resistant (MDR) bacteria. Unfortunately, proper surveillance and documentation of MDR pathogens is lacking in Pakistan. The alarming increase in the prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae is a serious problem. From this perspective, we analysed published data regarding ESBL-producing Enterobacteriaceae in different regions of Pakistan.

Methods

A meta-analysis was performed to determine the prevalence of ESBL-producing Enterobacteriaceae in Pakistan. A Web-based search was conducted in electronic databases, including PubMed, Scopus and PakMedi Net (for non-indexed Pakistani journals). Articles published (in either indexed or non-indexed journals) between January 2002 and July 2016 were included in the study. Relevant data were extracted, and statistical analysis was performed using the Metaprop command of STATA version 14.1.

Results

A total of 68 studies were identified from the electronic data base search, and 55 of these studies met our inclusion criteria. Pakistan’s overall pooled proportion of ESBL-producers was 0.40 (95% CI: 0.34–0.47). The overall heterogeneity was significant (I2 = 99.75%, p < 0.001), and significant ES = 0 (Z = 18.41, p < 0.001) was found. OXA, SHV, TEM and CTX-M were the most commonly found gene variants for ESBLs in these studies.

Conclusion

The prevalence of ESBL-producing Enterobacteriaceae is high in Pakistan. Little is known about the annual frequency of ESBLs and their prevalence in different provinces of Pakistan. No data are available regarding ESBL frequency in Baluchistan. This underscores an urgent demand for regular surveillance to address this antimicrobial resistance problem. Surveillance to better understand the annual ESBL burden is crucial to improve national and regional guidelines.

Update of incidence and antimicrobial susceptibility trends of Escherichia coli and Klebsiella pneumoniae isolates from Chinese intra-abdominal infection patients

Background

To evaluate in vitro susceptibilities of aerobic and facultative Gram-negative bacterial (GNB) isolates from intra-abdominal infections (IAIs) to 12 selected antimicrobials in Chinese hospitals from 2012 to 2014.

Methods

Hospital acquired (HA) and community acquired (CA) IAIs were collected from 21 centers in 16 Chinese cities. Extended spectrum beta-lactamase (ESBL) status and antimicrobial susceptibilities were determined at a central laboratory using CLSI broth microdilution and interpretive standards.

Results

From all isolated strains the Enterobacteriaceae (81.1%) Escherichia coli accounted for 45.4% and Klebsiella pneumoniae for 20.1%, followed by Enterobacter cloacae (5.2%), Proteus mirabilis (2.1%), Citrobacter freundii (1.8%), Enterobacter aerogenes (1.8%), Klebsiella oxytoca (1.4%), Morganella morganii (1.2%), Serratia marcescens (0.7%), Citrobacter koseri (0.3%), Proteus vulgaris (0.3%) and others (1.0%). Non- Enterobacteriaceae (18.9%) included Pseudomonas aeruginosa (9.8%), Acinetobacter baumannii (6.7%), Stenotrophomonas maltophilia (0.9%), Aeromonas hydrophila (0.4%) and others (1.1%). ESBL-screen positive Escherichia coli isolates (ESBL+) showed a decreasing trend from 67.5% in 2012 to 58.9% in 2014 of all Escherichia coli isolates and the percentage of ESBL+ Klebsiella pneumoniae isolates also decreased from 2012 through 2014 (40.4% to 26.6%), which was due to reduced percentages of ESBL+ isolates in HA IAIs for both bacteria. The overall susceptibilities of all 5160 IAI isolates were 87.53% to amikacin (AMK), 78.12% to piperacillin-tazobactam (TZP) 81.41% to imipenem (IMP) and 73.12% to ertapenem (ETP). The susceptibility of ESBL-screen positive Escherichia coli strains was 96.77%–98.8% to IPM, 91.26%–93.16% to ETP, 89.48%–92.75% to AMK and 84.86%–89.34% to TZP, while ESBL-screen positive Klebsiella pneumoniae strains were 70.56%–80.15% susceptible to ETP, 80.0%–87.5% to IPM, 83.82%–87.06% to AMK and 63.53%–68.38% to TZP within the three year study. Susceptibilities to all cephalosporins and fluoroquinolones were less than 50% beside 66.5% and 56.07% to cefoxitin (FOX) for ESBL+ Escherichia coli and Klebsiella pneumoniae strains respectively.

Conclusions

The total ESBL+ rates decreased in Escherichia coli and Klebsiella pneumoniae IAI isolates due to fewer prevalence in HA infections. IPM, ETP and AMK were the most effective antimicrobials against ESBL+ Escherichia coli and Klebsiella pneumoniae IAI isolates in 2012–2014 and a change of fluoroquinolone regimens for Chinese IAIs is recommended.

Electronic supplementary material

The online version of this article (10.1186/s12879-017-2873-z) contains supplementary material, which is available to authorized users.

Antibiotic-Resistant Extended Spectrum ß-Lactamase- and Plasmid-Mediated AmpC-Producing Enterobacteriaceae Isolated from Retail Food Products and the Pearl River in Guangzhou, China

We conducted a survey in 2015 to evaluate the presence of extended spectrum β-lactamase (ESBL)- and plasmid-mediated AmpC-producing Enterobacteriaceae in retail food and water of the Pearl River in Guangzhou, China, as well as their antibiotic resistance profiles. Samples (88 fresh food samples and 43 water samples) from eight different districts were analyzed by direct plating and after enrichment. Multidrug-resistant strains were found in 41.7 and 43.4% of food and water samples, respectively. ESBLs were found in 3.4 and 11.6% of food and water samples, respectively, and AmpC producers were found in 13.6 and 16.3% of food and water samples, respectively. Molecular characterization revealed the domination of bla_CTX−Mgenes; plasmidic AmpC was of the type DHA-1 both in food and water samples. Thirteen of Fifty one β-lactamase-producing positive isolates were detected to be transconjugants, which readily received the β-lactamase genes conferring resistance to β-lactam antibiotics as well as some non-β-lactam antibiotics. These findings provide evidence that retail food and the river water may be considered as reservoirs for the dissemination of β-lactam antibiotics, and these resistance genes could readily be transmitted to humans through the food chain and water.

E. coli bacteremia in comparison to K. pneumoniae bacteremia: influence of pathogen species and ESBL production on 7-day mortality

In a previous study, we demonstrated prolonged length of hospital stay in cases of extended-spectrum beta-lactamase (ESBL)-positive K. pneumoniae bacteremia compared to bacteremia cases due to E. coli (ESBL-positive and –negative) and ESBL-negative K. pneumoniae. The overall mortality was significantly higher in bacteremia cases resulting from ESBL-positive pathogens but also in K. pneumoniae cases disregarding ESBL-production. In order to examine whether pathogen species rather than multidrug resistance might affect mortality risk, we reanalyzed our dataset that includes 1.851 cases of bacteremia.

An observational study of the universal use of octenidine to decrease nosocomial bloodstream infections and MDR organisms

OBJECTIVES

To investigate the effect of universal decolonization with octenidine on the incidence of ICU-acquired bloodstream infections (BSI) and MDR organisms (MDRO).

METHODS

A system-wide change in practice was performed in the ICUs of a university hospital with three campuses (eight medical ICUs and nine surgical ICUs). All ICUs had a general admission screening strategy for MRSA with subsequent isolation in the 12 month baseline period, which was stopped. After a wash-in period of 1 month, decolonization of the nose with octenidine nasal gel and octenidine wash cloths was introduced. The endpoints were ICU-acquired BSI and ICU-acquired MDRO isolates from clinical cultures. Segmented regression analysis of interrupted time series was used to assess the effect of intervention.

RESULTS

A total of 29 532 ICU patients (16 677 surgical and 12 855 medical) were included in the study. The baseline incidence density of ICU-acquired BSI was 5.1 per 1000 patient days and the baseline ICU-acquired MRSA rate was 0.97 per 1000 patient days. Whereas no significant effect on either outcome was found in surgical ICUs, we identified a significant effect on ICU-acquired BSI for the intervention in medical ICUs by means of multivariate analysis (incidence rate ratio 0.78; 95% CI 0.65-0.94). In addition, the intervention was also effective in decreasing ICU-acquired MRSA in medical ICUs (incidence rate ratio 0.58; 95% CI 0.41-0.82). No effect on ICU-acquired VRE and Gram-negative MDRO was found.

CONCLUSIONS

System change was successful by decreasing infection rates in medical ICUs and improving the management in all ICUs.

Meta-analysis of proportion estimates of Extended-Spectrum-Beta-Lactamase-producing Enterobacteriaceae in East Africa hospitals

Background

A high proportion of Extended-Spectrum-Beta-Lactamase (ESBL) producing Enterobacteriaceae is causing common infections in all regions of the world. The burden of antibiotic resistance due to ESBL in East Africa is large but information is scarce and thus it is unclear how big the problem really is. To gain insight into the magnitude and molecular epidemiology of ESBL-producing Enterobacteriaceae in East Africa a literature search was performed in PubMed on 31 July 2015 to retrieve articles with relevant information on ESBL.

Methods and results

Meta-analysis was performed to determine overall proportion estimate of ESBL-producing Enterobacteriaceae. A total of 4076 bacterial isolates were included in the analysis. The overall pooled proportion of ESBL-producing Enterobacteriaceae among included surveys done in East African hospitals was found to be 0.42 (95 % CI: 0.34–0.50). Heterogeneity (I²) between countries’ proportions in ESBL was significantly high (96.95 % and p < 0.001). The frequently detected genes encoding ESBL were CTX-M, TEM, SHV and OXA while the most infrequent reported genes were KPC and NDM.

Conclusion

The available studies show a very wide variation in resistance due to ESBL between countries. This highlights a need for active surveillance systems which can help understand the actual epidemiology of ESBL, aid in formulating national or regional guidelines for proper screening of ESBL, and support developing standardized approaches for managing patients colonized with ESBL.

Electronic supplementary material

The online version of this article (doi:10.1186/s13756-016-0117-4) contains supplementary material, which is available to authorized users.

Outbreak of multidrug-resistant Escherichia coli sequence type 131 in a neonatal intensive care unit: efficient active surveillance prevented fatal outcome

BACKGROUND

Outbreaks of infections with multidrug-resistant bacteria in neonatal intensive care units (NICUs) pose a major threat, especially to extremely preterm infants. This study describes a 35-day outbreak of multidrug-resistant Escherichia coli (E. coli) in a tertiary-level NICU in Germany.

AIM

To underline the importance of surveillance policies in the particularly vulnerable cohort of preterm infants and to describe the efficacy of outbreak control strategies.

METHODS

Data were collected retrospectively from medical reports. Infants and environment were tested for E. coli.

FINDINGS

The outbreak affected a total of 13 infants between 25(+1) and 35(+0) weeks of gestation with seven infants showing signs of infection. The outbreak strain was identified as E. coli sequence type 131. Environmental screening provided no evidence for an environmental source. Through colonization surveillance and immediate and adequate treatment of potentially infected preterm infants, no fatalities occurred. Outbreak control was achieved by strict contact precautions, enhanced screening and temporary relocation of the NICU. Relocation and reconstruction improved the NICU's structural layout, focusing on isolation capacities. Follow-up indicated carriage for several months in some infants.

CONCLUSION

Routine surveillance allowed early detection of the outbreak. The identification of carriers of the outbreak strain was successfully used to direct antibiotic treatment in case of infection. Enhanced hygienic measures and ward relocation were instrumental in controlling the outbreak.

Epidemiology of healthcare associated infections in Germany: Nearly 20 years of surveillance

OBJECTIVE

To describe the epidemiology of healthcare-associated infections (HAI) in hospitals participating in the German national nosocomial infections surveillance system (KISS).

METHOD

The epidemiology of HAI was described for the surveillance components for intensive care units (ITS-KISS), non-ICUs (STATIONS-KISS), very low birth weight infants (NEO-KISS) and surgical site infections (OP-KISS) in the period from 2006 to 2013. In addition, risk factor analyses were performed for the most important infections of ICU-KISS, NEO-KISS and OP-KISS.

RESULTS

Data from a total of 3,454,778 ICU patients from 913 ICUs, 618,816 non-ICU patients from 142 non-ICU wards, 53,676 VLBW from 241 neonatal intensive care units (NICU) and 1,005,064 surgical patients from operative departments from 550 hospitals were used for analysis. Compared with baseline data, a significant reduction of primary bloodstream infections (PBSI) and lower respiratory tract infections (LRTI) was observed in ICUs with the maximum effect in year 5 (or longer participation) (incidence rate ratio 0.60 (CI95 0.50-0.72) and 0.61 (CI95 0.52-0.71) respectively). A significant reduction of PBSI and LRTI was also observed in NEO-KISS when comparing the baseline situation with the 5th year of participation (hazard ratio 0.70 (CI95 0.64-0.76) and 0.43 (CI95 0.35-0.52)). The effect was smaller in operative departments after the introduction of OP-KISS (OR 0.80; CI95 0.64-1.02 in year 5 or later for all procedure types combined). Due to the large database, it has not only been possible to confirm well-known risk factors for HAI, but also to identify some new interesting risk factors like seasonal and volume effects.

CONCLUSIONS

Participating in a national surveillance system and using surveillance data for internal quality management leads to substantial reduction of HAI. In addition, a surveillance system can identify otherwise not recognized risk factors which should - if possible - be considered for infection control management and for risk adjustment in the benchmarking process.

Features of the course of nosocomial meningitis in patients of neurosurgical intensive care unit

OBJECTIVE

To determine the incidence rate and risk factors of nosocomial meningitis in patients with complicated postoperative period.

MATERIAL AND METHODS

We report the results of prospective observation of the course of bacterial meningitis in patients with complicated postoperative period at neurosurgical intensive care unit in 2010-2014.

RESULTS

Nosocomial meningitis (NM) developed in 146 patients, which accounted for 12.6±1.0% (CI, 10.74-14.66). Patients with meningitis were characterized by longer stay at ICU, prolonged mechanical ventilation, need for central venous access and invasive hemodynamic monitoring, as well as longer course of antibacterial therapy. Frequency of invasive monitoring of intracranial pressure was similar in these two groups of patients. Bloodstream infections (14.8% vs. 4.9%; p<0.000), respiratory tract infections (55% vs. 35.6%; p<0.000), and urinary tract infections (56.4% vs. 30.9%; p<0.000) were more frequently observed in patients with NM. The following significant differences were observed between the group of NM patients and the control group: more frequent use of external ventricular drain (72.5% vs. 26.1%; p<0.000), number of reoperations (64.7% vs. 36.3%; p<0.000), and the total operating room time (417.3 min vs. 337.5 min; p<0.000). Etiology was ascertained in 61.0±4.0% of cases of nosocomial meningitis. CoNS (33.0%) and Acinetobacter baumannii (21.3%) were the main pathogens isolated from cerebrospinal fluid. The mortality in patients with meningitis was 31.5±3.8%.

CONCLUSION

External ventricular drain, repeated surgery, long-term stay in the operating room, as well as other types of infections may be considered as risk factors for developing nosocomial meningitis in neurosurgical patients at ICU.