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Intestinal colonization with multidrug-resistant Enterobacterales: screening, epidemiology, clinical impact, and strategies to decolonize carriers. Eur J Clin Microbiol Infect Dis 2023; 42:229-254. [PMID: 36680641 PMCID: PMC9899200 DOI: 10.1007/s10096-023-04548-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 01/11/2023] [Indexed: 01/22/2023]
Abstract
The clinical impact of infections due to extended-spectrum β-lactamase (ESBL)- and/or carbapenemase-producing Enterobacterales (Ent) has reached dramatic levels worldwide. Infections due to these multidrug-resistant (MDR) pathogens-especially Escherichia coli and Klebsiella pneumoniae-may originate from a prior asymptomatic intestinal colonization that could also favor transmission to other subjects. It is therefore desirable that gut carriers are rapidly identified to try preventing both the occurrence of serious endogenous infections and potential transmission. Together with the infection prevention and control countermeasures, any strategy capable of effectively eradicating the MDR-Ent from the intestinal tract would be desirable. In this narrative review, we present a summary of the different aspects linked to the intestinal colonization due to MDR-Ent. In particular, culture- and molecular-based screening techniques to identify carriers, data on prevalence and risk factors in different populations, clinical impact, length of colonization, and contribution to transmission in various settings will be overviewed. We will also discuss the standard strategies (selective digestive decontamination, fecal microbiota transplant) and those still in development (bacteriophages, probiotics, microcins, and CRISPR-Cas-based) that might be used to decolonize MDR-Ent carriers.
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Mullié C, Lemonnier D, Adjidé CC, Maizel J, Mismacque G, Cappe A, Carles T, Pierson-Marchandise M, Zerbib Y. Nosocomial outbreak of monoclonal VIM carbapenemase-producing Enterobacter cloacae complex in an intensive care unit during the COVID-19 pandemic: an integrated approach. J Hosp Infect 2021; 120:48-56. [PMID: 34861315 PMCID: PMC8631059 DOI: 10.1016/j.jhin.2021.11.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/24/2021] [Accepted: 11/24/2021] [Indexed: 01/18/2023]
Abstract
Background An outbreak of VIM carbapenemase-expressing Enterobacter cloacae complex occurred between March and October 2020 in an intensive care unit (ICU) of a tertiary care and teaching hospital in France. At the same time, the hospital was facing the COVID-19 first wave. Aim To describe the management of an outbreak caused by a VIM-producing Enterobacter cloacae complex strain during the COVID-19 pandemic in an ICU and to show the importance of an integrated approach. Methods A multi-focal investigation was conducted including descriptive and molecular epidemiology, environmental screening, and assessment of infection prevention and control measures. Findings A total of 14 cases were identified in this outbreak with a high attributable mortality rate (85.7%). The outbreak management was coordinated by a crisis cell, and involved the implementation of multi-disciplinary actions such as: enhanced hygiene measures, microbiological and molecular analysis of patients and environmental E. cloacae complex strains, and simulation-based teaching. All 23 E. cloacae complex strains isolated from patients and environment samples belonged to multi-locus sequence type ST78 and carried bla-VIM4 gene. Using Fourier transform infrared spectroscopy, all but two isolates were also found to belong to a single cluster. Although the source of this outbreak could not be pinpointed, the spread of the strain was controlled thanks to this multi-focal approach and multi-disciplinary implementation. Conclusion This investigation highlighted the usefulness of Fourier transform infra-red spectroscopy in the rapid typing of outbreak strains as well as the importance of an integrated approach to successfully fight against multidrug-resistant micro-organism dissemination and healthcare-associated infections.
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Affiliation(s)
- C Mullié
- Laboratoire Hygiène Risque Biologique & Environnement, CHU Amiens Picardie, Amiens, France; Laboratoire AGIR UR UPJV 4294, Université de Picardie Jules Verne, Amiens, France.
| | - D Lemonnier
- Unité d'Hygiène et d'Epidémiologie Hospitalière, CHU Amiens Picardie, Amiens, France.
| | - C C Adjidé
- Laboratoire Hygiène Risque Biologique & Environnement, CHU Amiens Picardie, Amiens, France
| | - J Maizel
- Service de Médecine Intensive et Réanimation, CHU Amiens Picardie, Amiens, France
| | - G Mismacque
- Unité d'Hygiène et d'Epidémiologie Hospitalière, CHU Amiens Picardie, Amiens, France
| | - A Cappe
- Département de Pharmacie Clinique, CHU Amiens Picardie, Amiens, France
| | - T Carles
- Département de Pharmacie Clinique, CHU Amiens Picardie, Amiens, France
| | - M Pierson-Marchandise
- Service Prévention, Evaluations, Vigilances et Amélioration des Pratiques, CHU Amiens Picardie, Amiens, France
| | - Y Zerbib
- Service de Médecine Intensive et Réanimation, CHU Amiens Picardie, Amiens, France
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Carriage of Multidrug-Resistant Bacteria in Healthy People: Recognition of Several Risk Groups. Antibiotics (Basel) 2021; 10:antibiotics10101163. [PMID: 34680744 PMCID: PMC8533013 DOI: 10.3390/antibiotics10101163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/08/2021] [Accepted: 09/21/2021] [Indexed: 12/16/2022] Open
Abstract
The increase in multidrug-resistant (MDR) bacteria in hospitalized people and the hospital environment has been thoroughly documented. In contrast, little is known about their presence in the community. However, increasing evidence is showing a high level of carriage in people without infectious signs. Colonized people can later develop infections due to MDR bacteria and may be able to transmit them to susceptible people (the number of which is increasing worldwide), for example, people with comorbidities such as diabetes, cancer, or inflammatory diseases and those in extreme age groups. Risk factors for the acquisition of MDR bacteria are as follows: (1) residence or travel in countries with high levels of MDR bacteria; (2) occupational risks such as health workers or people with close contact with animals (farmers, veterinarians) who frequently use antibiotics; and (3) comorbidities. Eradication is rather difficult and, thus far, has not shown clear-cut results. Preventive measures will be important in the future with a reinforcement of hygienic measures not only in the hospital, but also in the community.
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Tkadlec J, Kalova A, Brajerova M, Gelbicova T, Karpiskova R, Smelikova E, Nyc O, Drevinek P, Krutova M. The Intestinal Carriage of Plasmid-Mediated Colistin-Resistant Enterobacteriaceae in Tertiary Care Settings. Antibiotics (Basel) 2021; 10:258. [PMID: 33806455 PMCID: PMC8002115 DOI: 10.3390/antibiotics10030258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 12/13/2022] Open
Abstract
Background: In order to estimate the prevalence of plasmid borne colistin resistance and to characterize in detail the mcr-positive isolates, we carried out a sentinel testing survey on the intestinal carriage of plasmid-mediated colistin-resistant Enterobacteriaceae in hospitalized patients. Methods: Between June 2018 and September 2019, 1922 faecal samples from hospitalised patients were analysed by selective culture in presence of colistin (3.5 mg/L), and in parallel by direct detection of the mcr-1 to mcr-8 genes by qPCR. The mcr-positive isolates were characterised by whole-genome sequencing. Results: The prevalence of the mcr-1 gene was 0.21% (n = 4/1922); the mcr-2 to 8 genes were not detected. The mcr-1 gene was found to be localised in the IncX4 (n = 3) and IncHI2 (n = 1) plasmid type. One Escherichia coli isolate was susceptible to colistin due to the inactivation of the mcr-1 gene through the insertion of the IS2 element; however, the colistin resistance was inducible by culture in low concentrations of colistin. One human mcr-1 positive E. coli isolate was related genetically to the mcr-1 E. coli isolate derived from turkey meat of Czech origin. Conclusions:mcr-mediated colistin resistance currently poses little threat to patients hospitalised in Czech healthcare settings. The presence of the mcr-1 gene in the human population has a possible link to domestically produced, retail meat.
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Affiliation(s)
- Jan Tkadlec
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University, 150 06 Prague, Czech Republic; (M.B.); (E.S.); (O.N.); (P.D.); (M.K.)
- Department of Medical Microbiology, Motol University Hospital, 150 06 Prague, Czech Republic
| | - Alzbeta Kalova
- Department of Microbiology and Antimicrobial Resistance, Veterinary Research Institute, 621 00 Brno, Czech Republic; (T.G.); (R.K.); (A.K.)
- Department of Experimental Biology, Faculty of Science, Masaryk University, 611 37 Brno, Czech Republic
| | - Marie Brajerova
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University, 150 06 Prague, Czech Republic; (M.B.); (E.S.); (O.N.); (P.D.); (M.K.)
- Department of Medical Microbiology, Motol University Hospital, 150 06 Prague, Czech Republic
| | - Tereza Gelbicova
- Department of Microbiology and Antimicrobial Resistance, Veterinary Research Institute, 621 00 Brno, Czech Republic; (T.G.); (R.K.); (A.K.)
| | - Renata Karpiskova
- Department of Microbiology and Antimicrobial Resistance, Veterinary Research Institute, 621 00 Brno, Czech Republic; (T.G.); (R.K.); (A.K.)
| | - Eva Smelikova
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University, 150 06 Prague, Czech Republic; (M.B.); (E.S.); (O.N.); (P.D.); (M.K.)
- Department of Medical Microbiology, Motol University Hospital, 150 06 Prague, Czech Republic
| | - Otakar Nyc
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University, 150 06 Prague, Czech Republic; (M.B.); (E.S.); (O.N.); (P.D.); (M.K.)
- Department of Medical Microbiology, Motol University Hospital, 150 06 Prague, Czech Republic
| | - Pavel Drevinek
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University, 150 06 Prague, Czech Republic; (M.B.); (E.S.); (O.N.); (P.D.); (M.K.)
- Department of Medical Microbiology, Motol University Hospital, 150 06 Prague, Czech Republic
| | - Marcela Krutova
- Department of Medical Microbiology, 2nd Faculty of Medicine, Charles University, 150 06 Prague, Czech Republic; (M.B.); (E.S.); (O.N.); (P.D.); (M.K.)
- Department of Medical Microbiology, Motol University Hospital, 150 06 Prague, Czech Republic
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