Prevalence and risk factors for colonisation and infection with carbapenem-resistant Enterobacterales in intensive care units: A prospective multicentre study

Risk factors and molecular epidemiology of colonizing carbapenem-resistant Enterobacterales in pediatric inpatient in Shenzhen, China

OBJECTIVES

The spread of CRE has been rapid on a global scale and represents a significant challenge in nosocomial infections worldwide. The aim is to evaluate the risk factors for CRE colonization and to describe the molecular and clinical characteristics of CRE colonization in pediatric inpatients in Shenzhen, China.

METHODS

We collected stool specimens from 2474 randomly selected pediatric inpatient hospitalized in 2 pediatric hospitals in Shenzhen between January 2023 and December 2023 for subsequent microbiological analysis, including microbial culture, species identification, antimicrobial sensitivity testing, genetic characterization and multilocus sequence typing (MLST). In addition, we conducted a case-control study to identify potential risk factors for gastrointestinal CRE colonization.

RESULTS

Of the 2474 non-replicating pediatric stool specimens collected, 3.6 % (n = 90) test positive for CRE. The most dominant CRE species were Escherichia coli (n = 67, 74.5 %), and Klebsiella pneumoniae (n = 17, 19.0 %). Multidrug resistance and carbapenemase production were observed in most CRE isolates. In CR E. coli and CR K. pneumoniae, the blaNDM was the predominant resistance gene, accounting for 95.5 % and 76.5 %, respectively. MLST showed considerable clonal diversity among the CR E. coli and CR K. pneumoniae isolates and the most common ST in CR E. coli was ST48 (n = 6, 9.0 %) and ST35 in CR K. pneumoniae (n = 4, 23.5 %).

CONCLUSIONS

This study once again shows that pediatric inpatients in South China were colonized by a diversity of CRE strains, increasing the likelihood of difficult-to-treat infections. Hospitals and competent authorities should take appropriate public health measures, to prevent the further spread of CRE.

Phenotypic and genomic changes in enteric Klebsiella populations during long-term ICU patient hospitalization: the role of RamR regulation

Acquired antimicrobial resistance and metabolic changes are central for bacterial host adaptation during the long-term hospitalization of patients. We aimed to analyze the genomic and phenotypic evolution of enteric Klebsiella populations in long-term intensive care unit (ICU) patients. Weekly rectal swabs were prospectively collected from all patients admitted to the ICU in a teaching hospital from December 2018 to February 2019. The inclusion criterion for patients was hospitalization for more than 15 days in the ICU without any history of hospitalization or antibiotic treatment for the 3 months prior to admission. Among them, enteric Klebsiella pneumoniae species complex (KpSC) populations were detected. For each isolate, extensive antimicrobial resistance profiles were determined using the disk diffusion method, and the whole genome was sequenced using an Illumina platform. In silico typing methods, such as Multilocus Sequence Typing (MLST), core-genome MLST, SNP typing, resistome characterization and mutation point detection, were applied. During the study period, 471 patients were admitted to ICUs. Among them, 21 patients met the inclusion criteria, and only 5 patients (24%) carried unique and distinct KpSC populations during 2-10 weeks in the gut that as detected at admission and excluding acquisition during the ICU stay. One patient showed a rare ST1563 K. variicola persistent carriage for 7 consecutive weeks, which displayed important antimicrobial resistance phenotype changes in the 2 last weeks. In-depth in silico characterization and RNA sequencing of these strains revealed a mutation within the ramR transcriptional regulator resulting in overexpression of the ramA regulator and decreased expression of acrR, which controls antibiotic efflux. This mutation also impacts tolerance to biliary salts. This study revealed the importance of endogenous colonization of KpSC populations in the gut throughout the patient's long-term ICU stay and highlighted the role of ramR in drug susceptibility.

IMPORTANCE

The Klebsiella pneumoniae species complex (KpSC) is one of the major causes of nosocomial infections, especially in intensive care unit (ICUs). These bacteria are frequently highly resistant to antibiotics, leading to an increase in morbidity and mortality. The origins of multidrug-resistant KpSC strains isolated from ICU patients are still unclear, with at least two hypotheses of acquisition paths: (i) endogenous KpSC populations that are or became resistant to antibiotics and/or (ii) hospital acquisition of circulating KpSC clones. Genomic changes observed in this study might reveal mechanisms to better adapt to KpSC in the patient's gut in the face of heavy ICU medical care pressure.

Kotter's 8-step change model to improve hand hygiene compliance in intensive care unit: A 41-month prospective longitudinal quality improvement study

BACKGROUND

Despite numerous studies assessing bundled interventions to enhance hand hygiene compliance (HHC), compliance rates persist at suboptimal levels. Our objective was to employ Kotter's Change Model (KCM) to enhance HHC and conduct a comprehensive process evaluation among medical staff within the intensive care unit (ICU).

METHODS

KCM was implemented at the ICU of Zhongnan Hospital of Wuhan University from March 2018 to August 2021, with a 41-month longitudinal monitoring of HHC. The primary outcome focused on the absolute monthly change in HHC. Secondary outcomes encompassed the HHC characteristics across different phases, varying trends in HHC concerning different hand hygiene opportunities and occupations, quarterly incidences of central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI).

RESULTS

This study included 20,222 hand hygiene actions and 24,195 opportunities. The overall HHC was 83.58 % (95 %CI, 83.11 %-84.04 %). Following the KCM implementation, HHC surged from 35.71 % (95 % CI, 22.99 %-50.83 %) to 87.75 % (95 % CI, 85.53 %-89.67 %), reflecting a notable increase of 145.73 %. The most rapid growth in HHC occurred post-patient contact, elevating from 35.29 % to 89.8 %. Despite escalating patient numbers and treatment complexities annually, the quarterly rates of CLABSI (0 ‰-3.53 ‰) and CAUTI (0.96 ‰-4.26 ‰) remained consistently low.

CONCLUSION

Utilizing KCM systematically alters healthcare providers' perception of hand hygiene, fostering an environment that advocates for and sustains improved HHC among ICU personnel.

IMPLICATIONS FOR CLINICAL PRACTICE

The Kotter's change model can be an effective framework for healthcare organizations to systematically improve and maintain hand hygiene compliance among healthcare providers, which can in turn help reduce healthcare-associated infections.

Perioperative interventions for the prevention of surgical wound infection in adult patients undergoing left ventricular assist devices implantation: A scoping review

BACKGROUND

Surgical wound infection is the most frequent type of care health associated infection. Lack of knowledge about the prevention of surgical wound infection in patients undergoing left ventricular assist device implantation could significantly undermine the potential benefits of surgical intervention.

OBJECTIVES

This study aimed to map the recommendations for adult patients undergoing left ventricular assist device implantation.

DESIGN

This is a scoping review, being registered in the Open Science Framework under DOI https://doi.org/10.17605/OSF.IO/Q76B3 (https://osf.io/q76b3/).

METHOD

Left ventricular assist device coordinators and nurse specialists in dermatology and stomatherapy conducted a scoping review in Scopus, The Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), limited to the period between 2015 and 2022. The results of this scoping review will be discussed and presented in separate articles. This paper will synthesize research evidence on the perioperative topic.

RESULTS

The initial searches resulted in 771 studies. Sixty nine met the eligibility criteria and were included in the scoping review. Eight articles addressing the perioperative topic that answered the question of this article were included.

CONCLUSION

Although this scoping review included heterogeneous, and scarce studies with left ventricular assist device patients. As such, there are many promising future research directions for this topic.

IMPLICATIONS FOR CLINICAL PRACTICE

Infection surveillance should be an integral part of left ventricular assist device implantation programs in health care institutions. Velvet completely buried in subcutaneous tissues reduces transmission system infection. Triple tunnel method reduces transmission system infection risk.

Associated Risk Factors and Clinical Outcomes of Bloodstream Infections among COVID-19 Intensive Care Unit Patients in a Tertiary Care Hospital

Introduction

The COVID-19 infection is an ongoing public health crisis causing millions of deaths worldwide. COVID-19 patients admitted to the intensive care unit (ICU) are more vulnerable to acquire secondary bloodstream infections (sBSIs) which cause a significant morbidity and mortality. Thus, we aim to assess the risk factors of sBSIs and outcomes in COVID-19 ICU patients.

Methods

One hundred blood culture samples with growth (cases) and other 100 blood culture with no growth(controls) were collected.. All the demographic data, laboratory data and antimicrobial resistance pattern were analysed . Blood culture bottle received in the Microbiology laboratory were loaded into Automated blood culture system. Flagged bottles were processed for final identification by MALDI TOF and automated antibiotic susceptibility testing. Flagged bottles were processed for final identification by MALDI TOF and automated antibiotic susceptibility testing.

Results

Raised C-reactive protein (CRP) (P = 0.0035), interleukin-6 (P = 0.0404), mechanical ventilation (MV) (P = 0.024), prior antimicrobial exposure (P = 0.002), longer ICU stay with median 11 days (P = 0.022), and higher mortality rate (P = 0.001) were significantly associated with the BSI. A significant proportion of BSIs were Gram-negative bacteria (n = 115) such as Acinetobacter baumannii 38 (33%) and Klebsiella pneumoniae 30 (26%). Monomicrobial organisms in blood yielded a higher proportion in our study 72 (72%). The highest resistance for Acinetobacter species (50) was observed with ceftazidime 29 (96.6%) amikacin 48 (96%), meropenem 48 (96%), cefotaxime 47 (94%), ciprofloxacin 46 (92%), and netilmicin 46 (92%). K. pneumoniae was highly resistant to cefotaxime 29 (96.6%), ceftazidime 29 (96.6%), ciprofloxacin 22 (73.3%), and cefuroxime 21 (70%). Among Gram-positive organisms, Enterococcus species showed that a resistance for high-level gentamicin and penicillin was 66.6%.

Conclusions

Raised CRP, need of MV, prior antimicrobial exposure, and longer ICU stay should alarm clinicians for BSI. Hence, our study highlights the associated risk factors for BSI and emphasizes adherence to hospital infection control policies and antibiotic stewardship program.

Risk factors for surgical site infection following cardiac surgery in a region endemic for multidrug resistant organisms

OBJECTIVES

To identify risk factors for surgical site infections following cardiosurgery in an area endemic for multidrug resistant organisms.

DESIGN

Single-center, historical cohort study including patients who underwent cardiosurgery during a 6-year period (2014-2020).

SETTING

Joint Commission International accredited, multiorgan transplant center in Palermo, Italy.

MAIN OUTCOME MEASURES

Surgical site infection was the main outcome.

RESULTS

On a total of 3609 cardiosurgery patients, 184 developed surgical site infection (5.1 %). Intestinal colonization with multidrug resistant organisms was more frequent in patients with surgical site infections (69.6 % vs. 33.3 %; p < 0.001). About half of surgical site infections were caused by Gram-negative bacteria (n = 97; 52.7 %). Fifty surgical site infections were caused by multidrug resistant organisms (27.1 %), with extended-spectrum Beta-lactamase-producing Enterobacterales (n = 16; 8.7 %) and carbapenem-resistant Enterobacterales (n = 26; 14.1 %) being the predominant resistance problem. However, in only 24 of surgical site infections caused by multidrug resistant organisms (48 %), mostly carbapenem-resistant Enterobacterales (n = 22), a pathogen match between the rectal surveillance culture and surgical site infections clinical culture was demonstrated. Nevertheless, multivariate logistic regression analysis identified a rectal swab culture positive for multidrug resistant organisms as an independent risk factor for SSI (odds ratio 3.95, 95 % confidence interval 2.79-5.60). Other independent risk factors were female sex, chronic dialysis, diabetes mellitus, previous cardiosurgery, previous myocardial infarction, being overweight/obese, and longer intubation time.

CONCLUSION

In an area endemic for carbapenem-resistant Enterobacterales, intestinal colonization with multidrug resistant organisms was recognized as independent risk factor for surgical site infections.

IMPLICATIONS FOR CLINICAL PRACTICE

No causal relationship between colonization with resistant pathogens and subsequent infection could be demonstrated. However, from a broader epidemiological perspective, having a positive multidrug resistant organisms colonization status appeared a risk factor for surgical site infections. Therefore, strict infection control measures to prevent cross-transmission remain pivotal (e.g., nasal decolonization, hand hygiene, and skin antisepsis).

Integration of metagenome and metabolome analysis reveals the correlation of gut microbiota, oxidative stress, and inflammation in Coilia nasus under air exposure stress and salinity mitigation

Due to the strong response to air exposure, high mortality was occurred in Coilia nasus. Previous studies reported that 10 ‰ NaCl could significantly reduce mortality in C. nasus under air exposure. To investigate the mechanisms that 10 ‰ NaCl can alleviate stress, community structure and metabolism of the intestinal flora of C. nasus were detected via metagenome and metabolome. In this study, C. nasus were divided into control group (C), air exposure group without 10 ‰ NaCl (AE), and air exposure group with 10 ‰ NaCl (AES). After air exposure stress and salinity mitigation, the mortality, intestinal microorganisms, metabolites, and physiological biomarkers were analyzed. The results showed that the mortality rate of C. nasus was reduced after salinity reduction; the antioxidant capacity was elevated compared to the AE group; and anti-inflammatory capacity was increased in the AES group compared to the AE group. Metagenomic sequencing results showed that the levels of harmful bacteria (E. coli, Aeromonas) in the Candida nasus gut increased after air exposure; beneficial bacteria (Actinobacteria, Corynebacteria) in the C. nasus gut increased after salinity reduction. Metabolomics analyses showed that AE decreased the expression of beneficial metabolites and increased the expression of harmful metabolites; AES increased beneficial metabolites and decreased harmful metabolites. Correlation analysis showed that in the AE group, beneficial metabolites were negatively correlated with oxidative stress and inflammatory response, while harmful metabolites were positively correlated with oxidative stress and inflammatory response, and were associated with bacterial communities such as Gillisia, Alkalitalia, Avipoxvirus, etc.; the correlation of metabolites with oxidative stress and inflammatory response was opposite to that of AE in the case of AES, and was associated with Lentilactobacillus, Cyanobacterium, and other bacterial communities. Air exposure caused damage to Candida rhinoceros and 10 ‰ salinity was beneficial in alleviating C. nasus stress. These results will provide new insights into methods and mechanisms to mitigate stress in fish.

Prevalence of intestinal colonization and nosocomial infection with carbapenem-resistant Enterobacteriales in children: a retrospective study

Objective

We investigated the epidemiological surveillance of the intestinal colonization and nosocomial infection of carbapenem-resistant Enterobacteriales (CRE) isolates from inpatients, which can provide the basis for developing effective prevention.

Methods

A total of 96 CRE strains were collected from 1,487 fecal samples of hospitalized children between January 2016 and June 2017, which were defined as the "CRE colonization" group. In total, 70 CRE clinical isolates were also randomly selected for the comparison analysis and defined as the "CRE infection" group. The antimicrobial susceptibility of all strains was determined by the microdilution broth method. Polymerase chain reaction (PCR) was used to analyze carbapenemase genes, plasmid typing, and integrons. Multilocus sequence typing was further used to determine clonal relatedness.

Results

In the "CRE colonization" group, Klebsiella pneumoniae was mostly detected with a rate of 42.7% (41/96), followed by Escherichia coli (34.4%, 33/96) and Enterobacter cloacae (15.6%, 15/96). The ST11 KPC-2 producer, ST8 NDM-5 producer, and ST45 NDM-1 producer were commonly present in carbapenem-resistant K. pneumoniae (CRKPN), carbapenem-resistant E. coli (CRECO), and carbapenem-resistant E. cloacae (CRECL) isolates, respectively. In the "CRE infection" group, 70% (49/70) of strains were K. pneumoniae, with 21.4% E. cloacae (15/70) and 5.7% E. coli (4/70). The ST15 OXA-232 producer and ST48 NDM-5 producer were frequently observed in CRKPN isolates, while the majority of NDM-1-producing CRECL isolates were assigned as ST45. Phylogenetic analysis showed that partial CRE isolates from intestinal colonization and nosocomial infection were closely related, especially for ST11 KPC-2-producing CRKPN and ST45 NDM-1-producing CRECL. Furthermore, plasmid typing demonstrated that IncF and IncFIB were the most prevalent plasmids in KPC-2 producers, while IncX3/IncX2 and ColE were widely spread in NDM producer and OXA-232 producer, respectively. Then, class 1 integron intergrase intI1 was positive in 74.0% (71/96) of the "CRE colonization" group and 52.9% (37/70) of the "CRE infection" group.

Conclusion

This study revealed that CRE strains from intestinal colonization and nosocomial infection showed a partial correlation in the prevalence of CRE, especially for ST11 KPC-2-producing CRKPN and ST45 NDM-1-producing CRECL. Therefore, before admission, long-term active screening of rectal colonization of CRE isolates should be emphasized.