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Powell J, Beirne I, Minihan B, O’Connell NH, Sharma S, Dunworth M, Philip RK, Dunne CP. Neonatal bacteraemia in Ireland: A ten-year single-institution retrospective review. PLoS One 2024; 19:e0306855. [PMID: 39178209 PMCID: PMC11343407 DOI: 10.1371/journal.pone.0306855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 06/25/2024] [Indexed: 08/25/2024] Open
Abstract
Neonatal sepsis is a catastrophic condition of global concern, with reported mortality rates exceeding 10%. Bloodstream infections are an important cause of sepsis, and epidemiological studies of these infections are crucial for predicting the most common aetiological agents and antimicrobial susceptibility patterns and for developing antimicrobial guidelines. For the ten-year study period from July 2013 to June 2023, all neonatal bacteraemia cases were reviewed prospectively using an enhanced surveillance protocol. The patients were stratified according to their age at the time of blood culture collection: early onset if diagnosed in the first 72 hours of life, and late onset if diagnosed after that time. During the study period, 170 blood cultures were positive from 144 patients, of which 89 specimens from 64 patients represented the growth of significant pathogens. Coagulase-negative staphylococci (CoNS) were the most common pathogens identified (52%, 33/64), followed by Escherichia coli (14%, 9/64), Group B Streptococcus (GBS: 11%, 7/64) and Staphylococcus aureus (11%, 7/64). GBS was more commonly identified in early onset patients, while CoNS were predominantly associated with late onset. The presence of an intravascular catheter, maternal urinary tract infections and the receipt of total parenteral nutrition or transfused blood were identified as significant risk factors. The fatality rate was 8% (5/64). in summary, this study provides a detailed overview of the epidemiology of neonatal bacteraemia in a large teaching hospital in the Midwest of Ireland over a decade.
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Affiliation(s)
- James Powell
- Department of Microbiology, University Hospital Limerick, Limerick, Ireland
- School of Medicine and Centre for Interventions in Infection, Inflammation and Immunity (4i), University of Limerick, Limerick, Ireland
| | - Irene Beirne
- Department of Paediatrics, Division of Neonatology, University Maternity Hospital Limerick, Limerick, Ireland
| | - Brid Minihan
- Department of Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Nuala H. O’Connell
- Department of Microbiology, University Hospital Limerick, Limerick, Ireland
- School of Medicine and Centre for Interventions in Infection, Inflammation and Immunity (4i), University of Limerick, Limerick, Ireland
| | - Santosh Sharma
- School of Medicine and Centre for Interventions in Infection, Inflammation and Immunity (4i), University of Limerick, Limerick, Ireland
| | - Margo Dunworth
- Department of Paediatrics, Division of Neonatology, University Maternity Hospital Limerick, Limerick, Ireland
| | - Roy K. Philip
- Department of Paediatrics, Division of Neonatology, University Maternity Hospital Limerick, Limerick, Ireland
- University of Limerick School of Medicine, Limerick, Ireland
| | - Colum P. Dunne
- School of Medicine and Centre for Interventions in Infection, Inflammation and Immunity (4i), University of Limerick, Limerick, Ireland
- School of Pharmacy, Queen’s University Belfast, Belfast, Northern Ireland
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Powell J, Daly M, O'Connell NH, Dunne CP. Seek and you shall find: Yersinia enterocolitica in Ireland's drinking water. Ir J Med Sci 2024; 193:1885-1890. [PMID: 38381378 PMCID: PMC11294261 DOI: 10.1007/s11845-024-03641-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/14/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Three Yersinia species were identified from samples of drinking water from diverse geographic regions of Ireland. Conventional commercial biochemical identification systems classified them as Yersinia enterocolitica. Since this organism is the most common cause of bacterial gastroenteritis in some countries, further investigation was warranted. The aim of the study was to provide a microbial characterisation of three Yersinia species, to determine their pathogenicity, and to review the incidence rate of Yersinia enterocolitica detection in our region. METHODS Organism identification was performed using conventional commercial diagnostic systems MALDI-TOF, API 20E, API 50CHE, TREK Sensititre GNID and Vitek 2 GN, and whole genome sequencing (WGS) was performed. Historical data for detections was extracted from the lab system for 2008 to 2023. RESULTS All three isolates gave "good" identifications of Yersinia enterocolitica on conventional systems. Further analysis by WGS matched two of the isolates with recently described Yersinia proxima, and the third was a member of the non-pathogenic Yersinia enterocolitica clade 1Aa. DISCUSSION Our analysis of these three isolates deemed them to be Yersinia species not known currently to be pathogenic, but determining this necessitated the use of next-generation sequencing and advanced bioinformatics. Our work highlights the importance of having this technology available to public laboratories, either locally or in a national reference laboratory. The introduction of molecular technologies for the detection of Yersinia species may increase the rate of detections. Accurate identification of significant pathogens in environmental, public health and clinical microbiology laboratories is critically important for the protection of society.
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Affiliation(s)
- James Powell
- Department of Microbiology, University Hospital Limerick, Limerick, Ireland
- School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity (4I), University of Limerick, Limerick, Ireland
| | - Maureen Daly
- Department of Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Nuala H O'Connell
- Department of Microbiology, University Hospital Limerick, Limerick, Ireland
- School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity (4I), University of Limerick, Limerick, Ireland
| | - Colum P Dunne
- School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity (4I), University of Limerick, Limerick, Ireland.
- School of Medicine, University of Limerick, Limerick, Ireland.
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Kelly SA, O'Connell NH, Thompson TP, Dillon L, Wu J, Creevey C, Powell J, Gilmore BF, Dunne CP. A novel characterized multi-drug-resistant Pseudocitrobacter sp. isolated from a patient colonized while admitted to a tertiary teaching hospital. J Hosp Infect 2024; 145:193-202. [PMID: 38215945 DOI: 10.1016/j.jhin.2023.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Reports of nosocomial infections typically describe recognised microorganisms. Here, a novel bacterial species was isolated, based on rectal swab screening for carbapenemases post-admission, then phenotypically and genetically characterized. METHODS Sensititre, Vitek and API kits, MALDI and Illumina MiSeq were employed before profiles and phylogeny were compared with other related species. FINDINGS Determined to be a possible Enterobacterales, the isolate was found to have 99.7% 16s rRNA identity to Pseudocitrobacter corydidari; an Asian cockroach-associated species. Given the highly conserved/low variability of 16S rRNA genes in Enterobacterales, average nucleotide identity (ANI) analysis compared the new isolate's genome with those of 18 Enterobacteriaceae species, including confirmed species of Pseudocitrobacter and unnamed Pseudocitrobacter species in the SILVA database. Of these, Pseudocitrobactercorydidari had the highest ANI at 0.9562. The published genome of the only known isolate of P.corydidari does not include Antimicrobial Resistance Genes (ARGs), with exception of potential drug efflux transporters. In contrast, our clinical isolate bears recognised antimicrobial resistance genes, including Klebsiella pneumoniae carbapenemase. The associated genome suggests resistance to carbapenems, β-lactams, sulfonamides, fluoroquinolones, macrolides, aminoglycosides and cephalosporins. Phenotypic antimicrobial resistance was confirmed. CONCLUSION Evident variations in ARG profiles, human colonization and origin in a clinically relevant niche that is geographically, physically and chemically disparate lend credibility for divergent evolution or, less likely, parallel evolution with P. corydidari. Genome data for this new species have been submitted to GENBANK using the proposed nomenclature Pseudocitrobacter limerickensis. The patient was colonized, rather than infected, and did not require antimicrobial treatment.
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Affiliation(s)
- S A Kelly
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - N H O'Connell
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland; School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity, University of Limerick, Limerick, Ireland
| | - T P Thompson
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - L Dillon
- School of Biological Sciences, Queen's University Belfast, Belfast, UK
| | - J Wu
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - C Creevey
- School of Biological Sciences, Queen's University Belfast, Belfast, UK
| | - J Powell
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland; School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity, University of Limerick, Limerick, Ireland
| | - B F Gilmore
- School of Pharmacy, Queen's University Belfast, Belfast, UK
| | - C P Dunne
- School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity, University of Limerick, Limerick, Ireland.
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Powell J, Crowley CM, Minihan B, Imcha M, O’Connell NH, Philip RK, Dunne CP. The microbial pathology of maternal perinatal sepsis: A single-institution retrospective five-year review. PLoS One 2023; 18:e0295210. [PMID: 38150416 PMCID: PMC10752550 DOI: 10.1371/journal.pone.0295210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/16/2023] [Indexed: 12/29/2023] Open
Abstract
INTRODUCTION Greater than half of in-hospital maternal deaths are caused by sepsis, a condition that occurs when infection exceeds local tissue containment and results in organ dysfunction. Determining the source of infection can be challenging. Microbiological cultures of the uterine cavity are often difficult to obtain, so antimicrobial susceptibility results may not be available to guide treatment. The aim of this retrospective study was to assess the potential clinical value of microbiology samples used in the maternal "septic screen" of patients in an Irish maternity hospital. METHODS A review was completed of all maternal "septic screen" (i.e., high vaginal swabs, placenta swabs, blood cultures, throat swabs and urine samples) microbiology results from July 2016 to December 2021. RESULTS In the relevant period, 845 patients were subject to a "septic screen", of whom 430 also had a placental swab collected. These 430 patients comprise our study population. 2% of blood cultures yielded potential pathogens, compared with 37%, 33%, 9% and 7% respectively for placental swabs, high vaginal swabs, throat swabs and urine specimens. 95% of blood cultures were sterile, compared with 52%, 0%, 0% and 53% respectively for placental swabs, high vaginal swabs, throat swabs and urine specimens. CONCLUSION Of the five microbiological specimen types examined, placental swabs yielded the highest number of potential pathogens. Our results suggest that placental swabs are useful specimens for detecting potential pathogens from the uterine cavity, the most common source of perinatal infections.
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Affiliation(s)
- James Powell
- Department of Microbiology, University Hospital Limerick, Limerick, Ireland
- School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity (4i), University of Limerick, Limerick, Ireland
| | - Clare M. Crowley
- Department of Obstetrics and Gynaecology, University Maternity Hospital Limerick, Limerick, Ireland
| | - Brid Minihan
- Department of Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Mendinaro Imcha
- Department of Obstetrics and Gynaecology, University Maternity Hospital Limerick, Limerick, Ireland
| | - Nuala H. O’Connell
- Department of Microbiology, University Hospital Limerick, Limerick, Ireland
- School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity (4i), University of Limerick, Limerick, Ireland
| | - Roy K. Philip
- Division of Neonatology, Department of Paediatrics, University Maternity Hospital Limerick, Limerick, Ireland
- University of Limerick School of Medicine, Limerick, Ireland
| | - Colum P. Dunne
- School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity (4i), University of Limerick, Limerick, Ireland
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Domegan L, Brehony C, Fitzpatrick F, O'Connell K, Dinesh B, Cafferkey J, Burns K. Social network and genomic analysis of an OXA-48 carbapenemase-producing Enterobacterales hospital ward outbreak in Ireland, 2018-2019. Infect Prev Pract 2023; 5:100282. [PMID: 37168234 PMCID: PMC10164899 DOI: 10.1016/j.infpip.2023.100282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/28/2023] [Indexed: 05/13/2023] Open
Abstract
Background Nosocomial transmission and outbreaks of carbapenemase-producing Enterobacterales (CPE) represent a challenge to healthcare systems. In July 2018, a CPE hospital ward outbreak was declared. Our aim was to investigate transmission patterns, using social network analysis and genomics in a nosocomial CPE outbreak. Methods A retrospective descriptive analysis of all patients (cases and contacts) admitted to a ward experiencing a CPE outbreak (2018-2019) was undertaken. A case had a negative CPE admission screen, and subsequent positive test. A contact shared a multi-bed area and/or facility with a case (>4 hours). Social networks, including genomics data and ward locations, were constructed. Network metrics were analysed. Findings Forty-five cases and 844 contacts were analysed. The median age of cases was 78 years (IQR 67-83), 58% (n=26) were male and 100% had co-morbidities. The median outbreak ward length-of-stay (LOS) was 17 days (IQR 10-34). OXA-48 CPE was confirmed in all cases and from 26 environmental samples. Social networks identified clusters by time, gender and species/sequence type/plasmid. Network metrics indicated potential superspreading involving a subset of patients with behavioural issues. Conclusion Social networks elucidated high resolution transmission patterns involving two related OXA-48 plasmids, multiple species/genotypes and potential super-spreading. Interventions prevented intra-hospital spread. An older patient cohort, extended hospital LOS and frequent intra-ward bed transfers, coupled with suboptimal ward infrastructure, likely prolonged this outbreak. We recommend social network analysis contemporaneously with genomics (on case and environmental samples) for complex nosocomial outbreaks and bespoke care plans for patients with behavioural issues on outbreak wards.
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Affiliation(s)
- Lisa Domegan
- Health Service Executive, Health Protection Surveillance Centre, Dublin, Ireland
- European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control, (ECDC), Stockholm, Sweden
- Corresponding author. Address: Health Service Executive, Health Protection Surveillance Centre, Dublin, Ireland.
| | - Carina Brehony
- Health Service Executive, Health Protection Surveillance Centre, Dublin, Ireland
- European Public Health Microbiology Training (EUPHEM), European Centre for Disease Prevention and Control, (ECDC), Stockholm, Sweden
| | - Fidelma Fitzpatrick
- Department of Clinical Microbiology, Infection Prevention & Control, Beaumont Hospital, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland
| | - Karina O'Connell
- Department of Clinical Microbiology, Infection Prevention & Control, Beaumont Hospital, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland
| | - Binu Dinesh
- Department of Clinical Microbiology, Infection Prevention & Control, Beaumont Hospital, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland
| | - Jacqueline Cafferkey
- Department of Clinical Microbiology, Infection Prevention & Control, Beaumont Hospital, Dublin, Ireland
| | - Karen Burns
- Department of Clinical Microbiology, Infection Prevention & Control, Beaumont Hospital, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland
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Daly M, Powell J, O'Connell NH, Murphy L, Dunne CP. Antimicrobial Resistance Is Prevalent in E. coli and Other Enterobacterales Isolated from Public and Private Drinking Water Supplies in the Republic of Ireland. Microorganisms 2023; 11:1224. [PMID: 37317198 DOI: 10.3390/microorganisms11051224] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 06/16/2023] Open
Abstract
High levels of bacterial antimicrobial resistance (AMR) have been reported in many environmental studies conducted in Ireland and elsewhere. The inappropriate use of antibiotics in both human and animal healthcare as well as concentrations of residual antibiotics being released into the environment from wastewaters are thought to be contributing factors. Few reports of AMR in drinking water-associated microbes are available for Ireland or internationally. We analysed 201 enterobacterales from group water schemes and public and private water supplies, only the latter having been surveyed in Ireland previously. The organisms were identified using conventional or molecular techniques. Antimicrobial susceptibility testing for a range of antibiotics was performed using the ARIS 2X interpreted in accordance with EUCAST guidelines. A total of 53 Escherichia coli isolates, 37 Serratia species, 32 Enterobacter species and enterobacterales from seven other genera were identified. A total of 55% of isolates were amoxicillin resistant, and 22% were amoxicillin-clavulanic acid resistant. A lower level of resistance (<10%) was observed to aztreonam, chloramphenicol, ciprofloxacin, gentamicin, ceftriaxone and trimethoprim-sulfamethoxazole. No resistance to amikacin, piperacillin/tazobactam, ertapenem or meropenem was detected. The level of AMR detected in this study was low but not insignificant and justifies ongoing surveillance of drinking water as a potential source of antimicrobial resistance.
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Affiliation(s)
- Maureen Daly
- Department of Clinical Microbiology, University Hospital Limerick, V94 F858 Limerick, Ireland
- Biomedical Sciences Research Institute, University of Ulster, Coleraine BT52 1SA, UK
| | - James Powell
- Department of Clinical Microbiology, University Hospital Limerick, V94 F858 Limerick, Ireland
- Centre for Interventions in Infection, Inflammation & Immunity (4i), School of Medicine, University of Limerick, V94 T9PX Limerick, Ireland
| | - Nuala H O'Connell
- Department of Clinical Microbiology, University Hospital Limerick, V94 F858 Limerick, Ireland
- Centre for Interventions in Infection, Inflammation & Immunity (4i), School of Medicine, University of Limerick, V94 T9PX Limerick, Ireland
| | - Liz Murphy
- Public Health Laboratory, Raheen Business Park, V94 H9YE Limerick, Ireland
| | - Colum P Dunne
- Centre for Interventions in Infection, Inflammation & Immunity (4i), School of Medicine, University of Limerick, V94 T9PX Limerick, Ireland
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O'Connell NH, Mulchrone C, Lynskey M, Heffernan SC, O'Brien B, Powell J, Dunne CP. Off-label novel application of diagnostic multiplex molecular platforms for environmental detection of carbapenemase-producing Enterobacterales. J Hosp Infect 2023; 133:103-104. [PMID: 36565932 DOI: 10.1016/j.jhin.2022.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Affiliation(s)
- N H O'Connell
- Department of Clinical Microbiology, University Limerick Hospital Group, Limerick, Ireland; Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland; School of Medicine, University of Limerick, Limerick, Ireland.
| | - C Mulchrone
- Department of Clinical Microbiology, University Limerick Hospital Group, Limerick, Ireland
| | - M Lynskey
- Department of Clinical Microbiology, University Limerick Hospital Group, Limerick, Ireland
| | - S C Heffernan
- Department of Clinical Microbiology, University Limerick Hospital Group, Limerick, Ireland
| | - B O'Brien
- Department of Infection Prevention and Control, University Limerick Hospital Group, Limerick, Ireland
| | - J Powell
- Department of Clinical Microbiology, University Limerick Hospital Group, Limerick, Ireland; Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - C P Dunne
- Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland; School of Medicine, University of Limerick, Limerick, Ireland
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Powell J, Porter E, Rafferty S, Field S, O'Connell NH, Dunne CP. Dermatology mycology diagnostics in Ireland: National deficits identified in 2022 that are relevant internationally. Mycoses 2023; 66:249-257. [PMID: 36448403 PMCID: PMC10107536 DOI: 10.1111/myc.13549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Conventional testing methods for dermatophytes are time-consuming, and resource limitations in our institution have prompted curtailed access to these diagnostics. OBJECTIVES Evaluation of our hospital's dermatological mycology diagnostic services and similar services nationally. METHODS This was a retrospective observational study on skin, hair and nail mycology samples in our institution comparing twenty five-year periods (2011-2015 and 2016-2021), including analysis of dermatology clinic data and correspondence related to fungal infection. A survey of national public hospitals' laboratories was conducted to evaluate their mycology testing capabilities. RESULTS The total 5 year test count prior to curtailment was 4851 specimens comprising 90% (n = 4344) from general practice and 6% (n = 290) from dermatology clinics. For the 5 years post curtailment, 64.5% (582/903) of specimens were from dermatology clinics. Dermatology clinic data demonstrated doubling of attendances (for all conditions) and of correspondence related to fungal infection. During this time also, national dermatological antifungal purchasing increased 11%. Ten of 28 Irish public hospital laboratories reported the provision of in-house dermatological mycology testing, and none had routine availability of susceptibility or molecular testing of dermatophytes. CONCLUSION This study is the first to report an appraisal of dermatological fungal diagnostic services in Ireland. Insufficient testing capacity implies that patients are either being treated for fungal infection without appropriate diagnostic confirmation, or being left untreated because of the lack of access to diagnostics. The introduction of molecular detection methods and susceptibility systems would enhance testing capabilities and reduce the requirement for the external referral.
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Affiliation(s)
- James Powell
- Department of Microbiology, University Hospital Limerick, Limerick, Ireland.,School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity (4i), University of Limerick, Limerick, Ireland
| | - Emma Porter
- Department of Dermatology, University Hospital Limerick, Limerick, Ireland
| | - Siobhan Rafferty
- Department of Dermatology, University Hospital Limerick, Limerick, Ireland
| | - Sinead Field
- Department of Dermatology, University Hospital Limerick, Limerick, Ireland
| | - Nuala H O'Connell
- Department of Microbiology, University Hospital Limerick, Limerick, Ireland.,School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity (4i), University of Limerick, Limerick, Ireland
| | - Colum P Dunne
- School of Medicine and Centre for Interventions in Infection, Inflammation, and Immunity (4i), University of Limerick, Limerick, Ireland
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O'Connell N, Gasior S, Slevin B, Power L, Barrett S, Bhutta S, Minihan B, Powell J, Dunne C. Microbial epidemiology and clinical risk factors of carbapenemase-producing Enterobacterales amongst Irish patients from first detection in 2009 until 2020. Infect Prev Pract 2022; 4:100230. [PMID: 35935263 PMCID: PMC9352914 DOI: 10.1016/j.infpip.2022.100230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background Carbapenemase producing Enterobacterales (CPE) are major public health threats. Aim To review microbial epidemiology of CPE, as well as clinical risk factors and infections, amongst CPE positive patients over 12 years in an Irish tertiary hospital. Methods Retrospective observational study of data extracted from a laboratory CPE database, electronic healthcare records and manual review of patient charts. Common risk factors, treatment regimens for all CPE related infections, and clinical outcomes were ascertained. Findings Among CPE strains isolated from 460 patients, Klebsiella pneumoniae carbapenemase (KPC) was the carbapenemase most frequently detected, accounting for 87.4% (459) of all CPE enzymes. Citrobacter species 177 (33.7%) were the most common species harbouring this enzyme. 428 CPE positive patients (93%) were identified in the acute hospital setting; the most common risk factor for CPE acquisition was history of hospitalisation, observed in 305 (66%) cases. Thirty patients (6.5%) had confirmed infections post-acquisition, of which four were bloodstream infections. There were 19 subsequent episodes of non CPE-related bacteraemia in this cohort. All causal mortality at 30 days was 41 patients (8.9%). However, clinical review determined that CPE was an indirect associative factor in 8 patient deaths. Conclusions In this tertiary hospital setting, microbial epidemiology is changing; with both OXA-48 enzymes and KPC-producing Citrobacter species becoming more prevalent. Whilst the burden of CPE related infections, especially bacteraemia, was low over the study period, it remains critical that basic infection prevention and control practices are adhered to lest the observed changes in epidemiology result in an increase in clinical manifestations.
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Affiliation(s)
- N.H. O'Connell
- Department of Clinical Microbiology University Limerick Hospital Group (ULHG), Limerick, Ireland
- Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
| | - S. Gasior
- School of Medicine, University of Limerick, Limerick, Ireland
| | - B. Slevin
- Department of Infection Prevention and Control, ULHG, Limerick, Ireland
| | - L. Power
- Department of Clinical Microbiology University Limerick Hospital Group (ULHG), Limerick, Ireland
| | - S. Barrett
- Department of Pharmacy, ULHG, Limerick, Ireland
| | - S.I. Bhutta
- Department of Gastroenterology, ULHG, Limerick, Ireland
| | - B. Minihan
- Department of Clinical Microbiology University Limerick Hospital Group (ULHG), Limerick, Ireland
| | - J. Powell
- Department of Clinical Microbiology University Limerick Hospital Group (ULHG), Limerick, Ireland
- Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - C.P. Dunne
- Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
- Corresponding author. Address: Foundation Chair and Director of Research, School of Medicine, University of Limerick, Ireland. Tel.: +35361234703.
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Minihan B, McAuliffe E, Powell J, Wong SL, Wilkie K, Murphy C, Maher A, Power L, O'Connell NH, Dunne CP. Association between tocilizumab treatment of hyperinflammatory patients with COVID-19 in a critical care setting and elevated incidence of hospital-acquired bacterial and invasive fungal infections. J Hosp Infect 2022; 126:29-36. [PMID: 35472487 PMCID: PMC9033628 DOI: 10.1016/j.jhin.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 12/29/2022]
Abstract
Background Tocilizumab is an interleukin-6 inhibitor that reduces mortality and the need for invasive mechanical ventilation, while increasing the possibility of successful hospital discharge for hyperinflammatory patients with severe coronavirus disease 2019 (COVID-19). No increase in adverse events or serious infections has been reported previously. Aim To describe the characteristics and outcomes of patients with severe COVID-19 in critical care who received tocilizumab, and to compare mortality and length of hospital stay for patients who received tocilizumab (N=41) with those who did not (N=33). Methods Retrospective review of data related to patients with COVID-19 who received tocilizumab in a critical care setting from 1st January to 31st December 2021. Findings Amongst COVID-19 survivors, those who had received tocilizumab had longer intensive care unit (ICU) stays (median length 21 vs 9 days) and hospital stays (45 vs 34 days) compared with those who had not received tocilizumab. Thirty-day mortality (29% vs 36%; P=0.5196) and 60-day mortality (37% and 42%; P=0.6138) were not significantly lower in patients who received tocilizumab. Serious bacterial and fungal infections occurred at higher frequency amongst patients who received tocilizumab [odds ratio (OR) 2.67, 95% confidence interval (CI) 1.04–6.86; P=0.042], and at significantly higher frequency than in non-COVID-19 ICU admissions (OR 5.26, 95% CI 3.08–9.00; P<0.0001). Conclusions In this single-centre study, patients in critical care with severe COVID-19 who received tocilizumab had a greater number of serious bacterial and fungal infections, but this may not have been a direct effect of tocilizumab treatment.
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Affiliation(s)
- B Minihan
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - E McAuliffe
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - J Powell
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - S L Wong
- Department of Anaesthesia and Critical Care, University Hospital Limerick, Limerick, Ireland
| | - K Wilkie
- Department of Anaesthesia and Critical Care, University Hospital Limerick, Limerick, Ireland
| | - C Murphy
- Department of Anaesthesia and Critical Care, University Hospital Limerick, Limerick, Ireland
| | - A Maher
- Department of Pharmacy, University Hospital Limerick, Limerick, Ireland
| | - L Power
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - N H O'Connell
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland; Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland; School of Medicine, University of Limerick, Limerick, Ireland
| | - C P Dunne
- Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland; School of Medicine, University of Limerick, Limerick, Ireland.
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11
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Humphreys H, Cormican M, Brennan W, Burns K, O'Donovan D, Dalchan T, Keane S, Sheahan A. Reflections on a national public health emergency response to carbapenemase-producing Enterobacterale s (CPE). Epidemiol Infect 2022; 150:1-19. [PMID: 35300746 PMCID: PMC9006571 DOI: 10.1017/s0950268822000218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/31/2022] [Accepted: 01/31/2022] [Indexed: 11/20/2022] Open
Abstract
Carbapenemase-producing Enterobacterales (CPE) are important globally. In 2017, Ireland declared a national public health emergency to address CPE in acute hospitals. A National Public Health Emergency Team and an expert advisory group (EAG) were established. The EAG has identified key learnings to inform future strategies. First, there is still an opportunity to prevent CPE becoming endemic. Second, damp environmental reservoirs in hospitals are inadequately controlled. Third, antibiotic stewardship remains important in control. Finally, there is no current requirement to extend screening to detect CPE outside of acute hospitals. These conclusions and their implications may also be relevant in other countries.
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Affiliation(s)
- Hilary Humphreys
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Martin Cormican
- Antimicrobial Resistance and Infection Control Team, Health Service Executive, Dublin, Ireland
- Department of Bacteriology, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Wendy Brennan
- Carbapenemase-producing Enterobacterales Reference Laboratory, Galway University Hospital, Galway, Ireland
| | - Karen Burns
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Microbiology, Beaumont Hospital, Dublin, Ireland
| | - Diarmuid O'Donovan
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Therese Dalchan
- Antimicrobial Resistance and Infection Control Team, Health Service Executive, Dublin, Ireland
| | - Shirley Keane
- Antimicrobial Resistance and Infection Control Team, Health Service Executive, Dublin, Ireland
| | - Anne Sheahan
- Antimicrobial Resistance and Infection Control Team, Health Service Executive, Dublin, Ireland
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12
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Dadashi M, Sameni F, Bostanshirin N, Yaslianifard S, Khosravi-Dehaghi N, Nasiri MJ, Goudarzi M, Hashemi A, Hajikhani B. Global Prevalence and Molecular Epidemiology of mcr-Mediated Colistin Resistance in Escherichia coli Clinical Isolates: A Systematic Review. J Glob Antimicrob Resist 2021; 29:444-461. [PMID: 34788692 DOI: 10.1016/j.jgar.2021.10.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/10/2021] [Accepted: 10/25/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND AND AIM The continuing rise in infections caused by multi-drug resistant (MDR) bacteria is one of the most serious public health issues in today's societies. Colistin is a last-resort antimicrobial medication used to treat infections caused by MDR gram-negative bacteria; therefore resistance to this antibiotic is extremely hazardous. The current study aimed to evaluate the global prevalence and distribution of colistin resistance genes among human clinical isolates of Escherichia coli (E. coli) as a systematic review. METHODS PubMed, Embase, and Web of Science databases were systematically searched. For further evaluation, all original English-language articles that demonstrated colistin resistance in E. coli clinical isolates published between 2000 and 2020 were examined. RESULTS Out of 4857 initial articles, after various stages of review and evaluation, 190 related articles were selected. More than 79 % of the publications selected in this research were published from 2014 to 2020. In Asia, Europe, America, Africa, and Oceania, the prevalence of mobilized colistin resistance (mcr) producing colistin-resistant E. coli was 66.72%, 25.48%, 5.19%, 2.27%, and 0.32 %, respectively. CONCLUSION The recent widespread spreading of E. coli strains harboring mcr conferring colistin resistance, especially in Asia and Europe, is concerning and needs more attention.
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Affiliation(s)
- Masoud Dadashi
- Department of Microbiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran; Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Fatemeh Sameni
- Department of Microbiology, School of Medicine, Shahed University, Tehran, Iran
| | - Nazila Bostanshirin
- Department of Microbiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Somayeh Yaslianifard
- Department of Microbiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Nafiseh Khosravi-Dehaghi
- Department of Pharmacognosy, School of Pharmacy, Alborz University of Medical Sciences, Karaj, Iran; Evidence-Based Phytotherapy and Complementary Medicine Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Mohammad Javad Nasiri
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Goudarzi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Hashemi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bahareh Hajikhani
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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13
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Lüneberg K, Amábile-Cuevas CF, Mucito-Varela E, Martínez L, Salinas E, López-Vidal Y, Siebe C, Rosas I. Metallo-beta-lactamase-producing Escherichia coli in the sewage of Mexico City: where do they come from? Can J Microbiol 2021; 68:139-145. [PMID: 34662521 DOI: 10.1139/cjm-2021-0284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
While monitoring the presence of antibiotic resistance in municipal wastewater bacteria from Mexico City, five Escherichia coli isolates were found to be resistant to carbapenems, antibiotics of "last resort" used mostly in hospitals. Further analysis revealed that these carbapenem-resistant isolates carried the gene encoding a metallo-beta-lactamase, NDM-5. The gene was found to be beared by a large, ∼145 kb conjugative plasmid, which also carries putative genes encoding resistance to sulfonamides, trimethoprim, tetracycline, ciprofloxacin, and chloramphenicol (although no phenotypic chloramphenicol resistance was detected) and quaternary-ammonium compounds. The plasmid also carried gene mobility determinants, such as integron integrase and two transposases. In addition to the direct public health threat posed by the presence of such multi-resistant organisms in wastewater released into the environment and used for crop irrigation; it is particularly concerning that carbapenem-resistant E. coli is rather rare in Mexican hospitals (<1%), but was found in small, 100 mL samples of municipal wastewater. This suggests that these organisms are under-reported by clinical microbiology laboratories, underlining the usefulness of wastewater monitoring, or that there is an unknown source of such carbapenem-resistant organisms that are being dumped into the wastewater. The source of these bacteria must be assessed and controlled to prevent further spread of this multi-resistance plasmid among other environmental and clinical microorganisms.
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Affiliation(s)
- Kathia Lüneberg
- Laboratorio de Aerobiología, Centro de Ciencias de la Atmósfera, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | | | - Eduardo Mucito-Varela
- Programa de Inmunología Molecular Microbiana, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Leticia Martínez
- Laboratorio de Aerobiología, Centro de Ciencias de la Atmósfera, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Eva Salinas
- Laboratorio de Aerobiología, Centro de Ciencias de la Atmósfera, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Yolanda López-Vidal
- Programa de Inmunología Molecular Microbiana, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Christina Siebe
- Departamento de Ciencias Ambientales y del Suelo, Instituto de Geología, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Irma Rosas
- Laboratorio de Aerobiología, Centro de Ciencias de la Atmósfera, Universidad Nacional Autónoma de México, Mexico City, Mexico
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14
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Feng K, Jia N, Zhu P, Sy S, Liu Y, Dong D, Zhu S, Zhang J, Liu Y, Martins FS, Gong H, Lv Z, Yu M, Sy SKB, Zhu Y. Aztreonam/avibactam effect on pharmacodynamic indices for mutant selection of Escherichia coli and Klebsiella pneumoniae harbouring serine- and New Delhi metallo-β-lactamases. J Antimicrob Chemother 2021; 76:2875-2883. [PMID: 34383928 DOI: 10.1093/jac/dkab292] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/17/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Ceftazidime/avibactam is not active against MBL-producing bacteria. Combining ceftazidime/avibactam or avibactam with aztreonam can counter the resistance of MBL-producing Enterobacterales. The aim of this study was to evaluate whether the addition of avibactam could reduce or close the mutant selection window (MSW) of aztreonam in Escherichia coli and Klebsiella pneumoniae harbouring MBLs; MSW is a pharmacodynamic (PD) parameter for the selection of emergent resistant mutants. METHODS In vitro susceptibility of 19 clinical isolates to ceftazidime/avibactam, aztreonam alone, and in co-administration (aztreonam/ceftazidime/avibactam and aztreonam/avibactam) was determined, as well as the mutant prevention concentration (MPC). The fraction of time within 24 h that the free drug concentration was within the MSW (fTMSW) and the fraction of time that the free drug concentration was above the MPC (fT>MPC) in both plasma and epithelial lining fluid (ELF) were determined from simulations of 10 000 profiles. The joint PTA was used to derive a joint cumulative fraction of response (CFR). RESULTS All isolates were resistant to ceftazidime/avibactam or aztreonam. Combining aztreonam and avibactam or ceftazidime/avibactam resulted in synergistic bactericidal activities against all isolates. Synergism was primarily due to the aztreonam/avibactam combination. For aztreonam/avibactam dosing regimens evaluated in clinical trials, fT>MPC values were >90% and >80%, whereas fTMSW measures were <10% and <20% in plasma and ELF, respectively. The CFR was 100% for aztreonam/avibactam against the collection of clinical isolates. CONCLUSIONS Effective antimicrobial combination optimized the PD parameters measuring selection for emergent mutants by increasing fT>MPC and reducing fTMSW.
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Affiliation(s)
- Kun Feng
- School of Medicine and Pharmacy, Ocean University of China, Qingdao 266003, PR China
| | - Nan Jia
- Department of Laboratory Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266003, PR China
| | - Peijuan Zhu
- Department of Pharmacology, University of Pennsylvania, Philadelphia, PA, USA
| | - Serubbabel Sy
- Department of Chemical Engineering, University of Waterloo, Waterloo, Ontario, Canada
| | - Yanfei Liu
- Department of Laboratory Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266003, PR China
| | - Dandan Dong
- Department of Laboratory Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266003, PR China
| | - Shixing Zhu
- School of Medicine and Pharmacy, Ocean University of China, Qingdao 266003, PR China
| | - Jiayuan Zhang
- School of Medicine and Pharmacy, Ocean University of China, Qingdao 266003, PR China
| | - Yuwei Liu
- School of Medicine and Pharmacy, Ocean University of China, Qingdao 266003, PR China
| | | | - Hugh Gong
- Department of Statistics, Valparaiso University, Valparaiso, IN, USA
| | - Zhihua Lv
- School of Medicine and Pharmacy, Ocean University of China, Qingdao 266003, PR China.,Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, Qingdao 266003, PR China
| | - Mingming Yu
- School of Medicine and Pharmacy, Ocean University of China, Qingdao 266003, PR China.,Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, Qingdao 266003, PR China
| | - Sherwin K B Sy
- Department of Statistics, State University of Maringá, Maringá, Paraná, Brazil
| | - Yuanqi Zhu
- Department of Laboratory Medicine, the Affiliated Hospital of Qingdao University, Qingdao 266003, PR China
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15
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Arato V, Raso MM, Gasperini G, Berlanda Scorza F, Micoli F. Prophylaxis and Treatment against Klebsiella pneumoniae: Current Insights on This Emerging Anti-Microbial Resistant Global Threat. Int J Mol Sci 2021; 22:4042. [PMID: 33919847 PMCID: PMC8070759 DOI: 10.3390/ijms22084042] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 02/07/2023] Open
Abstract
Klebsiella pneumoniae (Kp) is an opportunistic pathogen and the leading cause of healthcare-associated infections, mostly affecting subjects with compromised immune systems or suffering from concurrent bacterial infections. However, the dramatic increase in hypervirulent strains and the emergence of new multidrug-resistant clones resulted in Kp occurrence among previously healthy people and in increased morbidity and mortality, including neonatal sepsis and death across low- and middle-income countries. As a consequence, carbapenem-resistant and extended spectrum β-lactamase-producing Kp have been prioritized as a critical anti-microbial resistance threat by the World Health Organization and this has renewed the interest of the scientific community in developing a vaccine as well as treatments alternative to the now ineffective antibiotics. Capsule polysaccharide is the most important virulence factor of Kp and plays major roles in the pathogenesis but its high variability (more than 100 different types have been reported) makes the identification of a universal treatment or prevention strategy very challenging. However, less variable virulence factors such as the O-Antigen, outer membrane proteins as fimbriae and siderophores might also be key players in the fight against Kp infections. Here, we review elements of the current status of the epidemiology and the molecular pathogenesis of Kp and explore specific bacterial antigens as potential targets for both prophylactic and therapeutic solutions.
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Affiliation(s)
| | | | | | | | - Francesca Micoli
- GSK Vaccines Institute for Global Health (GVGH) S.r.l., via Fiorentina 1, 53100 Siena, Italy; (V.A.); (M.M.R.); (G.G.); (F.B.S.)
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16
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Foley M, Duffy F, Skally M, McCormack F, Finn C, O'Connor M, Cafferkey J, Thomas T, Burns K, Fitzpatrick F, O'Connell K, Smyth EG, Humphreys H. Evolving epidemiology of carbapenemase-producing Enterobacterales: one hospital's infection prevention and control response over nine years. J Hosp Infect 2021; 112:61-68. [PMID: 33812939 DOI: 10.1016/j.jhin.2021.03.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/28/2021] [Accepted: 03/28/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Preventing carbapenemase-producing Enterobacterales (CPE) transmission is a significant challenge for hospital infection prevention and control teams (IPCTs). Control measures include screening at-risk patients, contact tracing, and the isolation of carriers with contact precautions. AIM The evolution of infection prevention and control measures was assessed in a tertiary acute care hospital with predominately multi-bedded patient accommodation, from 2011 to 2019 as cases of CPE increased. The implications for, and the response and actions of, the IPCT were also reviewed. METHODS CPE data collected prospectively from our laboratory, IPCT, and outbreak meeting records were reviewed to assess how the IPCT adapted to the changing epidemiology, from sporadic cases, to outbreaks and to localized endemic CPE. FINDINGS Of 178 cases, 152 (85%) were healthcare-associated and there was a marked increase in cases from 2017. The number of screening samples tested annually increased from 1190 in 2011 to 16,837 in 2019, and six outbreaks were documented, with larger outbreaks identified in later years. OXA-48 carbapenemase was detected in 88% of isolates and attendance at outbreak meetings alone accounted for 463.5 h of IPCT members, and related staff time. CONCLUSION Despite considerable efforts and time invested by the IPCT, the number of CPE cases is increasing year-on-year, with more outbreaks being reported in later years, albeit partly in response to increased screening requirements. Infrastructural deficits, the changing epidemiology of CPE, and national policy are major factors in the increasing number of cases.
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Affiliation(s)
- M Foley
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland
| | - F Duffy
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland
| | - M Skally
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland
| | - F McCormack
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland
| | - C Finn
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland
| | - M O'Connor
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland
| | - J Cafferkey
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland
| | - T Thomas
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - K Burns
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland; Health Protection Surveillance Centre, Dublin, Ireland
| | - F Fitzpatrick
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - K O'Connell
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - E G Smyth
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - H Humphreys
- Department of Microbiology and Infection Prevention and Control, Beaumont Hospital, Dublin, Ireland; Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland.
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17
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Teoh T, Powell J, Kelly J, McDonnell C, Whelan R, O'Connell N, Dunne C. Outcomes of point-of-care testing for influenza in the emergency department of a tertiary referral hospital in Ireland. J Hosp Infect 2021; 110:45-51. [DOI: 10.1016/j.jhin.2021.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/12/2021] [Accepted: 01/12/2021] [Indexed: 12/25/2022]
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18
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Molecular epidemiology of an extended multiple-species OXA-48 CPE outbreak in a hospital ward in Ireland, 2018–2019. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e54. [PMID: 36168481 PMCID: PMC9495434 DOI: 10.1017/ash.2021.206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 02/05/2023]
Abstract
Objectives: Molecular epidemiological description of an OXA-48 CPE outbreak affecting a tertiary-care hospital ward in Ireland over an extended period (2018–2019). Methods: Microbiological testing and whole-genome sequencing (WGS) were performed on all 56 positive OXA-48 outbreak case isolates. Results: In total, 7 different species were identified: Enterobacter hormaechei (n = 35, 62.5%), Escherichia coli (n = 12, 21.4%), Klebsiella pneumoniae (n = 5, 8.9%), Klebsiella oxytoca (n = 1, 1.8%), Klebsiella michiganensis (n = 1, 1.8%), Citrobacter freundii (n = 1, 1.8%), and Serratia marcesens (n = 1, 1.8%). E. hormaechei ST78 was the most common genotype (n = 14, 25%). Two major pOXA-48 plasmid types were identified throughout the outbreak, ‘types’ 1 and 2, and 5 major E. hormaechei clonal groupings were identified: ST78, ST108, ST1126, ST135, and ST66. Within each of the ST108, ST1126, ST135 and ST66 groups, the pOXA-48 harbored within each isolate were the same. Within ST78, 9 isolates contained the pOXA48 ‘type 2’ plasmid and 5 contained the ‘type 1’ plasmid. Environmental specimens were taken from different outbreak ward locations: handwash basins, sink and shower drains, and taps. Of 394 environmental specimens, OXA-48 CPE was isolated from 26 (6.6%). Conclusions: This prolonged outbreak of OXA-48 CPE was confined to one ward, but it exemplifies the complexity and difficulty in the control of these organisms. With multiple species and genotypes involved, they may be better described as ‘plasmid outbreaks.’ WGS provided insights into this diversity and potential transmission among cases, though its usefulness would be enhanced by analysis as close as possible to real time so that interventions can be implemented as soon as data are available.
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19
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Mawdsley S. What are acute NHS trusts in England doing to prevent the cross-border spread of carbapenem-resistant Enterobacteriaceae? J Infect Prev 2020; 21:196-201. [PMID: 33193822 DOI: 10.1177/1757177420935633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 04/15/2020] [Indexed: 11/16/2022] Open
Abstract
Background Carbapenem-resistant Enterobacteriaceae (CRE) pose a significant threat to global public health as these organisms have the potential to cause infections which are easily spread and are associated with high mortality rates. Aim/Objective The aim of this study was to establish which screening strategies acute NHS trusts in England have chosen to adopt and whether or not that strategy has prevented or is likely to prevent the cross-border spread of CRE. Methods All acute NHS trusts in England were invited to participate in a multicentre quantitative study. Participants were asked to complete a questionnaire relating to their local CRE screening protocol. Findings/Results Of the 91 participating trusts, 83 (91.2%) adhere to Public Health England (2013) guidance. However, only 22 (24.2%) trusts have adopted the European Centre for Disease Prevention and Control (2016) recommendations. In total, 31 (34.1%) trusts reported incidences of person-to-person transmission, of which 45.2% were related to foreign travel. Furthermore, 31 (34.1%) trusts reported that patients who have had an admission to a hospital in the UK not known to have a high prevalence of healthcare-associated CRE in the last 12 months had screened positive. Discussion This study has demonstrated that inter-hospital transmission is as much of a concern as cross-border spread. Mandatory participation in enhanced surveillance could provide PHE with the epidemiological evidence required to support this stance and help to develop new national guidance.
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Affiliation(s)
- Sharon Mawdsley
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
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20
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Politi L, Gartzonika K, Spanakis N, Zarkotou O, Poulou A, Skoura L, Vrioni G, Tsakris A. Emergence of NDM-1-producing Klebsiella pneumoniae in Greece: evidence of a widespread clonal outbreak. J Antimicrob Chemother 2020; 74:2197-2202. [PMID: 31065697 DOI: 10.1093/jac/dkz176] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/13/2019] [Accepted: 03/29/2019] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES NDM-producing Enterobacteriaceae clinical isolates remain uncommon in the European region. We describe the emergence and broad dissemination of one successful NDM-1-producing Klebsiella pneumoniae clone in Greek hospitals. METHODS During a 4 year survey (January 2013-December 2016), 480 single-patient carbapenem non-susceptible K. pneumoniae isolates, phenotypically MBL positive, were consecutively recovered in eight Greek hospitals from different locations and subjected to further investigation. Antimicrobial susceptibility testing, combined-disc test, identification of resistance genes by PCR and sequencing, molecular fingerprinting by PFGE, plasmid profiling, replicon typing, conjugation experiments and MLST were performed. RESULTS Molecular analysis confirmed the presence of the blaNDM-1 gene in 341 (71%) K. pneumoniae isolates. A substantially increasing trend of NDM-1-producing K. pneumoniae was noticed during the survey (R2 = 0.9724). Most blaNDM-1-carrying isolates contained blaCTX-M-15, blaOXA-1, blaOXA-2 and blaTEM-1 genes. PFGE analysis clustered NDM-1 producers into five distinct clonal types, with five distinct STs related to each PFGE clone. The predominant ST11 PFGE clonal type was detected in all eight participating hospitals, despite adherence to the national infection control programme; it was identical to that observed in the original NDM-1 outbreak in Greece in 2011, as well as in a less-extensive NDM-1 outbreak in Bulgaria in 2015. The remaining four ST clonal types (ST15, ST70, ST258 and ST1883) were sporadically detected. blaNDM-1 was located in IncFII-type plasmids in all five clonal types. CONCLUSIONS This study gives evidence of possibly the largest NDM-1-producing K. pneumoniae outbreak in Europe; it may also reinforce the hypothesis of an NDM-1 clone circulating in the Balkans.
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Affiliation(s)
- Lida Politi
- Department of Microbiology, Medical School, University of Athens, Athens, Greece
| | | | - Nicholas Spanakis
- Department of Microbiology, Medical School, University of Athens, Athens, Greece
| | - Olympia Zarkotou
- Department of Microbiology, Tzaneio General Hospital, Piraeus, Greece
| | - Aggeliki Poulou
- Department of Microbiology, Serres General Hospital, Serres, Greece
| | - Lemonia Skoura
- Department of Microbiology, AHEPA University Hospital, Thessaloniki, Greece
| | - Georgia Vrioni
- Department of Microbiology, Medical School, University of Athens, Athens, Greece
| | - Athanasios Tsakris
- Department of Microbiology, Medical School, University of Athens, Athens, Greece
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21
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Genovese C, La Fauci V, D'Amato S, Squeri A, Anzalone C, Costa GB, Fedele F, Squeri R. Molecular epidemiology of antimicrobial resistant microorganisms in the 21th century: a review of the literature. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:256-273. [PMID: 32420962 PMCID: PMC7569612 DOI: 10.23750/abm.v91i2.9176] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/10/2020] [Indexed: 12/26/2022]
Abstract
Healthcare-associated infections (HAIs) are the most frequent and severe complication acquired in healthcare settings with high impact in terms of morbidity, mortality and costs. Many bacteria could be implicated in these infections, but, expecially multidrug resistance bacteria could play an important role. Many microbial typing technologies have been developed until to the the bacterial whole-genome sequencing and the choice of a molecular typing method therefore will depend on the skill level and resources of the laboratory and the aim and scale of the investigation. In several studies the molecular investigation of pathogens involved in HAIs was performed with many microorganisms identified as causative agents such as Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Clostridium difficile, Acinetobacter spp., Enterobacter spp., Enterococcus spp., Staphylococcus aureus and several more minor species. Here, we will describe the most and least frequently reported clonal complex, sequence types and ribotypes with their worldwide geographic distribution for the most important species involved in HAIs.
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Affiliation(s)
- Cristina Genovese
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.
| | - Vincenza La Fauci
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.
| | - Smeralda D'Amato
- Postgraduate Medical School in Hygiene and Preventive Medicine, University of Messina, Italy.
| | - Andrea Squeri
- Department of Human Pathology of the adult and developmental age Gaetano Barresi, University of Messina, Messina, Italy.
| | - Carmelina Anzalone
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.
| | - Gaetano Bruno Costa
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.
| | - Francesco Fedele
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.
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22
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Dunne CP, Ryan P, Connolly R, Dunne SS, Kaballo MA, Powell J, Woulfe B, O'Connell NH, Gupta RK. Management of Staphylococcus aureus bacteraemia (SAB) in the oncology patient: Further evidence supports prompt removal of central venous catheters and shorter duration of intravenous antimicrobial therapy. Infect Prev Pract 2020; 2:100037. [PMID: 34368689 PMCID: PMC8335915 DOI: 10.1016/j.infpip.2020.100037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/06/2020] [Indexed: 11/27/2022] Open
Abstract
Background Staphylococcus aureus bacteraemia (SAB) is associated with relatively high risk of complications and high levels of mortality. Internationally, SAB management guidelines lack consensus and especially so regarding oncology patients. This is likely a reflection of insufficient randomised control trials (RCT) and the diversity of SAB patient populations. However, there are 2011 guidelines recommending a minimum of 14 days of appropriate IV antibiotic therapy for SAB. Objective We wished to determine whether our practice of shortened duration of intravenous antimicrobial therapy in favour of oral administration proved as effective as recommended guidelines in a mixed oncology patient cohort. Methods Retrospective review of patient records that included any SAB episode among oncology patients from January 2002 to December 2015. Medical chart reviews were undertaken to determine patient demographics, clinical management & antimicrobial therapy, duration of stay, presence of a central venous catheter (CVC) and outcome. Results Our CVC removal rate was just 73% in SAB where CVC was the identified source of infection, with an attributable mortality rate (<4%) far lower than would be expected. Antimicrobial therapy durations were considerably lower (10 days) than current recommendations of 14 days IV therapy. The recurrence rate of 15% was also significantly lower than has been reported previously. Conclusions Our observations contribute new insights concerning the management of SAB in oncology patients. Our findings suggest that therapeutic approaches should perhaps remain individualised and reflective of patient characteristics taking into consideration the complex nature of oncology patients.
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Affiliation(s)
- Colum P Dunne
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - Phelim Ryan
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - Roisin Connolly
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Suzanne S Dunne
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - Mohammed A Kaballo
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - James Powell
- Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Bernie Woulfe
- Department of Medical Oncology, University Hospital Limerick, Limerick, Ireland
| | - Nuala H O'Connell
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland.,Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Rajnish K Gupta
- Department of Medical Oncology, University Hospital Limerick, Limerick, Ireland
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23
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Dziri R, Ayari I, Barguellil F, Ouzari HI, El Asli MS, Klibi N. First Report of NDM and VIM Coproducing Klebsiella pneumoniae in Tunisia and Emergence of Novel Clones. Microb Drug Resist 2019; 25:1282-1286. [DOI: 10.1089/mdr.2019.0115] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Raoudha Dziri
- Laboratory of Microorganisms and Active Biomolecules, Department of Biology, Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Imen Ayari
- Laboratory of Microorganisms and Active Biomolecules, Department of Biology, Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Farouk Barguellil
- Service of Microbiology, Military Hospital of Tunis HMPIT, Tunis, Tunisia
- Department of Microbiology, Faculty of Pharmacy, University of Monastir, Monastir, Tunisia
| | - Hadda-Imen Ouzari
- Laboratory of Microorganisms and Active Biomolecules, Department of Biology, Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Mohamed Selim El Asli
- Service of Microbiology, Military Hospital of Tunis HMPIT, Tunis, Tunisia
- Department of Microbiology, Faculty of Pharmacy, University of Monastir, Monastir, Tunisia
| | - Naouel Klibi
- Laboratory of Microorganisms and Active Biomolecules, Department of Biology, Faculty of Sciences of Tunis, University of Tunis El Manar, Tunis, Tunisia
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24
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Affiliation(s)
- J Gray
- Journal of Hospital Infection, 162 King's Cross Road, London WC1X 9DH, UK.
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25
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O’Connor R, O’Doherty J, O’Regan A, O’Neill A, McMahon C, Dunne CP. Medical management of acute upper respiratory infections in an urban primary care out-of-hours facility: cross-sectional study of patient presentations and expectations. BMJ Open 2019; 9:e025396. [PMID: 30772860 PMCID: PMC6398638 DOI: 10.1136/bmjopen-2018-025396] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 12/12/2018] [Accepted: 01/02/2019] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES The purpose of this study was to examine the expectations of patients attending an urban primary care out-of-hours (OOH) facility with acute upper respiratory tract infection (acute URTI) regarding clinical examination, symptom management, information on their condition, reassurance, antibiotic treatment and other possible options including referral. DESIGN Cross-sectional design. SETTING One urban primary care OOH facility located in the midwest of Ireland. PARTICIPANTS 457 patients filled out a questionnaire while waiting in the OOH facility; 22 surveys were excluded as the patients did not present with symptoms of acute URTI resulting in 435 patients' data being included in this study. There were 59.5% female participants and 40.5% male participants. RESULTS 435 patients with acute URTI symptoms participated in the survey, representing 25.4% of those attending the single branch where the survey was conducted (n=1715). Of the study participants, 43% were aged under 6 years and 60% were women. The most common presenting symptoms were cough (72%), throat ache (46%) and common cold (26%). The most common expectations were for further examination (53%), reassurance (51%), information (49%) and medication for cough (47%), with 34% expecting an antibiotic. CONCLUSIONS Only one in three patients attending this primary care OOH facility with acute URTI symptoms had an expectation of antibiotics, with most seeking further assessment, information and reassurance. Recognition of such expectations may be important considerations for clinicians when deciding on management options for patients with acute URTI.
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Affiliation(s)
- Raymond O’Connor
- Graduate Entry Medical School, University of Limerick Faculty of Education and Health Sciences, Limerick, Ireland
| | - Jane O’Doherty
- Graduate Entry Medical School, University of Limerick Faculty of Education and Health Sciences, Limerick, Ireland
| | - Andrew O’Regan
- Graduate Entry Medical School, University of Limerick Faculty of Education and Health Sciences, Limerick, Ireland
| | - Aoife O’Neill
- Department of Mathematics and Statistics, University of Limerick, Limerick, Ireland
| | - Claire McMahon
- Clinical Quality and Administration Department, Shannondoc Out of Hours General Practitioner Service, Limerick, Ireland
| | - Colum P Dunne
- Graduate Entry Medical School, University of Limerick Faculty of Education and Health Sciences, Limerick, Ireland
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26
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O’Doherty J, Leader LFW, O’Regan A, Dunne C, Puthoopparambil SJ, O’Connor R. Over prescribing of antibiotics for acute respiratory tract infections; a qualitative study to explore Irish general practitioners' perspectives. BMC FAMILY PRACTICE 2019; 20:27. [PMID: 30764777 PMCID: PMC6374900 DOI: 10.1186/s12875-019-0917-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 02/04/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Anti-microbial resistance (AMR) is a global threat to public health and antibiotics are often unnecessarily prescribed for acute respiratory tract infections (ARTIs) in general practice. We aimed to investigate why general practitioners (GPs) continue to prescribe antibiotics for ARTIs despite increasing knowledge of their poor efficacy and worsening antimicrobial resistance. METHODS We used an explorative qualitative study design. Thirteen GPs were recruited through purposive sampling to represent urban and rural settings and years of experience. They were based in general practices within the Mid-West of Ireland. GPs took part in semi-structured interviews that were digitally audio recorded and transcribed. RESULTS Three main themes and three subthemes were identified. Themes include (1) non-comprehensive guidelines; how guideline adherence can be difficult, (2) GPs under pressure; pressures to prescribe from patients and perceived patient expectations and (3) Unnecessary prescribing; how to address it and the potential of public interventions to reduce it. CONCLUSIONS GPs acknowledge their failure to implement guidelines because they feel they are less usable in clinical situations. GPs felt pressurised to prescribe, especially for fee-paying patients and in out of hours settings (OOH), suggesting the need for interventions that target the public's perceptions of antibiotics. GPs behaviours surrounding prescribing antibiotics need to change in order to reduce AMR and change patients' expectations.
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Affiliation(s)
- Jane O’Doherty
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Leonard F. W. Leader
- Royal College of Surgeons in Ireland - Medical University of Bahrain, Busaiteen, Muharraq Governorate, Kingdom of Bahrain
| | - Andrew O’Regan
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Colum Dunne
- Centre for Infections in Infection, Inflammation & Immunity (41), Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Soorej Jose Puthoopparambil
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
- International Maternal and Child Health (IMCH), Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Raymond O’Connor
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
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27
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Dunne C, Slevin B, Treacy P, O'Connell N. Opportunities lost may be the greatest cost of CPE outbreaks. J Hosp Infect 2019; 101:194-195. [DOI: 10.1016/j.jhin.2018.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 10/15/2018] [Indexed: 11/27/2022]
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28
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NDM Metallo-β-Lactamases and Their Bacterial Producers in Health Care Settings. Clin Microbiol Rev 2019; 32:32/2/e00115-18. [PMID: 30700432 DOI: 10.1128/cmr.00115-18] [Citation(s) in RCA: 377] [Impact Index Per Article: 75.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
New Delhi metallo-β-lactamase (NDM) is a metallo-β-lactamase able to hydrolyze almost all β-lactams. Twenty-four NDM variants have been identified in >60 species of 11 bacterial families, and several variants have enhanced carbapenemase activity. Klebsiella pneumoniae and Escherichia coli are the predominant carriers of bla NDM, with certain sequence types (STs) (for K. pneumoniae, ST11, ST14, ST15, or ST147; for E. coli, ST167, ST410, or ST617) being the most prevalent. NDM-positive strains have been identified worldwide, with the highest prevalence in the Indian subcontinent, the Middle East, and the Balkans. Most bla NDM-carrying plasmids belong to limited replicon types (IncX3, IncFII, or IncC). Commonly used phenotypic tests cannot specifically identify NDM. Lateral flow immunoassays specifically detect NDM, and molecular approaches remain the reference methods for detecting bla NDM Polymyxins combined with other agents remain the mainstream options of antimicrobial treatment. Compounds able to inhibit NDM have been found, but none have been approved for clinical use. Outbreaks caused by NDM-positive strains have been reported worldwide, attributable to sources such as contaminated devices. Evidence-based guidelines on prevention and control of carbapenem-resistant Gram-negative bacteria are available, although none are specific for NDM-positive strains. NDM will remain a severe challenge in health care settings, and more studies on appropriate countermeasures are required.
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29
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O'Connor R, O'Doherty J, O'Regan A, Dunne C. Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review. Ir J Med Sci 2018; 187:969-986. [PMID: 29532292 PMCID: PMC6209023 DOI: 10.1007/s11845-018-1774-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 02/23/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Antimicrobial resistance is an emerging global threat to health and is associated with increased consumption of antibiotics. Seventy-four per cent of antibiotic prescribing takes place in primary care. Much of this is for inappropriate treatment of acute respiratory tract infections. AIMS To review the published literature pertaining to antibiotic prescribing in order to identify and understand the factors that affect primary care providers' prescribing decisions. METHODS Six online databases were searched for relevant paper using agreed criteria. One hundred ninety-five papers were retrieved, and 139 were included in this review. RESULTS Primary care providers are highly influenced to prescribe by patient expectation for antibiotics, clinical uncertainty and workload induced time pressures. Strategies proven to reduce such inappropriate prescribing include appropriately aimed multifaceted educational interventions for primary care providers, mass media educational campaigns aimed at healthcare professionals and the public, use of good communication skills in the consultation, use of delayed prescriptions especially when accompanied by written information, point of care testing and, probably, longer less pressurised consultations. Delayed prescriptions also facilitate focused personalised patient education. CONCLUSION There is an emerging consensus in the literature regarding strategies proven to reduce antibiotic consumption for acute respiratory tract infections. The widespread adoption of these strategies in primary care is imperative.
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Affiliation(s)
- Ray O'Connor
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland.
| | - Jane O'Doherty
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
| | - Andrew O'Regan
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
| | - Colum Dunne
- Graduate Entry Medical School, University of Limerick, Limerick City, Limerick, 000, Ireland
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30
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Dunne CP, Kingston L, Slevin B, O'Connell NH. Hand hygiene and compliance behaviours are the under-appreciated human factors pivotal to reducing hospital-acquired infections. J Hosp Infect 2018; 98:328-330. [PMID: 29486215 DOI: 10.1016/j.jhin.2018.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 02/20/2018] [Indexed: 10/17/2022]
Affiliation(s)
- C P Dunne
- Centre for Interventions in Infection, Inflammation and Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
| | - L Kingston
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | - B Slevin
- University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - N H O'Connell
- Centre for Interventions in Infection, Inflammation and Immunity (4i), Graduate Entry Medical School, University of Limerick, Limerick, Ireland; University Hospital Limerick, Dooradoyle, Limerick, Ireland
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31
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Mahon BM, Brehony C, McGrath E, Killeen J, Cormican M, Hickey P, Keane S, Hanahoe B, Dolan A, Morris D. Indistinguishable NDM-producing Escherichia coli isolated from recreational waters, sewage, and a clinical specimen in Ireland, 2016 to 2017. ACTA ACUST UNITED AC 2018; 22:30513. [PMID: 28449738 PMCID: PMC5476983 DOI: 10.2807/1560-7917.es.2017.22.15.30513] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 04/12/2017] [Indexed: 12/22/2022]
Abstract
In this study, New Delhi metallo-beta-lactamase (NDM)-producing Enterobacteriaceae were identified in Irish recreational waters and sewage. Indistinguishable NDM-producing Escherichia coli by pulsed-field gel electrophoresis were isolated from sewage, a fresh water stream and a human source. NDM-producing Klebsiella pneumoniae isolated from sewage and seawater in the same area were closely related to each other and to a human isolate. This raises concerns regarding the potential for sewage discharges to contribute to the spread of carbapenemase-producing Enterobacteriaceae.
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Affiliation(s)
- Bláthnaid M Mahon
- Antimicrobial Resistance and Microbial Ecology Group, School of Medicine, National University of Ireland, Galway, Ireland
| | - Carina Brehony
- Antimicrobial Resistance and Microbial Ecology Group, School of Medicine, National University of Ireland, Galway, Ireland
| | - Elaine McGrath
- Carbapenemase-Producing Enterobacteriaceae Reference Laboratory, Department of Medical Microbiology, University Hospital Galway, Galway, Ireland.,Department of Medical Microbiology, University Hospital Galway, Galway, Ireland
| | - James Killeen
- Antimicrobial Resistance and Microbial Ecology Group, School of Medicine, National University of Ireland, Galway, Ireland
| | - Martin Cormican
- Antimicrobial Resistance and Microbial Ecology Group, School of Medicine, National University of Ireland, Galway, Ireland.,Carbapenemase-Producing Enterobacteriaceae Reference Laboratory, Department of Medical Microbiology, University Hospital Galway, Galway, Ireland.,Department of Medical Microbiology, University Hospital Galway, Galway, Ireland
| | - Paul Hickey
- Environmental Health Service, HSE West, Galway, Ireland
| | - Shane Keane
- Environmental Health Service, HSE West, Galway, Ireland
| | - Belinda Hanahoe
- Department of Medical Microbiology, University Hospital Galway, Galway, Ireland
| | - Ann Dolan
- Galway County Council, Galway, Ireland
| | - Dearbháile Morris
- Antimicrobial Resistance and Microbial Ecology Group, School of Medicine, National University of Ireland, Galway, Ireland
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32
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van Loon K, Voor In 't Holt AF, Vos MC. A Systematic Review and Meta-analyses of the Clinical Epidemiology of Carbapenem-Resistant Enterobacteriaceae. Antimicrob Agents Chemother 2018; 62:e01730-17. [PMID: 29038269 PMCID: PMC5740327 DOI: 10.1128/aac.01730-17] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 09/29/2017] [Indexed: 01/23/2023] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) are major health care-associated pathogens and responsible for hospital outbreaks worldwide. To prevent a further increase in CRE infections and to improve infection prevention strategies, it is important to summarize the current knowledge about CRE infection prevention in hospital settings. This systematic review aimed to identify risk factors for CRE acquisition among hospitalized patients. In addition, we summarized the environmental sources/reservoirs and the most successful infection prevention strategies related to CRE. A total of 3,983 potentially relevant articles were identified and screened. Finally, we included 162 studies in the systematic review, of which 69 studies regarding risk factors for CRE acquisition were included in the random-effects meta-analysis studies. The meta-analyses regarding risk factors for CRE acquisition showed that the use of medical devices generated the highest pooled estimate (odds ratio [OR] = 5.09; 95% confidence interval [CI] = 3.38 to 7.67), followed by carbapenem use (OR = 4.71; 95% CI = 3.54 to 6.26). To control hospital outbreaks, bundled interventions, including the use of barrier/contact precautions for patients colonized or infected with CRE, are needed. In addition, it is necessary to optimize the therapeutic approach, which is an important message to infectious disease specialists, who need to be actively involved in a timely manner in the treatment of patients with known CRE infections or suspected carriers of CRE.
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Affiliation(s)
- Karlijn van Loon
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Anne F Voor In 't Holt
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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33
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Magiorakos AP, Burns K, Rodríguez Baño J, Borg M, Daikos G, Dumpis U, Lucet JC, Moro ML, Tacconelli E, Simonsen GS, Szilágyi E, Voss A, Weber JT. Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings: guidance from the European Centre for Disease Prevention and Control. Antimicrob Resist Infect Control 2017; 6:113. [PMID: 29163939 PMCID: PMC5686856 DOI: 10.1186/s13756-017-0259-z] [Citation(s) in RCA: 177] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 09/11/2017] [Indexed: 12/25/2022] Open
Abstract
Background Infections with carbapenem-resistant Enterobacteriaceae (CRE) are increasingly being reported from patients in healthcare settings. They are associated with high patient morbidity, attributable mortality and hospital costs. Patients who are “at-risk” may be carriers of these multidrug-resistant Enterobacteriaceae (MDR-E). The purpose of this guidance is to raise awareness and identify the “at-risk” patient when admitted to a healthcare setting and to outline effective infection prevention and control measures to halt the entry and spread of CRE. Methods The guidance was created by a group of experts who were functioning independently of their organisations, during two meetings hosted by the European Centre for Disease Prevention and Control. A list of epidemiological risk factors placing patients “at-risk” for carriage with CRE was created by the experts. The conclusions of a systematic review on the prevention of spread of CRE, with the addition of expert opinion, were used to construct lists of core and supplemental infection prevention and control measures to be implemented for “at-risk” patients upon admission to healthcare settings. Results Individuals with the following profile are “at-risk” for carriage of CRE: a) a history of an overnight stay in a healthcare setting in the last 12 months, b) dialysis-dependent or cancer chemotherapy in the last 12 months, c) known previous carriage of CRE in the last 12 months and d) epidemiological linkage to a known carrier of a CRE. Core infection prevention and control measures that should be considered for all patients in healthcare settings were compiled. Preliminary supplemental measures to be implemented for “at-risk” patients on admission are: pre-emptive isolation, active screening for CRE, and contact precautions. Patients who are confirmed positive for CRE will need additional supplemental measures. Conclusions Strengthening the microbiological capacity, surveillance and reporting of new cases of CRE in healthcare settings and countries is necessary to monitor the epidemiological situation so that, if necessary, the implemented CRE prevention strategies can be refined in a timely manner. Creating a large communication network to exchange this information would be helpful to understand the extent of the CRE reservoir and to prevent infections in healthcare settings, by applying the principles outlined here. This guidance document offers suggestions for best practices, but is in no way prescriptive for all healthcare settings and all countries. Successful implementation will result if there is local commitment and accountability. The options for intervention can be adopted or adapted to local needs, depending on the availability of financial and structural resources. Electronic supplementary material The online version of this article (10.1186/s13756-017-0259-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A P Magiorakos
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - K Burns
- Beaumont Hospital, Royal College of Surgeons in Ireland & Health Protection Surveillance Centre, Dublin, Ireland
| | - J Rodríguez Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena / Universidad de Sevilla / Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - M Borg
- Departments of Infection Control & Sterile Services, Mater Dei Hospital, MSD2090, Msida, Malta
| | - G Daikos
- First Department of Medicine, Laikon General Hospital, Athens, Greece
| | - U Dumpis
- Department of Infectious diseases and Infection Control. Pauls Stradins University Hospital, Riga, Latvia
| | - J C Lucet
- Infection Control Unit, Bichat Claude Bernard Hospital, AP-HP, Paris, France
| | - M L Moro
- Agenzia Sanitaria e Sociale Regione Emilia-Romagna, Bologna, Italy
| | - E Tacconelli
- Division of Infectious Diseases, Department Internal Medicine 1, DZIF Center, Tübingen University, Tübingen, Germany
| | - G Skov Simonsen
- Department of Microbiology and Infection Control, University Hospital of North Norway, and UiT - The Arctic University of Norway, Tromsø, Norway
| | - E Szilágyi
- Department of Epidemiology and Hospital Hygiene, National Public Health and Medical Officer Service, Budapest, Hungary
| | - A Voss
- Department of Medical Microbiology, Radboud University Medical Centre and Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - J T Weber
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA USA
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Dunne CP, Keinänen-Toivola MM, Kahru A, Teunissen B, Olmez H, Gouveia I, Melo L, Murzyn K, Modic M, Ahonen M, Askew P, Papadopoulos T, Adlhart C, Crijns FRL. Anti-microbial coating innovations to prevent infectious diseases (AMiCI): Cost action ca15114. Bioengineered 2017; 8:679-685. [PMID: 28453429 PMCID: PMC5736330 DOI: 10.1080/21655979.2017.1323593] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 04/20/2017] [Accepted: 04/24/2017] [Indexed: 11/10/2022] Open
Abstract
Worldwide, millions of patients are affected annually by healthcare-associated infection (HCAI), impacting up to 80,000 patients in European Hospitals on any given day. This represents not only public health risk, but also an economic burden. Complementing routine hand hygiene practices, cleaning and disinfection, antimicrobial coatings hold promise based, in essence, on the application of materials and chemicals with persistent bactericidal or -static properties onto surfaces or in textiles used in healthcare environments. The focus of considerable commercial investment and academic research energies, such antimicrobial coating-based approaches are widely believed to have potential in reduction of microbial numbers on surfaces in clinical settings. This belief exists despite definitive evidence as to their efficacy and is based somewhat on positive studies involving, for example, copper, silver or gold ions, titanium or organosilane, albeit under laboratory conditions. The literature describes successful delay and/or prevention of recontamination following conventional cleaning and disinfection by problematic microbes such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin resistant enterococci (VRE), among others. However, there is a scarcity of studies assessing antimicrobial surfaces other than copper in the clinical environment, and a complete lack of published data regarding the successful implementation of these materials on clinically significant outcomes (including HCAI). Through its Cooperation in Science and Technology program (COST), the European Commission has funded a 4-year initiative to establish a network of stakeholders involved in development, regulation and use of novel anti-microbial coatings for prevention of HCAI. The network (AMiCI) comprises participants of more than 60 universities, research institutes and companies across 29 European countries and, to-date, represents the most comprehensive consortium targeting use of these emergent technologies in healthcare settings. More specifically, the network will prioritise coordinated research on the effects (both positive and negative) of antimicrobial coatings in healthcare sectors; know-how regarding availability and mechanisms of action of (nano)-coatings; possible adverse effects of such materials (e.g., potential emergence of microbial resistance or emission of toxic agents into the environment); standardised performance assessments for antimicrobial coatings; identification and dissemination of best practices by hospitals, other clinical facilities, regulators and manufacturers.
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Affiliation(s)
- Colum P. Dunne
- Centre for Interventions in Infection, Inflammation & Immunity (4i) and Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | | | - Anne Kahru
- Laboratory of Environmental Toxicology, National Institute of Chemical Physics and Biophysics, Tallinn, Estonia
- Academy of Sciences, Tallinn, Estonia
| | | | - Hulya Olmez
- TÜBİTAK MAM Material Institute, Gebze, Kocaeli, Turkey
| | - Isabel Gouveia
- FibEntech - Fiber Materials and Environmental Technologies Research Unit, University of Beira Interior, Covilhã, Portugal
| | - Luis Melo
- Faculty of Engineering, University of Beira Interior, Covilhã, Portugal
| | | | - Martina Modic
- Department of Surface Engineering and Electronics, Jozef Stefan Institute, Ljubljana, Slovenia
| | - Merja Ahonen
- Satakunta University of Applied Sciences, Rauma, Finland
| | - Pete Askew
- Industrial Microbiological Services Ltd (IMSL), Hants, United Kingdom
| | - Theofilos Papadopoulos
- Laboratory of Microbiology and Infectious Diseases, School of Veterinary Medicine, Aristotle University, Auth Campus, Thessaloniki, Greece
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Savov E, Politi L, Spanakis N, Trifonova A, Kioseva E, Tsakris A. NDM-1 Hazard in the Balkan States: Evidence of the First Outbreak of NDM-1-Producing Klebsiella pneumoniae in Bulgaria. Microb Drug Resist 2017; 24:253-259. [PMID: 28876169 DOI: 10.1089/mdr.2017.0230] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
New Delhi MBL (NDM) carbapenemase-producing Klebsiella pneumoniae has become one of the most concerning multidrug-resistant pathogens. The Balkan counties are considered a reservoir for the spread of such strains based on several reports documenting NDM infections after hospitalization in this region. Nevertheless, NDM-producing K. pneumoniae have been only occasionally documented from Balkans. The current study documents the first polyclonal outbreak caused by NDM-1-producing K. pneumoniae in Bulgaria. From July 2015 to April 2016, all 25 single-patient carbapenem-nonsusceptible K. pneumoniae isolates were collected. Phenotypic and molecular screening revealed that 17 produced NDM-1 carbapenemase. All NDM-1 producers harbored blaCTX-M-15, blaCMY-4, blaTEM-1, and blaOXA-2; five also harbored blaOXA-1. In all cases, blaNDM-1 was flanked upstream by ISAba125 element and downstream by bleMBL. Pulsed-field gel electrophoresis (PFGE) clustered NDM-1-positive isolates into four distinct clonal types, A to D. MLST assigned isolates of the dominant clonal type A (n = 14) to sequence type (ST) 11, while isolates of clonal types B, C, and D to ST16, ST15, and ST391, respectively. Of interest, ST11 isolates belonged to the same PFGE type as those of the recently described NDM-1 ST11 clonal outbreak in Greece. Traveling abroad or overseas hospitalization was not reported in any case, suggesting most likely intra- and interhospital dissemination. The study presents the first polyclonal outbreak of NDM-producing K. pneumoniae in the Balkans and underlines the need for larger epidemiological studies in the region to illustrate commonalities in the transmission of NDM clones and possible sources in the community.
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Affiliation(s)
- Encho Savov
- 1 Laboratory of Microbiology , Military Medical Academy, Sofia, Bulgaria
| | - Lida Politi
- 2 Department of Microbiology, Medical School, University of Athens , Athens, Greece
| | - Nicholas Spanakis
- 2 Department of Microbiology, Medical School, University of Athens , Athens, Greece
| | - Angelina Trifonova
- 1 Laboratory of Microbiology , Military Medical Academy, Sofia, Bulgaria
| | - Elena Kioseva
- 1 Laboratory of Microbiology , Military Medical Academy, Sofia, Bulgaria
| | - Athanasios Tsakris
- 2 Department of Microbiology, Medical School, University of Athens , Athens, Greece
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O'Connell NH, Tansey P, Dunne SS, Dunne CP. Timely publishing of experiences and sharing of knowledge. J Hosp Infect 2017; 97:315-316. [PMID: 28669675 DOI: 10.1016/j.jhin.2017.06.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 06/26/2017] [Indexed: 11/24/2022]
Affiliation(s)
- N H O'Connell
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland; University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - P Tansey
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - S S Dunne
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - C P Dunne
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland.
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Mahida N, Clarke M, White G, Vaughan N, Boswell T. Outbreak of Enterobacter cloacae with New Delhi metallo-β-lactamase (NDM)-1: challenges in epidemiological investigation and environmental decontamination. J Hosp Infect 2017; 97:64-65. [PMID: 28552405 DOI: 10.1016/j.jhin.2017.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 05/22/2017] [Indexed: 10/19/2022]
Affiliation(s)
- N Mahida
- Department of Clinical Microbiology, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - M Clarke
- Infection Prevention and Control Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - G White
- Department of Clinical Microbiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - N Vaughan
- Infection Prevention and Control Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - T Boswell
- Department of Clinical Microbiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Becoming patient-centred: sobering insight into CPE-positive patients' experiences of clinical care. J Hosp Infect 2017; 96:129-130. [PMID: 28434628 DOI: 10.1016/j.jhin.2017.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/02/2017] [Indexed: 11/22/2022]
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