Rapid spread of methicillin-resistant Staphylococcus aureus in a new hospital in the broad-spectrum antibiotic era

Prevalence, antimicrobial susceptibility pattern and multidrug resistance of methicillin-resistant Staphylococcus aureus isolated from clinical samples at a tertiary care teaching hospital: an observational, cross-sectional study from the Himalayan country, Nepal

OBJECTIVE

We sought to determine the prevalence and antimicrobial susceptibility pattern of methicillin-resistant Staphylococcus aureus (MRSA) isolated from the clinical samples at a tertiary care hospital in Nepal.

METHODS

Cross-sectional, observational study design.

STUDY SETTING

The study was carried out at a tertiary care facility, the largest public hospital, Tribhuvan University Teaching Hospital (TUTH), Nepal.

PARTICIPANTS

A total of 7433 clinical samples from hospital inpatients and outpatients available in the TUTH microbiology laboratory were examined. The study included clinical samples from the patients of either sex and across all age groups that had been clinically determined to have S. aureus infections.

RESULTS

Of 7433 clinical samples analysed, S. aureus was recovered from 499 (6.71%). The prevalence of MRSA was discovered to be 26.4% (95% CI 21.6% to 30.4%). The major sources of MRSA were pus, 71 (18.5%). MRSA isolates encountered 100% resistance to penicillin and cloxacillin, followed by ciprofloxacin (80.5%), erythromycin (79.8%), cephalexin (64.9%), cotrimoxazole (61.1%) and clindamycin (58.5%). Chloramphenicol (17.9%), and gentamicin (27.4%), on the other hand, exhibited minimal resistance. None of the isolates were resistant to vancomycin (0.0%). Prevalence of multidrug resistance (MDR) was markedly higher in MRSA, 94.05% (95% CI 89.4% to 98.6%), compared with methicillin-sensitive S. aureus, 52.12% (95% CI 46.2% to 57.8%).

CONCLUSION

Our study indicated a high rate of MRSA and MDR-SA (Multidrug-resistant Staphylococcus aureus) prevalence in a Nepalese tertiary care hospital. Therefore, given the widespread burden of MRSA and the threat of the emergence of resistance to commonly used antibiotics, there is a need for the development, adoption and enforcement of appropriate control policies in these hospital settings. Regular surveillance, reporting mechanism as well as prudent use of antimicrobial agents are crucial to combating the progression of MDR-MRSA prevalence and antibiotic resistance.

Characterizations of the endolysin Lys84 and its domains from phage qdsa002 with high activities against Staphylococcus aureus and its biofilms

Staphylococcus aureus (S. aureus), particularly methicillin-resistant S. aureus (MRSA), and its biofilms are great threats in the food industry. Bacteriophage-encoded endolysins are promising tools to inhibit pathogens and to eliminate their biofilms. In this work, a virulent phage qdsa002 against S. aureus ATCC43300 (MRSA) was isolated, and the phage's endolysin (Lys84) and its domains were expressed and purified. Morphological and genome analyses demonstrated that qdsa002 is a Twort-like phage from Myoviridae. Lys84 contains two catalytic domains (CHAP and Amidase_2) and one cell binding domain (SH3b). This endolysin exhibits a strong lytic activity against S. aureus and has a wider bactericidal spectrum than qdsa002. Moreover, Lys84 exceed 10 μM effectively removed around 90 % of the biofilms of S. aureus. Besides, CHAP and Amidase_2 domains remained 61.20 % and 59.46 % of lytic activity as well as 84.31 % and 70.11 % of anti-biofilm activity of Lys84, respectively. The lytic and anti-biofilm activities of the combination of CHAP and Amidase_2 were close to 90 % of those of Lys84. These results indicated that Lys84 and its domains might be alternative antimicrobials for controlling S. aureus and its biofilms.

Recovery of antimicrobial susceptibility in methicillin-resistant Staphylococcus aureus (MRSA): a retrospective, epidemiological analysis in a secondary care hospital, Sapporo, Japan

Anti-methicillin-resistant Staphylococcus aureus (MRSA) drugs are critical final options for treating MRSA infection. This study investigated the percentage of all S. aureus isolates that are resistant to methicillin and also MRSA susceptibility to other antimicrobial agents in the JR Sapporo Hospital inpatient service. The inpatient service MRSA percentages for Japan, Hokkaido, and JR Sapporo Hospital from 2010-2019 were compared, exploring the annual rate of change in the MRSA percentage. We also investigated the antimicrobial use density (AUD) and its relationship with MRSA antimicrobial susceptibility in the JR Sapporo Hospital during 2019. The MRSA percentage in JR Sapporo Hospital was 61.5% (95% CI [52.6-69.7]) in 2010 but was only 51.6% (95% CI [41.6-61.5]) in 2019, which is a 1.43% (95% CI [0.42-2.43]) annual decrease (p = 0.05). Regarding the MRSA antimicrobial susceptibility rate in JR Sapporo Hospital, the highest rates of annual increase were seen for minocycline (3.11% (95% CI [2.25-3.94])) followed by fosfomycin (2.85% (95% CI [1.83-3.85])). Positive correlations with the AUD of anti-MRSA drugs were identified for susceptibility to erythromycin (p < 0.01), clindamycin (p = 0.002), and levofloxacin (p = 0.0005). A recovery of MRSA antimicrobial susceptibility was observed in our antibiogram dataset. Our study supports the potential for appropriate antimicrobial agent use in reviving MRSA antimicrobial susceptibility.

Evaluation of Surgical Antimicrobial Prophylaxis and Incidence of Surgical Site Infection at Borumeda Hospital, Northeast Ethiopia: Retrospective Cross-Sectional Study

Background

Surgical site infections are global healthcare problems. Although surgical site infections are preventable, they still cause significant morbidity, high death rates, and financial stress on national budgets and individual patients. Inappropriate uses of surgical antimicrobial prophylaxis are increasing and worsening patients’ quality of life. This study determined the incidence and risk factors of surgical site infections.

Methods

Institution-based retrospective cross-sectional study was conducted using a structured data abstraction format on patients who were attending at the surgical ward of Borumeda hospital from April 1, 2017, to March 31, 2019. The data were collected during July 15–30, 2019. A systematic random sampling technique was employed to select 227 surgical cases. Multivariate logistic regression was computed using the statistical package for social sciences version 23.

Results

The incidence of surgical site infections was 46.7%. Prophylaxis was administered to 188 (82.8%) surgical cases. Prophylaxis was recommended for 151 (66.5%). Out of these, only 143 (94.7%) received prophylaxis. One hundred seventy-four (78.4%) of the procedures had appropriate indication. The compliance of surgical antimicrobial prophylaxis use was 13.7%. The predictors of surgical site infections were receiving prophylaxis more than 24 h after surgery (AOR=3.53, 95% CI: 1.22–10.17), clean-contaminated wounds (AOR=4.54, 95% CI: 1.33–15.53), surgical procedure of thyroidectomy (AOR=5.2, 95% CI: 0.9–21.4), appendectomy (AOR = 29, 95% CI: 6.2–141.7), cholecystectomy (AOR = 21, 95% CI: 3.5 −126.7), hernia (AOR= 8.8, 95% CI: 1.2–62.2), skin and deep tissue (AOR = 125, 95% CI: 7.8–196.7), and orthopedic (AOR=57, 95% CI: 1.6–209.5).

Conclusion

There was high inconsistency between surgical antimicrobial prophylaxis practice and international surgical site infections prevention guideline. Wrong selection of antimicrobial agents was the most noncompliant to the guidelines. The incidence of surgical antimicrobial prophylaxis was high and requires due attention. The duration of postoperative prophylaxis should be kept to less than 24 h.

Management of community-acquired pneumonia in immunocompetent adults: updated Swedish guidelines 2017

Based on expert group work, Swedish recommendations for the management of community-acquired pneumonia in adults are here updated. The management of sepsis-induced hypotension is addressed in detail, including monitoring and parenteral therapy. The importance of respiratory support in cases of acute respiratory failure is emphasized. Treatment with high-flow oxygen and non-invasive ventilation is recommended. The use of statins or steroids in general therapy is not found to be fully supported by evidence. In the management of pleural infection, new data show favourable effects of tissue plasminogen activator and deoxyribonuclease installation. Detailed recommendations for the vaccination of risk groups are afforded.

Real-time monitoring of antimicrobial use density to reduce antimicrobial resistance through the promotion of antimicrobial heterogeneity in a haematology/oncology unit

BACKGROUND

In haematology/oncology units, the frequent and heavy use of broad-spectrum antimicrobials can lead to outbreaks of antimicrobial resistance. Increasing antimicrobial heterogeneity might be a useful strategy for preventing such resistance.

METHODS

A real-time antimicrobial use density (AUD) monitoring system (RAMS) was developed to precisely assess antimicrobial heterogeneity. This study was prospectively conducted over a 39 month period and involved 970 patients. Patient-specific antimicrobial therapy with five carbapenems (meropenem, biapenem, panipenem/betamipron, imipenem/cilastatin and doripenem) and four non-carbapenems (piperacillin/tazobactam, ceftazidime, cefozopran and cefepime) was prescribed in the first 12 months. A first-line antimicrobial was selected from among nine antimicrobials according to a predetermined schedule for the next 15 months. AUD-based antimicrobial selection was implemented using the RAMS during the last 12 months. We compared our findings for the RAMS period with those for the other periods to determine the effects of RAMS-based AUD monitoring on antimicrobial resistance.

RESULTS

The mean absolute difference between the AUD values of carbapenems and non-carbapenems (AUD deviation) was 6.0% in the RAMS period (range 0.5%-15.8%) and antimicrobial heterogeneity (AUD deviation <10%) was achieved in 10 out of 12 months (83.3%). Furthermore, during the RAMS period, AUD deviation was significantly smaller and the frequency of outbreaks of antimicrobial-resistant strains other than Stenotrophomonas maltophilia was significantly decreased (from 7.9% to 3.5%; P < 0.01) compared with the other periods.

CONCLUSIONS

The longer period of stable antimicrobial heterogeneity achieved by the RAMS strengthened its preventive effects against antimicrobial resistance. Optimal antimicrobial heterogeneity based on real-time AUD monitoring could reduce the frequency of outbreaks of antimicrobial resistance.

Anti-staphylococcal, anti-HIV and cytotoxicity studies of four South African medicinal plants and isolation of bioactive compounds from Cassine transvaalensis (Burtt. Davy) codd

Background

Medicinal plants represent an important opportunity to rural communities in Africa, as a source of affordable medicine and as a source of income. Increased patient awareness about safe usage is important as well as more training with regards to traditional medicine. The aim of this study was to evaluate the ethnomedicinal prowess of some indigenous South African plants commonly used in Eastern Cape Province of South Africa for the treatment of skin and respiratory tract infections, HIV and their toxicity potential.

Methods

Cassine transvaalensis, Vangueria infausta, Croton gratissimus and Vitex ferruginea were tested for antibacterial activities against Staphylococcus aureus and Staphylococcus epidermidis using Kirby-Bauer disk diffusion and minimum inhibition concentration (MIC). Cytotoxic and anti-HIV-1 activities of plants were tested using MTT Assay (3- (Dimethylthiozole-2-yl-2,5-diphenyltetrazolium bromide)) and anti- HIV-1iib assay. In search of bioactive lead compounds, Cassine transvaalensis which was found to be the most active plant extract against the two Staphylocoous bacteria was subjected to various chromatographic. Thin layer chromatography, Column chromatography and Nuclear Magnetic Resonance (NMR), (¹H-¹H, ¹³C-¹³C, in DMSO_d6, Bruker 600 MHz) were used to isolate and characterize 3-Oxo-28-hydroxylbetuli-20(29)-ene and 3,28-dihydroxylbetuli-20(29)-ene bioactive compounds from C. transvaalensis.

Results

The four plants studied exhibited bioactive properties against the test isolates. The zones of inhibition ranged between 16 mm to 31 mm for multi-drug resistant staphylococci species. MIC values varied between 0.6 and 0.02 μg/ml. C. gratissimus and C. transvaalensis exhibited the abilities to inhibit HIV-1_iib. Two bioactive compounds were isolated from C. transvaalensis.

Conclusion

Data from this study reveals the use of these plant by traditional healers in the Eastern Cape. Furthermore, C. transvaalensis and C. gratissimus were found to be more active as against HIV-1iib. While C. transvaalensis was most active against the two Staphylococcus bacteria.

Y, El-Sayed AS, Abdel-Rahman ME. Prophylactic antibiotics and wound infection

INTRODUCTION

Surgical site infections account for 14%-25% of all nosocomial infections. The main aims of this study were to audit the use of prophylactic antibiotic, to quantify the rate of post-operative wound infection, and to identify risk factors for its occurrence in general surgery.

METHODOLOGY

A cross-sectional study was conducted in the General Surgery Department in Khartoum Teaching Hospital- Sudan. All Adult patients (age ≥18 years) admitted during March 1(st) to 31(st) October 2010 were recruited. Multivariable logistic analysis was done to identify wound infection risk factors. Prescriptions were audited against predetermined criteria.

RESULTS

A total of 540 patients were recruited; (females73.7% of total ). The performed surgical procedures were 547. The rate of wound infection was 10.9%. Multivariable logistic analysis showed that; ASA score ≥ 3; (p= <0.001), wound class (p= 0.001), and laparoscopic surgical technique; (p= 0.002) were significantly associated with prevalence of wound infection. Surgical prophylaxis was unnecessarily given to 311 (97.5%) of 319 patients for whom it was not recommended. Prophylaxis was recommended for 221 patients; of them 218 (98.6 %) were given preoperative dose in the operating rooms. Evaluation of prescriptions for those patients showed that; spectrum of antibiotic was adequate for 160 (73.4%) patients, 143 (65.6%) were given accurate doses, only 4 (1.8%) had the first preoperative dose/s in proper time window, and for 186 (85.3%) of them prophylaxis was extended post-operatively. Only 36 (6.7%) prescriptions were found to be complying with the stated criteria.

CONCLUSION

The rate of wound infection was high and prophylactic antibiotics were irrationally used. Multiple interventions are needed to correct the situation.

Association between ward-specific antimicrobial use density and methicillin-resistant Staphylococcu aureus surveillance: a 60-month study

It is not known whether or not ward-specific antimicrobial use density (AUD) affects the ratio of methicillin-resistant Staphylococcus aureus (MRSA) in culture-positive S. aureus. A 60-month study was attempted to ascertain the association between inpatient MRSA ratio and ward-specific AUDs as well as the former and latter study intervals, specimen types, and ward specialty. During the study, the professionals in infection control regulated the use of broad-spectrum antimicrobials and those for MRSA. By both month and ward, the ratio of inpatients positive for MRSA to those positive for S. aureus was calculated. Factors associated with MRSA ratio included AUDs averaged for the sampling month and its previous month, outpatient MRSA ratio by age, ward specialty, specimen type, and half intervals to represent historical changes. Of a total of 4,245 strains of S. aureus isolated during the 5-year study, 2,232 strains (52.6%) were MRSA. By year, outpatient MRSA ratio at age ≥15 decreased in later years, as did inpatient MRSA ratio. Multivariate analysis for inpatient MRSA ratio revealed a positive risk in AUDs for meropenem (odds ratio [OR] 1.761; 95% confidence interval [CI] 1.761–2.637, P = 0.01), imipenem-cilastatin (OR 1.583; 95% CI 1.087–2.306, P = 0.02), ampicillin-sulbactam (OR 1.623; 95% CI 1.114–2.365, P = 0.01), and minocycline (OR 1.680; CI 1.135–2.487, P = 0.01), respiratory care ward (OR 2.292; 95% CI 1.085–4.841, P = 0.03), and outpatient MRSA ratio (OR 1.536; 95% CI 1.070–2.206, P = 0.02). Use of broad-spectrum antimicrobials, such as meropenem, imipenem-cilastatin, and ampicillin-sulbactam may increase inpatient MRSA ratio. Ward factor should be included in MRSA surveillance because of the possible effect on AUD and considering patients’ backgrounds.

Swedish guidelines on the management of community-acquired pneumonia in immunocompetent adults--Swedish Society of Infectious Diseases 2012

This document presents the 2012 evidence based guidelines of the Swedish Society of Infectious Diseases for the in- hospital management of adult immunocompetent patients with community-acquired pneumonia (CAP). The prognostic score 'CRB-65' is recommended for the initial assessment of all CAP patients, and should be regarded as an aid for decision-making concerning the level of care required, microbiological investigation, and antibiotic treatment. Due to the favourable antibiotic resistance situation in Sweden, an initial narrow-spectrum antibiotic treatment primarily directed at Streptococcus pneumoniae is recommended in most situations. The recommended treatment for patients with severe CAP (CRB-65 score 2) is penicillin G in most situations. In critically ill patients (CRB-65 score 3-4), combination therapy with cefotaxime/macrolide or penicillin G/fluoroquinolone is recommended. A thorough microbiological investigation should be undertaken in all patients, including blood cultures, respiratory tract sampling, and urine antigens, with the addition of extensive sampling for more uncommon respiratory pathogens in the case of severe disease. Recommended measures for the prevention of CAP include vaccination for influenza and pneumococci, as well as smoking cessation.