Trend in healthcare-associated infections due to vancomycin-resistant Enterococcus at a hospital in the era of COVID-19: More than hand hygiene is needed

The features of multidrug-resistant organisms between 2016 and March 2023 and its change after the end of zero-COVID-19 policy in a teaching hospital in Shenzhen, China

BACKGROUND

To investigate the clinical distribution and changing trend of antibiotic resistance profiles of multidrug-resistant organisms (MDROs), a retrospective study was undertaken.

METHODS

The characteristics of MDROs isolated from 2016 to March 2023 were retrospectively analysed. The detection rate of these MDROs was compared prior to COVID-19 (Period 1, 2016-2019), during the COVID-19 pandemic with restrictions (Period 2, 2020-2022), and after the end of zero-policy (Period 3, Jan-March, 2023). Antibiotic-resistant genes were detected.

RESULTS

The overall detection rates of CRPA, CRAB, CREC, CRKP, MRSA, and VREfm were 22.6%, 22.6%, 1.3%, 4.0%, 19.5%, and 3.1%, respectively. The detection rate of CRAB was significantly lower in Period 2 and 3 compared with Period 1 (P < 0.0001). The detection rate of CRPA and VREfm was significantly increased in Period 3 compared with Period 1 and 2 (P < 0.0001). The resistance rate to ticarcillin/clavulanic acid (TIM) and piperacillin/tazobactam (TZP) has gradually increased in CRPA since 2018. NDM and KPC were the most common carbapenemase genes identified in CREC (60.0%) and CRKP isolates (47.8%), respectively. All the 10 VREfm isolates carried the vanA gene.

CONCLUSIONS

The detection rate of CRAB has decreased since 2018, but a significantly increased prevalence of CRPA and VREfm was seen after the end of zero-policy. An increasing resistance rate to TIM and TZP was seen in CRPA. NDM, KPC, and vanA were the common genes harboured by CREC, CRKP, and VREfm, respectively. Ongoing surveillance after the COVID-19 era is suggested.

When it rains it pours: An increased prevalence of intestinal carriage of vancomycin-resistant Enterococcus faecium related to higher use of oral vancomycin in a tertiary care Hungarian clinical centre during the years of the COVID-19 pandemic

OBJECTIVES

This study aims to investigate the association between oral vancomycin consumption and intestinal vancomycin-resistant Enterococcus carriage in the pre- and COVID era in the clinical centre of the University of Szeged, Hungary.

METHODS

This retrospective microbiological examination was carried out using electronically collected data, corresponding to the period between 1 January 2018 and 31 December 2022, at the Department of Medical Microbiology. Data included isolated species and the according antimicrobial susceptibility patterns. Annual consumption data for oral vancomycin consumption were exported from the database of the central pharmacy of the clinical centre. As a strain typing procedure, Fourier transform infrared spectroscopy analysis was used.

RESULTS

There was a significant increase in the number of faecal vancomycin-resistant Enterococcus isolates throughout the study. The prevalence increased significantly during the years of the pandemic. The use of orally administered vancomycin in the clinical centre increased significantly. A strong positive correlation existed between the two phenomena. Several strains with different resistance patterns spread in the clinical centre. Two of these occurred in greater numbers, differing in their high-level aminoglycoside resistance. However, the overall resistance of these strains was stagnating. FTIR analysis revealed that 59 of the 62 strains were also divided into 2 large clusters differing partially in their high-level aminoglycoside resistance.

CONCLUSIONS

During the pandemic, intestinal VRE carriage among clinical centre patients increased significantly, linked to increased oral vancomycin use. Different strains spread, with aminoglycoside resistance being the primary distinction. This highlights the negative impact of the pandemic on VRE carriage.

A scoping review of bacterial resistance among inpatients amidst the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic disrupted antimicrobial stewardship and infection prevention operations worldwide, raising concerns for an acceleration of antimicrobial resistance (AMR). Therefore, we aimed to define the scope of peer reviewed research comparing AMR in inpatient bacterial clinical cultures before and after the start of the COVID-19 pandemic.

METHODS

We conducted a scoping review and searched PubMed, Scopus, and Web of Science through 15 June 2023. Our inclusion criteria were: (1) English language, (2) primary evidence, (3) peer-reviewed, (4) clinical culture data from humans, (5) AMR data for at least one bacterial order/species, (6) inpatient setting, (7) use of statistical testing to evaluate AMR data before and during the COVID-19 pandemic. Reviewers extracted country, study design, type of analysis, study period, setting and population, number of positive cultures or isolates, culture type(s), method of AMR analysis, organisms, and AMR results. Study results were organised by organism and antibiotic class or resistance mechanism. AMR results are also summarised by individual study and across all studies.

RESULTS

In total, 4805 articles were identified with 55 papers meeting inclusion criteria. Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus were the most commonly studied organisms. There were 464 bacterial AMR results across all studies with 82 (18%) increase, 71 (15%) decrease, and 311 (67%) no change results.

CONCLUSIONS

The literature examining the impact of COVID-19 on AMR among inpatients is diverse with most results reflecting no change pre/post pandemic. Ongoing inquiry is needed into evolving patterns in AMR post COVID-19.

Rinse, gel, and foam - is there any evidence for a difference in their effectiveness in preventing infections?

BACKGROUND

Following publication of the 2009 World Health Organizations Guidelines for Hand Hygiene in Health Care, a debate has emerged regarding the relative antimicrobial efficacy of the different formats (rinse, gel, foam) of ABHRs and their ability to contribute to reduction of healthcare-associated infections (HAIs).

METHODS

Data regarding the in-vivo antimicrobial efficacy of ABHRs and other factors that likely affect their effectiveness in reducing HAIs were reviewed, and a comprehensive review of studies that reported the effectiveness of each of the three ABHR formats to improve hand hygiene compliance and reduce HAIs was conducted.

RESULTS

The amount of rubbing time it takes for hands to feel dry (dry time) is the major driver of ABHR antimicrobial efficacy. ABHR format is not a major factor, and several studies found that rinse, gel, and foam ABHRs have comparable in-vivo antimicrobial efficacy. Other factors that likely impact the ability of ABHRs to reduce transmission of healthcare-associated pathogens and HAIs include ABHR formulation, the volume applied to hands, aesthetic characteristics, skin tolerance, acceptance by healthcare personnel, and hand hygiene compliance rates. When accompanied by complementary strategies, promoting the use of each of the three ABHR formats has been associated with improvements in hand hygiene compliance rates. A review of 67 studies failed to identify an ABHR format that was significantly more effective in yielding statistically significant reductions in transmission of healthcare-associated pathogens or HAIs.

CONCLUSIONS

Current evidence is insufficient to definitively determine if one ABHR format is more effective in reducing transmission of healthcare-associated pathogens and HAIs. More rigorous studies such as multicenter randomized controlled trials comparing the different formats are needed to establish if one format is significantly more effective in reducing HAIs.

Not only COVID-19: a systematic review of anti-COVID-19 measures and their effect on healthcare-associated infections

BACKGROUND

Healthcare-associated infections (HAIs) burden healthcare globally. Amid the SARS-CoV-2 pandemic, intensified infection control measures, such as mask usage and hand hygiene, were implemented.

AIM

To assess the efficacy of these measures in preventing HAIs among hospitalized patients.

METHODS

Using the PICO framework (Population, Intervention, Comparison, Outcome), the study focused on hospitalized patients and the effectiveness of anti-COVID-19 measures in preventing HAIs. A systematic review of literature published in 2020-2022 was conducted, examining interventions such as mask usage, hand hygiene, and environmental cleaning.

FINDINGS

This systematic review analysed 42 studies: two in 2020, 21 in 2021, and 19 in 2022. Most studies were from high-income countries (28). Most studies (30 out of 42) reported a reduction in HAIs after implementing anti-COVID-19 measures. Gastrointestinal infections and respiratory tract infections showed significant reduction, unlike bloodstream infections and urinary tract infections. Some wards, like cardiology and neurology, experienced reduced HAIs, unlike intensive care units and coronary care units. There was an increase in studies reporting no effect of hygiene measures on HAIs in 2022, eventually indicating a shift in effectiveness over time.

CONCLUSION

Anti-COVID-19 measures have shown selective efficacy in preventing HAIs. The study emphasizes the need for context-specific strategies and increased focus on regions with limited resources. Continued research is essential to refine infection control practices, especially in high-risk settings.

Impact of infection prevention and control practices, including personal protective equipment, on the prevalence of hospital-acquired infections in acute care hospitals during COVID-19: a systematic review and meta-analysis

BACKGROUND

The COVID-19 pandemic has posed an unprecedented challenge to healthcare systems globally. Personal protective equipment has played a fundamental role in protecting healthcare workers and patients, but its effectiveness in reducing hospital-acquired infections (HAIs) during the pandemic remains a subject of debate.

AIM

To conduct a synthesis and meta-analysis of the best available evidence of the prevalence of HAIs using a before/after approach.

METHODS

A three-step search strategy was undertaken to locate published and unpublished studies. A search was performed in MEDLINE, CINAHL, Embase, PsycINFO, and Google Scholar. Screening of studies, data extraction and critical appraisal were performed by four independent reviewers. Meta-analysis was conducted using Review Manager. The review is reported in accordance with PRISMA and JBI guidelines for systematic reviews.

FINDINGS

Fifteen studies were included in the review. Three studies indicated a statistically significant increase in the number of positive cultures during the COVID-19 period compared to the pre-COVID-19 period. Pooled data showed a non-significant decrease in the number of patients with positive cultures in the COVID-19 period compared to pre-COVID-19. There were no significant differences in various bacterial infections except for a significant decrease in respiratory infections. Pooled data for central line-associated bloodstream infections (CLABSIs) indicated a significant increase during the COVID-19 period, but one study reported an increase in CLABSI incidence.

CONCLUSION

The evidence from this review demonstrates a mixed impact of the COVID-19 pandemic precautions on HAIs.

Adsorption of an antiseptic in a functionalized fixed-bed: Analysis of breakthrough scenarios and validation of simplistic models defending a novel proposition

BACKGROUND

Chlorhexidine gluconate (CHG) and cetrimide, which are widely used in various pharmaceutical compositions, are considered potentially hazardous compounds. This combination was largely used during and after Covid 19 pandemic for sanitization. Removal of these two compounds from pharmaceutical waste-water with commercial and functionalized activated carbon in a packed bed column is reported.

METHODS

Effects of changes in bed height, flow rate, and initial concentration on the performance of the packed bed are analyzed using Yoon-Nelson, BDST and Thomas models for commercial scale-up operation. The effects of primary design parameters like bed depth and operating parameters like inflow rate and inlet concentration of influent wastewater are studied on the extent of removal of cetrimide and chlorhexidine gluconate. Granular activated carbon (GAC) is functionalized using HF and NH4OH. The extent of enhanced adsorption using the functionalized GAC is demonstrated using breakthrough curves.

SIGNIFICANT FINDINGS

K. H. Chu's iconic proposition is validated. Breakthrough time (BT) increases with bed heights and it is less in the case of cetrimide as compared to chlorhexidine gluconate. This shows that cetrimide wins in the competition and occupies the pores much faster than CHG. Mostly, BT-CHG (GAC) < BT-CHG (FAC-HF) < BT-CHG (FAC-NH3) and BT-cetrimide (GAC) < BT-cetrimide (FAC-NH3) < BT-cetrimide (FAC-HF) for a particular bed height. BT-CHG(FAC-HF)BT-cetrimide(FAC-HF) Collapse

Key Words

• Adsorption
• Breakthrough
• Covid-19
• Packed bed column
• Pharmaceutical wastewater
• Semi-empirical models

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MESH Headings

• Charcoal
• Water Purification
• Anti-Infective Agents, Local
• Adsorption
• Water Pollutants, Chemical/analysis
• Wastewater
• Cetrimonium
• Pharmaceutical Preparations
• Chlorhexidine/analogs & derivatives

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Grants Collapse

Affiliation(s)

Debamita Pal Department of Chemical Engineering, Jadavpur University, Kolkata, 700032, West Bengal, India
Debasree Banerjee Department of Chemical Engineering, Jadavpur University, Kolkata, 700032, West Bengal, India
Ujjaini Sarkar Department of Chemical Engineering, Jadavpur University, Kolkata, 700032, West Bengal, India.

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Assessment of antibiotic resistance patterns in Central Taiwan during the COVID-19 pandemic: A retrospective study

BACKGROUND

Antimicrobial resistance (AMR) is a growing worldwide public health issue due to the overuse and inappropriate use of antibiotics. AMR has been more prevalent during the coronavirus pandemic of 2019 (COVID-19) compared to previous periods. Therefore, this study was conducted to evaluate the AMR profile of common bacteria that were isolated for routine analysis during the pandemic of COVID-19 in Central Taiwan. The main goal of this study was to examine and analyze the AMR patterns both before and after the start of the COVID-19 pandemic.

METHODS

We conducted a retrospective analysis of clinical samples collected from two different time periods: the 1-year period before the onset of the COVID-19 pandemic (January 2019 to December 2019) and the 2-year period following the start of the pandemic (September 2020 to September 2022). The data for this study were obtained from clinical records, and both bacterial identification and antibiotic susceptibility testing were performed using the Phoenix identification system.

RESULTS

Among the 8152 bacterial isolates obtained during the study period from September 2020 to September 2022, 4022 (49.3%) were Escherichia coli, 1346 (16.5%) were Klebsiella pneumoniae, 1156 (14.2%) were Staphylococcus aureus, 887 (10.9%) were Pseudomonas aeruginosa, 376 (4.6%) were Enterococcus faecium, and 365 (4.5%) were Acinetobacter baumannii. The overall prevalence of resistant bacteria during the COVID-19 pandemic was as follows: vancomycin-resistant Enterococcus, 69%; carbapenem-resistant A. baumannii, 65%; methicillin-resistant S. aureus, 49%; carbapenem-resistant K. pneumoniae, 29%; carbapenem-resistant P. aeruginosa, 17%; and carbapenem-resistant E. coli, 2%. Carbapenem-resistant A. baumannii, vancomycin-resistant Enterococcus, carbapenem-resistant K. pneumoniae, and carbapenem-resistant E. coli increased by 19%, 10%, 2%, and 1%, respectively. On the other hand, carbapenem-resistant P. aeruginosa and methicillin-resistant S. aureus decreased by 6%, respectively.

CONCLUSION

This study provides a comprehensive assessment of AMR during the COVID-19 pandemic in Central Taiwan. Understanding the prevalence of AMR is crucial for preventing infection and formulating disease prevention policies. Further research is warranted to elucidate the correlation between AMR and the severity of infection in COVID-19 patients.

The experience of an antimicrobial stewardship program and antibiotic consumption and resistance trends during the COVID-19 pandemic at a tertiary care center in Beirut

BACKGROUND

Antimicrobial Resistance, a global concern, worsened with the COVID-19 pandemic that caused a surge of critically ill patients, increased antimicrobial consumption, and the spread of infections with multidrug-resistant organisms (MDROs). Antimicrobial Stewardship Programs (ASP) aim to optimize antimicrobial utilization to fight resistance. We aim to describe the ASP experience and to study antimicrobial consumption and MDRO rates among COVID-19 patients at a tertiary care center in Beirut.

METHODS

We compiled the ASP interventions, defined as ASP team recommendations, from January 2019 until December 2021. Data on antimicrobial consumption, expressed as a defined daily dose (DDD) per 100 patient days, was collected per quarter for all antimicrobials and restricted antimicrobials per ASP guidance. Our primary objective was to report on the ASP experience, and the secondary objective was to reflect on the rates of MDROs among hospitalized COVID-19 patients with respiratory or bloodstream bacterial co-infections between March 2020 and September 2021.

RESULTS

9922 ASP interventions were documented during this study period, with a noticeable correlation between COVID-19 surges in Lebanon and the number of ASP interventions. Acceptance rates for these recommendations improved over time, with a noticeable decrease in the proportion of interventions related to de-escalation and discontinuation of broad-spectrum antimicrobials. We noted an increase in all antimicrobial consumption after the onset of the pandemic, peaking in Q4 2020 (142.8 DDD of anti-infectives/100 patient days) and Q1 2021 (79.1 DDD of restricted anti-infectives/100 patient days). As expected, MDROs, particularly ESKAPE organisms (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Carbapenem-resistant Enterobacteriaceae) accounted for 24% of isolates obtained from this cohort.

CONCLUSION

This study highlights the experience of the ASP as we adapted to the COVID-19 pandemic. The ASP team maintained its operations and continued to monitor antibiotic consumption and provide recommendations to limit antibiotic misuse in an effort to mitigate the impact of the pandemic on antimicrobial resistance.

Use of Multiple Doses of Intravenous Infusion of Umbilical Cord-Mesenchymal Stem Cells for the Treatment of Adult Patients with Severe COVID-19-Related Acute Respiratory Distress Syndrome: Literature Review

Objectives

Acute respiratory distress syndrome (ARDS) is a critical complication in severe COVID-19 patients. The intravenous infusion (IVF) of umbilical cord- (UC-) mesenchymal stem cells (MSCs), validated to substantially reduce the release of several inflammatory cytokines in vivo, was also shown to exhibit benefits in improving hypoxemia among severe COVID-19 patients. A single dose of IVF-UC-MSCs therapy for severe COVID-19 patients was shown to alleviate the initial ARDS severity, but have 50%-67% case-fatality rates. In Taiwan, few adult patients with severe COVID-19-induced ARDS receiving compassionate adjuvant treatment consisting of either a single dose (1-10 × 106 cells/kg body weight (kg BW)) or three doses (5 × 106 cells/kg BW in each dose) of IVF-UC-MSCs had good outcomes. However, the optimal dosage and rounds of IVF-UC-MSCs administration for the treatment of severe COVID-19 patients with ARDS are undetermined.

Methods

We reviewed the 2020-2022 PubMed literature database concerning the clinical efficacy of IVF-UC-MSCs among severe COVID-19 patients.

Results

The data of COVID-19 case series in the PubMed literature revealed a notable heterogeneity in the therapeutic dosage (a single dose: 1-10 × 106 cells/kg BW; and three doses: 50-200 × 106 cells/kg BW in each dose) and the post-ARDS days of IVF-UC-MSCs administration (a single dose: 1-12; and multiple doses: 5-14) for the treatment of severe COVID-19-associated ARDS. The survival rates among these severe COVID-19 patients ranged from 50% to 76%. However, an overall rate of 93.1% of significant improvement in hypoxemia was observed for the COVID-19 survivors receiving IVF-UC-MSCs at the initial ARDS stage.

Conclusions

According to our analysis, the ideal treatment dosage of IVF-UC-MSCs for severe COVID-19-induced ARDS is likely 5 × 106 cells/kg BW for three cycles within 5 days of ARDS onset in severe COVID-19 patients.

The Hidden Cost of COVID-19: Focus on Antimicrobial Resistance in Bloodstream Infections

Antibiotic resistance is one of the greatest growing public health threats and a worldwide priority. According to the WHO, drug-resistant diseases may cause 10 million deaths a year by 2050 and have a substantial impact on the global economy, driving up to 24 million people into poverty. The ongoing COVID-19 pandemic has exposed the fallacies and vulnerability of healthcare systems worldwide, displacing resources from existing programs and reducing funding for antimicrobial resistance (AMR) fighting efforts. Moreover, as already seen for other respiratory viruses, such as flu, COVID-19 is often associated with superinfections, prolonged hospital stays, and increased ICU admissions, further aggravating healthcare disruption. These events are accompanied by widespread antibiotic use, misuse, and inappropriate compliance with standard procedures with a potential long-term impact on AMR. Still, COVID-19-related measures such as increasing personal and environmental hygiene, social distancing, and decreasing hospital admissions could theoretically help the AMR cause. However, several reports have shown increased antimicrobial resistance during the COVID-19 pandemic. This narrative review focuses on this "twindemic", assessing the current knowledge of antimicrobial resistance in the COVID-19 era with a focus on bloodstream infections and provides insights into the lessons learned in the COVID-19 field that could be applied to antimicrobial stewardship initiatives.

Trends in Antibiotic Resistance of Nosocomial and Community-Acquired Infections in Italy

The World Health Organization has recently identified three categories of pathogens, namely: critical, high, and medium priority, according to the need for new antibiotics. Critical priority pathogens include carbapenem-resistant microorganism (CPO) such as A. baumannii and P. aeruginosa, K. pneumoniae, and Enterobacter spp., whereas vancomycin-resistant E. faecium (VRE), methicillin and vancomycin-resistant S. aureus (MRSA) are in the high priority list. We compared the trend of antimicrobial resistants (AMRs) in clinical isolates, divided by year and bacteria spp., of samples obtained from nosocomial and community patients. Patient records were collected, including age, sex, site of infection, isolated organisms, and drug susceptibility patterns. From 2019 to 2022, a total of 113,635 bacterial isolates were tested, of which 11,901 resulted in antimicrobial resistants. An increase in the prevalence of several antibiotics resistant bacteria was observed. Specifically, the percentage of CPO cases increased from 2.62% to 4.56%, the percentage of MRSA increased from 1.84% to 2.81%, and the percentage of VRE increased from 0.58% to 2.21%. AMRs trend resulted in increases in CPO and MRSA for both community and nosocomial. Our work aims to highlight the necessity of preventive and control measures to be adopted in order to reduce the spread of multidrug-resistant pathogens.