Antibiotic-resistant organisms establish reservoirs in new hospital built environments and are related to patient blood infection isolates

Healthcare as a driver, reservoir and amplifier of antimicrobial resistance: opportunities for interventions

Antimicrobial resistance (AMR) is a global health challenge that threatens humans, animals and the environment. Evidence is emerging for a role of healthcare infrastructure, environments and patient pathways in promoting and maintaining AMR via direct and indirect mechanisms. Advances in vaccination and monoclonal antibody therapies together with integrated surveillance, rapid diagnostics, targeted antimicrobial therapy and infection control measures offer opportunities to address healthcare-associated AMR risks more effectively. Additionally, innovations in artificial intelligence, data linkage and intelligent systems can be used to better predict and reduce AMR and improve healthcare resilience. In this Review, we examine the mechanisms by which healthcare functions as a driver, reservoir and amplifier of AMR, contextualized within a One Health framework. We also explore the opportunities and innovative solutions that can be used to combat AMR throughout the patient journey. We provide a perspective on the current evidence for the effectiveness of interventions designed to mitigate healthcare-associated AMR and promote healthcare resilience within high-income and resource-limited settings, as well as the challenges associated with their implementation.

A narrative review and update on drain-related outbreaks

BACKGROUND

Outbreaks linked to hospital drainage systems are well reported, and continue to present challenges to incident management teams. Such outbreaks can be protracted and complex, with multi-modal strategies being required for remediation.

AIM

To summarize recent drain-related outbreaks, investigate whether multi-modal control measures are being implemented, and determine any antecedent factors.

METHODS

Databases were searched for drain-related outbreaks over a 5-year period. Search terms employed included 'healthcare drainage outbreaks', 'drain outbreaks', 'drainage system outbreaks', 'sink outbreaks' and 'shower outbreaks'. Information was collected on country of origin, pathogens involved, unit affected, drain types, patient numbers, drainage system interventions, type of drain disinfectant, infection control interventions, typing method, outcomes and any antecedent factors.

FINDINGS

Nineteen drain-related outbreak studies were reviewed. The majority of incidents were due to carbapenemase-producing Enterobacterales, and were from critical care settings. Most (16/19) studies recognized the need for a multi-modal approach. Information on the success of interventions was not documented for all incidents, but 13/19 studies reported no further cases after control measures. Variation in the choice of agent and frequency of application exists with regards to drain disinfection. Seven studies discussed antecedent factors.

CONCLUSION

Despite drain-related outbreaks being reported for the last 24 years and review articles on the subject, outbreaks continue to pose significant challenges. There is currently no UK guidance on the management of drain-related outbreaks or the design of new buildings to mitigate the risk. Addressing the challenges from hospital drainage systems should be considered a priority by agencies and guidance developers.

Controlling the hospital aquatic reservoir of multidrug-resistant organisms: a cross-sectional study followed by a nested randomized trial of sink decontamination

OBJECTIVES

The hospital water environment is an important reservoir of multidrug-resistant organisms (MDROs) and presents a risk for patient safety. We assessed the effectiveness of thermal and chemical interventions on sinks contaminated with MDRO in the hospital setting.

METHODS

We conducted a cross-sectional assessment of MDRO contamination of sinks and toilets in 26 clinical wards of a tertiary care hospital. MDRO-contaminated sink traps were then replaced and randomized (1:1:1) to receive chemical (sodium hypochlorite), thermal disinfection (steam), or no intervention. Interventions were repeated weekly for 4 weeks. Sinks were resampled 7 days after the last intervention. The primary outcome was the proportion of decontaminated sinks. MDROs of interest were extended spectrum beta-lactamase (ESBL) producing and carbapenemase-producing Enterobacterales, and non-fermentative Gram-negative bacilli.

RESULTS

In the cross-sectional assessment, at least one MDRO was identified in 258 (36%) of the 748 samples and in 91 (47%) of the 192 water sources. In total, 57 (42%) of the 137 sinks and 34 (62%) of the 55 toilets were contaminated with 137 different MDROs. The most common MDRO were ESBL Enterobacterales (69%, 95/137), followed by Verona Integron-Borne Metallo-β-Lactamase (VIM) carbapenemase producing Pseudomonas aeruginosa (9%, 12/137) and Citrobacter spp. (6%, 5/137). In the nested randomized trial, five of the 16 sinks (31%) in the chemical disinfection group were decontaminated, compared with 8 of 18 (44%) in the control group (OR 0.58; 95% CI, 0.14-2.32) and 9 of 17 (53%) in the thermal disinfection group (OR 1.40; 95% CI, 0.37-5.32).

DISCUSSION

Our study failed to demonstrate an added benefit of repeated chemical or thermal disinfection, beyond changing sink traps, in the MDRO decontamination of sinks. Routine chlorine-based disinfection of sinks may need to be reconsidered.

Persistent enrichment of multidrug-resistant Klebsiella in oral and nasal communities during long-term starvation

BACKGROUND

The human oral and nasal cavities can act as reservoirs for opportunistic pathogens capable of causing acute infection. These microbes asymptomatically colonize the human oral and nasal cavities which facilitates transmission within human populations via the environment, and they routinely possess clinically significant antibiotic resistance genes. Among these opportunistic pathogens, the Klebsiella genus stands out as a notable example, with its members frequently linked to nosocomial infections and multidrug resistance. As with many colonizing opportunistic pathogens, the essential transmission factors influencing the spread of Klebsiella species among both healthy and diseased individuals remain unclear.

RESULTS

Here, we explored a possible explanation by investigating the ability of oral and nasal Klebsiella species to outcompete their native microbial community members under in vitro starvation conditions, which could be analogous to external hospital environments or the microenvironment of mechanical ventilators. When K. pneumoniae and K. aerogenes were present within a healthy human oral or nasal sample, the bacterial community composition shifted dramatically under starvation conditions and typically became enriched in Klebsiella species. Furthermore, introducing K. pneumoniae exogenously into a native microbial community lacking K. pneumoniae, even at low inoculum, led to repeated enrichment under starvation. Precise monitoring of K. pneumoniae within these communities undergoing starvation indicated rapid initial growth and prolonged viability compared to other members of the microbiome. K. pneumoniae strains isolated from healthy individuals' oral and nasal cavities also exhibited resistance to multiple classes of antibiotics and were genetically similar to clinical and gut isolates. In addition, we found that in the absence of Klebsiella species, other understudied opportunistic pathogens, such as Peptostreptococcus, increased in relative abundance under starvation conditions.

CONCLUSIONS

Our findings establish an environmental and microbiome community circumstance that allows for the enrichment of Klebsiella species and other opportunistic pathogens. Klebsiella's enrichment may hinge on its ability to quickly outgrow other members of the microbiome. The ability to outcompete other commensal bacteria and to persist under harsh environmental conditions could be an important factor that contributes to enhanced transmission in both commensal and pathogenic contexts. Video Abstract.

Stenotrophomonas maltophilia: The Landscape in Critically Ill Patients and Optimising Management Approaches

The aim of this review is to synthesise the key aspects of the epidemiology, current microbiological diagnostic challenges, antibiotic resistance rates, optimal antimicrobial management, and most effective prevention strategies for Stenotrophomonas maltophilia (SM) in the intensive care unit (ICU) population. In recent years, resistance surveillance data indicate that SM accounts for less than 3% of all healthcare-associated infection strains, a percentage that doubles in the case of ventilator-associated pneumonia (VAP). Interestingly, SM ranks as the third most isolated non-glucose fermenter Gram-negative bacilli (NFGNB). Although this NFGNB genus has usually been considered a bystander and colonising strain, recently published data warn about its potential role as a causative pathogen of severe infections, particularly pneumonia and bloodstream infections (BSI), not only for the classical immunocompromised susceptible host patients but also for critically ill ones even without overt immunosuppression. Indeed, it has been associated with crude 28-day mortality as high as 54.8%, despite initial response following targeted therapy. Additionally, alongside its intrinsic resistance to a wide range of common antimicrobials, various worldwide and local surveillance studies raise concerns about an increase in ICU settings regarding resistance to first-line drugs such as cotrimoxazole or tigecycline. This scenario alerts ICU physicians to the need to reconsider the best stewardship approach when SM is isolated in obtained samples from critically ill patients. Despite the coverage of this multidrug-resistant bacterium (MDRB) provided by some traditional and a non-negligible number of current pipeline antimicrobials, an ecological and cost-effective strategy is needed in the present era.

Non-Canonical Aspects of Antibiotics and Antibiotic Resistance

The understanding of antibiotic resistance, one of the major health threats of our time, is mostly based on dated and incomplete notions, especially in clinical contexts. The "canonical" mechanisms of action and pharmacodynamics of antibiotics, as well as the methods used to assess their activity upon bacteria, have not changed in decades; the same applies to the definition, acquisition, selective pressures, and drivers of resistance. As a consequence, the strategies to improve antibiotic usage and overcome resistance have ultimately failed. This review gathers most of the "non-canonical" notions on antibiotics and resistance: from the alternative mechanisms of action of antibiotics and the limitations of susceptibility testing to the wide variety of selective pressures, lateral gene transfer mechanisms, ubiquity, and societal factors maintaining resistance. Only by having a "big picture" view of the problem can adequate strategies to harness resistance be devised. These strategies must be global, addressing the many aspects that drive the increasing prevalence of resistant bacteria aside from the clinical use of antibiotics.

Point prevalence of evidence-based antimicrobial use among hospitalized patients in sub-Saharan Africa: a systematic review and meta-analysis

Excessive and improper use of antibiotics causes antimicrobial resistance which is a major threat to global health security. Hospitals in sub-Saharan Africa (SSA) has the highest prevalence of antibiotic use. This systematic review and meta-analysis aimed to determine the pooled point prevalence (PPP) of evidence-based antimicrobial use among hospitalized patients in SSA. Literature was retrieved from CINAHL, EMBASE, Google Scholar, PubMed, Scopus, and Web of Science databases. Meta-analysis was conducted using STATA version 17. Forest plots using the random-effect model were used to present the findings. The heterogeneity and publication bias were assessed using the I2 statistics and Egger's test. The protocol was registered in PROSPERO with code CRD42023404075. The review was conducted according to PRISMA guidelines. A total of 26, 272 study participants reported by twenty-eight studies published from 10 countries in SSA were included. The pooled point prevalence of antimicrobial use in SSA were 64%. The pooled estimate of hospital wards with the highest antibiotic use were intensive care unit (89%). The pooled prevalence of the most common clinical indication for antibiotic use were community acquired infection (41%). The pooled point prevalence of antimicrobial use among hospitalized patients were higher in SSA. Higher use of antibiotics was recorded in intensive care units. Community acquired infection were most common clinical case among hospitalized patients. Health systems in SSA must design innovative digital health interventions to optimize clinicians adhere to evidence-based prescribing guidelines and improve antimicrobial stewardship.

Epidemiology of healthcare-associated Pseudomonas aeruginosa in intensive care units: are sink drains to blame?

BACKGROUND

Pseudomonas aeruginosa (PA) is a common cause of healthcare-associated infection (PA-HAI) in the intensive care unit (ICU).

AIM

To describe the epidemiology of PA-HAI in ICUs in Ontario, Canada, and to identify episodes of sink-to-patient PA transmission.

METHODS

This was a prospective cohort study of patients in six ICUs from 2018 to 2019, with retrieval of PA clinical isolates, and PA-screening of antimicrobial-resistant organism surveillance rectal swabs, and of sink drain, air, and faucet samples. All PA isolates underwent whole-genome sequencing. PA-HAI was defined using US National Healthcare Safety Network criteria. ICU-acquired PA was defined as PA isolated from specimens obtained ≥48 h after ICU admission in those with prior negative rectal swabs. Sink-to-patient PA transmission was defined as ICU-acquired PA with close genomic relationship to isolate(s) previously recovered from sinks in a room/bedspace occupied 3-14 days prior to collection date of the relevant patient specimen.

FINDINGS

Over ten months, 72 PA-HAIs occurred among 60/4263 admissions. The rate of PA-HAI was 2.40 per 1000 patient-ICU-days; higher in patients who were PA-colonized on admission. PA-HAI was associated with longer stay (median: 26 vs 3 days uninfected; P < 0.001) and contributed to death in 22/60 cases (36.7%). Fifty-eight admissions with ICU-acquired PA were identified, contributing 35/72 (48.6%) PA-HAIs. Four patients with five PA-HAIs (6.9%) had closely related isolates previously recovered from their room/bedspace sinks.

CONCLUSION

Nearly half of PA causing HAI appeared to be acquired in ICUs, and 7% of PA-HAIs were associated with sink-to-patient transmission. Sinks may be an under-recognized reservoir for HAIs.

The ICU environment contributes to the endemicity of the "Serratia marcescens complex" in the hospital setting

Serratia marcescens is an opportunistic pathogen historically associated with sudden outbreaks in intensive care units (ICUs) and the spread of carbapenem-resistant genes. However, the ecology of S. marcescens populations in the hospital ecosystem remains largely unknown. We combined epidemiological information of 1,432 Serratia spp. isolates collected from sinks of a large ICU that underwent demographic and operational changes (2019-2021) and 99 non-redundant outbreak/non-outbreak isolates from the same hospital (2003-2019) with 165 genomic data. These genomes were grouped into clades (1-4) and subclades (A and B) associated with distinct species: Serratia nematodiphila (1A), S. marcescens (1B), Serratia bockelmannii (2A), Serratia ureilytica (2B), S. marcescens/Serratia nevei (3), and S. nevei (4A and 4B). They may be classified into an S. marcescens complex (SMC) due to the similarity between/within subclades (average nucleotide identity >95%-98%), with clades 3 and 4 predominating in our study and publicly available databases. Chromosomal AmpC β-lactamase with unusual basal-like expression and prodigiosin-lacking species contrasted classical features of Serratia. We found persistent and coexisting clones in sinks of subclades 4A (ST92 and ST490) and 4B (ST424), clonally related to outbreak isolates carrying blaVIM-1 or blaOXA-48 on prevalent IncL/pB77-CPsm plasmids from our hospital since 2017. The distribution of SMC populations in ICU sinks and patients reflects how Serratia species acquire, maintain, and enable plasmid evolution in both "source" (permanent, sinks) and "sink" (transient, patients) hospital patches. The results contribute to understanding how water sinks serve as reservoirs of Enterobacterales clones and plasmids that enable the persistence of carbapenemase genes in healthcare settings, potentially leading to outbreaks and/or hospital-acquired infections.IMPORTANCEThe "hospital environment," including sinks and surfaces, is increasingly recognized as a reservoir for bacterial species, clones, and plasmids of high epidemiological concern. Available studies on Serratia epidemiology have focused mainly on outbreaks of multidrug-resistant species, overlooking local longitudinal analyses necessary for understanding the dynamics of opportunistic pathogens and antibiotic-resistant genes within the hospital setting. This long-term genomic comparative analysis of Serratia isolated from the ICU environment with isolates causing nosocomial infections and/or outbreaks within the same hospital revealed the coexistence and persistence of Serratia populations in water reservoirs. Moreover, predominant sink strains may acquire highly conserved and widely distributed plasmids carrying carbapenemase genes, such as the prevalent IncL-pB77-CPsm (pOXA48), persisting in ICU sinks for years. The work highlights the relevance of ICU environmental reservoirs in the endemicity of certain opportunistic pathogens and resistance mechanisms mainly confined to hospitals.

Identification of carbapenem-resistant organism (CRO) contamination of in-room sinks in intensive care units in a new hospital bed tower

BACKGROUND

The origins and timing of inpatient room sink contamination with carbapenem-resistant organisms (CROs) are poorly understood.

METHODS

We performed a prospective observational study to describe the timing, rate, and frequency of CRO contamination of in-room handwashing sinks in 2 intensive care units (ICU) in a newly constructed hospital bed tower. Study units, A and B, were opened to patient care in succession. The patients in unit A were moved to a new unit in the same bed tower, unit B. Each unit was similarly designed with 26 rooms and in-room sinks. Microbiological samples were taken every 4 weeks from 3 locations from each study sink: the top of the bowl, the drain cover, and the p-trap. The primary outcome was sink conversion events (SCEs), defined as CRO contamination of a sink in which CRO had not previously been detected.

RESULTS

Sink samples were obtained 22 times from September 2020 to June 2022, giving 1,638 total environmental cultures. In total, 2,814 patients were admitted to study units while sink sampling occurred. We observed 35 SCEs (73%) overall; 9 sinks (41%) in unit A became contaminated with CRO by month 10, and all 26 sinks became contaminated in unit B by month 7. Overall, 299 CRO isolates were recovered; the most common species were Enterobacter cloacae and Pseudomonas aeruginosa.

CONCLUSION

CRO contamination of sinks in 2 newly constructed ICUs was rapid and cumulative. Our findings support in-room sinks as reservoirs of CRO and emphasize the need for prevention strategies to mitigate contamination of hands and surfaces from CRO-colonized sinks.

Unveiling therapeutic efficacy of extract and multi-targeting phytocompounds from Christella dentata (Forssk.) Brownsey & Jermy against multidrug-resistant Pseudomonas aeruginosa

Christella dentata (Forssk.) Brownsey & Jermy has been commonly used in traditional medicinal practices but its effects on multi-drug-resistant (MDR) bacteria have remained unexplored. We aimed to assess the in vitro antibacterial potential of the ethanol extract of Christella dentata (EECD) against MDR Pseudomonas aeruginosa and to identify potential multi-targeting antibacterial phytocompounds through computer-aided drug design focusing on the LasR and LpxC proteins. PPS, FT-IR and GC-MS were used for profiling of the phytocompounds in EECD. The antimicrobial activity of EECD was assessed using in vitro agar well diffusion, disc diffusion, MIC and MBC. Computer-aided drug design was used to identify multi-targeting leads from GC-MS-annotated phytocompounds. EECD exhibited dose-dependent antibacterial activity and revealed the presence of 51 phytocompounds in GC-MS analysis. Among these, three phytocompounds; (2E,4E)-N-isobutylhexadeca-2,4-dienamide (CID 6442402), bicyclo[4.3.0]nonane, 2,2,6,7-tetramethyl-7-hydroxy- (CID 536446) and 1,4-diethylbenzene (CID 7734) were identified as promising antibacterial phytocompounds as they strongly bonded with LasR and LpxC. Of them, CID 536446 and CID 7734 exhibited multiple targeting abilities with LasR and LpxC. On further screening, both CID 536446 and CID 7734 exhibited favorable drug-able, pharmacokinetics and toxicity properties. Finally, molecular dynamics (MD) simulation proved the binding stability of bicyclo[4.3.0]nonane, 2,2,6,7-tetramethyl-7-hydroxy- and 1,4-diethylbenzene to active pockets of LasR and LpxC. The results of this study offer scientific validation for the traditional use of Christella dentata in bacterial infection-related diseases. It also suggests that bicyclo[4.3.0]nonane, 2,2,6,7-tetramethyl-7-hydroxy- and 1,4-diethylbenzene from Christella dentata might be responsible for the antibacterial activity and could act as phytopharmacological leads for the development of LasR and LpxC inhibitors against MDR P. aeruginosa.

Early life exposure of infants to benzylpenicillin and gentamicin is associated with a persistent amplification of the gut resistome

BACKGROUND

Infant gut microbiota is highly malleable, but the long-term longitudinal impact of antibiotic exposure in early life, together with the mode of delivery on infant gut microbiota and resistome, is not extensively studied.

METHODS

Two hundred and eight samples from 45 infants collected from birth until 2 years of age over five time points (week 1, 4, 8, 24, year 2) were analysed. Based on shotgun metagenomics, the gut microbial composition and resistome profile were compared in the early life of infants divided into three groups: vaginal delivery/no-antibiotic in the first 4 days of life, C-section/no-antibiotic in the first 4 days of life, and C-section/antibiotic exposed in first 4 days of life. Gentamycin and benzylpenicillin were the most commonly administered antibiotics during this cohort's first week of life.

RESULTS

Newborn gut microbial composition differed in all three groups, with higher diversity and stable composition seen at 2 years of age, compared to week 1. An increase in microbial diversity from week 1 to week 4 only in the C-section/antibiotic-exposed group reflects the effect of antibiotic use in the first 4 days of life, with a gradual increase thereafter. Overall, a relative abundance of Actinobacteria and Bacteroides was significantly higher in vaginal delivery/no-antibiotic while Proteobacteria was higher in C-section/antibiotic-exposed infants. Strains from species belonging to Bifidobacterium and Bacteroidetes were generally persistent colonisers, with Bifidobacterium breve and Bifidobacterium bifidum species being the major persistent colonisers in all three groups. Bacteroides persistence was dominant in the vaginal delivery/no-antibiotic group, with species Bacteroides ovatus and Phocaeicola vulgatus found to be persistent colonisers in the no-antibiotic groups. Most strains carrying antibiotic-resistance genes belonged to phyla Proteobacteria and Firmicutes, with the C-section/antibiotic-exposed group presenting a higher frequency of antibiotic-resistance genes (ARGs).

CONCLUSION

These data show that antibiotic exposure has an immediate and persistent effect on the gut microbiome in early life. As such, the two antibiotics used in the study selected for strains (mainly Proteobacteria) which were multiple drug-resistant (MDR), presumably a reflection of their evolutionary lineage of historical exposures-leading to what can be an extensive and diverse resistome. Video Abstract.

Cross-contamination of carbapenem-resistant Gram-negative bacteria between patients and the hospital environment in the first year of a newly built surgical ward

BACKGROUND

Transmission and outbreaks of carbapenem-resistant Gram-negative bacteria (CRGN) in hospitals are often associated with contamination of the wastewater environment. We performed a prospective observational study to investigate the colonization of the hospital wastewater environment during the first year of occupancy of the surgical intermediate and intensive care units of a newly constructed building at the University Hospital of Heidelberg, Germany.

METHODS

We performed monthly screening of the wastewater system (toilets and sinks) for 12 months, starting 1 month before opening (1st October 2020 to 30th October 2021). Admission and weekly rectal screening of patients for CRGN were also performed in parallel. Bacterial isolates were characterized by whole-genome sequencing.

RESULTS

Twenty-seven of 1978 (1.4%) admitted patients were colonized/infected with CRGN. A total of 29 CRGN isolates from 24 patients and 52 isolates were available for sequencing. Within the first month of occupancy, we identified seven patients colonized/infected with CRGN, while none were found in the environmental reservoirs. The first detection of CRGN isolates in the sewage system started five months after the first occupancy. Two previously non-colonized patients were colonized/infected with Pseudomonas aeruginosa strains colonizing the sewage system. The significant identity of plasmids carrying the carbapenemase gene suggests that long-term colonization of the sewage system facilitates the emergence of new carbapenem-resistant clones.

CONCLUSION

Cross-contamination between patients and the hospital environment is bidirectional. Our study demonstrated that contamination of the hospital wastewater environment may lead to persistent colonization and may serve as a reservoir for nosocomial acquisition of CRGN.

Insights into the Microbiome and Antibiotic Resistance Genes from Hospital Environmental Surfaces: A Prime Source of Antimicrobial Resistance

Hospital environmental surfaces are potential reservoirs for transmitting hospital-associated pathogens. This study aimed to profile microbiomes and antibiotic resistance genes (ARGs) from hospital environmental surfaces using 16S rRNA amplicon and metagenomic sequencing at a tertiary teaching hospital in Malaysia. Samples were collected from patient sinks and healthcare staff counters at surgery and orthopaedic wards. The samples' DNA were subjected to 16S rRNA amplicon and shotgun sequencing to identify bacterial taxonomic profiles, antibiotic resistance genes, and virulence factor pathways. The bacterial richness was more diverse in the samples collected from patient sinks than those collected from staff counters. Proteobacteria and Verrucomicrobia dominated at the phylum level, while Bacillus, Staphylococcus, Pseudomonas, and Acinetobacter dominated at the genus level. Staphylococcus epidermidis and Staphylococcus aureus were prevalent on sinks while Bacillus cereus dominated the counter samples. The highest counts of ARGs to beta-lactam were detected, followed by ARGs against fosfomycin and cephalosporin. We report the detection of mcr-10.1 that confers resistance to colistin at a hospital setting in Malaysia. The virulence gene pathways that aid in antibiotic resistance gene transfer between bacteria were identified. Environmental surfaces serve as potential reservoirs for nosocomial infections and require mitigation strategies to control the spread of antibiotic resistance bacteria.

How to Defeat Multidrug-Resistant Bacteria in Intensive Care Units. A Lesson from the COVID-19 Pandemic. Prevention, Reservoirs, and Implications for Clinical Practice

Background: Intensive care unit (ICU) patients are at high risk of infection due to multiple invasive procedures, malnutrition, or immunosuppression. The rapid increase in infections with multidrug-resistant organisms (MDRO) during the COVID-19 pandemic caused a dilemma, as the rules of the sanitary regime in ICU rooms were strictly adhered to in the prevailing epidemiological situation. The combat to reduce the number of infections and pathogen transmission became a priority for ICU staff. This study aimed to assess whether eliminating environmental reservoirs and implementing improved procedures for patient care and decontamination and washing equipment in the ICU reduced the incidence of infections caused by MDR strains. Material and methods: The study retrospectively analyzed data in the ICU during the COVID-19 pandemic. The samples were collected based on microbiological culture and medical records in the newly opened ICU (10 stations) and hospital wards where COVID-19 patients were hospitalized. Environmental inoculations were performed during the COVID-19 pandemic every 4-6 weeks unless an increase in the incidence of infections caused by MDR strains was observed. Through microbiological analysis, environmental reservoirs of MDR pathogens were identified. The observation time was divided into two periods, before and after the revised procedures. The relationship between isolated strains of Klebsiella pneumoniae NDM from patients and potential reservoirs within the ICU using ERIC-PCR and dice methods was analyzed. Results: An increased frequency of infections and colonization caused by MDRO was observed compared to the preceding years. A total of 23,167 microbiological tests and 6,985 screening tests for CPE and MRSA bacilli were collected. The pathogen spread was analyzed, and the findings indicated procedural errors. Assuming that the transmission of infections through the staff hands was significantly limited by the restrictive use of personal protective equipment, the search for a reservoir of microorganisms in the environment began. MDR strains were grown from the inoculations collected from the hand-wash basins in the wards and from inside the air conditioner on the ceiling outside the patient rooms. New types of decontamination mats were used in high-risk areas with a disinfectant based on Glucoprotamine. Active chlorine-containing substances were widely used to clean and disinfect surfaces. Conclusions: Infections with MDR strains pose a challenge for health care. Identification of bacterial reservoirs and comprehensive nursing care significantly reduce the number of nosocomial infections.

Persistent enrichment of multidrug resistant Klebsiella in oral and nasal communities during long-term starvation

The human oral and nasal cavities can act as reservoirs for opportunistic pathogens capable of causing acute infection. These microbes asymptomatically colonize the human oral and nasal cavities which facilitates transmission within human populations via the environment, and they routinely possess a clinically-significant antibiotic-resistance genes. Among these opportunistic pathogens, the Klebsiella genus stands out as a notable example, with its members frequently linked to nosocomial infections and multidrug resistance. As with many colonizing opportunistic pathogens, how Klebsiella transitions from an asymptomatic colonizer to a pathogen remains unclear. Here, we explored a possible explanation by investigating the ability of oral and nasal Klebsiella to outcompete their native microbial community members under in vitro starvation conditions, which could be analogous to external hospital environments. When Klebsiella was present within a healthy human oral or nasal sample, the bacterial community composition shifted dramatically under starvation conditions and typically became dominated by Klebsiella. Furthermore, introducing K. pneumoniae exogenously into a native microbial community lacking K. pneumoniae, even at low inoculum, led to repeated dominance under starvation. K.pneumoniae strains isolated from healthy individuals' oral and nasal cavities also exhibited resistance to multiple classes of antibiotics and were genetically similar to clinical and gut isolates. In addition, we found that in the absence of Klebsiella, other understudied opportunistic pathogens, such as Peptostreptococcus, dominate under starvation conditions. Our findings establish an environmental circumstance that allows for the outgrowth of Klebsiella and other opportunistic pathogens. The ability to outcompete other commensal bacteria and to persist under harsh environmental conditions may contribute to the colonization-to-infection transition of these opportunistic pathogens.

Molecular distribution of biocide resistance genes and susceptibility to biocides among vancomycin resistant Staphylococcus aureus (VRSA) isolates from intensive care unit (ICU) of cardiac hospital- A first report from Pakistan

Background

The study was conducted with the aim to investigate the VRSA isolates in terms of their susceptibility to routinely used biocides influenced by the co-occurrence of biocide resistant gene (BRGs) and efflux pumps genes.

Methodology

Frequently touched surfaces within intensive care unit (ICU) of cardiac hospital were classified into three primary sites i.e., structure, machines and miscellaneous. Over a period of six months (January 2021 to July 2021) twenty three swabs samples were collected from these sites. Subsequently, these samples underwent both phenotypic and molecular methods for VRSA isolation and identification. Susceptibility and efficacy testing of biocides (benzalkonium chloride (BAC), cetrimide (CET) and chlorhexidine gluconate (CHG)) were evaluated using microdilution broth and suspension method. Furthermore, specific primers were used for singleplex PCR targeting BRGs (cepA, qacA, and qacE) and efflux pump (norA, norB, norC, sepA, mepA and mdeA) associated genes.

Results

We found that 72.2 % S. aureus demonstrate the presence of vanA or vanB genes with no significant difference among three sites (p > 0.05). cepA is the most dominant BRGs followed by qacA and qacE from structure site as compared to other sites (p < 0.05). BAC showed reduced biocide susceptibility and MIC50. There was no significant difference between presence or absence of BRGs and high MIC values of VRSA isolates from all three sites. However, efflux pump genes (EFPGs) particularly norA and norA + sepA had a significant association with BRGs and reduced biocide.

Conclusion

BAC is the most effective disinfectant against VRSA. Proper and controlled use of BAC is required to overcome the VRSA contamination. We recommend continuous monitoring of the BRGs prevalence for better prevention of microorganism dissemination and infection control in hospitals.

Current viewpoint on the epidemiology of nonfermenting Gram-negative bacterial strains

PURPOSE OF REVIEW

This article aims to review the epidemiology of nonfermenting Gram-negative bacilli (NFGNB) based on recent literature reports, particularly, of the less common, but with emerging clinical significance species.

RECENT FINDINGS

The reported frequency of multidrug-resistant Acinetobacter baumannii and Pseudomonas aeruginosa is increasing, with very significant variability, however, between different countries. Apart from the major NFGNB, that is, A. baumannii and P. aeruginosa, already recognized as of critical importance healthcare risks, several other NFGNB genera have been increasingly associated with diverse severe infections, such as Stenotrophomonas maltophilia, Burkholderia spp., Elizabethkingia spp., Chryseobacterium spp., Achromobacter spp., Alcaligenes spp., Sphingomonas spp., Shewanella spp. and Ralstonia spp., among others.

SUMMARY

The exploration of the epidemiology, as well as the pathogenic potential of the of the less frequent, but emerging and increasingly reported NFGNB, is crucial, not only for immunocompromised patients, but also for critically ill patients without overt immunosuppression. As we are heading fast towards a postantibiotic era, such information would contribute to the optimal antimicrobial management, that is, providing prompt, appropriate antimicrobial coverage when needed and, at the same time, avoiding overuse and/or inappropriate use of antimicrobial therapy. Also, it would help to better understand their transmission dynamics and to develop effective prevention strategies.

Healthcare-Associated Infections and the Hospital Bed

OBJECTIVE

Bedframes are a potential source of bacterial contamination, fomites, and healthcare-associated infections for patients with active skin wounds and other underlying conditions. Bedframes also differ in their design, materials, texture, and ease of disassembly for cleaning. In this study, the authors evaluated five hospital bedframes in terms of retained soil and ease of cleaning as rated by volunteers.

METHODS

Hospital mattresses were placed on five different bedframes and soiled with mock bodily fluids containing Geobacillus stearothermophilus endospores as an indicator organism for contamination. In a second set of experiments, volunteers evaluated the bedframes for ease of cleaning; fewer than 30% of the volunteers had experience cleaning in hospitals or had previously received infection-control training. Questionnaires evaluated subjective measures such as ease of cleaning and texture.

RESULTS

Researchers observed a strong correlation between the initial amount of soil retained, the most probable number calculations of endospore counts, and the number of washes to reach extinction (no detectable endospores). Although volunteers' rankings for ease of cleaning were independent of the amount of soil retained, their rankings correlated with the actual washes to reach undetectable limits and bedframe materials that were perceived as harder to clean.

CONCLUSIONS

This study demonstrates the importance of both bedframe design and user cleaning experience in reducing bedframes as a source of healthcare-associated infections.

Intensive care unit sinks are persistently colonized with multidrug resistant bacteria and mobilizable, resistance-conferring plasmids

Contamination of hospital sinks with microbial pathogens presents a serious potential threat to patients, but our understanding of sink colonization dynamics is largely based on infection outbreaks. Here, we investigate the colonization patterns of multidrug-resistant organisms (MDROs) in intensive care unit sinks and water from two hospitals in the USA and Pakistan collected over 27 months of prospective sampling. Using culture-based methods, we recovered 822 bacterial isolates representing 104 unique species and genomospecies. Genomic analyses revealed long-term colonization by Pseudomonas spp. and Serratia marcescens strains across multiple rooms. Nanopore sequencing uncovered examples of long-term persistence of resistance-conferring plasmids in unrelated hosts. These data indicate that antibiotic resistance (AR) in Pseudomonas spp. is maintained both by strain colonization and horizontal gene transfer (HGT), while HGT maintains AR within Acinetobacter spp. and Enterobacterales, independent of colonization. These results emphasize the importance of proactive, genomic-focused surveillance of built environments to mitigate MDRO spread. IMPORTANCE Hospital sinks are frequently linked to outbreaks of antibiotic-resistant bacteria. Here, we used whole-genome sequencing to track the long-term colonization patterns in intensive care unit (ICU) sinks and water from two hospitals in the USA and Pakistan collected over 27 months of prospective sampling. We analyzed 822 bacterial genomes, representing over 100 different species. We identified long-term contamination by opportunistic pathogens, as well as transient appearance of other common pathogens. We found that bacteria recovered from the ICU had more antibiotic resistance genes (ARGs) in their genomes compared to matched community spaces. We also found that many of these ARGs are harbored on mobilizable plasmids, which were found shared in the genomes of unrelated bacteria. Overall, this study provides an in-depth view of contamination patterns for common nosocomial pathogens and identifies specific targets for surveillance.

Intensive Care Unit Sluice Room Sinks as Reservoirs and Sources of Potential Transmission of Carbapenem-Resistant Bacteria in a South African Tertiary Care Hospital

Purpose

Carbapenem-resistant bacteria (CRB) pose a major health risk to patients in intensive care units (ICU) across African hospitals. There are hardly any data about the role of hospital sinks as reservoirs of CRB in resource-poor African settings. Furthermore, the specific within-sink location of the highest concentration of pathogens and the role of splash back as a transmission mechanism remains poorly clarified.

Methods

We swabbed ICU sluice room sinks in a tertiary hospital in Cape Town, South Africa. Swabs were taken from four different parts of the sluice room sinks (tap-opening, trap, below the trap, and u-bend). Dilutions were prepared and plated on carbapenem-infused agar. Colonies were identified and drug resistance profiles were determined using a biochemical analyser. To evaluate the potential transmission from the sink, similar plates were placed at fixed distances from the sink when the tap was turned on and off.

Results

CRB were isolated from the trap, water interface below the trap, and the u-bend (the latter harboured the highest density of CRB species). Five CRB, resistant to at least 7 antibiotic classes, were isolated including Pseudomonas, Klebsiella, Citrobacter, Serratia, and Providencia. CRB could be cultured from droplets that fell on agar-containing plates placed at a varying distance from the trap.

Conclusion

There is a higher density of CRB in the u-bend of ICU sluice room sinks which can act as a potential source of transmission. The data inform targeted CRB transmission-interruption strategies in resource-poor settings.

Potential sources of contamination on textiles and hard surfaces identified as high-touch sites near the patient environment

The hospital environment represents an important mediator for the transmission of healthcare-associated infections through direct and indirect hand contact with hard surfaces and textiles. In this study, bacteria on high-touch sites, including textiles and hard surfaces in two care wards in Sweden, were identified using microbiological culture methods and 16S rDNA sequencing. During a cross-sectional study, 176 high-touch hard surfaces and textiles were identified and further analysed using microbiological culture for quantification of total aerobic bacteria, Staphylococcus aureus, Clostridium difficile and Enterobacteriacae. The bacterial population structures were further analysed in 26 samples using 16S rDNA sequencing. The study showed a higher frequency of unique direct hand-textile contacts (36 per hour), compared to hard surfaces (2.2 per hour). Hard surfaces met the recommended standard of ≤ 5 CFU/cm2 for aerobic bacteria and ≤ 1 CFU/cm2 for S. aureus (53% and 35%, respectively) to a higher extent compared to textiles (19% and 30%, respectively) (P = 0.0488). The number of bacterial genera was higher on textiles than on the hard surfaces. Staphylococcus (30.4%) and Corynebacterium (10.9%) were the most representative genera for textiles and Streptococcus (13.3%) for hard surfaces. The fact that a big percentage of the textiles did not fulfil the criteria for cleanliness, combined with the higher bacterial diversity, compared to hard surfaces, are indicators that textiles were bacterial reservoirs and potential risk vectors for bacterial transmission. However, since most of the bacteria found in the study belonged to the normal flora, it was not possible to draw conclusions of textiles and hard surfaces as sources of healthcare associated infections.

Environmental Contamination and Persistence of Clostridioides difficile in Hospital Wastewater Systems

Clostridioides difficile produces an environmentally resistant dormant spore morphotype that infected patients shed to the hospital environment. C. difficile spores persist in clinical reservoirs that are not targeted by hospital routine cleaning protocols. Transmissions and infections from these reservoirs present a hazard to patient safety. This study aimed to assess the impact of patients acutely suffering from C. difficile-associated diarrhea (CDAD) on C. difficile environmental contamination to identify potential reservoirs. Twenty-three hospital rooms accommodating CDAD inpatients with corresponding soiled workrooms of 14 different wards were studied in a German maximum-care hospital. Additionally, four rooms that never accommodated CDAD patients were examined as negative controls. Stagnant water and biofilms from sinks, toilets, and washer disinfector (WD) traps as well as swabs from cleaned bedpans and high-touch surfaces (HTSs) were sampled. For detection, a culture method was used with selective medium. A latex agglutination assay and a Tox A/B enzyme-linked immunosorbent assay were performed with suspect colonies. Stagnant water and biofilms in hospital traps (29%), WDs (34%), and HTSs (37%) were found to be reservoirs for large amounts of C. difficile during the stay of CDAD inpatients that decreased but could persist 13 ± 6 days after their discharge (13%, 14%, and 9.5%, respectively). Control rooms showed none or only slight contamination restricted to WDs. A short-term cleaning strategy was implemented that reduced C. difficile in stagnant water almost entirely. IMPORTANCE Wastewater pipes are microbial ecosystems. The potential risk of infection emanating from the wastewater for individuals is often neglected, since it is perceived to remain in the pipes. However, sewage systems start with siphons and are thus naturally connected to the outside world. Wastewater pathogens do not only flow unidirectionally to wastewater treatment plants but also retrogradely, e.g., through splashing water from siphons to the hospital environment. This study focused on the pathogen C. difficile, which can cause severe and sometimes fatal diarrheas. This study shows how patients suffering from such diarrheas contaminate the hospital environment with C. difficile and that contamination persists in siphon habitats after patient discharge. This might pose a health risk for hospitalized patients afterward. Since this pathogen's spore morphotype is very environmentally resistant and difficult to disinfect, we show a cleaning measure that can almost entirely eliminate C. difficile from siphons.

Environmental contamination across multiple hospital departments with multidrug-resistant bacteria pose an elevated risk of healthcare-associated infections in Kenyan hospitals

BACKGROUND

Healthcare-associated infections (HAIs) are often caused by multidrug-resistant (MDR) bacteria contaminating hospital environments which can cause outbreaks as well as sporadic transmission.

METHODS

This study systematically sampled and utilized standard bacteriological culture methods to determine the numbers and types of MDR Enterococcus faecalis/faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter species, and Escherichia coli (ESKAPEE) from high-touch environments of five Kenyan hospitals; level 6 and 5 hospitals (A, B, and C), and level 4 hospitals (D and E), in 2018. Six hundred and seventeen high-touch surfaces across six hospital departments; surgical, general, maternity, newborn, outpatient and pediatric were sampled.

RESULTS

78/617 (12.6%) of the sampled high-touch surfaces were contaminated with MDR ESKAPEE; A. baumannii, 23/617 (3.7%), K. pneumoniae, 22/617 (3.6%), Enterobacter species, 19/617 (3.1%), methicillin resistant S. aureus (MRSA), 5/617 (0.8%), E. coli, 5/617 (0.8%), P. aeruginosa, 2/617 (0.3%), and E. faecalis and faecium, 2/617 (0.3%). Items found in patient areas, such as beddings, newborn incubators, baby cots, and sinks were the most frequently contaminated. Level 6 and 5 hospitals, B, 21/122 (17.2%), A, 21/122 (17.2%), and C, 18/136 (13.2%), were more frequently contaminated with MDR ESKAPEE than level 4 hospitals; D, 6/101 (5.9%), and E, 8/131 (6.1%). All the sampled hospital departments were contaminated with MDR ESKAPEE, with high levels observed in newborn, surgical and maternity. All the A. baumannii, Enterobacter species, and K. pneumoniae isolates were non-susceptible to piperacillin, ceftriaxone and cefepime. 22/23 (95.6%) of the A. baumannii isolates were non-susceptible to meropenem. In addition, 5 K. pneumoniae isolates were resistant to all the antibiotics tested except for colistin.

CONCLUSION

The presence of MDR ESKAPEE across all the hospitals demonstrated gaps in infection prevention practices (IPCs) that should be addressed. Non-susceptibility to last-line antibiotics such as meropenem threatens the ability to treat infections.

Nosocomial transmission of multi-drug-resistant organisms in Ukrainian hospitals: results of a multi-centre study (2019-2021)

BACKGROUND

The increasing emergence and spread of multi-drug-resistant organisms (MDROs) in hospitals is a public health problem and continues to challenge infection control and hospital epidemiology practice worldwide.

AIM

The aim of this study was to characterize the epidemiology of transmission of MDROs via healthcare workers (HCWs) and the environment in the hospital wards/patient rooms.

METHODS

A multi-centre prospective observational study was conducted in 17 hospitals in Ukraine. Species identification was performed with standard microbial methods. β-Lactamase genes were investigated by polymerase chain reaction. Pulsed-field gel electrophoresis (PFGE) was used to determine the genetic similarity between isolates.

FINDINGS

Among 51,656 isolates, 19.5% were MDROs. The proportions of MDROs among isolates from patients with healthcare-associated infections, environmental surfaces and HCWs (hands, gown/gloves) were 29.2%, 16.3% and 24.2%, respectively. In 51.9% of the tested isolates, identical MDROs were found in clinical isolates, environmental samples and HCWs' hands. Meticillin resistance was found in 32.4% of Staphylococcus aureus (MRSA) isolates, and vancomycin resistance was found in 28.9% of enterococci (VRE). Resistance to third-generation cephalosporins was detected in 48.4% of Enterobacterales, and carbapenem resistance in 19.1%. Overall, 37.4% of MDROs had broad-spectrum β-lactamase genes, including extended-spectrum β-lactamase (35.8%), OXA-type (29.7%), AmpC-type (25.1%), KPC-type (25.7%) and metallo-β-lactamases, including IMP-type (5.7%), VIM-type (31.7%) and NDM-1 (21.3%).

CONCLUSIONS

In Ukrainian hospitals the prevalence of healthcare-associated infections caused by MDROs continues to increase, while infection control gaps in healthcare settings facilitate their transmission between patients.

Bacteriophage-antibiotic combination therapy against extensively drug-resistant Pseudomonas aeruginosa infection to allow liver transplantation in a toddler

Post-operative bacterial infections are a leading cause of mortality and morbidity after ongoing liver transplantation. Bacteria causing these infections in the hospital setting can exhibit high degrees of resistance to multiple types of antibiotics, which leads to major therapeutic hurdles. Alternate ways of treating these antibiotic-resistant infections are thus urgently needed. Phage therapy is one of them and consists in using selected bacteriophage viruses - viruses who specifically prey on bacteria, naturally found in various environmental samples - as bactericidal agents in replacement or in combination with antibiotics. The use of phage therapy raises various research questions to further characterize what determines therapeutic success or failure. In this work, we report the story of a toddler who suffered from extensively drug-resistant Pseudomonas aeruginosa sepsis after liver transplantation. He was treated by a bacteriophage-antibiotic intravenous combination therapy for 86 days. This salvage therapy was well tolerated, without antibody-mediated phage neutralization. It was associated with objective clinical and microbiological improvement, eventually allowing for liver retransplantation and complete resolution of all infections. Clear in vitro phage-antibiotic synergies were observed. The occurrence of bacterial phage resistance did not result in therapeutic failure, possibly due to phage-induced virulence tradeoffs, which we investigated in different experimental models.

Microbial Burden Estimation of Food Items, Built Environments, and the International Space Station Using Film Media

The use of film media involves considerably less preparation, waste, and incubator space than conventional agar-media-based assays and has proven in past studies to provide counts of cultivable microbes similar to those of traditional agar media. Film media also have the advantage of allowing sample volumes similar to those used in pour plates and, therefore, are well-suited for cultivable microbial counts in extremely low-biomass environments such as clean rooms or space habitats, particularly where the subsequent isolation of colonies is necessary. As the preparation of film media plates relies on water cohesion/adhesion rather than manual spreading, they may have future applications in low- or microgravity settings. In this study, cultivable microbial count performance was compared between agar media and film media in three kinds of samples: food items, surfaces in built environments on Earth (homes), and on the environmental surfaces of the International Space Station (ISS). Easy Plates (Kikkoman Corporation) and Petrifilm (3M) were compared with traditional agar plating for food and home surfaces, while only Easy Plates were compared with agar for ISS samples. For both food items and built environments on Earth, both types of film media performed comparably to agar media for bacterial counts, with R² values of 0.94–0.96. Fungal counts for built-environment samples had a lower correlation between film and agar counts, with R² values of 0.72–0.73. Samples from the ISS, which ranged from below detection to 10³ CFU per 100 cm², had R² values of 0.80 for bacterial counts and 0.73 for fungal counts, partially due to multiple samples recording below the detection limit for agar or too numerous to count, and the growth of fungal species on R2A medium. The species compositions of isolates picked from agar vs. film media plates were similar; however, further phylogenetic analysis is needed to confirm the differential microbial diversity composition. Overall, film media such as Easy Plates and Petrifilm are viable alternatives to agar plates for low-biomass built environments as well as for food samples, and the two brands tested in this study performed equally well.