Colonization with third-generation cephalosporin-resistant Enterobacteriaceae on hospital admission: prevalence and risk factors

Antimicrobial resistance patterns of WHO priority pathogens isolated in hospitalized patients in Japan: A tertiary center observational study

BACKGROUND

After issuing the "Global action plan on antimicrobial resistance" in 2015, the World Health Organization (WHO) established a priority pathogens list for supporting research and development of novel antimicrobials. We conducted a comprehensive analysis of the WHO priority organisms in a Japanese tertiary hospital to apprehend the local AMR epidemiology.

METHODS

Data were obtained from electrical medical records in Osaka University Hospital between January 2010 and March 2021. The critical, high, and medium "priority pathogens list" categories of the WHO were used to compare results between the early (2010-2015) and late (2016-2021) phases.

RESULTS

Out of 52,130 culture-positive specimens, a total of 9,872 (18.9%) contained WHO priority isolates. In comparison to early phases, late phases were likely to have higher rates of carbapenem resistance in Pseudomonas aeruginosa (15.7% vs 25.0%, P<0.001), 3rd generation cephalosporin resistance in Escherichia coli (11.5% vs 17.8%, P<0.001) as well as Klebsiella pneumoniae (1.6% vs 4.4%, P<0.001), and ampicillin resistance in Haemophilus influenzae (2.4% vs 3.9%, P<0.001). After 2015, however, the proportion of methicillin-resistant and vancomycin-intermediate Staphylococcus aureus was low. In this study, in-hospital mortality was comparable among patients with resistance to the three WHO priority pathogen types: critical (5.9%), high (3.9%), and medium (3.8%), and no significant change was observed between two phases in each category. However, significant interactions for in-hospital mortality were observed in subgroup analyses between "critical priority" AMR and the presence of comorbid conditions, such as chronic kidney disease or diabetes mellitus.

CONCLUSIONS

To implement better antimicrobial stewardship policies and practices, local priority pathogens and "high-risk" patients for in-hospital death need to be acknowledged and evaluated periodically.

Regional patient transfer patterns matter for the spread of hospital-acquired pathogens

Pathogens typically responsible for hospital-acquired infections (HAIs) constitute a major threat to healthcare systems worldwide. They spread via hospital (or hospital-community) networks by readmissions or patient transfers. Therefore, knowledge of these networks is essential to develop and test strategies to mitigate and control the HAI spread. Until now, no methods for comparing healthcare networks across different systems were proposed. Based on healthcare insurance data from four German federal states (Bavaria, Lower Saxony, Saxony and Thuringia), we constructed hospital networks and compared them in a systematic approach regarding population, hospital characteristics, and patient transfer patterns. Direct patient transfers between hospitals had only a limited impact on HAI spread. Whereas, with low colonization clearance rates, readmissions to the same hospitals posed the biggest transmission risk of all inter-hospital transfers. We then generated hospital-community networks, in which patients either stay in communities or in hospitals. We found that network characteristics affect the final prevalence and the time to reach it. However, depending on the characteristics of the pathogen (colonization clearance rate and transmission rate or even the relationship between transmission rate in hospitals and in the community), the studied networks performed differently. The differences were not large, but justify further studies.

Surface water in Lower Saxony: A reservoir for multidrug-resistant Enterobacterales

The emergence of extended-spectrum β-lactamase and carbapenemase-producing Enterobacterales (ESBL-E and CPE, respectively) is a threat to modern medicine, as infections become increasingly difficult to treat. These bacteria have been detected in aquatic environments, which raises concerns about the potential spread of antibiotic resistance through water. Therefore, we investigated the occurrence of ESBL-E and CPE in surface water in Lower Saxony, Germany, using phenotypic and genotypic methods. Water samples were collected from two rivers, five water canals near farms, and 18 swimming lakes. ESBL-E and CPE were isolated from these samples using filters and selective agars. All isolates were analyzed by whole genome sequencing. Multidrug-resistant Enterobacterales were detected in 4/25 (16%) water bodies, including 1/2 rivers, 2/5 water canals and 1/18 lakes. Among all samples, isolates belonging to five different species/species complexes were detected: Escherichia coli (n = 10), Enterobacter cloacae complex (n = 4), Citrobacter freundii (n = 3), Citrobacter braakii (n = 2), and Klebsiella pneumoniae (n = 2). Of the 21 isolates, 13 (62%) were resistant at least to 3rd generation cephalosporins and eight (38%) additionally to carbapenems. CPE isolates harbored blaKPC-2 (n = 5), blaKPC-2 and blaVIM-1 (n = 2), or blaOXA-181 (n = 1); additionally, mcr-9 was detected in one isolate. Two out of eight CPE isolates were resistant to cefiderocol and two to colistin. Resistance to 3rd generation cephalosporins was mediated by ESBL (n = 10) or AmpC (n = 3). The presence of AmpC-producing Enterobacterales, ESBL-E and CPE in northern German surface water samples is alarming and highlights the importance of aquatic environments as a potential source of MDR bacteria.

It is (not) always on Friday: inter-hospital patient transfers in orthopedic and trauma surgery

BACKGROUND

While inter-hospital transfers for patients who have suffered major trauma have been well investigated, patient flows for other injured patients, or cases with orthopedic complications, are rarely described. This study aims to analyze the affected collective and to show possible reasons, patterns, and pitfalls to optimize the process in future.

MATERIALS AND METHODS

In a prospective cohort study, all consecutive transfers to a Level I trauma center in Germany were documented and assessed. Patients suffering a major trauma were excluded. Data on the primary treating hospital, patient characteristics, and differences between emergency and elective surgery were analyzed.

RESULTS

A total of 227 patients were included; 162 were injured, while 65 had suffered a complication after elective orthopedic surgery or had a complex orthopedic pathology. The most common diagnoses leading to transfer were pathologies of the extremities (n = 62), pathologies of the spine (n = 50), and infections (n = 18). The main reasons stated by the transferring hospitals were a lack of expertise (137 cases) and a lack of capacity (43 cases). There was a significantly higher rate of transfers due to trauma (n = 162) than for orthopedic patients (n = 65), p < 0.0001.

CONCLUSION

There is currently no structured procedure or algorithm for transferring patients in orthopedics and trauma surgery.

Colonization with extended spectrum beta-lactamase and carbapenemases producing Enterobacteriaceae among hospitalized patients at the global level: A systematic review and meta-analysis

BACKGROUND

Gut commensal bacteria can mediate resistance against pathogenic bacteria. However, exposure to antibiotics and hospitalization may facilitate the emergence of multidrug resistant bacteria. We aimed to conduct a systematic review and meta-analysis to provide comprehensive evidence about colonization rate of extended spectrum beta-lactamase and carbapenemases producing Enterobacteriaceae.

METHOD

We used PubMed, Google Scholar and Web of Science data bases to search studies from January 1, 2016 to August10, 2022 about colonization rate of extended spectrum beta-lactamase and carbapenemase producing Enterobacteriaceae. Data were extracted from eligible studies and analyzed using Stata version 16 software. The quality of included studies was assessed using the Joanna Briggs Institute Critical Appraisal tools, and publication bias was assessed using funnel plot and eggers test.

RESULTS

We identified 342 studies from the comprehensive data search and data were extracted from 20 studies. The pooled estimate of extended spectrum beta-lactamase and carbapenemase producing Enterobacteriaceae were 45.6%(95%CI: 34.11-57-10) and 16.19% (95% CI: 5.46-26.91) respectively. The predominant extended spectrum beta-lactamase producers were E. coli,32.99% (95% CI: 23.28-42.69) and K. pneumoniae, 11.43% (95% CI:7.98-14.89). Prolonged hospitalization was linked to carbapenemase producing Enterobacteriaceae colonization with the odds of 14.77 (95% CI: -1.35-30.90) at admission and 45.63 (95% CI: 0.86-92.12) after ≥7 days of admission.

CONCLUSION

The pooled estimate of extended spectrum beta-lactamase and carbapenemase producing Enterobacteriaceae were high. This indicates the need for strong mitigation strategies to minimize the spread of multidrug-resistant bacteria at the healthcare facilities.

The effect of re-directed patient flow in combination with targeted infection control measures on the spread of multi-drug-resistant Enterobacteriaceae in the German health-care system: a mathematical modelling approach

OBJECTIVE

The introduction of multi-drug-resistant Enterobacteriaceae (MDR-E) by colonized patients transferred from high-prevalence countries has led to several large outbreaks of MDR-E in low-prevalence countries, with the risk of propagated spread to the community. The goal of this study was to derive a strategy to counteract the spread of MDR-E at the regional health-care network level.

METHODS

We used a hybrid ordinary differential equation and network model built based on German health insurance data to evaluate whether the re-direction of patient flow in combination with targeted infection control measures can counteract the spread of MDR-E in the German health-care system. We applied pragmatic re-direction strategies focusing on a reduced choice of hospitals for subsequent stays after initial hospitalization but not manipulating direct transfers because these are most likely determined by medical needs.

RESULTS

The re-direction strategies alone did not reduce the system-wide spread of MDR-E (system-wide prevalence of MDR-E is 18.7% vs. 25.7%/29.9%). In contrast, targeted hospital-based infection control measures restricted to institutions with the highest institutional basic reproduction numbers in the network were identified as an effective tool for reducing system-wide prevalence (system-wide prevalence of MDR-E is 18.7% vs. 9.3%). If these measures were applied to the top one-third of hospitals, the system-wide prevalence could be reduced by approximately 80% (system-wide prevalence of 18.7% vs. 3.5% for one-third of patients subjected to interventions). A combination of this hospital-based intervention and patient re-direction strategies could not improve the effectiveness of the hospital-based approach (system-wide prevalence of MDR-E is 9.3% vs. 14.2%/14.3%).

CONCLUSIONS

The pragmatic patient re-direction strategies were not capable of restricting the spread of MDR-E in a simulation of the German health-care system; in contrast, hospital-based interventions focusing on institutions identified based on network transmission patterns seem to be a promising approach for sustainable reduction of the spread of MDR-E through the German population.

Vancomycin-resistant Enterococcus faecium: admission prevalence, sequence types and risk factors-a cross-sectional study in seven German university hospitals from 2014 to 2018

OBJECTIVES

Assessment of vancomycin-resistant Enterococcus faecium (VREfm) prevalence upon hospital admission and analysis of risk factors for colonization.

METHODS

From 2014 to 2018, patients were recruited within 72 hours of admission to seven participating German university hospitals, screened for VREfm and questioned for potential risk factors (prior multidrug-resistant organism detection, current/prior antibiotic consumption, prior hospital, rehabilitation or long-term care facility stay, international travel, animal contact and proton pump inhibitor [PPI]/antacid therapy). Genotype analysis was done using cgMLST typing. Multivariable analysis was performed.

RESULTS

In 5 years, 265 of 17,349 included patients were colonized with VREfm (a prevalence of 1.5%). Risk factors for VREfm colonization were age (adjusted OR [aOR], 1.02; 95% CI, 1.01-1.03), previous (aOR, 2.71; 95% CI, 1.87-3.92) or current (aOR, 2.91; 95% CI, 2.60-3.24) antibiotic treatment, prior multidrug-resistant organism detection (aOR, 2.83; 95% CI, 2.21-3.63), prior stay in a long-term care facility (aOR, 2.19; 95% CI, 1.62-2.97), prior stay in a hospital (aOR, 2.91; 95% CI, 2.05-4.13) and prior consumption of PPI/antacids (aOR, 1.29; 95% CI, 1.18-1.41). Overall, the VREfm admission prevalence increased by 33% each year and 2% each year of life. 250 of 265 isolates were genotyped and 141 (53.2%) of the VREfm were the emerging ST117. Multivariable analysis showed that ST117 and non-ST117 VREfm colonized patients differed with respect to admission year and prior multidrug-resistant organism detection.

DISCUSSION

Age, healthcare contacts and antibiotic and PPI/antacid consumption increase the individual risk of VREfm colonization. The VREfm admission prevalence increase in Germany is mainly driven by the emergence of ST117.

Surveillance and Genomic Analysis of Third-Generation Cephalosporin-Resistant and Carbapenem-Resistant Klebsiella pneumoniae Complex in Germany

To analyse the epidemiology and population structure of third-generation cephalosporin-resistant (3GCR) and carbapenem-resistant (CR) Klebsiella pneumoniae complex isolates, patients were screened for rectal colonisation with 3GCR/CR K. pneumoniae complex on admission to six German university hospitals (2016–2019). Also collected were 3GCR/CR and susceptible K. pneumoniae isolates from patients with bloodstream infections (2016–2018). Whole-genome sequencing was performed followed by multilocus sequencing typing (MLST), core-genome MLST, and resistome and virulome analysis. The admission prevalence of 3GCR K. pneumoniae complex isolates during the 4-year study period was 0.8%, and 1.0 bloodstream infection per 1000 patient admissions was caused by K. pneumoniae complex (3GCR prevalence, 15.1%). A total of seven K. pneumoniae complex bloodstream isolates were CR (0.8%). The majority of colonising and bloodstream 3GCR isolates were identified as K. pneumoniae, 96.7% and 98.8%, respectively; the remainder were K. variicola and K. quasipneumoniae. cgMLST showed a polyclonal population of colonising and bloodstream isolates, which was also reflected by MLST and virulome analysis. CTX-M-15 was the most prevalent extended-spectrum beta-lactamase, and 29.7% of the colonising and 48.8% of the bloodstream isolates were high-risk clones. The present study provides an insight into the polyclonal 3GCR K. pneumoniae population in German hospitals.

Intestinal colonisation with hypervirulent or third-generation cephalosporin-resistant Klebsiella pneumoniae strains upon hospital admission in a general ward in Taiwan

We aimed to investigate the clinical characteristics of patients with hypervirulent and/or third-generation cephalosporin-resistant (3GCR) Klebsiella pneumoniae intestinal colonisation upon admission to a general ward at the Taipei Veterans General Hospital in Taiwan in 2017. Stool surveillance culture was obtained from the patients, and clinical characteristics of these patients were studied retrospectively. The K. pneumoniae strains were characterised for antimicrobial susceptibility, mechanisms of the 3GCR phenotype, and the presence of rmpA/A2 genes, which are markers of hypervirulent strains. Whole genome sequencing (WGS) was used to identify the relationship between the colonising and subsequent infection strains. Of the 408 patients admitted to the general ward, 87 patients with intestinal K. pneumoniae colonisation were identified. Twenty-eight (32.2 %) and nine (10.3 %) patients carried 3GCR and hypervirulent K. pneumoniae strains, respectively. Long-term care facility residents and diabetes mellitus were more common in patients colonised with 3GCR strains than those with hypervirulent strains. The 28-d mortality rate was similar between the two groups. The major resistance mechanisms among the 3GCR strains involved the production of extended-spectrum beta-lactamases genes (67.9 %) and bla_DHA-1 (64.3 %). One patient colonised with K. pneumoniae developed subsequent bacteraemia caused by the same strain. In conclusion, 3GCR strains were more common than hypervirulent strains in the patients, but the clinical outcomes were similar. Future studies to elucidate the risk factors for intestinal carriage of hypervirulent and 3GCR K. pneumoniae strains are needed for early identification and better management of these patients.

High prevalence of multidrug-resistant Gram-negative bacteria carriage in children screened prospectively for multidrug resistant organisms at admission to a paediatric hospital, Hamburg, Germany, September 2018 to May 2019

Background

Increasing resistance to antibiotics poses medical challenges worldwide. Prospective data on carriage prevalence of multidrug resistant organisms (MDRO) in children at hospital admission are limited and associated risk factors are poorly defined.

Aim

To determine prevalence of MDRO carriage in children at admission to our paediatric hospital in Hamburg and to identify MDRO carriage risk factors.

Methods

We prospectively obtained and cultured nasal/throat and inguinal/anal swabs from children (≤ 18 years) at admission between September 2018 and May 2019 to determine prevalence of meticillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant Gram-negative bacteria (MRGN) and vancomycin-resistant enterococcus (VRE) and associated species. We collected medical histories using a questionnaire and evaluated 31 risk factors using logistic regression models.

Results

MDRO carriage prevalence of 3,964 children was 4.31% (95% confidence interval (CI): 3.69–5.00). MRSA carriage prevalence was 0.68% (95% CI: 0.44–0.99), MRGN prevalence was 3.64% (95% CI: 3.07–4.28) and VRE prevalence 0.08% (95% CI: 0.02–0.22). MDRO carriage was associated with MRGN history (odds ratio (OR): 6.53; 95% CI: 2.58–16.13), chronic condition requiring permanent care (OR: 2.67; 95% CI: 1.07–6.13), antibiotic therapy (OR: 1.92, 95% CI: 1.24–2.94), living in a care facility (OR: 3.34; 95% CI: 0.72–12.44) and refugee status in previous 12 months (OR: 1.91; 95% CI: 0.27–8.02). Compared to established practice, screening using risk-factors had better diagnostic sensitivity (86.13%; 95% CI: 80.89–91.40) and specificity (73.54%; 95% CI: 72.12–74.97).

Conclusion

MRGN carriage was higher than MRSA and VRE. Extended risk-factor-based admission screening system seems warranted.

OUP accepted manuscript

Objectives

The widespread intestinal carriage of ESBL-producing Escherichia coli (ESBL E. coli) among both patients and healthy individuals is alarming. However, the global prevalence and trend of this MDR bacterium in healthcare settings remains undetermined. To address this knowledge gap, we performed a comparative meta-analysis of the prevalence in community and healthcare settings.

Methods

Our systematic review included 133 articles published between 1 January 2000 and 22 April 2021 and indexed in PubMed, EMBASE or Google Scholar. A random-effects meta-analysis was performed to obtain the global pooled prevalence (community and healthcare settings). Subgroup meta-analyses were performed by grouping studies using the WHO regions and 5 year intervals of the study period.

Results

We found that 21.1% (95% CI, 19.1%–23.2%) of inpatients in healthcare settings and 17.6% (95% CI, 15.3%–19.8%) of healthy individuals worldwide carried ESBL E. coli in their intestine. The global carriage rate in healthcare settings increased 3-fold from 7% (95% CI, 3.7%–10.3%) in 2001–05 to 25.7% (95% CI, 19.5%–32.0%) in 2016–20, whereas in community settings it increased 10-fold from 2.6% (95% CI, 1.2%–4.0%) to 26.4% (95% CI, 17.0%–35.9%) over the same period.

Conclusions

The global and regional human intestinal ESBL E. coli carriage is increasing in both community and healthcare settings. Carriage rates were generally higher in healthcare than in community settings. Key relevant health organizations should perform surveillance and implement preventive measures to address the spread of ESBL E. coli in both settings.

OUP accepted manuscript

Background

With increasing resistance to common antibiotics the treatment of urinary tract infections has become challenging and alternative therapeutic options are needed. In the present study, we evaluate the activity of three older and less frequently used antibiotics against MDR Enterobacterales.

Methods

Susceptibility of mecillinam, temocillin and nitroxoline was assessed in Enterobacterales isolated from urinary specimens with elevated MICs of third-generation cephalosporins. Susceptibility was determined by the recommended reference MIC methods and additionally by disc diffusion. All isolates were characterized for common β-lactamases by phenotypic and molecular assays.

Results

In total 394 Enterobacterales were included. The most common resistance mechanisms were ESBLs (n = 273), AmpC (n = 132), carbapenemases [n = 12, including OXA-48-like (n = 8), VIM (n = 2), KPC (n = 1) and NDM (n = 1)] or others (n = 2). Resistance was observed in 59% of isolates to ceftazidime, in 41% to piperacillin/tazobactam and in 54% to ciprofloxacin. In comparison, resistance was less frequent against mecillinam (15%), temocillin (13%) or nitroxoline (2%). Mecillinam showed higher activity in Enterobacter spp., Escherichia coli and in OXA-48-like-producing isolates compared with temocillin, which was more active in Proteus mirabilis and in ESBL-producing isolates. Activity of nitroxoline was high against all isolates, including carbapenemase-producing isolates. Correlation between disc diffusion and MIC methods was good for mecillinam and moderate for temocillin and nitroxoline.

Conclusions

Mecillinam, temocillin and nitroxoline show good to excellent in vitro activity in MDR Enterobacterales. The activity of mecillinam and temocillin was higher in certain species and restricted depending on β-lactamase production while nitroxoline showed universally high activity irrespective of species or β-lactamase present.

Novel insights into pivotal risk factors for rectal carriage of extended-spectrum-β-lactamase-producing enterobacterales within the general population in Lower Saxony, Germany

AIMS

To estimate the prevalence of extended-spectrum-β-lactamase (ESBL)-producing enterobacterales (ESBL-E) carriage in the general population of Lower Saxony, Germany, and to identify risk factors for being colonized.

METHODS AND RESULTS

Participants were recruited through local press and information events. Detection of ESBL-E by culture was conducted using ESBL-selective chromagar plates containing third-generation cephalosporins. Identification of pathogens was performed using matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF)_technology on Vitek mass spectrometry. Antibiotic susceptibility testing was conducted by microdilution (Vitek II) and an ESBL confirmation assay was carried out using a combination disk test. Of 527 randomly collected stool samples from healthy volunteers, 5.5% were tested positive for ESBL-E. Post-stratification for age and gender yielded a similar population estimate (5.9%). People traveling abroad and taking antibiotics had the greatest rectal ESBL-E carriage.

CONCLUSIONS

Potential risk factors (eg, working in healthcare facilities, recent inpatient stay) did not attribute to rectal ESBL-E carriage as other factors (eg, travelling, taking antibiotics). Rectal ESBL-E carriage within the general population seems to be high.

SIGNIFICANCE AND IMPACT OF THE STUDY

The known risk factors for carriage with MDRO might not be fully applicable to ESBL-E and require further examination in order to develop effective strategies for the prevention of ESBL-E dissemination within the general population.

Carriage of Multidrug-Resistant Bacteria in Healthy People: Recognition of Several Risk Groups

The increase in multidrug-resistant (MDR) bacteria in hospitalized people and the hospital environment has been thoroughly documented. In contrast, little is known about their presence in the community. However, increasing evidence is showing a high level of carriage in people without infectious signs. Colonized people can later develop infections due to MDR bacteria and may be able to transmit them to susceptible people (the number of which is increasing worldwide), for example, people with comorbidities such as diabetes, cancer, or inflammatory diseases and those in extreme age groups. Risk factors for the acquisition of MDR bacteria are as follows: (1) residence or travel in countries with high levels of MDR bacteria; (2) occupational risks such as health workers or people with close contact with animals (farmers, veterinarians) who frequently use antibiotics; and (3) comorbidities. Eradication is rather difficult and, thus far, has not shown clear-cut results. Preventive measures will be important in the future with a reinforcement of hygienic measures not only in the hospital, but also in the community.

Detection of Multidrug-Resistant Enterobacterales-From ESBLs to Carbapenemases

Multidrug-resistant Enterobacterales (MDRE) are an emerging threat to global health, leading to rising health care costs, morbidity and mortality. Multidrug-resistance is commonly caused by different β-lactamases (e.g., ESBLs and carbapenemases), sometimes in combination with other resistance mechanisms (e.g., porin loss, efflux). The continuous spread of MDRE among patients in hospital settings and the healthy population require adjustments in healthcare management and routine diagnostics. Rapid and reliable detection of MDRE infections as well as gastrointestinal colonization is key to guide therapy and infection control measures. However, proper implementation of these strategies requires diagnostic methods with short time-to-result, high sensitivity and specificity. Therefore, research on new techniques and improvement of already established protocols is inevitable. In this review, current methods for detection of MDRE are summarized with focus on culture based and molecular techniques, which are useful for the clinical microbiology laboratory.

Use of proton pump inhibitors and cholangitis complicated with multi-drug resistant bacteria

BACKGROUND

Multidrug-resistant bacteria (MDRB) has rapidly spread worldwide and become a serious problem. Proton pump inhibitors (PPIs) are a class of commonly prescribed medications, but recent studies have suggested the increased risk of infection with MDRB in PPI users. We evaluated the association between PPI use and incidence of cholangitis with MDRB.

METHODS

Consecutive patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) between January 2010 and August 2019 were included in this retrospective study. The incidence of cholangitis with MDRB was compared between regular and non-regular PPI users.

RESULTS

A total of 1224 regular PPI users and 1528 non-regular PPI users were identified. There was no clinically significant difference in age and sex between the groups. Indication of ERCP was different between the groups. The number of ERCP sessions during the study periods was higher in regular PPI users. The incidence of cholangitis with MDRB was significantly higher in regular PPI users (3.0% vs 1.1%; P < .001). Multivariable-adjusted odds ratio for cholangitis with MDRB comparing regular PPI users to non-regular users was 2.19 (95% confidence interval 1.20-4.00; P = .01).

CONCLUSIONS

Regular PPI use was associated with a higher risk of cholangitis with MDRB.

Prevalence of third-generation cephalosporin-resistant Enterobacterales colonization on hospital admission and ESBL genotype-specific risk factors: a cross-sectional study in six German university hospitals

OBJECTIVES

To assess the admission prevalence of third-generation cephalosporin-resistant Enterobacterales (3GCREB) and to assess whether risk factors vary by β-lactamase genotype.

METHODS

Adult patients were recruited within 72 h of admission to general wards of six university hospitals in 2014 and 2015. Rectal swabs were screened for 3GCREB and isolates were analysed phenotypically and genotypically. Patients were questioned on potential risk factors. Multivariable analyses were performed to identify risk factors for 3GCREB colonization and for specific β-lactamases.

RESULTS

Of 8753 patients screened, 828 were 3GCREB positive (9.5%). Eight hundred and thirteen isolates were available for genotyping. CTX-M-15 was the most common ESBL (38.0%), followed by CTX-M-1 (22.5%), CTX-M-14 (8.7%), CTX-M-27 (7.5%) and SHV-ESBL (4.4%). AmpC was found in 11.9%. Interestingly, 18 Escherichia coli isolates were AmpC positive, 12 of which (67%) contained AmpC on a gene of plasmid origin [CMY (n = 10), DHA (n = 2)]. Risk factors for 3GCREB colonization varied by genotype. Recent antibiotic exposure and prior colonization by antibiotic-resistant bacteria were risk factors for all β-lactamases except CTX-M-14 and CTX-M-27. Travel outside Europe was a risk factor for CTX-M-15 and CTX-M-27 [adjusted OR (aOR) 3.49, 95% CI 2.88-4.24 and aOR 2.73, 95% CI 1.68-4.43]. A previous stay in a long-term care facility was associated with CTX-M-14 (aOR 3.01, 95% CI 1.98-4.59). A preceding hospital stay in Germany increased the risk of CTX-M-15 (aOR 1.27, 95% CI 1.14-1.41), while a prior hospital stay in other European countries increased the risk of SHV-ESBL colonization (aOR 3.85, 95% CI 1.67-8.92).

CONCLUSIONS

The detection of different ESBL types is associated with specific risk factor sets that might represent distinct sources of colonization and ESBL-specific dissemination routes.

Diversity of Plasmids and Genes Encoding Resistance to Extended-Spectrum β-Lactamase in Escherichia coli from Different Animal Sources

Antimicrobial resistance associated with the spread of plasmid-encoded extended-spectrum β-lactamase (ESBL) genes conferring resistance to third generation cephalosporins is increasing worldwide. However, data on the population of ESBL producing E. coli in different animal sources and their antimicrobial characteristics are limited. The purpose of this study was to investigate potential reservoirs of ESBL-encoded genes in E. coli isolated from swine, beef, dairy, and poultry collected from different regions of the United States using whole-genome sequencing (WGS). Three hundred isolates were typed into different phylogroups, characterized by BOX AIR-1 PCR and tested for resistance to antimicrobials. Of the 300 isolates, 59.7% were resistant to sulfisoxazole, 49.3% to tetracycline, 32.3% to cephalothin, 22.3% to ampicillin, 20% to streptomycin, 16% to ticarcillin; resistance to the remaining 12 antimicrobials was less than 10%. Phylogroups A and B1 were most prevalent with A (n = 92, 30%) and B1 (87 = 29%). A total of nine E. coli isolates were confirmed as ESBL producers by double-disk synergy testing and multidrug resistant (MDR) to at least three antimicrobial drug classes. Using WGS, significantly higher numbers of ESBL-E. coli were detected in swine and dairy manure than from any other animal sources, suggesting that these may be the primary animal sources for ESBL producing E. coli. These isolates carry plasmids, such as IncFIA(B), IncFII, IncX1, IncX4, IncQ1, CollRNAI, Col440I, and acquired ARGs aph(6)-Id, aph(3″)-Ib, aadA5, aph(3')-Ia, bla_CTX-M-15, bla_TEM-1B, mphA, ermB, catA1, sul1, sul2, tetB, dfrA17. One of the E. coli isolates from swine with ST 410 was resistant to nine antibiotics and carried more than 28 virulence factors, and this ST has been shown to belong to an international high-risk clone. Our data suggests that ESBL producing E. coli are widely distributed in different animal sources, but swine and dairy cattle may be their main reservoir.

Comparison of stool samples and rectal swabs with and without pre-enrichment for the detection of third-generation cephalosporin-resistant Enterobacterales (3GCREB)

To establish the optimal detection of third-generation cephalosporin-resistant Enterobacterales (3GCREB), the performance of four different screening methods has been investigated: stool samples without (A) and with (B) pre-enrichment and rectal swabs without (C) and with (D) pre-enrichment were contrasted. Pre-enrichment approaches (B and D) increased the detection of 3GCREB carriers by 29.4% (20/68 3GCREB carriers only found using pre-enrichment, p < 0.0001) compared to direct plating approaches (A and C). Moreover, the study demonstrates a minor advantage of stool samples in contrast to rectal swabs in both cases (with and without pre-enrichment). Registration number: DRKS00022520, 24 July 2020.

Prevalence and risk factors of colonisation with vancomycin-resistant Enterococci faecium upon admission to Germany's largest university hospital

Background: Hospital-acquired infections due to vancomycin-resistant enterococci (VRE) are emerging globally. The aims of our study were to estimate VRE colonisation prevalence in patients upon admission, to determine possible risk factors for VR E. faecium acquisition that already exist in the outpatient setting, and to monitor whether VRE-colonised patients developed a VRE infection during their current hospital stay.

Methods: In 2014 and 2015, patients admitted to non-intensive care units were screened for rectal VRE carriage. The study patients filled out a questionnaire on potential risk factors. Analyses were restricted to VR E. faecium carriage. All patients with VRE colonisation were retrospectively monitored for infections with VRE during their current hospital stay.

Results: In 4,013 enrolled patients, the VRE colonisation prevalence upon admission was 1.2% (n=48), and colonisation prevalence was 1.1% (n=45) for VR E. faecium. Only one VRE-colonised patient developed an infection with the detection of a VRE, among others. Colonisation with VR E. faecium was associated with current antibiotic use. Risk factors of VR E. faecium colonisation upon admission were increasing age, previous colonisation or infection with multidrug resistant organisms, sampling year 2015, and, within the previous six months, antibiotic exposure, a stay at a rehabilitation center, and a hospital stay.

Conclusions: We observed that antibiotic treatment which occurred prior admission influenced VR E. faecium prevalence upon admission. Thus, wise antibiotic use in outpatient settings plays a major role in the prevention of VR E. faecium acquisition.

Clinical and Economic Impact of Third-Generation Cephalosporin-Resistant Infection or Colonization Caused by Escherichia coli and Klebsiella pneumoniae: A Multicenter Study in China

Quantifying economic and clinical outcomes for interventions could help to reduce third-generation cephalosporin resistance and Escherichia coli or Klebsiella pneumoniae. We aimed to compare the differences in clinical and economic burden between third-generation cephalosporin-resistant E. coli (3GCREC) and third-generation cephalosporin-susceptible E. coli (3GCSEC) cases, and between third-generation cephalosporin-resistant K. pneumoniae (3GCRKP) and third-generation cephalosporin-susceptible K. pneumoniae (3GCSKP) cases. A retrospective and multicenter study was conducted. We collected data from electronic medical records for patients who had clinical samples positive for E. coli or K. pneumoniae isolates during 2013 and 2015. Propensity score matching (PSM) was conducted to minimize the impact of potential confounding variables, including age, sex, insurance, number of diagnoses, Charlson comorbidity index, admission to intensive care unit, surgery, and comorbidities. We also repeated the PSM including length of stay (LOS) before culture. The main indicators included economic costs, LOS and hospital mortality. The proportions of 3GCREC and 3GCRKP in the sampled hospitals were 44.3% and 32.5%, respectively. In the two PSM methods, 1804 pairs and 1521 pairs were generated, and 1815 pairs and 1617 pairs were obtained, respectively. Compared with susceptible cases, those with 3GCREC and 3GCRKP were associated with significantly increased total hospital cost and excess LOS. Inpatients with 3GCRKP were significantly associated with higher hospital mortality compared with 3GCSKP cases, however, there was no significant difference between 3GCREC and 3GCSEC cases. Cost reduction and outcome improvement could be achieved through a preventative approach in terms of both antimicrobial stewardship and preventing the transmission of organisms.

Molecular detection of extended spectrum β-lactamase genes in Escherichia coli clinical isolates from diarrhoeic children in Kano, Nigeria

The increase in antimicrobial resistance in developed and developing countries is a global public health challenge. In this context β-lactamase production is a major contributing factor to resistance globally. The aim of this study was to determine the prevalence of phenotypic and genotypic extended spectrum β-lactamases (ESBLs) in 296 E. coli isolates recovered from diarrhoeic children younger than five years in Kano whose susceptibility profile against 7 antimicrobials had been determined. The E. coli isolates were subjected to double disc synergy test for phenotypic ESBLs detection and ESBL associated genes (bla_CTX-M, bla_TEM and bla_SHV) were detected using conventional PCR. Phenotypically, 12.8% (38/296) E. coli isolates presented a ESBLs phenotype, with a significantly higher proportion in isolates from females compared with males (P-value = 0.024). bla_CTX-M 73.3% and bla_TEM 73.3% were the predominant resistance genes in the ESBLs positive E. coli (each detected in 22/30 isolates, of which 14 harboured both). In addition, 1/30 harboured bla_CTX-M + bla_TEM + bla_SHV genes simultaneously. This study demonstrates the presence of ESBLs E. coli isolates in clinically affected children in Kano, and demonstrates the circulation of bla_CTX-M and bla_TEM associated with those phenotypes. Enactment of laws on prudent antibiotic use is urgently needed in Kano.

Colonization with multi-drug-resistant organisms negatively impacts survival in patients with non-small cell lung cancer

Objectives

Multidrug-resistant organisms (MDRO) are considered an emerging threat worldwide. Data covering the clinical impact of MDRO colonization in patients with solid malignancies, however, is widely missing. We sought to determine the impact of MDRO colonization in patients who have been diagnosed with Non-small cell lung cancer (NSCLC) who are at known high-risk for invasive infections.

Materials and methods

Patients who were screened for MDRO colonization within a 90-day period after NSCLC diagnosis of all stages were included in this single-center retrospective study.

Results

Two hundred and ninety-five patients were included of whom 24 patients (8.1%) were screened positive for MDRO colonization (MDRO^pos) at first diagnosis. Enterobacterales were by far the most frequent MDRO detected with a proportion of 79.2% (19/24). MDRO colonization was present across all disease stages and more present in patients with concomitant diabetes mellitus. Median overall survival was significantly inferior in the MDRO^pos study group with a median OS of 7.8 months (95% CI, 0.0–19.9 months) compared to a median OS of 23.9 months (95% CI, 17.6–30.1 months) in the MDRO^neg group in univariate (p = 0.036) and multivariate analysis (P = 0.02). Exploratory analyses suggest a higher rate of non-cancer-related-mortality in MDRO^pos patients compared to MDRO^neg patients (p = 0.002) with an increased rate of fatal infections in MDRO^pos patients (p = 0.0002).

Conclusions

MDRO colonization is an independent risk factor for inferior OS in patients diagnosed with NSCLC due to a higher rate of fatal infections. Empirical antibiotic treatment approaches should cover formerly detected MDR commensals in cases of (suspected) invasive infections.

Time and personnel requirements for antimicrobial stewardship in small hospitals in a rural area in Germany

BACKGROUND

In order to control their anti-infectives consumption, hospitals are required to provide multidisciplinary teams comprising among others an infectiologist, a microbiologist and a pharmacist. Small hospitals though often do not dispose of the defaulted personnel. This study illustrates a solution for an antimicrobial stewardship program (ASP) in small community hospitals in a rural area in Germany.

METHODS

Four hospitals of ca. 200 beds each, jointly hired an antimicrobial stewardship expert to start a common ASP. This expert did rounds on every ward once a week, mostly as chard reviews with the physician in charge. Outside the rounds, he could be consulted by mail. Working time and number of visited patients were documented. Anti-infectives consumption, incidence of Clostridioides difficile infections (CDI) and mortality rates were retrieved from routinely collected data. The intervention period (01/2018-12/2018) was compared to the preintervention period (01/2017-12/2017).

RESULTS

3321 patients were visited in the intervention period. In average, 20 patients were seen per day and 20 min were needed per patient/ chard. About 65% of the expert's working time was needed for rounds, 15% for driving between the hospitals. The anti-infectives consumption of the 4 hospitals in the preintervention period amounted to 50 defined daily doses per 100 occupied bed days. The total consumption was reduced by 10% and of quinolones by 36%. The incidence of hospital-acquired CDI receded from 0.14 to 0.07 cases per 100 patient days (-50%, p = 0.001). The overall in-hospital mortality did not change.

CONCLUSIONS

A single expert was able to implement a successfull ASP in 4 hospitals. While multidisciplinary antimicrobial stewardship teams are ideal for tertiary care hospitals, small hospitals need a more practical solution. This survey shows that one expert can be sufficient for several small hospitals even with the distances in a rural setting.

The STAPH Score: A Predictor of Staphylococcus aureus as the Causative Microorganism of Native Vertebral Osteomyelitis

Background

Staphylococcus aureus (SA) is the most common causative microorganism in native vertebral osteomyelitis (NVO). Few studies have compared the clinical features of NVO due to SA (SA-NVO) and NVO due to other organisms (NSA-NVO). This study was conducted to validate a predictive score for SA-NVO to facilitate NVO treatment without broad-spectrum antimicrobial agents.

Methods

This retrospective study compared the clinical features of patients with SA-NVO and NSA-NVO who were diagnosed from 2004 to 2019. Univariate associations were assessed using χ ², Fisher's exact, or Mann-Whitney U test. Multivariable analysis was conducted using logistic regression. The optimal age cutoff point was determined by classification and regression tree analysis.

Results

Among 155 NVO patients, 98 (63.2%) had a microbiologically confirmed diagnosis: 40 (25.8%) with SA-NVO and 58 (37.4%) with NSA-NVO. Six predictors, either independently associated with SA-NVO or clinically relevant, were used to develop the STAPH prediction score: atopic dermatitis (Skin) (3 points); recent Trauma (2 points); Age < 67 years (1 point); Abscess (1 point); central venous Port catheter (2 points); and History of puncture (2 points). In a receiver operating characteristic analysis, the area under the curve was 0.84 (95% confidence interval, 0.76-0.91). The best cutoff point was 3. A score ≥3 had a sensitivity, specificity, positive predictive value, and negative predictive value of 58%, 84%, 84%, and 73%, respectively.

Conclusions

The STAPH score has relatively high specificity for use by clinicians to predict SA as the causative microorganism in patients with NVO until results of a confirmatory culture are available.

Controlling intestinal colonization of high-risk haematology patients with ESBL-producing Enterobacteriaceae: a randomized, placebo-controlled, multicentre, Phase II trial (CLEAR)

OBJECTIVES

We assessed the efficacy and safety of an oral antimicrobial regimen for short- and long-term intestinal eradication of ESBL-producing Escherichia coli and Klebsiella pneumoniae (ESBL-EC/KP) in immunocompromised patients.

METHODS

We performed a randomized (2:1), double-blind multicentre Phase II study in four haematology-oncology departments. Patients colonized with ESBL-EC/KP received a 7 day antimicrobial regimen of oral colistin (2 × 106 IU 4×/day), gentamicin (80 mg 4×/day) and fosfomycin (three administrations of 3 g every 72 h), or placebo. Faecal, throat and urine specimens were collected on day 0, 6 ± 2, 11 ± 2, 28 ± 4 and 42 ± 4 after treatment initiation, and the quantitative burden of ESBL-EC/KP, resistance genes and changes in intestinal microbiota were analysed. Clinicaltrials.gov: NCT01931592.

RESULTS

As the manufacture of colistin powder was suspended worldwide, the study was terminated prematurely. Overall, 29 (18 verum/11 placebo) out of 47 patients were enrolled. The short-term intestinal eradication was marginal at day 6 (verum group 15/18, 83.3% versus placebo 2/11, 18.2%; relative risk 4.58, 95% CI 1.29-16.33; Fisher's exact test P = 0.001) and not evident at later timepoints. Quantitative analysis showed a significant decrease of intestinal ESBL-EC/KP burden on day 6. Sustained intestinal eradication (day 28 + 42) was not achieved (verum, 38.9% versus placebo, 27.3%; P = 0.299). In the verum group, mcr-1 genes were detected in two faecal samples collected after treatment. Microbiome analysis showed a significant decrease in alpha diversity and a shift in beta diversity.

CONCLUSIONS

In this prematurely terminated study of a 7 day oral antimicrobial eradication regimen, short-term ESBL-EC/KP suppression was marginal, while an altered intestinal microbiota composition was clearly apparent.

Antimicrobial Susceptibility and Virulence of mcr-1-Positive Enterobacteriaceae in China, a Multicenter Longitudinal Epidemiological Study

This study was to investigate the prevalence of mcr-1-positive Enterobacteriaceae (MPE) in intra-abdominal infections (IAIs), urinary tract infections (UTIs), and lower respiratory tract infections (LRTIs) in China. A total of 6,401 Enterobacteriaceae isolates were collected consecutively from IAI, UTI, and LRTI patients in 19 hospitals across mainland China during 2014–2016. MPE isolates were screened by PCR detection for the mcr gene. The resistance profiles were tested by antimicrobial susceptibility test. All MPE isolates were characterized by pulsed-field gel electrophoresis (PFGE), multi-locus-sequence typing, O and H serotyping, and whole-genome sequencing. Among the 6,401 Enterobacteriaceae isolates, 17 Escherichia coli strains (0.27%) were positive for the mcr-1 gene. The MPE prevalence rates in IAI, UTI, and LRTI patients were 0.34% (12/3502), 0.23% (5/2154), and 0% (0/745), respectively. The minimum inhibition concentrations (MICs) of colistin against 3 isolates were of 0.5–2 mg/L, and 4–8 mg/L against other 14 isolates. All the 17 isolates were susceptible to meropenem, imipenem, tigecycline, and ceftazidime/avibactam. The 17 MPE isolates belonged to 14 different ST types, and those that belonged to the same STs were not clonal by PFGE. The mcr-1-harboring plasmid of ten MPE isolates could transfer to the recipients by conjugation and the colistin MICs of the transconjugants ranged from 0.5 to 8 mg/L. Mcr-1-carrying plasmids from the 17 MPE isolates could be grouped into four clusters, including 8 IncX4 type, 4 IncI2 type, 4 IncHI2A type, and 1 p0111 type. Multiple-drug resistance genes and virulence genes were detected. In conclusion, the prevalence of MPE in IAI, UTI, and LRTI were low in China, and no clonal transmission was identified in our study. Most MPE isolates exhibited low-level colistin resistance. However, our study indicated that MPE isolates always carried a variety of drug resistance and virulence genes, which should be paid more attention.

No evidence of carbapenemase-producing Enterobacteriaceae in stool samples of 1,544 asylum seekers arriving in Rhineland-Palatinate, Germany, April 2016 to March, 2017

Introduction: Since 2015, increased migration from Asia and Africa to Europe has raised public health concerns about potential importation of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE), specifically those producing carbapenemases (C-PE), into European hospitals.

Aims: To inform infection control practices about ESBL-PE prevalence in asylum seekers and to investigate whether C-PE prevalence exceeds that in the German population.

Methods: Cross-sectional study from April 2016–March 2017. Routinely collected stool samples from asylum seekers were tested for antibiotic resistant Enterobacteriaceae. Country/region of origin and demographic characteristics were explored as risk factors for faecal colonisation.

Results: Of 1,544 individuals, 294 tested positive for ESBL-PE colonisation (19.0%; 95% confidence intervals (CI): 17.0–21.0). Asylum seekers originating from Afghanistan/Pakistan/Iran had a prevalence of 29.3% (95% CI: 25.6–33.2), from Syria 20.4% (95% CI: 16.1–25.2) and from Eritrea/Somalia 11.9% (95% CI: 8.7–15.7). CTX-M-15 (79%) and CTX-M-27 (10%) were the most common ESBL determinants. Highest ESBL-PE prevalences were observed in boys under 10 years and women aged 20–39 years (interaction: p = 0.03). No individuals tested positive for C-PE. Faecal C-PE colonisation prevalence in asylum seekers was not statistically significantly different from prevalence reported in German communities.

Conclusion: In absence of other risk factors, being a newly arrived asylum seeker from a region with increased faecal ESBL-PE colonisation prevalence is not an indicator for C-PE colonisation and thus not a reason for pre-emptive screening and isolation upon hospital admission.

Colonization With Multidrug-Resistant Organisms Among Healthy Adults in the Community Setting: Prevalence, Risk Factors, and Composition of Gut Microbiome

BACKGROUND

The prevalence of colonization with multidrug-resistant organisms (MDROs) among healthy adults in the community is largely unknown. This study investigated the colonization rate of multidrug-resistant Enterobacteriaceae, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE) in the community in Taiwan, and compared the gut microbiota between MDRO carriers and non-carriers.

METHODS

This prospective cohort study was conducted from March 2017 to February 2018 at the Hsin-Chu and Jin-Shan branches of National Taiwan University Hospital. Nasal swabs and stool samples were obtained from healthy adults attending a health examination to screen for MDROs. Bacteria isolates of MDROs were tested for antibiotic susceptibility and resistant genes. Relevant data were collected using a standardized questionnaire to evaluate the risk factors for MDROs carriage, and 16S rRNA metagenomics sequencing was performed to analyze gut microbiota.

RESULTS

Among 187 participants, 4.6% (8/174) carried MRSA and 41.4% (77/186) carried third-generation cephalosporin-resistant (3GC-R) Escherichia coli or Klebsiella pneumoniae. The carriage rate of AmpC beta-lactamases and ESBL-producing strains were 16.1 and 27.4%, respectively. No carbapenem-resistant Enterobacteriaceae (CRE) or VRE were detected. The dominant resistant gene of E. coli isolates was CTX-M-type (73%), while that of K. pneumoniae was AmpC beta-lactamases (80%). In the multivariate analysis, the significant risk factors for carrying 3GC-R E. coli or K. pneumoniae were being an employee of technology company A [adjusted odds ratio (aOR) 4.127; 95% confidence interval (CI) 1.824-9.336; p = 0.001], and traveling to Southeast Asia in the past year (aOR 6.545; 95% CI 1.071-40.001; p = 0.042). The gut microbiota analysis showed that the phylum Proteobacteria and the family Enterobacteriaceae were significantly more abundant in 3GC-R E. coli and K. pneumoniae carriers.

CONCLUSION

A high rate of Taiwanese adults in the community carried 3GC-R Enterobacteriaceae, while no CRE or VRE colonization was noted. Compared with non-carriers, an expansion of Enterobacteriaceae in gut microbiota was found among 3GC-R Enterobacteriaceae carriers.

[Multi-Resistant Bacteria in Patients in Hospitals and Medical Practices as well as in Residents of Nursing Homes in Saxony - Results of a Prevalence Study 2017/2018]

OBJECTIVE

The aim of this study was to determine the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), multi-resistant gram-negative bacteria (MRGN) and vancomycin-resistant enterococci (VRE) in three study groups (hospital patients, residents in nursing homes for the elderly and patients in GP practices) and additionally, risk factors for carriage of multidrug-resistant organisms (MDRO).

METHODS

Screening for MDRO was performed as a point prevalence study by obtaining nasal, pharyngeal and rectal swabs or stool samples from voluntary participants in 25 hospitals, 14 nursing homes for the elderly as well as 33 medical practices in 12 of 13 districts of Saxony. Suspicious isolates were further examined phenotypically and partially by molecular methods. The participants completed a questionnaire on possible risk factors for MDRO colonisation; the data were statistically evaluated by correlation analyses.

RESULTS

In total, 1,718 persons, 629 from hospitals, 498 from nursing homes and 591 from medical practices, were examined. MDRO was detected in 8.4% of all participants; 1.3% persons tested positive for MRSA, 5.2% for 3MRGN, 0.1% for 4MRGN and 2.3% for VRE. Nine persons were colonized with more than one MDRO. The following independent risk factors could be significantly associated with the detection of MDRO: presence of a degree of care (MDRO), male sex (MDRO/VRE), current antibiosis (MDRO/VRE), antibiosis within the last 6 months (MDRO/MRSA/MRGN/VRE), current tumour disease (MDRO/3MRGN), peripheral artery disease (PAD) (MRSA) as well as urinary incontinence (3MRGN).

CONCLUSIONS

To our knowledge, this study represents the first survey of prevalence of different multiresistant pathogen groups in 3 study groups including outpatients in Germany. 3MRGN were the pathogens most frequently detected and were also found in patients of younger age groups. VRE were found almost exclusively in specific clinics. In addition to current and past antibiotic therapy, in particular the presence of PAD for MRSA detection, urinary incontinence for 3MRGN detection and a current tumour disease for MDRO and 3MRGN detection were determined as independent risk factors.

Evaluation of the Association Between Gastric Acid Suppression and Risk of Intestinal Colonization With Multidrug-Resistant Microorganisms: A Systematic Review and Meta-analysis

IMPORTANCE

Acid suppressants inhibit gastric acid secretion and disrupt the intestinal microbiome. Whether acid suppression increases the risk of colonization with multidrug-resistant microorganisms (MDROs) is unclear.

OBJECTIVES

To systematically examine the association of use of acid suppressants with the risk of colonization with MDROs and to perform a meta-analysis of current evidence.

DATA SOURCES

PubMed, Embase, the Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials were searched from database inception through July 8, 2019.

STUDY SELECTION

Study selection was performed independently by 2 authors (R.P.J.W. and C.M.J.E.V.-G.) on the basis of predefined selection criteria; conflicts were resolved by consensus or by an adjudicator (K.v.D.). Human observational studies (case control, cohort, and cross-sectional) and clinical trial designs were selected if they quantified the risk of MDRO colonization in users of acid suppressants in comparison with nonusers.

DATA EXTRACTION AND SYNTHESIS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) recommendations were followed. Data were extracted independently by the same 2 authors, and adjudication was conducted when necessary. Risk of bias was assessed according to a modified Newcastle-Ottawa Scale. Pooled odds ratios (ORs) were estimated using random-effects models; heterogeneity was evaluated using the I2 method.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was intestinal colonization with MDROs of the Enterobacterales order (producing extended-spectrum β-lactamases, carbapenemases, or plasmid-mediated AmpC β-lactamases), vancomycin-resistant enterococci, methicillin-resistant or vancomycin-resistant Staphylococcus aureus, or multidrug-resistant Pseudomonas or Acinetobacter species.

RESULTS

A total of 26 observational studies including 29 382 patients (11 439 [38.9%] acid suppressant users) met the selection criteria. Primary meta-analysis of 12 studies including 22 305 patients that provided adjusted ORs showed that acid suppression increased the odds of intestinal carriage of MDROs of the Enterobacterales order and of vancomycin-resistant enterococci by roughly 75% (OR = 1.74; 95% CI, 1.40-2.16; I2 = 68%). The odds were concordant with the secondary pooled analysis of all 26 studies (OR = 1.70; 95% CI, 1.44-1.99; I2 = 54%). Heterogeneity was partially explained by variations in study setting and the type of acid suppression.

CONCLUSIONS AND RELEVANCE

Acid suppression is associated with increased odds of MDRO colonization. Notwithstanding the limitations of observational studies, the association is plausible and is strengthened by controlling for confounders. In view of the global increase in antimicrobial resistance, stewardship to reduce unnecessary use of acid suppressants may help to prevent MDRO colonization.

Contact isolation versus standard precautions to decrease acquisition of extended-spectrum β-lactamase-producing Enterobacterales in non-critical care wards: a cluster-randomised crossover trial

BACKGROUND

The effectiveness of contact isolation for decreasing the spread of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) has been questioned. The aim of this study was to establish the benefits of contact isolation over standard precautions for reducing the incidence density of ESBL-E colonisation and infection in adult medical and surgical wards with an active surveillance culture programme.

METHODS

We did a cluster-randomised crossover trial in adult wards in four European university hospitals. Medical, surgical, or combined medical-surgical wards without critical care were randomised to continue standard precautions alone or implement contact isolation alongside standard precautions for 12 months, followed by a 1 month washout period and 12 months of the alternate strategy. Randomisation was done via a computer-generated sequence, with a block size of two consecutive wards. Only laboratory technicians and data analysts were masked to allocation. Patients were screened for ESBL-E carriage within 3 days of admission, once a week thereafter, and on discharge. The primary outcome was the incidence density of ESBL-E, defined as the acquisition rate per 1000 patient-days at risk at the ward level and assessed in the per-protocol population, which included all patients screened at least twice with a length of stay of more than 1 week for each intervention period. No specific safety measures were assessed given the minimal risk of adverse events. The trial is registered, ISRCTN57648070.

FINDINGS

We enrolled 20 wards from four hospitals in Germany (eight wards), the Netherlands (four wards), Spain (four wards), and Switzerland (four wards). Between Jan 6, 2014, and Aug 31, 2016, 38 357 patients were admitted to these wards. Among 15 184 patients with a length of stay of more than 1 week, 11 368 patients (75%) were screened at least twice. The incidence density of ward-acquired ESBL-E was 6·0 events per 1000 patient-days at risk (95% CI 5·4-6·7) during periods of contact isolation and 6·1 (5·5-6·7) during periods of standard precautions (p=0·9710). Multivariable analysis adjusted for length of stay, percentage of patients screened, and prevalence in first screening cultures yielded an incidence rate ratio of 0·99 (95% CI 0·80-1·22; p=0·9177) for care under contact isolation compared with standard precautions.

INTERPRETATION

Contact isolation showed no benefit when added to standard precautions for controlling the spread of ESBL-E on non-critical care wards with extensive surveillance screening.

FUNDING

European Commission.

Intestinal carriage of extended-spectrum beta-lactamase-producing Enterobacteriaceae at admission in a Portuguese hospital

To evaluate the prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae fecal carriers at admission in a Portuguese hospital and to determine the epidemiology and antimicrobial resistance patterns of ESBL-producing isolates. During a 2-month period, rectal swabs were collected at hospital admission from 151 at-risk patients. In addition, 48 rectal swabs were obtained from weekly screenings of 37 patients hospitalized for > 48 h. All ESBL/carbapenemase-producing isolates were tested for antimicrobial susceptibility and characterized by PFGE and MLST. The prevalence of ESBL producers at hospital admission was 17% and 24% among at-risk patients hospitalized for > 48 h, while the prevalence of carbapenemase producers was 3% in both cases. Most of the isolates were Escherichia coli (54%) and Klebsiella pneumoniae (41%). The most common ESBL identified was CTX-M-15 (n = 17/34; 50%), followed by CTX-M-27 (n = 10; 29%), CTX-M-33 (n = 4; 12%), SHV-12 (n = 2), and CTX-M-55 (n = 1). The 20 E. coli isolates were distributed into 16 PFGE types and nine sequence types (ST), with 60% of the isolates belonging to ST131. The 15 K. pneumoniae were grouped into 12 PFGE types and nine STs, with three STs (ST17, ST449, ST147) corresponding to 60% of the isolates. A high proportion of isolates showed resistance to ciprofloxacin (86%), trimethoprim-sulfamethoxazole (68%), tobramycin (57%), and gentamicin (43%). All isolates remained susceptible to fosfomycin. A high prevalence of ESBL-producing Enterobacteriaceae was found at hospital admission among at-risk patients and > 50% of the isolates showed resistance to first-line antibiotics for the treatment of lower urinary tract infections, leaving fosfomycin as an alternative.

Detection of High-Level Rifaximin Resistance in Enteric Bacteria by Agar Screen

Objectives: This study aimed at determining the prevalence of rifaximin resistance in a large collection of Enterobacterales resistant to third-generation cephalosporins. A simple agar screen was developed to detect high-level resistance. Methods: A total of 401 isolates nonsusceptible to third-generation cephalosporins (including 342 Escherichia coli and 39 Klebsiella spp. and 20 Enterobacter spp.) were tested by microdilution for their MICs of rifaximin and rifampicin. Isolates with a confirmed rifaximin minimal inhibitory concentration (MIC) of >64 mg/L and a number of high-level resistant, and susceptible control isolates were tested for growth on Mueller-Hinton agar supplemented with rifaximin or rifampicin at a concentration of 256 mg/L. Amino acid mutations in rpoB and the presence of rifaximin resistance-associated genes arabidopsis response regulator (arr) 2/3 were investigated. Results: Microdilution assays identified rifaximin resistance in nine E. coli and three Klebsiella spp. isolates with complete cross-resistance to rifampicin (MICs of both >64 mg/L). The rifaximin agar screen correctly identified 9/9 clinical E. coli isolates, 2/2 E. coli controls, and 3/3 Klebsiella spp. with high-level rifaximin resistance, and was negative in 45 control clinical isolates with rifaximin MICs ranging between 2 and 32 mg/L according to broth microdilution. All nine high-level rifaximin agar screen-positive E. coli clinical isolates (vs. none of the tested controls) had rpoB mutations or carried arr2/3. Conclusions: Our agar screen test has the potential to detect high-level rifaximin-resistant Enterobacterales. Such strains remain rare among extended spectrum beta-lactamase (ESBL)-positive enteric bacteria, but may emerge among patients receiving rifaximin for prevention of hepatic encephalopathy and spontaneous bacterial peritonitis or among patients receiving rifaximin for other indications.

Infections caused by extended-spectrum β-lactamase-producing Enterobacterales after rectal colonization with ESBL-producing Escherichia coli or Klebsiella pneumoniae

OBJECTIVES

Infections as a result of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) are considered infections with a high public health burden. In this study, we aimed to identify incidences of and risk factors for healthcare-associated infections (HAIs) after rectal colonization with ESBL-producing Escherichia coli (ESBL-EC) or Klebsiella pneumoniae (ESBL-KP).

METHODS

This prospective cohort study was performed in 2014 and 2015. Patients colonized with ESBL-EC or ESBL-KP were monitored for subsequent HAI with ESBL-E and other pathogens. In the case of an ESBL-E infection, rectal and clinical isolates were compared using pulsed-field gel electrophoresis (PFGE), and whole-genome sequencing (WGS) for ESBL-KP isolates. Proportional hazard models were applied to identify risk factors for HAIs, and to analyse competing risks.

RESULTS

Among all patients admitted to the hospital during the study period, 13.6% were rectally screened for third-generation cephalosporin-resistant Enterobacterales (3GCREB). A total of 2386 rectal carriers of ESBL-EC and 585 of ESBL-KP were included in the study. Incidence density (ID) for HAI with ESBL-E was 2.74 per 1000 patient days at risk (95% confidence interval (CI) 2.16-3.43) among carriers of ESBL-EC, while it was 4.44 per 1000 patient days at risk (95% CI 3.17-6.04) among carriers of ESBL-KP. In contrast, ID for HAI with other pathogens was 4.36 per 1000 patient days at risk (95% CI 3.62-5.21) among carriers of ESBL-EC, and 5.00 per 1000 patient days at risk (95% CI 3.64-6.69) among carriers of ESBL-KP. Cox proportional hazard regression analyses identified colonization with ESBL-KP (HR = 1.58, 95% CI 1.068-2.325) compared with ESBL-EC as independent risk factor for HAI with ESBL-E. The results were consistent over all competing risk analyses.

CONCLUSIONS

Clinicians should be aware of the increased risk of ESBL-E infections among patients colonized with ESBL-KP compared with ESBL-EC that might be caused by underlying diseases, higher pathogenicity of ESBL-KP and other factors.

[Antibiotic stewardship : Measures for optimizing prescription of anti-infective agents]

Antibiotic stewardship (ABS) comprises a bundle of different interventions to improve anti-infective treatment in a hospital setting. An important component of ABS interventions is the interdisciplinary approach to infection management. Besides improving infrastructural aspects on a hospital level, including surveillance of the use of anti-infective agents and nosocomial infections, collation and interpretation of statistics on resistance and formulation of local treatment guidelines, ABS teams go to the wards and advise treating physicians on antibiotic therapy. Frequent approaches for optimization are selection of substances, administration route, dosing of medication and duration of treatment. An important overall objective of ABS is the reduction of resistance induction in order to preserve the therapeutic efficiency of antibiotics. A number of studies have shown that this goal can be achieved in different clinical settings without negatively affecting patient outcome. The strategies of ABS can also be applied with no problems to critically ill patients on the intensive care unit.

Pathogenicity of Clinical OXA-48 Isolates and Impact of the OXA-48 IncL Plasmid on Virulence and Bacterial Fitness

OXA-48 is the most common carbapenemase in Enterobacterales in Germany and one of the most frequent carbapenemases worldwide. Several reports have associated bla_OXA–48 with a virulent host phenotype. To challenge this hypothesis, 35 OXA-48-producing clinical isolates of Escherichia coli (n = 15) and Klebsiella pneumoniae (n = 20) were studied in vitro, in vivo employing the Galleria mellonella infection model and by whole-genome sequencing. Clinical isolates belonged to 7 different sequence types (STs) in E. coli and 12 different STs in K. pneumoniae. In 26/35 isolates bla_OXA–48 was located on a 63 kb IncL plasmid. Horizontal gene transfer (HGT) to E. coli J53 was high in isolates with the 63 kb IncL plasmid (transconjugation frequency: ∼10³/donor) but low in isolates with non-IncL plasmids (<10^–6/donor). Several clinical isolates were both highly cytotoxic against human cells and virulent in vivo. However, 63 kb IncL transconjugants generated from these highly virulent isolates were not more cytotoxic or virulent when compared to the recipient strain. Additionally, no genes associated with virulence were detected by in silico analysis of OXA-48 plasmids. The 63 kb plasmid was highly stable and did not impair growth or fitness in E. coli J53. In conclusion, OXA-48 clinical isolates in Germany are diverse but typically harbor the same 63 kb IncL plasmid which has been reported worldwide. We demonstrate that this 63 kb IncL plasmid has a low fitness burden, high plasmid stability and can be transferred by highly efficient HGT which is likely the cause of the rapid dissemination of OXA-48 rather than the expansion of a single clone or gain of virulence.

Systematic Comparison of Four Methods for Detection of Carbapenemase-Producing Enterobacterales Directly from Blood Cultures

Early identification of infections caused by carbapenemase-producing Enterobacterales (CPE) can help to optimize patient treatment and improve outcome. In this study, protocols for rapid detection of carbapenemase production directly from positive blood cultures were developed applying a concentration and hemolysis step before a test for carbapenemase production was performed.

Early identification of infections caused by carbapenemase-producing Enterobacterales (CPE) can help to optimize patient treatment and improve outcome. In this study, protocols for rapid detection of carbapenemase production directly from positive blood cultures were developed applying a concentration and hemolysis step before a test for carbapenemase production was performed. Four different methods (three modified colorimetric assays [β-Carba, bcCarba NP, and NeoRapid Carb] and a variation of the carbapenem inactivation method [CIM] test with blood cultures [bcCIM]) were assessed on blood cultures spiked with 185 different molecularly characterized Enterobacterales isolates. The challenge collection included 81 carbapenemase-negative isolates and 104 CPEs (OXA-48 [n = 25], NDM [n = 20], KPC [n = 18], VIM [n = 25], GIM [n = 5], OXA-48-like [n = 9], and OXA-48-like plus NDM [n = 2]). The sensitivity/specificity was 99.0%/95.1% for bcCarba NP, 99.0%/91.4% for NeoRapid Carb, 100%/95.1% for β-Carba and 100%/100% for bcCIM. Weakly hydrolyzing carbapenemases (e.g., OXA-48-like) were also well detected by the assays. The time to result was 20 to 45 min for β-Carba, 2 to 3 h for bcCarba NP, 2.5 to 2 h for NeoRapid Carb, and 18 to 24 h for bcCIM. In conclusion, all assays demonstrated good detection of CPE. The protocols can be easily implemented in any clinical microbiology laboratory and could help to optimize therapy early in bloodstream infections by CPE.

Distinct impact of antibiotics on the gut microbiome and resistome: a longitudinal multicenter cohort study

BACKGROUND

The selection pressure exercised by antibiotic drugs is an important consideration for the wise stewardship of antimicrobial treatment programs. Treatment decisions are currently based on crude assumptions, and there is an urgent need to develop a more quantitative knowledge base that can enable predictions of the impact of individual antibiotics on the human gut microbiome and resistome.

RESULTS

Using shotgun metagenomics, we quantified changes in the gut microbiome in two cohorts of hematological patients receiving prophylactic antibiotics; one cohort was treated with ciprofloxacin in a hospital in Tübingen and the other with cotrimoxazole in a hospital in Cologne. Analyzing this rich longitudinal dataset, we found that gut microbiome diversity was reduced in both treatment cohorts to a similar extent, while effects on the gut resistome differed. We observed a sharp increase in the relative abundance of sulfonamide antibiotic resistance genes (ARGs) by 148.1% per cumulative defined daily dose of cotrimoxazole in the Cologne cohort, but not in the Tübingen cohort treated with ciprofloxacin. Through multivariate modeling, we found that factors such as individual baseline microbiome, resistome, and plasmid diversity; liver/kidney function; and concurrent medication, especially virostatic agents, influence resistome alterations. Strikingly, we observed different effects on the plasmidome in the two treatment groups. There was a substantial increase in the abundance of ARG-carrying plasmids in the cohort treated with cotrimoxazole, but not in the cohort treated with ciprofloxacin, indicating that cotrimoxazole might contribute more efficiently to the spread of resistance.

CONCLUSIONS

Our study represents a step forward in developing the capability to predict the effect of individual antimicrobials on the human microbiome and resistome. Our results indicate that to achieve this, integration of the individual baseline microbiome, resistome, and mobilome status as well as additional individual patient factors will be required. Such personalized predictions may in the future increase patient safety and reduce the spread of resistance.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02058888 . Registered February 10 2014.

High admission prevalence of fluoroquinolone resistance in third-generation cephalosporin-resistant Enterobacteriaceae in German university hospitals

Objectives

Fluoroquinolone resistance (FQR) in third-generation cephalosporin-resistant Enterobacteriaceae (3GCRE) presents serious limitations to antibiotic therapy. The aim of this study was to investigate whether the FQR proportion among 3GCRE differs between community-acquired (CA) and hospital-acquired (HA) isolates.

Methods

In a prospective observational study covering 2014 and 2015, we monitored the occurrence of 3GCRE in adult hospitalized patients in six German university hospitals. 3GCRE clinical isolates were subdivided into CA and HA. Multivariable analysis identified factors associated with in vitro non-susceptibility to ciprofloxacin.

Results

The dataset included 5721 3GCRE isolates of which 52.9% were HA and 52.7% exhibited FQR. Interestingly, the FQR proportion was higher in CA 3GCRE than in HA 3GCRE (overall, 60.1% versus 46.2%, respectively, P < 0.001). Multivariable analysis adjusting for age confirmed community acquisition as a risk factor for FQR [adjusted rate ratio (aRR) 1.33, 95% CI 1.17-1.53]. Escherichia coli and Klebsiella spp. were associated with a much higher FQR proportion than other Enterobacteriaceae species (aRR 8.14, 95% CI 6.86-9.65 and aRR 7.62 with 95% CI 6.74-8.61, respectively).

Conclusions

The high FQR proportion observed among CA 3GCRE, particularly in E. coli and Klebsiella spp., indicates that selection pressure in the outpatient setting needs to be addressed with antibiotic stewardship and other interventions in order to limit further spread of MDR.

Chlorhexidine-based decolonization to reduce healthcare-associated infections and multidrug-resistant organisms (MDROs): who, what, where, when, and why?

Body surface decolonization with chlorhexidine bathing and nasal mupirocin has become a simple solution for prevention of healthcare-associated infections. The clinical trial evidence for this practice will be reviewed to understand who benefits from this practice, for what reasons, and at what times. The method of bathing and nasal decolonization will also be discussed as proper application is needed for maximal effectiveness. Finally, the conflict between current effectiveness and future potential for fueling resistance is considered.

Antibiotic-resistant pathogens in different patient settings and identification of surveillance gaps in Switzerland - a systematic review

The prevalence of antimicrobial resistance (AMR) varies significantly among different patient populations. We aimed to summarise AMR prevalence data from screening studies in different patient settings in Switzerland and to identify surveillance gaps. We performed a systematic review, searching Pubmed, MEDLINE, Embase (01/2000–05/2017) and conference proceedings for Swiss studies reporting on carbapenemase-producing Enterobacteriaceae (CPE), extended-spectrum beta-lactamases (ESBL), mobilised colistin-resistance, methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) within different patient settings. We identified 2345 references and included 46 studies. For acute care patients, most screening data come from admission screenings, whereas AMR prevalence among hospitalised patients is largely unknown. Universal admission screenings showed ESBL-prevalences of 5–8% and MRSA-prevalences of 2–5%. For targeted screening, ESBL-prevalence ranged from 14–21%; MRSA-prevalence from 1–4%. For refugees, high ESBL (9–24%) and MRSA (16–24%) carriage rates were reported; returning travellers were frequently (68–80%) colonised with ESBL. Screening data for other pathogens, long-term care facility (LTCF) residents and pediatric populations were scarce. This review confirms high ESBL- and MRSA-carriage rates for risk populations in Switzerland. Emerging pathogens (CPE and VRE) and certain populations (inpatients, LTCF residents and children) are understudied. We encourage epidemiologists and public health authorities to consider these findings in the planning of future surveillance studies.

Rapid and Easy Detection of Carbapenemases in Enterobacterales in the Routine Laboratory Using the New GenePOC Carba/Revogene Carba C Assay

The novel, real-time PCR-based GenePOC Carba assay on the microfluidic revogene platform (GenePOC, Québec, Canada; now Meridian Bioscience, Cincinnati, OH, USA) was recently designed for the detection of bla _KPC, bla _NDM, bla _VIM, bla _OXA-48-like, and bla _IMP The goals of this study were to evaluate the performance of this assay, to assess its suitability for the routine microbiology laboratory, and to compare it to the Xpert Carba-R assay for the detection of carbapenemase-producing Enterobacterales (CPE) strains. The Xpert Carba-R assay (Cepheid) and the GenePOC Carba assay were challenged with a collection of 176 clinical Enterobacterales isolates. The collection included 133 CPE strains producing a total of 139 carbapenemases, including VIM (n = 48), OXA-48-like (n = 40), NDM (n = 29), KPC (n = 13), and IMP (n = 9). Six isolates produced two different carbapenemases, and 43 carbapenemase-negative isolates were included as negative controls. The overall sensitivity for carbapenemase detection was 96.4% (95% confidence interval [CI], 91.9% to 98.5%) for the Xpert Carba-R assay and 100% (95% CI, 97.3% to 100%) for the GenePOC assay. The four most common carbapenemases (NDM, KPC, OXA-48-like, and VIM) were detected with a sensitivity of 100% (95% CI, 97.1% to 100%) by the two tests, with all double carbapenemase producers being correctly detected by both assays. The sensitivity of the Xpert Carba-R assay for IMP was 44.4% (95% CI, 18.9% to 73.3%), while that of the GenePOC assay was 100% (95% CI, 70.1% to 100%). The specificity of both assays was 100% (95% CI, 91.8% to 100%). The GenePOC Carba assay showed excellent sensitivity and specificity for the five most common carbapenemases, including IMP variants. Its simplicity and short turnaround time make it suitable for use in the routine microbiology laboratory for CPE detection.

Antimicrobial usage in German acute care hospitals: results of the third national point prevalence survey and comparison with previous national point prevalence surveys

Objectives

Previous point prevalence surveys (PPSs) revealed the potential for improving antimicrobial usage (AU) in German acute care hospitals. Data from the 2016 German national PPS on healthcare-associated infections and AU were used to evaluate efforts in antimicrobial stewardship (AMS).

Methods

A national PPS in Germany was organized by the German National Reference Centre for Surveillance of Nosocomial Infections in 2016 as part of the European PPS initiated by the ECDC. The data were collected in May and June 2016. Results were compared with data from the PPS 2011.

Results

A total of 218 hospitals with 64 412 observed patients participated in the PPS 2016. The prevalence of patients with AU was 25.9% (95% CI 25.6%-26.3%). No significant increase or decrease in AU prevalence was revealed in the group of all participating hospitals. Prolonged surgical prophylaxis was found to be common (56.1% of all surgical prophylaxes on the prevalence day), but significantly less prevalent than in 2011 (P < 0.01). The most frequently administered antimicrobial groups were penicillins plus β-lactamase inhibitors (BLIs) (23.2%), second-generation cephalosporins (12.9%) and fluoroquinolones (11.3%). Significantly more penicillins plus BLIs and fewer second-generation cephalosporins and fluoroquinolones were used in 2016. Overall, an increase in the consumption of broad-spectrum antimicrobials was noted. For 68.7% of all administered antimicrobials, the indication was documented in the patient notes.

Conclusions

The current data reaffirm the points of improvement that previous data identified and reveal that recent efforts in AMS in German hospitals require further intensification.

Local prevalence of extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae intestinal carriers at admission and co-expression of ESBL and OXA-48 carbapenemase in Klebsiella pneumoniae: a prevalence survey in a Spanish University Hospital

OBJECTIVE

To assess the prevalence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae (ESBL-E) faecal carriers at admission in a University Hospital in Spain.

DESIGN

Prevalence survey.

SETTING

Pneumology, gastroenterology, urology and neurosurgery units at a university tertiary hospital in Madrid (Spain).

PARTICIPANTS

A total of 10 643 patients aged 18 and older admitted from March 2014 to April 2016 with a rectal swab taken at admission or as soon as possible within the first 48 hours.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of ESBL-E faecal carriers and prevalence of ESBL-E infections at admission.

RESULTS

The prevalance of ESBL-E carriers at admission was 7.69% (CI 95% 7.18 to 8.19). Most of the isolates were Escherichia coli (77.51%), followed by Klebsiella pneumoniae (20.71%). Eighty-eight (10.41%) of ESBL-E were simultaneous ESBL and carbapenemase (CP) producers, 1.83% in the case of E. coli and 42.86% among K. pneumoniae isolates. Of the ESBL typed, 52.15% belonged to the cefotaximases (CTX-M-15) type and 91.38% of the CP were oxacillinase (OXA-48) type. Only 0.43% patients presented an active infection by ESBL-E at admission.

CONCLUSIONS

The prevalence found in our study is very similar to that found in literature. However, we found a high percentage of simultaneous ESBL and CP producers, particularly in K. pneumoniae. Despite the high prevalence of colonised patients, the ESBL-infection rate at admission was very low.

ESBL colonization and acquisition in a hospital population: The molecular epidemiology and transmission of resistance genes

A prospective cohort study (German Clinical Trial Registry, No. 00005273) was performed to determine pre-admission colonization rates, hospital acquisition risk factors, subsequent infection rates and colonization persistence including the respective molecular epidemiology and transmission rates of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae (EPE). A total of 342 EPEs were isolated from rectal swabs of 1,334 patients on admission, at discharge and 6 months after hospitalization. Inclusion criteria were patients’ age > 18 years, expected length of stays > 48 hours, external referral. The EPEs were characterized by routine microbiological methods, a DNA microarray and ERIC-PCR. EPE colonization was found in 12.7 % of admitted patients, with the highest rate (23.8 %) in patients from nursing homes. During hospitalization, 8.1 % of the patients were de novo EPE colonized, and invasive procedures, antibiotic and antacid therapies were independent risk factors. Only 1/169 patients colonized on admission developed a hospital-acquired EPE infection. Escherichia coli was the predominant EPE (88.9 %), and 92.1% of the ESBL phenotypes could be related to CTX-M variants with CTX-M-1/15 group being most frequent (88.9%). A corresponding β-lactamase could not be identified in five isolates. Hospital-acquired EPE infections in patients colonized before or during hospitalization were rare. The diversity of the EPE strains was much higher than that of the underlying plasmids. In seven patients, transmission of the respective plasmid across different species could be observed indicating that the current strain-based surveillance approaches may underestimate the risk of inter-species transmission of resistance genes.

Impact of single-room contact precautions on hospital-acquisition and transmission of multidrug-resistant Escherichia coli: a prospective multicentre cohort study in haematological and oncological wards

OBJECTIVES

Colonization and infection with third-generation cephalosporin-resistant Escherichia coli (3GCR-EC) are frequent in haematological and oncological patients. In this high-risk setting, German guidelines recommend single-room contact precautions (SCP) for patients with 3GCR-EC that are non-susceptible to fluoroquinolones (F3GCR-EC). However, this recommendation is controversial, as evidence is limited.

METHODS

We performed a prospective, multicentre cohort study at four haematology and oncology departments assessing the impact of SCP on hospital-acquired colonization or bloodstream infection (BSI) with F3GCR-EC. Two sites performed SCP for F3GCR-EC patients including single rooms, gloves and gowns (SCP sites), and two did not (NCP sites). Active screening for 3GCR-EC was performed and isolates were characterized with molecular typing methods including whole genome sequencing and core genome multiple locus sequence typing to assess patient-to-patient transmission. Potential confounders were assessed by competing-risk regression analysis.

RESULTS

Within 12 months, 1386 patients at NCP sites and 1582 patients at SCP sites were included. Hospital-acquisition of F3GCR-EC was observed in 22/1386 (1.59%) and 16/1582 (1.01%) patients, respectively (p 0.191). There were 3/1386 (0.22%) patients with BSI caused by F3GCR-EC at NCP sites and 4/1582 (0.25%) at SCP sites (p 1.000). Patient-to-patient transmission occurred in three cases at NCP and SCP sites each (p 1.000). The number of patients needed to screen in order to prevent one patient-to-patient transmission of F3GCR-EC was determined to be 3729.

CONCLUSIONS

Use of SCP had no significant impact on hospital-acquisition or patient-to-patient transmission of F3GCR-EC in this high-risk setting.

Incidence of infections due to third generation cephalosporin-resistant Enterobacteriaceae - a prospective multicentre cohort study in six German university hospitals

Background

Infections caused by third generation cephalosporin-resistant Enterobacteriaceae (3GCREB) are an increasing healthcare problem. We aim to describe the 3GCREB infection incidence and compare it to prevalence upon admission. In addition, we aim to describe infections caused by 3GCREB, which are also carbapenem resistant (CRE).

Methods

In 2014-2015, we performed prospective 3GCREB surveillance in clinically relevant patient specimens (screening specimens excluded). Infections counted as hospital-acquired (HAI) when the 3GCREB was detected after the third day following admission, otherwise as community-acquired infection (CAI).

Results

Of 578,420 hospitalized patients under surveillance, 3367 had a 3GCREB infection (0.58%). We observed a similar 3GCREB CAI and HAI incidence (0.28 and 0.31 per 100 patients, respectively). The most frequent pathogen was 3GCR E. coli, in CAI and HAI (0.15 and 0.12 per 100 patients). We observed a CRE CAI incidence of 0.006 and a HAI incidence of 0.008 per 100 patients (0.014 per 1000 patient days).

Conclusions

Comparing the known 3GCREB admission prevalence of the participating hospitals (9.5%) with the percentage of patients with a 3GCREB infection (0.58%), we conclude the prevalence of 3GCREB in university hospitals to be about 16 times higher than suggested when only patients with 3GCREB infections are considered. Moreover, we find the HAI and CAI incidence caused by CRE in Germany to be relatively low.