Community-Onset Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae Invasive Infections in Children in a University Hospital in France

Surveillance and Resistance of Community-Onset Extended-Spectrum β-Lactamase-Producing Escherichia coli and Klebsiella pneumonia in Oral and Maxillofacial Surgery Site Infections

Background: The prevalence of community-onset infections of extended spectrum β-lactamase (ESBL)-producing strains has increased globally, yet surveillance and resistance in patients with oral and maxillofacial surgery site infections is less investigated. Patients and Methods: A retrospective cohort study was performed to investigate risk factors and resistance of ESBL-producing Escherichia coli (ESBL-EC) and ESBL-producing Klebsiella pneumonia (ESBL-KP) among community-onset patients with oral and maxillofacial surgery during January 2010 to December 2016. Demographic features, predisposing factors, clinical outcomes, and antibiotic agent costs were analyzed. Antimicrobial susceptibility testing of nine antimicrobial agents against ESBL-KP and ESBL-EC were measured. Results: Among 2,183 cultures from infection sites in patients with oral and maxillofacial surgery site (45 cases [2.06%]) were confirmed with community-onset ESBL-KP (24; 1.10%) or ESBL-EC (21; 0.96%) infection. Multivariable analysis showed the independent risk factors for ESBL-producing bacterial infection were prior history of hospitalization (adjusted odds ratio [aOR], 10.984; 95% confidence interval [CI], 5.965-59.879; p = 0.025) and malignant condition (aOR, 3.373; 95% CI 2.947-7.634; p = 0.024). Based on antimicrobial susceptibility testing, 57.8% ESBL-KP and ESBL-EC were found receiving inappropriate antimicrobial therapy, and antibiotic agent costs were higher than non-ESBL-producing bacterial infections ($493.8 ± $367.3 vs. $304.1 ± $334.7; p = 0.031). Conclusions: Infections caused by ESBL-KP and ESBL-EC among patients in sites with oral and maxillofacial surgery are associated with prior history of hospitalization and malignant conditions. Prompt detection and appropriate antibiotic administration for community-onset infections of ESBLs are necessary for such populations.

Drug resistance and susceptibility of amikacin in children with extended-spectrum beta-lactamase-producing Enterobacterales: a systematic review with meta-analysis

Antibiotic resistance surveillance may be essential to identify patterns of antibiotic resistance and guide treatment choices. Therefore, this systematic review and meta-analysis aimed to evaluate amikacin resistance and susceptibility in children with extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-PE). From inception to September 5, 2022, relevant studies were searched via PubMed, Embase, Cochrane Library, and Web of Science databases. A network meta-analysis was conducted to explore the sequencing of resistance rates in amikacin and other antibiotics. Totally, 26 studies with 2582 clusters of bacterial isolates were included. The resistance rate of amikacin in children with ESBL-PE was 10.1%, higher than the resistance rate of tigecycline (0.0%), ertapenem (0.4%), meropenem (0.7%), and imipenem (3.0%). For the drug susceptibility rate in children with ESBL-PE, the susceptibility rate of amikacin (89.7%) was lower than tigecycline (99.6%), imipenem (96.8%), meropenem (97.3%), and ertapenem (95.6%). Amikacin showed a low drug resistance and a high drug resistance in children with ESBL-PE infection, making it a good option for the treatment of the infection caused by ESBL-PE.

Carbapenem-Resistant Klebsiella pneumoniae Among Patients with Ventilator-Associated Pneumonia: Evaluation of Antibiotic Combinations and Susceptibility to New Antibiotics

Background

Carbapenemase-producing Gram-negative bacteria, particularly Klebsiella pneumoniae (K. pneumoniae), are at the forefront of the list of causative agents of ventilator-associated pneumonia (VAP). The treatment options for such infections are limited, and various antimicrobial combinations have been suggested as alternatives in clinical practice. New antibiotics, such as ceftazidime/avibactam, ceftolozane/tazobactam and cefiderocol, have shown advantages in both in vitro and clinical studies.

Purpose

To evaluate the in vitro effect of meropenem–ciprofloxacin and meropenem–colistin combinations on carbapenem-resistant (CR) K. pneumoniae VAP isolates and to determine their susceptibility to new antibiotics.

Methods

Seventy-three K. pneumoniae isolates from 176 endotracheal samples from VAP cases were studied. Antibiotic susceptibility testing and phenotypic detection of extended-spectrum β lactamase (ESBL) and carbapenemase production were done. CR K. pneumoniae isolates were tested for the five predominant carbapenemase genes (bla_KPC, bla_OXA-48, bla_NDM,bla_VIM, and bla_IMP). In vitro evaluation of meropenem–ciprofloxacin and meropenem–colistin combinations was done by MIC test strips. Susceptibility to new antibiotics was tested by disk diffusion method.

Results

Sixty-three (86.3%) of the isolates were ESBL producers and 52 (71.2%) were carbapenem resistant. Bla_NDM was the most prevalent carbapenemase gene (50%), followed by bla_OXA-48, (36.5%) then bla_KPC in (11.5%). Bla_VIM and bla_IMP were not detected. Meropenem–ciprofloxacin combination showed indifferent effect on all isolates, while meropenem–colistin combination showed 25% synergism, 15.4% addition and 59.6% indifference. All (100%) CR K. pneumoniae isolates were resistant to ceftolozane/tazobactam and 79% were resistant to ceftazidime/avibactam, while 96% were sensitive to cefiderocol.

Conclusion

A high rate of carbapenem resistance exists among VAP K. pneumoniae isolates. Meropenem–colistin combination and cefiderocol appear to be potential treatment options for infections caused by CR K. pneumoniae. Resistance to the tested new β-lactam/β-lactamase inhibitors was high, signifying a major threat.

[Antimicrobial resistance patterns in pediatric febrile urinary tract infection and empirical antibacterial therapy. An epidemiological study in secondary and tertiary care centers in the north-east of France in 2019-2020]

BACKGROUND

Febrile urinary tract infection (UTI) is a common health issue in pediatrics that can lead to serious infectious and renal complications, it requires early diagnosis and a targeted use of antibiotics. The aim of our study was to describe local bacterial agents causing febrile UTIs and their resistance patterns and confront the results with currently used empirical antibacterial therapy in pediatrics emergency departments in Strasbourg and Saverne.

PATIENTS AND METHODS

We used billing codes (international classification of diseases) to identify all inpatients treated for febrile UTIs in two French pediatric emergency departments between January 2019 and December 2020. Microbial results of urine cultures were retrieved from the laboratory information system.

RESULTS

Among 214 microbial results from 208 patients, the distribution of uropathogens was 82% Escherichia coli, with extended-spectrum beta-lactamase in 2.8%, 7% Enterococcus faecalis, 5% Klebsiella, 2% Proteus mirabilis. E. coli was resistant respectively to amoxicillin, amoxicillin/clavulanic acid and cotrimoxazol in 43, 33 and 14% of samples. A third-generation cephalosporin administered intravenously was mainly used (98%) as empirical treatment. Less than 2% of patients were treated with oral cephalosporin from the start.

CONCLUSION

We present the spectrum of uropathogens and susceptibility test results in pediatric UTIs as well as the susceptibility pattern of E. coli, a local treatment protocol was designed based on our results in conformity with national guidelines.

Extended-Spectrum Beta-Lactamase- and Carbapenemase-Producing Enterobacteriaceae Family of Bacteria from Diarrheal Stool Samples in Northwest Ethiopia

Background

Resistance among the commensal flora is a serious threat because they are highly populated ecosystems like the gut, maybe a source of extraintestinal infections. Infections due to extended-spectrum beta-lactamase (ESBL)- and carbapenemase (CPM)-producing Enterobacteriaceae family of bacteria impose a major global issue because they are usually resistant to multiple antimicrobial agents. Data on the fecal ESBL- and CPM-producing group of bacteria in developing countries including Ethiopia are limited mainly due to resource constraints. Thus, this study aimed to determine the prevalence of multidrug-resistant (MDR)-, ESBL-, and CPM-producing Enterobacteriaceae family of bacteria from diarrheal stool samples at the University Hospital, Northwest Ethiopia.

Materials and Methods

A hospital-based cross-sectional study was conducted involving a total of 384 study participants having gastrointestinal complaints from January to April 2019. A diarrheal stool sample was aseptically collected and inoculated on a MacConkey agar plate. After getting pure colonies, biochemical and antimicrobial susceptibility testing was done following standard microbiological techniques. ESBL production was screened using ceftazidime and cefotaxime and confirmed using a combined disk diffusion test. Carbapenemases were screened by meropenem disk and confirmed by the modified carbapenem inactivation method. Data were checked, cleaned, and entered using Epi Info version 7.1 and transferred to SPSS version 20 for analysis.

Result

A total of 404 Enterobacteriaceae groups of bacteria were isolated from 384 diarrheal stool samples. The overall prevalence of fecal MDR-, ESBL-, and CPM-producing group of Enterobacteriaceae was 196 (48.5%), 66 (16.3%), and 4 (1%), respectively. Of the total ESBL-producing Enterobacteriaceae, E. coli (41/66 (62.1%)) and K. pneumoniae (18/66 (27.3%)) were the most predominant isolates. One half of CPE has been observed in Citrobacter species and the rest in E. coli (25%) and P. vulgaris (25%). Conclusion and Recommendation. Finding the high rate of ESBL-producing Enterobacteriaceae and CPE requires strict infection control measures and careful selection of empirical therapy in the study area. Therefore, active surveillance with large sample size and better infection prevention control is needed.

Stewardship program on carbapenem prescriptions in a tertiary hospital for adults and children in France: a cohort study

Antimicrobial stewardship programs aim at reducing the overuse of broad-spectrum antibiotics such as carbapenems, but their impact remains unclear. We compared the use of carbapenems between paediatric and adult subjects admitted to a French tertiary hospital and described the intervention of an antibiotic stewardship team (AST). As part of AST routine activity, all adult and paediatric patients receiving carbapenems are identified in real time using a computer-generated alert system and reviewed by the AST. Data associated with carbapenem prescriptions were extracted for 2 years (2014-2015) and were compared between paediatric and adult wards. Prescription appropriateness (i.e. no clinically suitable narrower spectrum alternative to carbapenem for de-escalation) and AST intervention were analysed. In total, 775 carbapenem prescriptions for 291 children and 262 adults were included. Most patients (95%) had a comordity and 52% had known recent carriage of extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBLE). Most carbapenem prescriptions came from intensive care units (n = 269, 35%) and were initiated for urinary tract (n = 200, 27%), sepsis (n = 181, 25%), and lung (n = 153, 21%) infections. Carbapenems were initiated empirically in 537 (70%) cases, and an organism was isolated in 523 (67%) cases. Among the isolated organisms, 47% (n = 246) were ESBLE and 90% (n = 468) were susceptible to carbapenems, but an alternative existed in 61% (n = 320) of cases according to antibiotic susceptibility testing. Among prescriptions reviewed by the AST, 39% (n = 255) were considered non-appropriate and led to either antibiotic discontinuation (n = 47, 7%) or de-escalation (n = 208, 32%). Non-appropriate prescriptions were more frequent in paediatric wards (p = 0.01) and in microbiologically documented infections (p = 0.013), and less observed in immunocompromised patients (p = 0.009) or with a known ESBLE carriage (p < 0.001). Tailored stewardship programs are essential to better control carbapenem use and subsequent antimicrobial resistance.

Optimal Management of Complicated Infections in the Pediatric Patient: The Role and Utility of Ceftazidime/Avibactam

Antimicrobial resistance poses a substantial threat to global public health. The pursuit of new antibiotics has decreased and very few options have been investigated for the treatment of complicated multidrug-resistant Gram-negative (MDR-GN) infections in adult population and even less in pediatric patients. Ceftazidime-avibactam (CAZ-AVI) is novel cephalosporin/β-lactamase inhibitor (BL-BLI) combination with broad antibacterial spectrum. The aim of this review is to describe the current and future role CAZ-AVI in the pediatric population with suspected or confirmed MDR-GN infections.

Noncarbapenems for the Treatment of Urinary Tract Infections Caused by Extended-Spectrum β-Lactamase-Producing Bacteria

OBJECTIVES

Urinary tract infections (UTIs) caused by extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae are resistant to many conventional therapies, including third-generation cephalosporins. Carbapenems are considered first-line agents for ESBL infections, but their use is associated with increased multidrug resistance and should be reserved when absolutely necessary. Because of the increased rates of UTIs caused by ESBL-producing organisms and incidence of carbapenem resistance, safe and effective alternatives to carbapenems are needed. This study was conducted to evaluate the outcomes associated with the treatment of ESBL UTIs with noncarbapenem antibiotics.

METHODS

A retrospective cohort study of adults with ESBL UTIs was conducted at a community hospital. Patients were categorized as those receiving definitive carbapenem therapy and those receiving definitive noncarbapenem therapy. Calculated measurements included infection-related mortality, length of hospital stay, and duration of definitive antibiotic therapy. Microbiological failure was assessed as a secondary outcome. Data on the safety of antibiotic therapy were not collected. P < 0.05 was considered significant.

RESULTS

Fifty patients met inclusion criteria for the study, divided evenly between the two cohorts. No statistical differences were observed for length of hospital stay (P = 0.601), duration of therapy (P = 0.398), or rate of microbiological failure between the groups (P = 0.115).

CONCLUSIONS

Noncarbapenems did not demonstrate significant differences compared with carbapenems in the treatment of adults with ESBL UTIs. In certain patient populations, noncarbapenems that demonstrate in vitro activity may be appropriate for UTIs caused by ESBL-producing organisms.

Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae in Dairy Farm Environments: A New Zealand Perspective

Antimicrobial resistance (AMR) is a global issue for both human and animal health. Infections caused by antimicrobial-resistant bacteria present treatment option challenges and are often associated with heightened severity of infection. Antimicrobial use (AMU) in human and animal health is a main driver for the development of antimicrobial-resistant bacteria. Increasing levels of AMU and the development and spread of AMR in food-producing animals, especially in poultry and swine production, has been identified as a food safety risk, but dairy production systems have been less studied. A number of farm management practices may impact on animal disease and as a result can influence the use of antimicrobials and subsequently AMR prevalence. However, this relationship is multifactorial and complex. Several AMR transmission pathways between dairy cattle, the environment, and humans have been proposed, including contact with manure-contaminated pastures, direct contact, or through the food chain from contaminated animal-derived products. The World Health Organization has defined a priority list for selected bacterial pathogens of concern to human health according to 10 criteria relating to health and AMR. This list includes human pathogens such as the extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E), which can be associated with dairy cattle, their environment, as well as animal-derived food products. ESBL-E represent a potential risk to human and animal health and an emerging food safety concern. This review addresses two areas; first, the current understanding of the role of dairy farming in the prevalence and spread of AMR is considered, highlighting research gaps using ESBL-E as an exemplar; and second, a New Zealand perspective is taken to examine how farm management practices may contribute to on-farm AMU and AMR in dairy cattle.

Incidence and Outcomes of Infections Caused by Multidrug-Resistant Enterobacteriaceae in Children, 2007-2015

BACKGROUND

The escalating incidence of invasive disease caused by multidrug-resistant Gram-negative enteric Enterobacteriaceae (MDR-GNE) is a global concern. Scant published studies in which the epidemiology of these infections in children is described exist; previous studies focused mainly on adults, described circumscribed populations, or lacked clinical detail. The objective of this study was to examine and describe the incidence, risk factors, and outcomes associated with MDR-GNE infection in children.

METHODS

In this cohort study, we used data from 48 children's hospitals maintained by the Pediatric Health Information System. We documented the proportion of MDR-GNE diagnoses among children's hospital patients aged 0 to <18 years who were diagnosed with an Enterobacteriaceae-associated infection between January 1, 2007, and March 31, 2015, and we analyzed the association between MDR-GNE infection and hospital length of stay and death before discharge.

RESULTS

During the study period, 107610 discharges included a diagnosis code for Enterobacteriaceae infection, 724 (0.7%) of which included MDR-GNE infection. The incidence of MDR-GNE, and the proportion of infections with Enterobacteriaceae organisms that were MDR-GNE increased over the study period; from 0.2% in 2007 to 1.5% by 2015 (test for trend < .001). Almost one-quarter (23%) of the infections in children hospitalized for MDR-GNE were nosocomial. Increased odds of MDR-GNE infection were associated with older age and comorbid illnesses. Lengths of stay in patients with MDR-GNE infection were increased 20% (95% confidence interval, 9.9%-30.5%; P < .001) over those without MDR-GNE infection; the increased odds for death did not reach statistical significance (1.46 [95% confidence interval, 0.98-2.18]; P = .06). Results were robust to sensitivity analyses.

CONCLUSIONS

The incidence of pediatric MDR-GNE infection increased during 2007-2015. MDR-GNE infection was associated with increased length of stay, and we found a trend toward increased risk of death. Infections with Gram-negative enteric bacilli are becoming increasingly difficult to treat; considering the global burden of these antimicrobial-resistant organisms, interventions to curtail or even reverse this trend are needed urgently.

Febrile urinary-tract infection due to extended-spectrum beta-lactamase-producing Enterobacteriaceae in children: A French prospective multicenter study

Objectives

To assess the management of febrile urinary-tract infection (FUTIs) due to extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-E) in children, the Pediatric Infectious Diseases Group of the French Pediatric Society set up an active surveillance network in pediatric centers across France in 2014.

Materials and methods

We prospectively analysed data from 2014 to 2016 for all children < 18 years old who received antibiotic treatment for FUTI due to ESBL-E in 24 pediatric centers. Baseline demographic, clinical features, microbiological data and antimicrobials prescribed were collected.

Results

301 children were enrolled in this study. The median age was 1 year (IQR 0.02–17.9) and 44.5% were male. These infections occurred in children with history of UTIs (27.3%) and urinary malformations (32.6%). Recent antibiotic use was the main associated factor for FUTIs due to ESBL-E, followed by a previous hospitalization and travel history. Before drug susceptibility testing (DST), third-generation cephalosporins (3GC) PO/IV were the most-prescribed antibiotics (75.5%). Only 13% and 24% of children received amikacine alone for empirical or definitive therapy, respectively, whereas 88.7% of children had isolates susceptible to amikacin. In all, 23.2% of children received carbapenems in empirical and/or definitive therapy. Cotrimoxazole (24.5%), ciprofloxacin (15.6%) and non-orthodox clavulanate–cefixime combination (31.3%) were the most frequently prescribed oral options after obtaining the DST. The time to apyrexia and length of hospital stay did not differ with or without effective empirical therapy.

Conclusions

We believe that amikacin should increasingly take on a key role in the choice of definitive therapy of FUTI due to ESBL-E in children by avoiding the use of carbapenems.

Community-onset extended-spectrum β-lactamase producing Escherichia coli in urinary tract infections in children from 2015 to 2016: Prevalence, risk factors, and resistances

Over the past 10 years, the resistances among microbes are increasing gradually in Europe and greater resistances are seen in southern countries. We studied the prevalence of community-onset ESBL-producing Escherichia coli urinary tract infections in children.As secondary objectives, we analyzed associated risk factors and the resistance patterns in ESBL-producing E coli isolates.Retrospective observational study in a tertiary care hospital about children ≤14 years old with community-onset E coli urinary tract infection. The variables studied were age, sex, ESBL-producing, antibiotic therapy 7 to 30 days before the infection, hospitalization 7 to 30 days before the infection, nefrourologic pathology, and vesicoureteral reflux.Between January 1st, 2015 and December 31st, 2016, 229 isolates of E coli were obtained, of whom 21 (9.2%) where ESBL-producing E coli. Median age in non-ESBL-producing was 18 months versus 7 months in ESBL-producing group. Fourteen (66%) of the ESBL-producing group were men (P = .001), 5 (23.8%) were hospitalized 30 days before the infection (P = .001), 12 (57.1%) had nefrourological pathology (P = .003), 6 (28.5%) had vesicoureteral reflux (P = .032). Previous antibiotic therapy was not statistically significant. Multiple regression analyses between sex and 30 days previous hospitalization were r = 3.51 (P = .0001). Multidrug resistant isolates among ESBL-producing E coli was 12 (57%).The retrospective study allowed assessing the problem of ESBL-producing isolates in the outpatient settings. Some risk factors from past studies were confirmed and a combined risk is suggested. The resistant spectrum should be taken into account when choosing antibiotic regimens.

Aminoglycosides Monotherapy as First-Line Treatment for Febrile Urinary Tract Infection in Children

We report a retrospective monocentric descriptive study performed in CHI Creteil for 20 months to describe the management and outcome of amikacin monotherapy as an alternative to third-generation cephalosporins for empiric treatment of febrile urinary tract infection (FUTI) in children. Data were analyzed for 151 children, and 90 selected cases were classified as certain or highly probable FUTI. Escherichia coli infection was found in 89 cases. In all patients, fever was resolved within 72 hours after beginning amikacin treatment. Only 5.3% of children were febrile after 48 hours. The mean amikacin treatment duration was 3.05 ± 0.13 days before oral treatment began (guided by antibiotic susceptibility testing). Amikacin monotherapy seems effective for the initial management of FUTI in children.

The potential role of microbiota for controlling the spread of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) in neonatal population

The spread of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) in the hospital and also the community is worrisome. Neonates particularly are exposed to the risk of ESBL-PE acquisition and, owing to the immaturity of their immune system, to a higher secondary risk of ESBL-PE-related infection. Reducing the risk of acquisition in the hospital is usually based on a bundle of measures, including screening policies at admission, improving hand hygiene compliance, and decreasing antibiotic consumption. However, recent scientific data suggest new prevention opportunities based on microbiota modifications.

Healthcare costs doubled when children had urinary tract infections caused by extended-spectrum β-lactamase-producing bacteria

AIM

The impact of the emergence of antimicrobial resistant organisms has rarely been studied in children, including the healthcare costs of urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL)-producing bacteria. We evaluated the effect of ESBL on UTI healthcare costs and risk factors for paediatric UTIs.

METHODS

This retrospective case-control study covered 2005-2014 and focused on children below 16 years of age treated in a University hospital: 22 children with UTIs caused by ESBL-producing bacteria and 56 ESBL-negative UTI controls.

RESULTS

The median healthcare costs were 3929 Euros for the 22 ESBL patients and 1705 Euros for the 56 controls (p = 0.015). The mean and standard deviation length of hospital stay was 7.4 (5.9) days for the ESBL group and 3.6 (2.3) days for the controls (p = 0.007), and the figures for antibiotic treatment were 12.3 (5.5) days versus 5.8 (3.0) days (p < 0.001), respectively. The odd ratios for ESBL were underlying disease (6.63, p = 0.013), previous hospitalisation (6.07, p = 0.009) and antibiotic prophylaxis (5.20, p = 0.035).

CONCLUSION

Healthcare costs more than doubled when children had ESBL-related UTIs, mainly due to their increased length of stay. Effective oral antibiotics are urgently needed to treat paediatric infections caused by ESBL-producing bacteria.

Extended-spectrum β-lactamase-producing bacteria caused less than 5% of urinary tract infections in a paediatric emergency centre

AIM

The last decade has seen a significant increase in extended-spectrum β-lactamase (ESBL) secreting organisms responsible for paediatric urinary tract infections (UTIs), particularly in community-acquired infections. These expose patients to the risks of antibiotic treatment failure and renal scarring. This prospective study examined the prevalence and risk factors of febrile ESBL UTIs and their treatment in the paediatric emergency department of a university hospital.

METHODS

In this prospective observational study, all children from 0 to 16 years of age with febrile UTIs were included from May 2012 to April 2013. Cases with and without ESBL involvement were compared.

RESULTS

Of the 474 diagnosed febrile UTIs, 22 (4.6%) with a 95% confidence interval (95% CI) of 2.9-6.9 were due to an ESBL-producing organism. Escherichia coli was found in 85% of cases. Significant odds ratios (OR) for ESBL urinary tract infections were prior hospitalisation (OR 4.1, 95% CI 1.6-10.8), urinary tract abnormalities (OR 3.9, 95% CI 1.5-10.2) and previous antibiotic treatment (OR 3.1, 95% CI 1.2-8.8). All ESBL urinary tract infections had positive outcomes.

CONCLUSION

The prevalence of febrile ESBL urinary tract infections was less than 5% in a paediatric emergency department. This low rate was not high enough to justify changing our guidelines.

High Prevalence of ESBL-Producing Klebsiella pneumoniae Causing Community-Onset Infections in China

The aim of this work was to investigate the epidemiological and genetic characteristics of ESBL-producing Klebsiella pneumoniae (ESBL-Kp) causing community-onset infections. K. pneumoniae isolates were collected from 31 Chinese secondary hospitals between August 2010 and 2011. Genes encoding ESBL and AmpC beta-lactamases were detected by PCR. The isolates were assigned to sequence types (STs) using multi-locus sequence typing (MLST). Eleven ESBL-Kp strains were selected for whole-genome sequencing (WGS) for investigating the genetic environment and plasmids encoding ESBL genes. A total of 578 K. pneumoniae isolates were collected, and 184 (31.8%) carried ESBL genes. The prevalence of ESBL-Kp varied from different geographical areas of China (10.2–50.3%). The three most prevalent ESBL genes were bla_CTX-M-14 (n = 74), bla_CTX-M-15 (n = 60), and bla_CTX-M-3 (n = 40). MLST assigned 127 CTX-M-14 and CTX-M-15 producers to 54 STs, and CC17 was the most prevalent population (12.6%). STs (23, 37, and 86) that were known frequently associated with hypervirulent K. pneumoniae (hvKP) account for 14.1% (18/127). Phylogenetic analysis by concatenating the seven loci of MLST revealed the existence of ESBL-producing K. quasipneumoniae (two strains) and K. varricola (one strain), which was further confirmed by WGS. This study highlights the challenge of community-onset infections caused by ESBL-Kp in China. The prevalence of STs frequently associating with hvKP should be of concern. Surveillance of ESBL-KP causing community-onset infections now appears imperative.