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Lellouche J, Keren-Paz A, Rov R, Efrati Epchtien R, Frenk S, Hameir A, Temkin E, Schwartz D, Carmeli Y. Carbapenem-resistant Acinetobacter baumannii carrier detection: a simple and efficient protocol. Microbiol Spectr 2024; 12:e0406223. [PMID: 38426764 PMCID: PMC10986532 DOI: 10.1128/spectrum.04062-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/06/2024] [Indexed: 03/02/2024] Open
Abstract
Timely detection of carbapenem-resistant Acinetobacter baumannii (CRAB) carriers is essential to direct infection control measures. In this work, we aimed to develop a practical protocol to detect CRAB from screening samples. To choose a selective medium that detects CRAB with high sensitivity and specificity, 111 A. baumannii clinical isolates were inoculated on three types of agar: mSuperCARBA (SC), CHROMagar Acinetobacter (CaA), and modified CHROMagar Acinetobacter (mCaA) containing 4.5 mg/mL meropenem. SC was non-selective, CaA was the most sensitive (100%), but only moderately specific (72%), and mCaA was highly specific (97%) and sensitive (98%). Confirmation of the carbapenem-resistant phenotype using PCR-based detection of blaOXA-23, blaOXA-24, and blaOXA-58 genes was specific but not sensitive, detecting only 58% of CRAB isolates. Identification of A. baumannii using either gyrB or blaOXA-51 PCR was excellent. Next, we used the same methodology in routine screening for CRAB carriage. mCaA had the best yield, with high sensitivity but moderate specificity to differentiate between CRAB and other carbapenem-resistant organisms. Skin sampling using sponges and 6 hour enrichment was highly sensitive (98%), while other body sites had poor sensitivity (27%- 41%). Shorter incubation had slightly lower yield, and longer incubation did not improve the detection. Performing PCR for blaOXA-51 and gyrB on colonies growing on modified mCaA differentiated between CRAB and other species with high accuracy (98% and 99%, respectively). Based on our results, we present a procedure for easy and reliable detection of CRAB carriage using skin sampling, short enrichment, selection on mCaA, and PCR-based identification. IMPORTANCE Carbapenem-resistant Acinetobacter baumannii (CRAB) is a substantial cause of nosocomial infections, classified among the most significant multidrug-resistant pathogens by the World Health Organization and by the US Centers for Disease Control. Limiting the spread of CRAB is an important goal of infection control, but laboratory methods for identification of CRAB carriers are not standardized. In this work, we compared different selective agar plates, tested the efficiency of A. baumannii identification by PCR for species-specific genes, and used PCR-based detection of common resistance genes to confirm the carbapenem-resistant phenotype. During a prospective study, we also determined the optimal sample enrichment time. Based on our results, we propose a simple and efficient protocol for the detection of CRAB carriage using skin sampling, short enrichment, selection on appropriate agar plates, and PCR-based identification, resulting in a turn-around time of 24 hours.
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Affiliation(s)
- Jonathan Lellouche
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
- Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Alona Keren-Paz
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Reut Rov
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Reut Efrati Epchtien
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Sammy Frenk
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Amichay Hameir
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Elizabeth Temkin
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - David Schwartz
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Yehuda Carmeli
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
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Zheng C, Li D, Wang Y, Wang L, Huang Y, Yao J. Risk factors and genetic characteristics of the carriage of hypervirulent and carbapenem-resistant Acinetobacter baumannii among pregnant women. Front Microbiol 2024; 15:1351722. [PMID: 38572236 PMCID: PMC10987950 DOI: 10.3389/fmicb.2024.1351722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/16/2024] [Indexed: 04/05/2024] Open
Abstract
Background Carbapenem-resistant Acinetobacter baumannii (CRAB) and its emerging evolutionary branch toward hypervirulence have been neglected in pregnancy. Methods From September 2020 to August 2021, an active surveillance culture program encompassed 138 randomly selected pregnant women, with five subjected to sample collection at two different time points. The clinical characterization was explored through statistical analysis. Whole-genome sequencing, a Galleria mellonella infection model, and a global database were used to investigate the genetic characterization, pathogenicity, evolutionary history, and phylogenetic relationships of the isolates. Results Of the 41 CRAB isolates obtained, they were divided into four ClustersRS and an orphan pattern. ClusterRS 1 (n = 31), with eight complex types in pregnancy, was also the dominant ClusterRS globally, followed by ClusterRS 13 (n = 5), identified as hypervirulent KL49 CRAB, exhibiting phylogeographical specificity to Guangdong. A maternal carriage CRAB rate of 26.09% (36/138) was revealed, with half of the isolates representing novel complex types, prominently including CT3071, as the first KL7 isolates identified in Shenzhen. Both KL49 and KL7 isolates were most commonly found in the same participant, suggesting potential intraspecific competition as a possible reason for CRAB infection without carriers during pregnancy. The independent risk factors for carriers were revealed for the first time, including advanced maternal age, gestational diabetes mellitus, and Group B Streptococcus infection. Conclusion The significant carriage rate and enhanced virulence of CRAB during pregnancy emphasize the imperative for routine surveillance to forestall dissemination within this high-risk group, especially in Guangdong for ClusterRS 13 isolates.
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Affiliation(s)
- Chao Zheng
- Department of Gastroenterology, Shenzhen People’s Hospital (The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology), Shenzhen, China
- Bacteriology and Antibacterial Resistance Surveillance Laboratory, Shenzhen Institute of Respiratory Disease, Shenzhen People’s Hospital (The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology), Shenzhen, China
- Integrated Chinese and Western Medicine Postdoctoral Research Station, Jinan University, Guangzhou, China
- School of Materials and Environmental Engineering, Shenzhen Polytechnic University, Shenzhen, China
| | - Defeng Li
- Department of Gastroenterology, Shenzhen People’s Hospital (The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology), Shenzhen, China
| | - Yinglan Wang
- Department of Obstetrics and Gynecology, Shenzhen People’s Hospital (The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology), Shenzhen, China
| | - Lisheng Wang
- Department of Gastroenterology, Shenzhen People’s Hospital (The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology), Shenzhen, China
| | - Yuting Huang
- Bacteriology and Antibacterial Resistance Surveillance Laboratory, Shenzhen Institute of Respiratory Disease, Shenzhen People’s Hospital (The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology), Shenzhen, China
- Department of Head and Neck Surgery, Cancer Hospital Chinese Academy of Medical Sciences Shenzhen Center, Shenzhen, China
| | - Jun Yao
- Department of Gastroenterology, Shenzhen People’s Hospital (The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology), Shenzhen, China
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Nutman A, Levi GD, Keren-Paz A, Schwartz D, Masarwa S, Schechner V, Carmeli Y. Active surveillance for carbapenem-resistant Acinetobacter baumannii (CRAB) carriage. Microbiol Spectr 2023; 11:e0314623. [PMID: 37943045 PMCID: PMC10715071 DOI: 10.1128/spectrum.03146-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/01/2023] [Indexed: 11/10/2023] Open
Abstract
IMPORTANCE Our study's results provide promising evidence for the incorporation of a high-sensitivity carbapenem-resistant Acinetobacter baumannii (CRAB) screening method in healthcare settings. Such an approach could prove beneficial in enhancing infection prevention and control measures, leading to improved patient outcomes and potentially alleviating the burden of CRAB in healthcare systems.
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Affiliation(s)
- Amir Nutman
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gabrielle D. Levi
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Alona Keren-Paz
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - David Schwartz
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Samira Masarwa
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Vered Schechner
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehuda Carmeli
- National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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4
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Min EK, Yim SH, Choi MC, Lee JG, Joo DJ, Kim MS, Kim DG. Incidence, mortality, and risk factors associated with carbapenem-resistant Acinetobacter baumannii bacteremia within 30 days after liver transplantation. Clin Transplant 2023; 37:e14956. [PMID: 36860160 DOI: 10.1111/ctr.14956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/10/2023] [Accepted: 02/26/2023] [Indexed: 03/03/2023]
Abstract
Carbapenem-resistant Acinetobacter baumannii bacteremia (CRAB-B) is a fatal infectious complication of liver transplantation (LT). This study investigated the incidence, effects, and risk factors associated with CRAB-B during the early post-LT period. Among 1051 eligible LT recipients, 29 patients experienced CRAB-B within 30 days of LT with a cumulative incidence of 2.7%. In the patients with CRAB-B (n = 29) and matched controls (n = 145) by nested-case control design, the cumulative incidence of death on days 5, 10, and 30 from the index date was 58.6%, 65.5%, and 65.5%, and 2.1%, 2.8%, and 4.2%, respectively (p < .001). Pre-transplant MELD (OR 1.11, 95% confidence interval [CI] 1.04-1.19, p = .002), severe encephalopathy (OR 4.62, 95% CI 1.24-18.61, p = .025), donor body mass index (OR .57, 95% CI .41-.75, p < .001), and reoperation (OR 6.40, 95% CI 1.19-36.82, p = .032) were independent risk factors for 30-day CRAB-B. CRAB-B showed extremely high mortality within 30 days after LT, especially within 5 days after its occurrence. Therefore, assessment of risk factors and early detection of CRAB, followed by proper treatment, are necessary to control CRAB-B after LT.
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Affiliation(s)
- Eun-Ki Min
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Hyuk Yim
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Mun Chae Choi
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Geun Lee
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Jin Joo
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Myoung Soo Kim
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Deok-Gie Kim
- Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
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Calix JJ, de Almeida MCS, Potter RF, Wallace MA, Burnham CAD, Dantas G. Outpatient Clonal Propagation and Rapid Regional Establishment of an Emergent Carbapenem-Resistant Acinetobacter baumannnii Lineage Sequence Type 499Pas. J Infect Dis 2023; 227:631-640. [PMID: 36301240 PMCID: PMC10152498 DOI: 10.1093/infdis/jiac427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/29/2022] [Accepted: 10/25/2022] [Indexed: 11/13/2022] Open
Abstract
Eliminating carbapenem-resistant Acinetobacter baumannii (CRAb) disease requires comprehensive knowledge of how this noncommensal organism propagates among at-risk hosts. We molecularly characterized an ongoing surge of CRAb cases among patients in a Midwest US healthcare system, which coincided with sustained reductions in hospital-acquired CRAb infections and falloffs of cases associated with distinctly more resistant antibiotypes. Genome sequencing revealed surge isolates belonged to an emergent Pasteur scheme sequence type 499 and comprised multiple contemporaneous clonal clusters. Detailed query of health records revealed no consistent hospital source but instead identified various outpatient healthcare settings linked to cluster cases. We show that CRAb can rapidly establish a regional presence even without gains in breadth of antibiotic resistance and negligible contribution from sustained intrahospital transmission. As CRAb lineages may sidestep control efforts via outpatient epidemiological niches, our approach can be implemented to investigate outpatient CRAb propagation and inform subsequent local surveillance outside hospital settings.
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Affiliation(s)
- Juan J Calix
- Division of Infectious Diseases, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | | | - Robert F Potter
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Meghan A Wallace
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Carey-Ann D Burnham
- Division of Infectious Diseases, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Molecular Microbiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Gautam Dantas
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Molecular Microbiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Biomedical Engineering, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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Hazen JE, Di Venanzio G, Hultgren SJ, Feldman MF. Catheterization of mice triggers resurgent urinary tract infection seeded by a bladder reservoir of Acinetobacter baumannii. Sci Transl Med 2023; 15:eabn8134. [PMID: 36630484 PMCID: PMC10464790 DOI: 10.1126/scitranslmed.abn8134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 10/11/2022] [Indexed: 01/13/2023]
Abstract
The antibiotic-resistant bacterium Acinetobacter baumannii is a leading cause of hospital-associated infections. Despite surveillance and infection control efforts, new A. baumannii strains are regularly isolated from health care facilities worldwide. In a mouse model of urinary tract infection, we found that mice infected with A. baumannii displayed high bacterial burdens in urine for several weeks. Two months after the resolution of A. baumannii infection, inserting a catheter into the bladder of mice with resolved infection led to the resurgence of a same-strain urinary tract infection in ~53% of the mice within 24 hours. We identified intracellular A. baumannii bacteria in the bladder epithelial cells of mice with resolved infection, which we propose could act as a host reservoir that was activated upon insertion of a catheter, leading to a resurgent secondary infection.
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Affiliation(s)
- Jennie E. Hazen
- Department of Molecular Microbiology, Washington University School of Medicine; St Louis, MO 63110, USA
- Department of Molecular Microbiology, Center for Women’s Infectious Disease Research, Washington University School of Medicine; St Louis, MO 63110 USA
| | - Gisela Di Venanzio
- Department of Molecular Microbiology, Washington University School of Medicine; St Louis, MO 63110, USA
| | - Scott J. Hultgren
- Department of Molecular Microbiology, Washington University School of Medicine; St Louis, MO 63110, USA
- Department of Molecular Microbiology, Center for Women’s Infectious Disease Research, Washington University School of Medicine; St Louis, MO 63110 USA
| | - Mario F. Feldman
- Department of Molecular Microbiology, Washington University School of Medicine; St Louis, MO 63110, USA
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Chaudhuri S, Rasooli I, Oskouei RH, Pishgahi M, Jahangir A, Andisi VF, Schryvers AB. Hybrid antigens expressing surface loops of BauA from Acinetobacter baumannii are capable of inducing protection against infection. Front Immunol 2022; 13:933445. [PMID: 36045685 PMCID: PMC9420935 DOI: 10.3389/fimmu.2022.933445] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Acinetobacter baumannii is a human bacterial pathogen of increasing concern in clinical settings due to the emergence of antibiotic resistant strains and the lack of effective therapeutics. Researchers have been exploring new treatment options such as novel drug candidates and vaccines to prevent severe infections and mortality. Bacterial surface antigens that are essential to A. baumannii for acquiring micronutrients (e.g. iron, zinc) from nutrient restricted environments are being considered as targets for vaccines or immunotherapy due to their crucial role for growth and pathogenesis in the human host. BauA, the outer membrane receptor for the siderophore acinetobactin was targeted for vaccine development in this study. Due to challenges in the commercial production of membrane proteins for vaccines, a novel hybrid antigen method developed by our group was used. Exposed loops of BauA were selected and displayed on a foreign scaffold to generate novel hybrid antigens designed to elicit an immune response against the native BauA protein. The potential epitopes were incorporated into a scaffold derived from the C-lobe of Neisseria meningitidis transferrin binding protein B (TbpB), named the loopless C-lobe (LCL). Hybrid proteins displaying three selected loops (5, 7 and 8) individually or in combination were designed and produced and evaluated in an A. baumannii murine sepsis model as vaccine antigens. Immunization with the recombinant BauA protein protected 100% of the mice while immunization with hybrid antigens displaying individual loops achieved between 50 and 100% protection. The LCL scaffold did not induce a protective immune response, enabling us to attribute the observed protection elicited by the hybrid antigens to the displayed loops. Notably, the mice immunized with the hybrid antigen displaying loop 7 were completely protected from infection. Taken together, these results suggest that our hybrid antigen approach is a viable method for generating novel vaccine antigens that target membrane surface proteins necessary for bacterial growth and pathogenesis and the loop 7 hybrid antigen can be a foundation for approaches to combat A. baumannii infections.
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Affiliation(s)
- Somshukla Chaudhuri
- Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Iraj Rasooli
- Department of Biology, Shahed University, Tehran, Iran
| | | | | | - Abolfazl Jahangir
- Applied Biotechnology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Vahid Farshchi Andisi
- Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Anthony B. Schryvers
- Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- *Correspondence: Anthony B. Schryvers,
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Containment of a carbapenem-resistant Acinetobacter baumannii complex outbreak in a COVID-19 intensive care unit. Am J Infect Control 2022; 50:477-481. [PMID: 35227793 PMCID: PMC8881223 DOI: 10.1016/j.ajic.2022.02.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 01/10/2023]
Abstract
Background A carbapenem-resistant Acinetobacter baumannii outbreak in the COVID intensive care unit of a community hospital was contained using multidrug resistant organism guidelines. The purpose of this study is to report on an outbreak investigation and containment strategy that was used, and to discuss prevention strategy. Methods A multidisciplinary approach contained the spread of infection. Strategies implemented included consultation with experts, screening, and reversal of personal protective equipment conservation. Ensuring infection control best practices are maintained remain important efforts to reduce the spread of multidrug resistant organisms. Results Five patients with carbapenem-resistant Acinetobacter baumannii were identified from routine clinical cultures within one week and one patient was identified from active surveillance cultures. Discussion Personal protective equipment conservation, strategies to prevent health care personnel exposure, and patient surge staffing protocols may have increased the likelihood of multidrug resistant organism transmission. Environmental and behavioral infection control regulations with effective administrative guidance, active surveillance cultures, and antimicrobial stewardship are critical to prevent future outbreaks. Conclusions After outbreak containment strategies were implemented, no additional patients were identified with carbapenem-resistant Acinetobacter baumannii. Conventional infection prevention and control strategies were re-instituted. A multidisciplinary approach with continued focus on hand hygiene, environmental cleaning, and correct use of personal protective equipment needs to be put in place to successfully contain and prevent the spread of carbapenem resistant infections.
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Management of a Major Carbapenem-Resistant Acinetobacter baumannii Outbreak in a French Intensive Care Unit While Maintaining Its Capacity Unaltered. Microorganisms 2022; 10:microorganisms10040720. [PMID: 35456771 PMCID: PMC9031073 DOI: 10.3390/microorganisms10040720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 12/10/2022] Open
Abstract
We describe bundle measures implemented to overcome a protracted carbapenem-resistant Acinetobacter baumannii (CRAB) outbreak in an 18-bed trauma Intensive Care Unit (ICU) at Strasbourg University Hospital, a tertiary referral center in France. Outbreak cases were defined by a positive CRAB sample with OXA-23 profile during or after ICU say. To sustain the capacity of the busy trauma ICU, infection control bundles were purposely selected to control the outbreak without closing the ICU. During the outbreak, from May 2015 to January 2019, 141 patients were contaminated by CRAB, including 91 colonized and 50 infected patients. The conventional infection and prevention control (IPC) measures implemented included weekly active surveillance of patients’ samples, enhancement of environmental cleaning, interventions to improve hand hygiene compliance and antibiotic stewardship with audits. Supplemental measures were needed, including environmental samplings, health care workers’ (HCWs) hand sampling, chlorhexidine body-washing, relocation of the service to implement Airborne Disinfection System (ADS), replication of crisis cells, replacement of big environmental elements and improvement of HCW organization at the patient’s bedside. The final measure was the cohorting of both CRAB patients and HCW caring for them. Only the simultaneous implementation of aggressive and complementary measures made it possible to overcome this long-lasting CRAB epidemic. Facing many CRAB cases during a rapidly spreading outbreak, combining simultaneous aggressive and complementary measures (including strict patients and HCW cohorting), was the only way to curb the epidemic while maintaining ICU capacity.
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Abstract
Acinetobacter baumannii is an important hospital-associated pathogen that causes antibiotic resistant infections and reoccurring hospital outbreaks. A. baumannii’s ability to asymptomatically colonize patients is a risk factor for infection and exacerbates its spread. However, there is little information describing the mechanisms it employs to colonize patients. A. baumannii often colonizes the upper respiratory tract and skin. Antibiotic use is a risk factor for colonization and infection suggesting that A. baumannii likely competes with commensal bacteria to establish a niche. To begin to investigate this possibility, we cocultured A. baumannii and commensal bacteria of the upper respiratory tract and skin. In conditions that mimic iron starvation experienced in the host, we observed that A. baumannii inhibits Staphylococcus epidermidis, Staphylococcus hominis, Staphylococcus haemolyticus and Corynebacterium striatum. Then using an ordered transposon library screen we identified the A. baumannii siderophore acinetobactin as the causative agent of the inhibition phenotype. Using mass spectrometry, we show that acinetobactin is released from A. baumannii under our coculture conditions and that purified acinetobactin can inhibit C. striatum and S. hominis. Together our data suggest that acinetobactin may provide a competitive advantage for A. baumannii over some respiratory track and skin commensal bacteria and possibly support its ability to colonize patients. IMPORTANCE The ability of Acinetobacter baumannii to asymptomatically colonize patients is a risk factor for infection and exacerbates its clinical spread. However, there is minimal information describing how A. baumannii asymptomatically colonizes patients. Here we provide evidence that A. baumannii can inhibit the growth of many skin and upper respiratory commensal bacteria through iron competition and identify acinetobactin as the molecule supporting its nutritional advantage. Outcompeting endogenous commensals through iron competition may support the ability of A. baumannii to colonize and spread among patients.
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11
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Chan JL, Nazarian E, Musser KA, Snavely EA, Fung M, Doernberg SB, Pouch SM, Leekha S, Anesi JA, Kodiyanplakkal RP, Turbett SE, Walters MS, Epstein L. Prevalence of carbapenemase-producing organisms among hospitalized solid organ transplant recipients, five U.S. hospitals, 2019-2020. Transpl Infect Dis 2022; 24:e13785. [PMID: 34989092 DOI: 10.1111/tid.13785] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/29/2021] [Accepted: 12/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Passive reporting to the Centers for Disease Control and Prevention has identified carbapenemase-producing organisms (CPOs) among solid organ transplant (SOT) recipients, potentially representing an emerging source of spread. We analyzed CPO prevalence in wards where SOT recipients receive inpatient care to inform public health action to prevent transmission. METHODS From September 2019 to June 2020, five U.S. hospitals conducted consecutive point prevalence surveys (PPS) of all consenting patients admitted to transplant units, regardless of transplant status. We used the Cepheid Xpert® Carba-R assay to identify carbapenemase genes (blaKPC , blaNDM , blaVIM , blaIMP , blaOXA-48 ) from rectal swabs. Laboratory-developed molecular tests were used to retrospectively test for a wider range of blaIMP and blaOXA variants. RESULTS In total, 154 patients were screened and 92 (60%) were SOT recipients. CPOs were detected among 7 (8%) SOT recipients, from two of five screened hospitals: 4 blaKPC , 1 blaNDM , 2 blaOXA-23 . CPOs were detected in 2 (3%) of 62 non-transplant patients. In three of five participating hospitals, CPOs were not identified among any patients admitted to transplant units. CONCLUSIONS Longitudinal surveillance in transplant units, as well as PPS in areas with diverse CPO epidemiology, may inform the utility of routine screening in SOT units to prevent the spread of CPOs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- June L Chan
- Wadsworth Center, New York State Department of Health, Albany, NY
| | | | | | - Emily A Snavely
- Wadsworth Center, New York State Department of Health, Albany, NY
| | - Monica Fung
- University of California San Francisco, San Francisco, CA
| | | | | | - Surbhi Leekha
- University of Maryland Medical Center, Baltimore, MD
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Albert MJ, Al-Hashem G, Rotimi VO. Multiplex gyrB PCR Assay for Identification of Acinetobacter baumannii Is Validated by Whole Genome Sequence-Based Assays. Med Princ Pract 2022; 31:493-496. [PMID: 35944494 PMCID: PMC9801371 DOI: 10.1159/000526402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 08/07/2022] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE A multiplex gyrB PCR assay has been used to diagnose Acinetobacter baumannii. However, this assay has not been validated against the gold standard DNA-DNA hybridization assay, which is a laborious method. DNA-DNA hybridization assay is now replaced by whole genome sequence (WGS)-based methods. Two such methods are a k-mer-based search of sequence reads using the Kraken 2 program and average nucleotide identity (ANI). The objective was to validate the gyrB PCR assay with WGS-based methods. SUBJECTS AND METHODS We cultured 270 sequential A. baumannii isolates from the rectal swabs of 32 adult patients. The identity of the isolates was determined by gyrB PCR. The sequences of 269 isolates were determined by Illumina sequencing and the taxonomy was inferred by the Kraken 2 program and ANI. RESULTS All the 269 isolates were confirmed as A. baumannii by Kraken 2 and ANI. CONCLUSION The gyrB PCR assay is now validated for easy identification of A. baumannii in comparison with gold standard WGS-based assays.
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Chhatwal P, Ebadi E, Schwab F, Ziesing S, Vonberg RP, Simon N, Gerbel S, Schlüter D, Bange FC, Baier C. Epidemiology and infection control of carbapenem resistant Acinetobacter baumannii and Klebsiella pneumoniae at a German university hospital: a retrospective study of 5 years (2015-2019). BMC Infect Dis 2021; 21:1196. [PMID: 34837973 PMCID: PMC8627082 DOI: 10.1186/s12879-021-06900-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 11/22/2021] [Indexed: 01/01/2023] Open
Abstract
Background Carbapenem resistant (CR) Klebsiella pneumoniae (Kp) and Acinetobacter baumannii (Ab) are emerging multidrug resistant bacteria with very limited treatment options in case of infection. Both are well-known causes of nosocomial infections and outbreaks in healthcare facilities.
Methods A retrospective study was conducted to investigate the epidemiology of inpatients with CR Kp and CR Ab in a 1500-bed German university hospital from 2015 to 2019. We present our infection control concept including a weekly microbiologic screening for patients who shared the ward with a CR Kp or CR Ab index patient. Results Within 5 years, 141 CR Kp and 60 CR Ab cases were hospitalized corresponding to 118 unique patients (74 patients with CR Kp, 39 patients with CR Ab and 5 patients with both CR Ab and CR Kp). The mean incidence was 0.045 (CR Kp) and 0.019 (CR Ab) per 100 inpatient cases, respectively. Nosocomial acquisition occurred in 53 cases (37.6%) of the CR Kp group and in 12 cases (20.0%) of the CR Ab group. Clinical infection occurred in 24 cases (17.0%) of the CR Kp group and in 21 cases (35.0%) of the CR Ab group. 14 cases (9.9%) of the CR Kp group and 29 cases (48.3%) of the CR Ab group had a history of a hospital stay abroad within 12 months prior to admission to our hospital. The weekly microbiologic screening revealed 4 CR Kp cases caused by nosocomial transmission that would have been missed without repetitive screening. Conclusions CR Kp and CR Ab cases occurred infrequently. A history of a hospital stay abroad, particularly in the CR Ab group, warrants pre-emptive infection control measures. The weekly microbiologic screening needs further evaluation in terms of its efficiency. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06900-3.
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Affiliation(s)
- Patrick Chhatwal
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Ella Ebadi
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Frank Schwab
- Institute of Hygiene and Environmental Medicine, Charité, University Medicine Berlin, Hindenburgdamm 27, 12203, Berlin, Germany
| | - Stefan Ziesing
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Ralf-Peter Vonberg
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Nicolas Simon
- Centre for Information Management (ZIMt), Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Svetlana Gerbel
- Centre for Information Management (ZIMt), Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Dirk Schlüter
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Franz-Christoph Bange
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Claas Baier
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
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Mills JP, Marchaim D. Multidrug-Resistant Gram-Negative Bacteria: Infection Prevention and Control Update. Infect Dis Clin North Am 2021; 35:969-994. [PMID: 34752228 DOI: 10.1016/j.idc.2021.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Multidrug-resistant gram-negative bacteria (MDR-GNB) pose one of the greatest challenges to health care today because of their propensity for human-to-human transmission and lack of therapeutic options. Containing the spread of MDR-GNB is challenging, and the application of multifaceted infection control bundles during an evolving outbreak makes it difficult to measure the relative impact of each measure. This article will review the utility of various infection control measures in containing the spread of various MDR-GNB and will provide the supporting evidence for these interventions.
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Affiliation(s)
- John P Mills
- Division of Infectious Diseases, University of Michigan Medical School, F4177 University Hospital South, 1500 E. Medical Center Dr, Ann Arbor, MI 48109-5226, USA.
| | - Dror Marchaim
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Infectious Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
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15
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Soria-Segarra C, Delgado-Valverde M, Serrano-García ML, López-Hernández I, Navarro-Marí JM, Gutiérrez-Fernández J. [Infections in patients colonized with carbapenem-resistant Gram-negative bacteria in a medium Spanish city]. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2021; 34:450-458. [PMID: 34098663 PMCID: PMC8638834 DOI: 10.37201/req/021.2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/12/2021] [Accepted: 05/10/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Because there are few studies on the clinical implications of colonization by carbapenem-resistant gram-negative bacteria (CRB) this was analyzed in rectal smears (RS) and pharyngeals (PS) and its ability to predict infection/colonization. METHODS A cross-sectional, retrospective study from adult inpatients between January 2016 and December 2019 was conducted. The isolates were characterized by MicroScan and spectrometry of masses applying EUCAST 2018 cutoff points. The detection of carbapenemases was performed by PCR and Sanger sequencing; sequencies was assigned by MLST. The genetic relationship between the clinical isolates was made by pulsed field electrophoresis using the enzymes Xbal, Spel or Apal. RESULTS A total of 308 (86.03%) RS and 50 (13.97%) positive PS were detected, the RS had a 85% sensibility, 100% specificity, 100% positive predictive value and 97% negative predictive value. In RS, the following were isolated: 44% (n=135) Acinetobacter baumannii, 26% (n =80) Enterobacterales (20 KPC, 29 OXA-48, 22 VIM, 2 IMP, 7 NDM), 17% (n=53) Pseudomonas aeruginosa and 13% (n=40) Stenotrophomonas maltophilia. In the PS were isolated 44% (n=22) S. maltophilia, 40% (n = 20) A. baumannii, 8% (n=4) P. aeruginosa and 8% (n=4) Enterobacterales (3 VIM, 1 OXA). From the patients with simultaneous RS and PS, 41 (40.6%) had positivity in both smears, 45 (44.6%) only in RS and 15 (14.9%) only in PS. Colonization preceded infection in 81.3% (n=13) of the isolates; association between infection and colonization was found (p<0.001; χ2); and the episodes where the information was found all the isolates from the clinical samples and from the smears were similar. CONCLUSIONS The probability of predicting infection through the CRB colonized in different clinical samples is feasible. The RS has a major sensibility to detect colonization.
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Affiliation(s)
| | | | | | | | | | - J Gutiérrez-Fernández
- José Gutiérrez-Fernández. Laboratorio de Microbiología. Hospital Universitario Virgen de las Nieves. Avenida de las Fuerzas Armadas, 2, E-18014, Granada, Spain.
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16
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Mao P, Deng X, Yan L, Wang Y, Jiang Y, Zhang R, Yang C, Xu Y, Liu X, Li Y. Whole-Genome Sequencing Elucidates the Epidemiology of Multidrug-Resistant Acinetobacter baumannii in an Intensive Care Unit. Front Microbiol 2021; 12:715568. [PMID: 34589072 PMCID: PMC8473952 DOI: 10.3389/fmicb.2021.715568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/26/2021] [Indexed: 11/13/2022] Open
Abstract
The nosocomial pathogen Acinetobacter baumannii is a frequent cause of healthcare-acquired infections, particularly in critically ill patients, and is of serious concern due to its potential for acquired multidrug resistance. Whole-genome sequencing (WGS) is increasingly used to obtain a high-resolution view of relationships between isolates, which helps in controlling healthcare-acquired infections. Here, we conducted a retrospective study to identify epidemic situations and assess the percentage of transmission in intensive care units (ICUs). Multidrug-resistant A. baumannii (MDR-AB) were continuously isolated from the lower respiratory tract of different patients (at the first isolation in our ICU). We performed WGS, pulsed-field gel electrophoresis (PFGE), and multilocus-sequence typing (MLST) analyses to elucidate bacterial relatedness and to compare the performance of conventional methods with WGS for typing MDR-AB. From June 2017 to August 2018, A. baumannii complex strains were detected in 124 of 796 patients during their ICU stays, 103 of which were MDR-AB. Then we subjected 70 available MDR-AB strains to typing with WGS, PFGE, and MLST. Among the 70 A. baumannii isolates, 38 (54.29%) were isolated at admission, and 32(45.71%) were acquisition isolates. MLST identified 12 unique sequence types, a novel ST (ST2367) was founded. PFGE revealed 16 different pulsotypes. Finally, 38 genotypes and 23 transmissions were identified by WGS. Transmission was the main mode of MDR-AB acquisition in our ICU. Our results demonstrated that WGS was a discriminatory technique for epidemiological healthcare-infection studies. The technique should greatly benefit the identification of epidemic situations and controlling transmission events in the near future.
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Affiliation(s)
- Pu Mao
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaolong Deng
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Leping Yan
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Ya Wang
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yueting Jiang
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Rong Zhang
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Chun Yang
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yonghao Xu
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaoqing Liu
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yimin Li
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Li H, Zhang J, Wang Z, Yin Y, Gao H, Wang R, Jin L, Wang Q, Zhao C, Wang Z, Wang H. Evolution of Acinetobacter baumannii in Clinical Bacteremia Patients. Infect Drug Resist 2021; 14:3553-3562. [PMID: 34511946 PMCID: PMC8418358 DOI: 10.2147/idr.s320645] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/20/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction Colonization of the respiratory tract by Acinetobacter baumannii has been established as an independent risk factor for bacteremia. However, within-host evolution of A. baumannii in bacteremia has not been extensively investigated. Methods We performed whole-genome sequencing to discover the evolutionary characteristics that accompany the transition from respiratory tract carriage to bloodstream infection in three patients with A. baumannii bacteremia. Results Within-host genetic diversity was identified. A total of 21 single nucleotide variants (SNVs) were detected. Genic and intergenic evolution occurred particularly in secretion system, DNA recombination, and cell motility genes. Intergenic SNVs occurred more frequently compared to synonymous and non-synonymous SNVs, which indicated potential transcription or translation regulation. Non-synonymous mutations mostly occurred during the transition from respiratory tract carriage to bloodstream infection. Isolates of clonal complex 208 (CC208) had lower substitution rate with approximately 10−6 nucleotide substitutions per site year−1, compared with non-CC208 isolates (approximately 10−5). We found evidence for the occurrence of recombination in one patient. A total of 259 genes were found to be gained or lost during the within-host evolution, and 231 genes were only detected in one patient. Gene function annotation results suggested that most genes (71/259) were related to replication, recombination, and repair. Universal bloodstream specific genes were not found in all three patients, and only one putative membrane protein related gene was lost in two patients. Conclusion Our results indicated that within-host evolution of A. baumannii bacteremia was driven by mutations, gene content changes, and limited effect of recombination. Gene content diversity between different patients was identified, which suggested interplay of both host and pathogen factors in within-host genetic diversity. Secretion system-related genes showed higher frequency of genomic variations during the within-host evolution. Our findings enhanced our understanding of within-host evolution of A. baumannii bacteremia and provided a framework for discovering novel genomic changes and pathogenicity genes important for bacteremia, which will be validated in future studies.
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Affiliation(s)
- Henan Li
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, People's Republic of China
| | - Jiangang Zhang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, People's Republic of China
| | - Zhiren Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, People's Republic of China
| | - Yuyao Yin
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, People's Republic of China
| | - Hua Gao
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, People's Republic of China
| | - Ruobing Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, People's Republic of China
| | - Longyang Jin
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, People's Republic of China
| | - Qi Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, People's Republic of China
| | - Chunjiang Zhao
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, People's Republic of China
| | - Zhanwei Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, People's Republic of China
| | - Hui Wang
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, People's Republic of China
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18
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Meschiari M, Lòpez-Lozano JM, Di Pilato V, Gimenez-Esparza C, Vecchi E, Bacca E, Orlando G, Franceschini E, Sarti M, Pecorari M, Grottola A, Venturelli C, Busani S, Serio L, Girardis M, Rossolini GM, Gyssens IC, Monnet DL, Mussini C. A five-component infection control bundle to permanently eliminate a carbapenem-resistant Acinetobacter baumannii spreading in an intensive care unit. Antimicrob Resist Infect Control 2021; 10:123. [PMID: 34412693 PMCID: PMC8376111 DOI: 10.1186/s13756-021-00990-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 08/07/2021] [Indexed: 12/18/2022] Open
Abstract
Background Carbapenem-resistant Acinetobacter baumannii (CRAB) infection outbreaks are difficult to control and sometimes require cohorting of CRAB-positive patients or temporary ward closure for environmental cleaning. We aimed at controlling the deadly 2018 CRAB outbreak in a 12 bed- intensive care unit (ICU) including 9 beds in a 220 m2 open space. We implemented a new multimodal approach without ward closure, cohorting or temporarily limiting admissions. Methods A five-component bundle was introduced in 2018 including reinforcement of hand hygiene and sample extension of screening, application of contact precautions to all patients, enhanced environmental sampling and the one-time application of a cycling radical environmental cleaning and disinfection procedure of the entire ICU. The ICU-CRAB incidence density (ID), ICU alcohol-based hand rub consumption and antibiotic use were calculated over a period of 6 years and intervention time series analysis was performed. Whole genome sequencing analysis (WGS) was done on clinical and environmental isolates in the study period. Results From January 2013, nosocomial ICU-CRAB ID decreased from 30.4 CRAB cases per 1000 patients-days to zero cases per 1000 patients-days. Our intervention showed a significant impact (-2.9 nosocomial ICU-CRAB cases per 1000 bed-days), while no influence was observed for antibiotic and alcohol-based hand rub (AHR) consumption. WGS demonstrated that CRAB strains were clonally related to an environmental reservoir which confirms the primary role of the environment in CRAB ICU spreading. Conclusion A five-component bundle of continuous hand hygiene improvement, extended sampling at screening including the environment, universal contact precautions and a novel cycling radical environmental cleaning and disinfection procedure proved to be effective for permanently eliminating CRAB spreading within the ICU. Cohorting, admission restriction or ICU closure were avoided. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-021-00990-z.
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Affiliation(s)
- Marianna Meschiari
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria Policlinico and University of Modena and Reggio Emilia, Modena, Italy.
| | | | - Vincenzo Di Pilato
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | | | - Elena Vecchi
- Hospital Hygiene and Infection Control, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Erica Bacca
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Gabriella Orlando
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Erica Franceschini
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Mario Sarti
- Clinical Microbiology Laboratory, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Monica Pecorari
- Laboratory of Virology and Molecular Biology, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Antonella Grottola
- Laboratory of Virology and Molecular Biology, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Claudia Venturelli
- Clinical Microbiology Laboratory, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Stefano Busani
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero-Universitaria Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Lucia Serio
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero-Universitaria Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Massimo Girardis
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero-Universitaria Policlinico and University of Modena and Reggio Emilia, Modena, Italy
| | - Gian Maria Rossolini
- Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy.,IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Inge C Gyssens
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, 6525 GA, Nijmegen, The Netherlands
| | - Dominique L Monnet
- European Centre for Disease Prevention and Control (ECDC), Solna, Sweden
| | - Cristina Mussini
- Infectious Disease Clinic, Azienda Ospedaliero-Universitaria Policlinico and University of Modena and Reggio Emilia, Modena, Italy
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19
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Berneking L, Asar L, Both A, Berinson B, Aepfelbacher M, Lütgehetmann M, Rohde H. Performance of a loop-mediated isothermal amplification assay (Isoplex CRE-ART) to detect common carbapenemase-encoding genes in Gram-negative bacteria. J Med Microbiol 2021; 70. [PMID: 34251298 DOI: 10.1099/jmm.0.001379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Carbapenem-resistant Gram-negative bacteria (CR-GNB) are a major source of nosocomial infections worldwide. In this study, the ability of a loop-mediated isothermal amplification (LAMP)-based method (Isoplex CRE-ART) to rapidly detect carbapenemase-encoding genes bla OXA-48-like, bla OXA-23-like, bla OXA-24-like, bla KPC, bla VIM, bla NDM and bla IMP in 231 carbapenem-resistant Enterobacterales, Pseudomonas aeruginosa and Acinetobacter baumannii isolates was investigated. The accuracy of the LAMP test was compared to results of molecular isolate characterization using a Laboratory Developed Test multiplex carbapenemase PCR assay. The LAMP test correctly identified the presence of on-panel carbapenemases with a sensitivity of 99.16 % [95 % confidence interval (CI): 95.39-99.96 %] and a specificity of 98.21 % (95 % CI: 93.72-99.68 %) in 60 min. Our findings suggest that the Isoplex CRE-ART assay is able to rapidly identify carbapenemase genes in CR-GNB and improves options for pathogen characterization in the context of clinical microbiological and infection control diagnostics.
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Affiliation(s)
- Laura Berneking
- Universitätsklinikum Hamburg-Eppendorf, Medizinische Mikrobiologie, Virologie und Hygiene, Martinistraße 52, D-20246 Hamburg, Germany
| | - Lucia Asar
- Universitätsklinikum Hamburg-Eppendorf, Medizinische Mikrobiologie, Virologie und Hygiene, Martinistraße 52, D-20246 Hamburg, Germany
| | - Anna Both
- Universitätsklinikum Hamburg-Eppendorf, Medizinische Mikrobiologie, Virologie und Hygiene, Martinistraße 52, D-20246 Hamburg, Germany
| | - Benjamin Berinson
- Universitätsklinikum Hamburg-Eppendorf, Medizinische Mikrobiologie, Virologie und Hygiene, Martinistraße 52, D-20246 Hamburg, Germany
| | - Martin Aepfelbacher
- Universitätsklinikum Hamburg-Eppendorf, Medizinische Mikrobiologie, Virologie und Hygiene, Martinistraße 52, D-20246 Hamburg, Germany
| | - Marc Lütgehetmann
- Universitätsklinikum Hamburg-Eppendorf, Medizinische Mikrobiologie, Virologie und Hygiene, Martinistraße 52, D-20246 Hamburg, Germany
| | - Holger Rohde
- Universitätsklinikum Hamburg-Eppendorf, Medizinische Mikrobiologie, Virologie und Hygiene, Martinistraße 52, D-20246 Hamburg, Germany
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20
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Miltgen G, Bour M, Allyn J, Allou N, Vedani T, Vuillemenot JB, Triponney P, Martinet O, Lugagne N, Benoit-Cattin T, Dortet L, Birer A, Jaffar-Bandjee MC, Belmonte O, Plésiat P, Potron A. Molecular and epidemiological investigation of a colistin-resistant OXA-23-/NDM-1-producing Acinetobacter baumannii outbreak in the Southwest Indian Ocean Area. Int J Antimicrob Agents 2021; 58:106402. [PMID: 34293453 DOI: 10.1016/j.ijantimicag.2021.106402] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/29/2021] [Accepted: 07/03/2021] [Indexed: 11/29/2022]
Abstract
Dual resistance to colistin and carbapenems is a milestone reached by certain extensively-drug resistant (XDR) Gram-negative bacteria. This study describes the first outbreak of XDR colistin- and carbapenem-resistant OXA-23-/NDM-1-producing Acinetobacter baumannii (CCRAB) in the European overseas territory of Reunion Island (France, Indian Ocean). Between April 2019 and June 2020, 13 patients admitted to the University Hospital of Reunion Island were involved in the outbreak, of whom eight were infected and six died. The first case was traced to a medical evacuation from Mayotte Island (Comoros archipelago). An epidemiological link could be established for 11 patients. All of the collected CCRAB isolates showed the same resistance profile and co-produced intrinsic β-lactamases OXA-69 and ADC-191, together with acquired carbapenem-hydrolysing β-lactamases OXA-23 and NDM-1. A mutation likely involved in colistin resistance was detected in the two-component system PmrAB (D82N in PmrA). All of the isolates were found to belong to STPas1/STOx231 clonal complex and were phylogenetically indistinguishable. Their further characterization by whole-genome sequence analyses (whole-genome multi-locus sequence typing, single nucleotide polymorphisms) provided hints about the transmission pathways. This study pleads for strict application of control and prevention measures in institutions where the risk of imported XDR bacteria is high.
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Affiliation(s)
- Guillaume Miltgen
- Laboratoire de Bactériologie, Centre Hospitalier Universitaire La Réunion, Saint-Denis, France; UMR Processus Infectieux en Milieu Insulaire Tropical, CNRS 9192, INSERM U1187, IRD 249, Université de la Réunion, Sainte-Clotilde, France
| | - Maxime Bour
- Centre National de Référence de la Résistance aux Antibiotiques, Centre Hospitalier Universitaire de Besançon, Besançon, France
| | - Jérôme Allyn
- Réanimation polyvalente, Centre Hospitalier Universitaire La Réunion, Saint-Denis, France; Département d'informatique Clinique, Centre Hospitalier Universitaire La Réunion, Saint-Denis, France
| | - Nicolas Allou
- Réanimation polyvalente, Centre Hospitalier Universitaire La Réunion, Saint-Denis, France; Département d'informatique Clinique, Centre Hospitalier Universitaire La Réunion, Saint-Denis, France
| | - Thibaut Vedani
- Laboratoire de Bactériologie, Centre Hospitalier Universitaire La Réunion, Saint-Denis, France
| | - Jean-Baptiste Vuillemenot
- Centre National de Référence de la Résistance aux Antibiotiques, Centre Hospitalier Universitaire de Besançon, Besançon, France; Laboratoire de Bactériologie, UMR CNRS 6249 Chrono-Environnement, Faculté de Médecine-Pharmacie, Université Bourgogne Franche-Comté, Besançon, France
| | - Pauline Triponney
- Centre National de Référence de la Résistance aux Antibiotiques, Centre Hospitalier Universitaire de Besançon, Besançon, France
| | - Olivier Martinet
- Réanimation polyvalente, Centre Hospitalier Universitaire La Réunion, Saint-Denis, France
| | - Nathalie Lugagne
- Service d'Hygiène hospitalière, Centre Hospitalier Universitaire La Réunion, Saint-Denis, France
| | | | - Laurent Dortet
- Centre National de Référence de la Résistance aux Antibiotiques, Laboratoire associé, Centre Hospitalier Universitaire de Bicêtre, Le Kremlin-Bicêtre, France
| | - Aurélien Birer
- Centre National de Référence de la Résistance aux Antibiotiques, Laboratoire associé, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Olivier Belmonte
- Laboratoire de Bactériologie, Centre Hospitalier Universitaire La Réunion, Saint-Denis, France
| | - Patrick Plésiat
- Centre National de Référence de la Résistance aux Antibiotiques, Centre Hospitalier Universitaire de Besançon, Besançon, France; Laboratoire de Bactériologie, UMR CNRS 6249 Chrono-Environnement, Faculté de Médecine-Pharmacie, Université Bourgogne Franche-Comté, Besançon, France
| | - Anaïs Potron
- Centre National de Référence de la Résistance aux Antibiotiques, Centre Hospitalier Universitaire de Besançon, Besançon, France; Laboratoire de Bactériologie, UMR CNRS 6249 Chrono-Environnement, Faculté de Médecine-Pharmacie, Université Bourgogne Franche-Comté, Besançon, France.
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Surveillance cultures following a regional outbreak of carbapenem-resistant Acinetobacter baumannii. Infect Control Hosp Epidemiol 2021; 43:454-460. [PMID: 33985611 DOI: 10.1017/ice.2021.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The primary aim of this study was to assess the epidemiology of carbapenem-resistant Acinetobacter baumannii (CRAB) for 9 months following a regional outbreak with this organism. We also aimed to determine the differential positivity rate from different body sites and characterize the longitudinal changes of surveillance test results among CRAB patients. DESIGN Observational study. SETTING A 607-bed tertiary-care teaching hospital in Milwaukee, Wisconsin. PATIENTS Any patient admitted from postacute care facilities and any patient housed in the same inpatient unit as a positive CRAB patient. METHODS Participants underwent CRAB surveillance cultures from tracheostomy secretions, skin, and stool from December 5, 2018, to September 6, 2019. Cultures were performed using a validated, qualitative culture method, and final bacterial identification was performed using mass spectrometry. RESULTS In total, 682 patients were tested for CRAB, of whom 16 (2.3%) were positive. Of the 16 CRAB-positive patients, 14 (87.5%) were residents from postacute care facilities and 11 (68.8%) were African American. Among positive patients, the positivity rates by body site were 38% (6 of 16) for tracheal aspirations, 56% (9 of 16) for skin, and 82% (13 of 16) for stool. CONCLUSIONS Residents from postacute care facilities were more frequently colonized by CRAB than patients admitted from home. Stool had the highest yield for identification of CRAB.
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Zheng Y, Xu N, Pang J, Han H, Yang H, Qin W, Zhang H, Li W, Wang H, Chen Y. Colonization With Extensively Drug-Resistant Acinetobacter baumannii and Prognosis in Critically Ill Patients: An Observational Cohort Study. Front Med (Lausanne) 2021; 8:667776. [PMID: 33996866 PMCID: PMC8119758 DOI: 10.3389/fmed.2021.667776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 04/06/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Acinetobacter baumannii is one of the most frequently isolated opportunistic pathogens in intensive care units (ICUs). Extensively drug-resistant A. baumannii (XDR-AB) strains lack susceptibility to almost all antibiotics and pose a heavy burden on healthcare institutions. In this study, we evaluated the impact of XDR-AB colonization on both the short-term and long-term survival of critically ill patients. Methods: We prospectively enrolled patients from two adult ICUs in Qilu Hospital of Shandong University from March 2018 through December 2018. Using nasopharyngeal and perirectal swabs, we evaluated the presence of XDR-AB colonization. Participants were followed up for 6 months. The primary endpoints were 28-day and 6-month mortality after ICU admission. The overall survival rate was estimated by the Kaplan-Meier method. We identified risk factors associated with 28-day and 6-month mortality using the logistic regression model and a time-dependent Cox regression model, respectively. Results: Out of 431 patients, 77 were colonized with XDR-AB. Based on the Kaplan-Meier curve results, the overall survival before 28 days did not differ by colonization status; however, a significantly lower overall survival rate was obtained at 6 months in colonized patients. Univariate and multivariate analysis results confirmed that XDR-AB colonization was not associated with 28-day mortality, but was an independent risk factor of lower overall survival at 6 months (HR = 1.749, 95% CI = 1.174-2.608). Conclusions: XDR-AB colonization has no effect on short-term overall survival, but is associated with lower long-term overall survival in critically ill patients.
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Affiliation(s)
- Yue Zheng
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Nana Xu
- Cardiosurgery Care Unit, Department of Cardiosurgery, Qilu Hospital of Shandong University, Jinan, China
| | - Jiaojiao Pang
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Hui Han
- Department of Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Hongna Yang
- Department of Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Weidong Qin
- Department of Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Hui Zhang
- Department of Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Wei Li
- Department of Clinical Laboratory, Qilu Hospital of Shandong University, Jinan, China
| | - Hao Wang
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Department of Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- Department of Pharmacology, School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Yuguo Chen
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
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Nocera FP, Attili AR, De Martino L. Acinetobacter baumannii: Its Clinical Significance in Human and Veterinary Medicine. Pathogens 2021; 10:pathogens10020127. [PMID: 33513701 PMCID: PMC7911418 DOI: 10.3390/pathogens10020127] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/13/2021] [Accepted: 01/24/2021] [Indexed: 02/06/2023] Open
Abstract
Acinetobacter baumannii is a Gram-negative, opportunistic pathogen, causing severe infections difficult to treat. The A. baumannii infection rate has increased year by year in human medicine and it is also considered as a major cause of nosocomial infections worldwide. This bacterium, also well known for its ability to form biofilms, has a strong environmental adaptability and the characteristics of multi-drug resistance. Indeed, strains showing fully resistant profiles represent a worrisome problem in clinical therapeutic treatment. Furthermore, A. baumannii-associated veterinary nosocomial infections has been reported in recent literature. Particularly, carbapenem-resistant A. baumannii can be considered an emerging opportunistic pathogen in human medicine as well as in veterinary medicine.
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Affiliation(s)
- Francesca Paola Nocera
- Department of Veterinary Medicine and Animal Production, University of Naples “Federico II”, 80137 Naples, Italy;
| | - Anna-Rita Attili
- School of Biosciences and Veterinary Medicine, University of Camerino, 62024 Matelica, Italy;
| | - Luisa De Martino
- Department of Veterinary Medicine and Animal Production, University of Naples “Federico II”, 80137 Naples, Italy;
- Correspondence:
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Eigenbrod T, Reuter S, Gross A, Kocer K, Günther F, Zimmermann S, Heeg K, Mutters NT, Nurjadi D. Molecular characterization of carbapenem-resistant Acinetobacter baumannii using WGS revealed missed transmission events in Germany from 2012-15. J Antimicrob Chemother 2020; 74:3473-3480. [PMID: 31504593 DOI: 10.1093/jac/dkz360] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/03/2019] [Accepted: 07/17/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Infection and colonization with multi-resistant Acinetobacter baumannii causes therapeutic and economic problems in the nosocomial setting. Due to the sensitivity issue of screening schemes for A. baumannii, it is difficult to implement adequate transmission prevention measures. The high discriminatory power of WGS for transmission-chain analysis provides us with the necessary tool to study and identify transmission events. We retrospectively sequenced and analysed 39 A. baumannii isolates from 2012-15 to search for possible missed transmission events. METHODS Molecular typing by WGS was performed for non-repetitive (n=39) carbapenem-resistant A. baumannii. Retrospective assessment of patient records was performed to investigate and confirm possible transmission events. RESULTS Between July 2012 and September 2015, A. baumannii was isolated from 268 patients, of which 16% (42/268) were carbapenem resistant. Thirty-nine of these isolates were recoverable and sequenced. Fifteen percent (6/39) of these were resistant to all antibiotics tested. Most isolates belong to the circulating IC2 clonal type. SNP analysis revealed four potential outbreak clusters. Two of these clusters showed high concordance with the local spatio-temporal epidemiology, suggesting that transmission events were very likely. CONCLUSIONS Our data suggest that there were two independent transmission events, which would have been missed by conventional MLST owing to high clonality. The routine implementation of WGS can optimize surveillance and initiation of suitable containment measures. In addition, emerging resistance to salvage therapy is a major therapeutic problem and should be monitored closely.
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Affiliation(s)
- Tatjana Eigenbrod
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
| | - Sandra Reuter
- Medical Center - University of Freiburg, Institute for Infection Prevention and Hospital Epidemiology, Breisacher Strasse 115B, 79106, Freiburg, Germany
| | - Andrea Gross
- Medical Center - University of Freiburg, Institute for Infection Prevention and Hospital Epidemiology, Breisacher Strasse 115B, 79106, Freiburg, Germany
| | - Kaan Kocer
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany.,Deutsches Zentrum für Infektionsforschung (DZIF), Department of Infectious Diseases, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
| | - Frank Günther
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany.,Medical Microbiology and Hygiene, Marburg University Hospital, Hans-Meerwein-Straße 2, 35043, Marburg, Germany
| | - Stefan Zimmermann
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
| | - Klaus Heeg
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
| | - Nico T Mutters
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany.,Medical Center - University of Freiburg, Institute for Infection Prevention and Hospital Epidemiology, Breisacher Strasse 115B, 79106, Freiburg, Germany
| | - Dennis Nurjadi
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
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Qiao F, Huang W, Gao S, Cai L, Zhu S, Wei L, Kang Y, Tao C, Zong Z. Risk factor for intestinal carriage of carbapenem-resistant Acinetobacter baumannii and the impact on subsequent infection among patients in an intensive care unit: an observational study. BMJ Open 2020; 10:e035893. [PMID: 32912943 PMCID: PMC7482480 DOI: 10.1136/bmjopen-2019-035893] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To assess the incidence and the impact of carbapenem-resistant Acinetobacter baumannii (CRAB) intestinal carriage on subsequent CRAB infection and to study risk factors of acquiring CRAB intestinal carriage among patients in intensive care unit (ICU). DESIGN Observational study including a case-control study and a retrospective cohort study. SETTING A 50-bed general ICU of a university hospital, China. METHODS From May 2017 to April 2018, an observational study was conducted in a 50-bed general ICU of a university hospital in China. Rectal swabs were collected from ICU patients on admission and thereafter weekly. A case-control study was performed to analyse risk factors of the acquisition of CRAB intestinal carriage in ICU using multiple logistic regression. A retrospective cohort study was performed to address whether intestinal CRAB carriage could lead to an increased likelihood of subsequent CRAB infection using subdistribution hazard model regarding death in the ICU as a competing risk event. RESULTS CRAB intestinal carriage was detected in 6.87% (66/961; 95% CI 5.27% to 8.47%) of patients on ICU admission, whereas 11.97% (115/961; 95% CI 9.91% to 14.02%) of patients acquired CRAB intestinal carriage during the ICU stay. Pancreatitis (OR 2.16, 95% CI 1.28 to 3.67), haematological disease (OR 2.26, 95% CI 1.42 to 3.58), gastric tube feeding (OR 3.35, 95% CI 2.03 to 5.51) and use of carbapenems (OR 1.84, 95% CI 1.11 to 3.07) were independent risk factors for acquiring CRAB intestinal carriage. The incidence of subsequent CRAB infection was 2.24-fold in patients with CRAB intestinal carriage compared with that in patients without (95% CI 1.48 to 3.39, p<0.001). CONCLUSION More patients acquired CRAB intestinal carriage during their ICU stay than had on admission. Severity of illness, acute pancreatitis, tube feeding and use of carbapenems were independent risk factors of acquisition of CRAB intestinal carriage. Patients with CRAB intestinal carriage are more likely to develop CRAB infection.
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Affiliation(s)
- Fu Qiao
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wenzhi Huang
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shan Gao
- Department of Infection Control, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, Henan, China
| | - Lin Cai
- Intensive Care Unit, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shichao Zhu
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Wei
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Kang
- Intensive Care Unit, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chuanmin Tao
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhiyong Zong
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Center of Infectious Disease, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Detecting carbapenem-resistant Acinetobacter baumannii (CRAB) carriage: Which body site should be cultured? Infect Control Hosp Epidemiol 2020; 41:965-967. [PMID: 32618523 PMCID: PMC7511923 DOI: 10.1017/ice.2020.197] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We compared the yield of culturing various body sites to detect carriage of carbapenem-resistant Acinetobacter baumannii (CRAB). Culturing the skin using a premoistened sponge, with overnight enrichment and plating on CHROMagar MDR Acinetobacter, had the highest yield: 92%. Skin is satisfactory as a single site for active surveillance of CRAB.
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Control of a hospital-wide outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) using the Israeli national carbapenem-resistant Enterobacteriaceae (CRE) guidelines as a model. Infect Control Hosp Epidemiol 2020; 41:926-930. [PMID: 32539881 DOI: 10.1017/ice.2020.158] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To study the effect of implementing the Israeli national carbapenem-resistant enterobacteriaceae (CRE) guidelines on controlling a hospital-wide outbreak of Acinetobacter baumannii (CRAB). DESIGN A before-and-after study from 2014 to 2018. SETTING A 740-bed, secondary-care hospital in central Israel. INTERVENTION Acquisition of CRAB was defined as a positive culture taken at least 48 hours after admission or a positive sample identified upon admission in a patient who had been readmitted within 30 days after discharge from our institution. The intervention included maintaining a case registry of all CRAB patients, cohorting patients under strict contact isolation, using dedicated nursing staff and equipment, rigorous cleaning, education and close monitoring of hospital staff, and involvement of hospital management. RESULTS In total, 210 patients were identified with hospital-acquired CRAB: 141 before the intervention and 69 after the intervention. CRAB acquisition rates decreased by 77%, from 1.3 per 1,000 admissions before the intervention (2014-2015) to 0.3 per 1,000 admissions after the intervention (2016-2018) (P < .001). The decrease in acquisitions was observed hospital-wide, year by year (P for trend, <.001). In 2018, only 7 new acquisitions were detected in internal medicine wards (P = .058) and none in the ICUs (P = .006). CONCLUSIONS A structured intervention based on the Israeli CRE management guidelines was successful in controlling a hospital-wide CRAB outbreak.
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Abstract
PURPOSE OF REVIEW This review provides an overview of gastrointestinal tract colonization with carbapenemase-producing Enterobacteriaceae (CPE), including risk factors for colonization, determinants for duration of colonization, and whether patients can decolonize, either spontaneously or via targeted interventions. RECENT FINDINGS CPE colonization is disseminating globally with increasing numbers of carbapenemases being identified in increasing patient cohorts. Numerous risk factors including repeated healthcare contact, patient co-morbidities and international travel have all been linked to increased rates of colonization. Duration of colonization has been investigated in various healthcare settings and ranges many months or even years. Although new methods for expediting decolonization are being investigated, including faecal microbiota transplantation, high quality evidence of impact is lacking. SUMMARY Current evidence indicates that CPE colonization usually persists throughout the duration of most hospital admissions, although the majority of patients will subsequently spontaneously decolonize. Difficulties remain in determining the point at which patients can be considered decolonized because of the lack acceptable criteria for defining eradication. This has significance implications for infection prevention and control measures during the initial and subsequent hospital admissions. Strategies to reduce the healthcare burden of CPE colonization continue to rely predominantly on preventing acquisition, whereas decolonization efforts remain a focus of research.
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Valencia-Martín R, Gonzalez-Galan V, Alvarez-Marín R, Cazalla-Foncueva AM, Aldabó T, Gil-Navarro MV, Alonso-Araujo I, Martin C, Gordon R, García-Nuñez EJ, Perez R, Peñalva G, Aznar J, Conde M, Cisneros JM. A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital. Antimicrob Resist Infect Control 2019; 8:199. [PMID: 31827780 PMCID: PMC6894224 DOI: 10.1186/s13756-019-0658-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 11/25/2019] [Indexed: 11/29/2022] Open
Abstract
Background Acinetobacter baumannii causes frequently nosocomial infections worldwide. Its ability to survive on dry surfaces facilitates its spread and the persistence of endemic situations, especially in the intensive care units (ICUs). The objective of this paper is to describe a multicomponent intervention program designed to control a hyperendemic persistence of multidrug-resistant A. baumannii (MDR-Ab) and to characterize its impact. Methods Design: Quasi-experimental intervention study based on open cohorts. Setting: Public tertiary referral centre. Period: January 2009–August 2017. Intervention: multifaceted program based on environmental decontamination, hand hygiene, antimicrobial stewardship, contact precautions, active surveillance, weekly reports and regular meetings. Analysis: joinpoint regression and interrupted time-series analysis. Results The intervention was successfully implemented. Through the study period, the compliance with contact precautions changed from 0 to 100% and with hand hygiene, from 41.8 to 82.3%. Between 2012 and 2016, the antibiotic consumption decreased from 165.35 in to 150.44 daily-defined doses/1000 patients-days in the ICU. The incidence density of MDR-Ab in the ICU was 10.9 cases/1000 patients-days at the beginning of the intervention. After this moment, the evolution of the incidence density of MDR-Ab was: between months 0 and 6°, it remained stable; between months 7° and 10°: there was an intense decrease, with an average monthly percentage change (AMPC) = − 30.05%; from 11° month until the end, the decrease was lighter but continuous (AMPC:-2.77%), achieving an incidence density of 0 cases/1000 patients-days on the 18° month, without any new case for 12 months. From the 30° month until the end of the study period, several little outbreaks of MDR-Ab were detected, all of them rapidly controlled. The strains of MDR-Ab isolated during these outbreaks were not clonally related with the previously endemic one, which supports its eradication from the environmental reservoirs. Conclusion The multicomponent intervention performed by a multidisciplinary team was effective to eradicate the endemic MDR-Ab.
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Affiliation(s)
- R Valencia-Martín
- 1Departments of Infectious Diseases, Microbiology, and Preventive Medicine, University Hospital Virgen del Rocío-Institute of Biomedicine of Seville, Avenida Manuel Siurot s/n, 41013 Seville, Spain
| | - V Gonzalez-Galan
- 1Departments of Infectious Diseases, Microbiology, and Preventive Medicine, University Hospital Virgen del Rocío-Institute of Biomedicine of Seville, Avenida Manuel Siurot s/n, 41013 Seville, Spain
| | - R Alvarez-Marín
- 1Departments of Infectious Diseases, Microbiology, and Preventive Medicine, University Hospital Virgen del Rocío-Institute of Biomedicine of Seville, Avenida Manuel Siurot s/n, 41013 Seville, Spain
| | - A M Cazalla-Foncueva
- 1Departments of Infectious Diseases, Microbiology, and Preventive Medicine, University Hospital Virgen del Rocío-Institute of Biomedicine of Seville, Avenida Manuel Siurot s/n, 41013 Seville, Spain
| | - T Aldabó
- 2Department of Intensive Care, University Hospital Virgen del Rocío, Seville, Spain
| | - M V Gil-Navarro
- 3Department of Pharmacy, University Hospital Virgen del Rocío, Seville, Spain
| | - I Alonso-Araujo
- 2Department of Intensive Care, University Hospital Virgen del Rocío, Seville, Spain
| | - C Martin
- 2Department of Intensive Care, University Hospital Virgen del Rocío, Seville, Spain
| | - R Gordon
- 4Cleaning Service, University Hospital Virgen del Rocío, Seville, Spain
| | | | - R Perez
- 5University Hospital Virgen del Rocío, Seville, Spain
| | - G Peñalva
- 1Departments of Infectious Diseases, Microbiology, and Preventive Medicine, University Hospital Virgen del Rocío-Institute of Biomedicine of Seville, Avenida Manuel Siurot s/n, 41013 Seville, Spain
| | - J Aznar
- 1Departments of Infectious Diseases, Microbiology, and Preventive Medicine, University Hospital Virgen del Rocío-Institute of Biomedicine of Seville, Avenida Manuel Siurot s/n, 41013 Seville, Spain
| | - M Conde
- 1Departments of Infectious Diseases, Microbiology, and Preventive Medicine, University Hospital Virgen del Rocío-Institute of Biomedicine of Seville, Avenida Manuel Siurot s/n, 41013 Seville, Spain
| | - J M Cisneros
- 1Departments of Infectious Diseases, Microbiology, and Preventive Medicine, University Hospital Virgen del Rocío-Institute of Biomedicine of Seville, Avenida Manuel Siurot s/n, 41013 Seville, Spain
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Baier C, Beck M, Panagiota V, Lueck C, Kharazipour D, Hintze SC, Bollin R, Ebadi E, Ziesing S, Eder M, Bange FC, Beutel G. Infection control management and surveillance of carbapenem-resistant Gram-negative bacteria in hematopoietic stem cell recipients. Antimicrob Resist Infect Control 2019; 8:160. [PMID: 31649817 PMCID: PMC6805597 DOI: 10.1186/s13756-019-0606-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/06/2019] [Indexed: 02/03/2023] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is a curative treatment option for selected diseases of the hematopoietic system. In the context of HSCT, bloodstream infections caused by Gram-negative bacteria (GNB) significantly contribute to morbidity and mortality. Antibiotic treatment of bloodstream infections with carbapenem-resistant (CR) GNB presents a particular challenge. As a part of our infection control management, the admission of a patient who was known to be colonized with a CR Acinetobacter baumannii triggered an active weekly screening of all patients to determine the prevalence and potential transmission of CR GNB and CR Acinetobacter baumannii in particular. Over a 3 month period a total of 71 patients were regularly screened for colonization with CR GNB. Including the index patient, a total of three patients showed CR GNB colonization representing a prevalence of 4.2%. Nosocomial transmission of CR Acinetobacter baumannii or other CR GNB was not observed. However, the index patient developed a subsequent bloodstream infection with the CR Acinetobacter baumannii, therefore empiric antibiotic therapy based on the known resistance profile was initiated. A weekly prevalence screening for CR GNB might be an effective monitoring tool for potential transmission, may enhance existing infection control management concepts and may support the decision making for empiric antibiotic therapy.
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Affiliation(s)
- Claas Baier
- 1Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Maleen Beck
- 2Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Viktoria Panagiota
- 2Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Catherina Lueck
- 2Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Daniel Kharazipour
- 2Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Sophie Charlotte Hintze
- 3Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Robin Bollin
- 4Clinic for Nephrology, Hannover Medical School, Hannover, Germany
| | - Ella Ebadi
- 1Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Stefan Ziesing
- 1Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Matthias Eder
- 2Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Franz-Christoph Bange
- 1Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Gernot Beutel
- 2Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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Yoon YK, Ryu JM, Lee MJ, Lee SE, Yang KS, Lee CK, Kim MJ, Sohn JW. Active surveillance at the time of hospital admission for multidrug-resistant microorganisms among patients who had recently been hospitalized at health care facilities. Am J Infect Control 2019; 47:1188-1193. [PMID: 31122673 DOI: 10.1016/j.ajic.2019.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND This study aimed to investigate the epidemiology of multidrug-resistant microorganism (MDRO) carriage at hospital admission and to identify risk factors for MDRO influx into hospital settings. METHODS This cohort study was conducted at a 1,051-bed university-affiliated hospital in the Republic of Korea between July 1 and December 31, 2017. Active surveillance for MDRO carriage was performed within 48 hours of hospitalization in all adult patients who had prior hospitalization within the preceding 3 months. RESULTS During the study, 575 patients were admitted with a hospitalization history within 3 months. Active surveillance at hospital admission was performed in 192 eligible patients. Thirty-three (17.2%) patients with MDRO carriage were identified from active surveillance. In the multivariate logistic regression analysis, prior exposure to antibiotics within 90 days, hospitalization for ≥60 days before admission, cognitive dysfunction, percutaneous drainage, and underlying pulmonary diseases were identified as independent risk factors for MDRO influx. CONCLUSIONS Our findings suggest a significant prevalence of MDRO acquisition at acute care hospital admission in patients who had been recently hospitalized. To control the spread of MDRO, collaborations among health care institutions and targeted screening at hospital admission according to patient risk factors are warranted.
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Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea; Infection Control Unit, Korea University Medical Center, Seoul, Republic of Korea
| | - Jee Myung Ryu
- Infection Control Unit, Korea University Medical Center, Seoul, Republic of Korea
| | - Min Jung Lee
- Infection Control Unit, Korea University Medical Center, Seoul, Republic of Korea
| | - Sung Eun Lee
- Infection Control Unit, Korea University Medical Center, Seoul, Republic of Korea
| | - Kyung Sook Yang
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Chang Kyu Lee
- Department of Laboratory Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Min Ja Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jang Wook Sohn
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea.
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Warde E, Davies E, Ward A. Control of a multidrug-resistant Acinetobacter baumannii outbreak. ACTA ACUST UNITED AC 2019; 28:242-248. [PMID: 30811227 DOI: 10.12968/bjon.2019.28.4.242] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article describes the management of an outbreak of multidrug-resistant Acinetobacter baumannii (MDR-Ab) at an acute NHS Foundation Trust. The outbreak affected two respiratory wards and the initial outbreak lasted 9 months, with the first patient (index case) being identified in April 2015 and the final, tenth case, in September 2015. The outbreak was declared closed in January 2016, but a further two cases were identified in July and August 2016. Of the 12 identified patients, eight were colonised with the bacterium and four were infected. The four infections were of the respiratory tract with MDR-Ab, of identical variable number tandem repeat, isolated from sputum in all cases. All 12 patients were decolonised and this continued throughout the outbreak. Some negative rescreening results were achieved. At the time of the outbreak, decolonisation using octenidine had not been reported in any guidelines. The sensitivity of MDR-Ab to octenidine was microbiologically tested and antibacterial action of octenidine against this organism was demonstrated. The use of octenidine appeared to be one element in helping to control this testing situation. This report seeks to demonstrate not only the complexity of managing and containing an outbreak of MDR-Ab but also how, with the use of a range of effective infection prevention measures, the spread of this pathogen can be successfully controlled. It is hoped that this article will increase awareness among healthcare providers and infection prevention and control (IPC) teams of the threat posed by this organism in the healthcare environment.
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Affiliation(s)
- Elizabeth Warde
- Infection Prevention and Control Nurse, North Tees and Hartlepool NHS Foundation Trust
| | - Emma Davies
- Infection Prevention and Control Nurse, North Tees and Hartlepool NHS Foundation Trust
| | - Andrew Ward
- Senior Biomedical Scientist-Microbiology, North Tees and Hartlepool NHS Foundation Trust
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Likelihood of persistent carriage of carbapenem-resistant Acinetobacter baumannii on readmission in previously identified carriers. Infect Control Hosp Epidemiol 2019; 40:1188-1190. [DOI: 10.1017/ice.2019.210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
AbstractPatients with carbapenem-resistant Acinetobacter baumannii-positive clinical cultures during a prior hospitalization were screened using high sensitivity methods upon first readmission. Of 38 patients, 31.6% screened positive; 42% screened positive within 2 months from discharge, and 14% screened positive more than 5 months from discharge. Carriage was persistent up to 285 days.
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Yamamoto N, Hamaguchi S, Akeda Y, Santanirand P, Chaihongsa N, Sirichot S, Chiaranaicharoen S, Hagiya H, Yamamoto K, Kerdsin A, Okada K, Yoshida H, Hamada S, Oishi K, Malathum K, Tomono K. Rapid screening and early precautions for carbapenem-resistant Acinetobacter baumannii carriers decreased nosocomial transmission in hospital settings: a quasi-experimental study. Antimicrob Resist Infect Control 2019; 8:110. [PMID: 31297191 PMCID: PMC6598269 DOI: 10.1186/s13756-019-0564-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 06/18/2019] [Indexed: 12/17/2022] Open
Abstract
Background Active surveillance has the potential to prevent nosocomial transmission of carbapenem-resistant Acinetobacter baumannii (CRAB). We assessed whether rapid diagnosis using clinical specimen-direct loop-mediated isothermal amplification (LAMP), a rapid molecular diagnostic assay, and subsequent intervention, could reduce CRAB nosocomial transmission in intensive care units (ICUs). Methods A before and after (quasi-experimental) study was conducted in two ICUs at the Mahidol University Faculty of Medicine Ramathibodi Hospital with 3 months of observational period followed by 9 months of interventional period. All patients were screened for CRAB using both the culture and LAMP method from rectal swab and/or bronchial aspirates (intubated patients only) upon admission, weekly thereafter, and upon discharge. During the pre-intervention period, we performed contact precautions based on culture results. In contrast, during the intervention period, we initiated contact precautions within a few hours after sample collection on the basis of LAMP results. Results A total of 1335 patients were admitted to the ICUs, of which 866 patients (pre-intervention period: 187; intervention period: 679) were eligible for this study. Incidence rate of CRAB infection decreased to 20.9 per 1000 patient-days in the intervention period from 35.2 in the pre-intervention period (P < 0.02). The calculated hazard ratio of CRAB transmission was 0.65 (95% confidence interval [CI], 0.44–0.97). Risk factors for CRAB acquisition included exposure to carbapenem (hazard ratio, 2.54 [95% CI: 1.61–5.57]). Conclusions LAMP screening for CRAB upon ICU admission proved feasible for routine clinical practice. Rapid screening using LAMP followed by early intervention may reduce CRAB transmission rates in ICUs when compared to conventional intervention. Electronic supplementary material The online version of this article (10.1186/s13756-019-0564-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Norihisa Yamamoto
- 1Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan.,2Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Shigeto Hamaguchi
- 1Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan.,2Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Yukihiro Akeda
- 1Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan.,2Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Pitak Santanirand
- 3Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Narong Chaihongsa
- 3Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suntariya Sirichot
- 3Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Hideharu Hagiya
- 1Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan.,2Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Kouji Yamamoto
- 4Department of Medical Statistics, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Anusak Kerdsin
- 5Faculty of Public Health, Kasetsart University, Sakon Nakhon, Thailand
| | - Kazuhisa Okada
- 2Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Hisao Yoshida
- 1Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan
| | - Shigeyuki Hamada
- 2Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Kazunori Oishi
- 6Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan
| | - Kumthorn Malathum
- 3Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kazunori Tomono
- 1Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871 Japan
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Yagnik KJ, Kalyatanda G, Cannella AP, Archibald LK. Outbreak of Acinetobacter baumannii associated with extrinsic contamination of ultrasound gel in a tertiary centre burn unit. Infect Prev Pract 2019; 1:100009. [PMID: 34368675 PMCID: PMC8336045 DOI: 10.1016/j.infpip.2019.100009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/20/2019] [Indexed: 11/28/2022] Open
Abstract
Background During 2011 and 2012, an increase in occurrence of multidrug-resistant Acinetobacter baumannii infections was recorded in the Shands Hospital Burn Intensive Care Unit (BICU). An epidemic curve together with strain typing was consistent with an intermittent common source outbreak. An investigation was therefore initiated. Aim To identify risk factors for A. baumannii infection, characterize the source of the pathogen, implement control measures to terminate the outbreak, and institute preventive measures. Methods We conducted a retrospective case-control study; reviewed BICU infection control policies, practices and procedures, and patient exposure to healthcare workers (HCWs), and obtained epidemiologically-directed environmental cultures. Findings Eleven patients met the case definition. On multivariate analysis, case-patients were more likely to have undergone an ultrasound procedure in the BICU (adjusted odds ratio [AOR]: 19.5; confidence interval [CI]: 2.4-435) or have a FlexiSeal™ device (AOR: 11.9, CI:1.3-276). Epidemiologically-directed cultures of the environment, ultrasound equipment, and ultrasound gel from opened containers on the ultrasound trolley and in the Ultrasound Department were negative for the outbreak pathogen. Culture of an open ultrasound gel dispenser stored in the Ultrasound Department yielded an A. baumannii strain with DNA banding patterns identical to the outbreak strain. Conclusions Based on data from our epidemiologic, microbiologic, and observational studies, we believe that inadvertent extrinsic contamination of the gel dispenser occurred in the Ultrasound Department. Contaminated gel was then dispensed into multiuse vials of gel stored on the mobile carts. The outbreak was stemmed by instituting changes in practices in the Ultrasound Department, including introduction of single-use ultrasound vials and storage of ultrasound gel.
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Affiliation(s)
- Kruti J Yagnik
- University of Florida College of Medicine, Department of Medicine, Gainesville, FL, USA
| | - Gautam Kalyatanda
- University of Florida College of Medicine, Department of Medicine, Division of Infectious Diseases & Global Medicine, Gainesville, FL, USA
| | - Anthony P Cannella
- University of Florida College of Medicine, Department of Medicine, Division of Infectious Diseases & Global Medicine, Gainesville, FL, USA.,Malcolm Randall Veterans Health Administration Medical Centre, Gainesville, FL, USA.,University of Florida College of Medicine, Department of Molecular Genetics & Microbiology, Gainesville, FL, USA.,University of Florida College of Medicine, Emerging Pathogens Institute, Gainesville, FL, USA
| | - Lennox K Archibald
- University of Florida College of Medicine, Department of Medicine, Division of Infectious Diseases & Global Medicine, Gainesville, FL, USA.,Malcolm Randall Veterans Health Administration Medical Centre, Gainesville, FL, USA
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Wendel AF, Malecki M, Otchwemah R, Tellez-Castillo CJ, Sakka SG, Mattner F. One-year molecular surveillance of carbapenem-susceptible A. baumannii on a German intensive care unit: diversity or clonality. Antimicrob Resist Infect Control 2018; 7:145. [PMID: 30505434 PMCID: PMC6260569 DOI: 10.1186/s13756-018-0436-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 11/08/2018] [Indexed: 12/19/2022] Open
Abstract
Background A. baumannii is a common nosocomial pathogen known for its high transmission potential. A high rate of carbapenem-susceptible Acinetobacter calcoaceticus-Acinetobacter baumannii (ACB)-complex in clinical specimens led to the implementation of a pathogen-based surveillance on a 32-bed surgical intensive care unit (SICU) in a German tertiary care centre. Methods Between April 2017 and March 2018, ACB-complex isolates with an epidemiological link to the SICU were further assessed. Identification to the species level was carried out using a multiplex PCR targeting the gyrB gene, followed by RAPD, PFGE (ApaI) and whole genome sequencing (WGS, core genome MLST, SeqSphere+ software, Ridom). Additional infection prevention and control (IPC) measures were introduced as follows: epidemiological investigations, hand hygiene training, additional terminal cleaning and disinfection incl. UV-light, screening for carbapenem-susceptible A. baumannii and environmental sampling. Hospital-acquired infections were classified according to the CDC definitions. Results Fourty four patients were colonized/infected with one or two (different) carbapenem-susceptible ACB-complex isolates. Fourty three out of 48 isolates were classified as hospital-acquired (detection on or after 3rd day of admission). Nearly all isolates were identified as A. baumannii, only four as A. pittii. Twelve patients developed A. baumannii infections. Genotyping revealed two pulsotype clusters, which were confirmed to be cgMLST clonal cluster type 1770 (n = 8 patients) and type 1769 (n = 12 patients) by WGS. All other isolates were distinct from each other. Nearly all transmission events of the two clonal clusters were confirmed by conventional epidemiology. Transmissions stopped after a period of several months. Environmental sampling revealed a relevant dissemination of A. baumannii, but only a few isolates corresponded to clinical strains. Introduction of the additional screening revealed a significantly earlier detection of carbapenem-susceptible A. baumannii during hospitalization. Conclusions A molecular and infection surveillance of ACB-complex based on identification to the species level, classic epidemiology and genotyping revealed simultaneously occurring independent transmission events and clusters of hospital-acquired A. baumannii. This underlines the importance of such an extensive surveillance methodology in IPC programmes also for carbapenem-susceptible A. baumannii.
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Affiliation(s)
- Andreas F Wendel
- 1Institute of Hygiene, University Hospital I of Witten/Herdecke, Cologne Merheim Medical Centre, Cologne, Germany
| | - Monika Malecki
- 1Institute of Hygiene, University Hospital I of Witten/Herdecke, Cologne Merheim Medical Centre, Cologne, Germany
| | - Robin Otchwemah
- 1Institute of Hygiene, University Hospital I of Witten/Herdecke, Cologne Merheim Medical Centre, Cologne, Germany
| | | | - Samir G Sakka
- 3Department of Anesthesiology and Operative Intensive Care Medicine, University of Witten/Herdecke, Cologne Merheim Medical Centre, Cologne, Germany
| | - Frauke Mattner
- 1Institute of Hygiene, University Hospital I of Witten/Herdecke, Cologne Merheim Medical Centre, Cologne, Germany
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How to: molecular investigation of a hospital outbreak. Clin Microbiol Infect 2018; 25:688-695. [PMID: 30287413 DOI: 10.1016/j.cmi.2018.09.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 09/19/2018] [Accepted: 09/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Studying hospital outbreaks by using molecular tools, i.e. synthesizing the molecular epidemiology data to its appropriate clinical-epidemiologic context, is crucial in order to identify infection source, infer transmission dynamics, appropriately allocate prevention resources and implement control measures. Whole-genome sequencing (WGS) of pathogens has become the reference standard, as it is becoming more accessible and affordable. Consequently, sequencing of the full pathogen genome via WGS and major progress in fit-for-purpose genomic data analysis tools and interpretation is revolutionizing the field of outbreak investigations in hospitals. Metagenomics is an additional evolving field that might become commonly used in the future for outbreak investigations. Nevertheless, practitioners are frequently limited in terms of WGS or metagenomics, especially for local outbreak analyses, as a result of costs or logistical considerations, reduced or lack of locally available resources and/or expertise. As a result, traditional approaches, including pulsed-field gel electrophoresis, repetitive-element palindromic PCR and multilocus sequence typing, along with other typing methods, are still widely used. AIMS To provide practitioners with evidenced-based action plans for usage of the various typing techniques in order to investigate the molecular epidemiology of nosocomial outbreaks, of clinically significant pathogens in acute-care hospitals. SOURCES PubMed search with relevant keywords along with personal collection of relevant publications. CONTENT Representative case scenarios and critical review of the relevant scientific literature. IMPLICATIONS The review provides practical action plans to manage molecular epidemiologic investigations of outbreaks caused by clinically significant nosocomial pathogens, while prioritizing the use and timely integration of the various methodologies.
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Alves MM, Araújo LAD, Mrué F, Gomes CM, Oliveira MAPD, Neves RA, Silva-Júnior NJD, Melo-Reis PRD. IMMUNOMODULATING EFFECTS OF THE PURIFIED HEV B 13 FRACTION ON SEPTIC RATS. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2018; 30:93-97. [PMID: 29257842 PMCID: PMC5543785 DOI: 10.1590/0102-6720201700020004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 02/09/2017] [Indexed: 01/13/2023]
Abstract
Background: Sepsis is a potentially life-threatening complication of an infection that occurs when chemicals released into the bloodstream to fight the infection trigger inflammatory responses throughout the body, especially in the acute phase of the disease, producing excessive pro-inflammatory cytokines, leading to multiple organ injury and death. The Hev b 13 fraction has demonstrated biological activity capable of inducing IL-10 production and shrinking inflammatory disease lesions. Aim: To investigate the immunomodulating effects of the Hev b 13 fraction on septic rats. Methods: Acinetobacter baumannii was injected into the peritoneal cavity of the animals after sustaining a lesion in the pancreas, with the stomach as an entry point. After 10 h of infection, they were euthanized for blood and lung collection, followed by total and differential leukocyte count, determination of cytokine level and histopathological analysis. Results: Administering a single dose of the Hev b 13 fraction 2 h after sepsis induction significantly decreased total leukocyte count. Higher IL-10 and IL-4 and lower IL-6 production shrank the lung tissue lesions compared to the control groups. Conclusion: The Hev b 13 fraction exhibits an anti-inflammatory tendency, with potential for sepsis treatment.
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Affiliation(s)
- Maxley Martins Alves
- Laboratory of Experimental and Biotechnological Studies of the Post-Graduate Program in Environmental Sciences and Health, Area V, Campus I, Pontifical Catholic University of Goiás
| | - Lilhian Alves de Araújo
- Laboratory of Experimental and Biotechnological Studies of the Post-Graduate Program in Environmental Sciences and Health, Area V, Campus I, Pontifical Catholic University of Goiás.,Laboratory of Cytokines, Institute of Tropical Pathology and Public Health, Federal University of Goiás, Goiânia, GO, Brazil
| | - Fátima Mrué
- Laboratory of Experimental and Biotechnological Studies of the Post-Graduate Program in Environmental Sciences and Health, Area V, Campus I, Pontifical Catholic University of Goiás
| | - Clayson Moura Gomes
- Laboratory of Experimental and Biotechnological Studies of the Post-Graduate Program in Environmental Sciences and Health, Area V, Campus I, Pontifical Catholic University of Goiás.,Laboratory of Cytokines, Institute of Tropical Pathology and Public Health, Federal University of Goiás, Goiânia, GO, Brazil
| | | | - Roberpaulo Anacleto Neves
- Laboratory of Experimental and Biotechnological Studies of the Post-Graduate Program in Environmental Sciences and Health, Area V, Campus I, Pontifical Catholic University of Goiás
| | - Nelson Jorge da Silva-Júnior
- Laboratory of Experimental and Biotechnological Studies of the Post-Graduate Program in Environmental Sciences and Health, Area V, Campus I, Pontifical Catholic University of Goiás
| | - Paulo Roberto de Melo-Reis
- Laboratory of Experimental and Biotechnological Studies of the Post-Graduate Program in Environmental Sciences and Health, Area V, Campus I, Pontifical Catholic University of Goiás
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Hong J, Jang OJ, Bak MH, Baek EH, Park KH, Hong SI, Cho OH, Bae IG. Management of carbapenem-resistant Acinetobacter baumannii epidemic in an intensive care unit using multifaceted intervention strategy. Korean J Intern Med 2018; 33:1000-1007. [PMID: 29172401 PMCID: PMC6129627 DOI: 10.3904/kjim.2016.323] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 01/15/2017] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS We evaluated the effects of a multifaceted intervention for controlling a carbapenem-resistant Acinetobacter baumannii (CRAB) epidemic in an intensive care unit (ICU) with no restrictions on carbapenem use. METHODS This study was conducted in a medical ICU between April 2012 and June 2016. The baseline infection control programs included surveillance cultures, contact precautions, and environmental cleaning. However, increases in the detection of CRAB isolates beginning in May 2013 led to the implementation of a new protocol, consisting of universal glove and gown use with daily chlorhexidine bathing for all patients in combination with baseline programs. The efficacy of the intervention was subjected to interrupted time series (ITS) analysis. RESULTS The multifaceted intervention led to a decrease in the incidence of CRAB from 17.65 to 0.89 cases per 1,000 patient-days, during the study period (p < 0.001). ITS analysis revealed a significant change in the trend of CRAB incidence (-0.413, p < 0.001). Over this same period, mean monthly use of carbapenems increased from 143.54 ± 95.73 to 204.95 ± 78.43 doses per 1,000 patient-days (p = 0.018). CONCLUSION Our multifaceted intervention reduced the incidence of CRAB acquisition in an ICU where carbapenem use was not restricted.
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Affiliation(s)
- Jeongmin Hong
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Ok Jeom Jang
- Infection Control Office, Gyeongsang National University Hospital, Jinju, Korea
| | - Mi Hui Bak
- Infection Control Office, Gyeongsang National University Hospital, Jinju, Korea
| | - Eun Hwa Baek
- Infection Control Office, Gyeongsang National University Hospital, Jinju, Korea
| | - Ki-Ho Park
- Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Sun In Hong
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Oh-Hyun Cho
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
- Infection Control Office, Gyeongsang National University Hospital, Jinju, Korea
- Correspondence to Oh-Hyun Cho, M.D. Department of Internal Medicine, Gyeongsang National University School of Medicine, 79 Gangnam-ro, Jinju 52727, Korea Tel: +82-55-750-8745 Fax: +82-55-755-9078 E-mail:
| | - In-Gyu Bae
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
- Infection Control Office, Gyeongsang National University Hospital, Jinju, Korea
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, Korea
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Ng DHL, Marimuthu K, Lee JJ, Khong WX, Ng OT, Zhang W, Poh BF, Rao P, Raj MDR, Ang B, De PP. Environmental colonization and onward clonal transmission of carbapenem-resistant Acinetobacter baumannii (CRAB) in a medical intensive care unit: the case for environmental hygiene. Antimicrob Resist Infect Control 2018; 7:51. [PMID: 29644052 PMCID: PMC5891964 DOI: 10.1186/s13756-018-0343-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 04/03/2018] [Indexed: 12/22/2022] Open
Abstract
Background In May 2015, we noticed an increase in carbapenem-resistant Acinetobacter baumannii (CRAB) infections in the Medical Intensive Care Unit (MICU). To investigate this, we studied the extent of environmental contamination and subsequent onward clonal transmission of CRAB. Methods We conducted a one-day point prevalence screening (PPS) of the patients and environment in the MICU. We screened patients using endotracheal tube aspirates and swabs from nares, axillae, groin, rectum, wounds, and exit sites of drains. We collected environmental samples from patients’ rooms and environment outside the patients’ rooms. CRAB isolates from the PPS and clinical samples over the subsequent one month were studied for genetic relatedness by whole genome sequencing (WGS). Results We collected 34 samples from seven patients and 244 samples from the environment. On the day of PPS, we identified 8 CRAB carriers: 3 who screened positive and 5 previously known clinical infections. We detected environmental contamination in nearly two-thirds of the rooms housing patients with CRAB. WGS demonstrated genetic clustering of isolates within rooms but not across rooms. We analysed 4 CRAB isolates from clinical samples following the PPS. One genetically-related CRAB was identified in the respiratory sample of a patient with nosocomial pneumonia, who was admitted to the MICU five days after the PPS. Conclusion The extensive environmental colonization of CRAB by patients highlights the importance of environmental hygiene. The transmission dynamics of CRAB needs further investigation.
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Affiliation(s)
- Deborah H L Ng
- 1Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 304833 Singapore
| | - Kalisvar Marimuthu
- 1Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 304833 Singapore.,2National University of Singapore, 21 Lower Kent Ridge Road, Singapore, 119077 Singapore
| | - Jia Jun Lee
- 1Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 304833 Singapore
| | - Wei Xin Khong
- 1Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 304833 Singapore
| | - Oon Tek Ng
- 1Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 304833 Singapore
| | - Wei Zhang
- 3Infection Control Unit, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 304833 Singapore
| | - Bee Fong Poh
- 3Infection Control Unit, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 304833 Singapore
| | - Pooja Rao
- 4Department of Laboratory Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 304833 Singapore
| | - Maya Devi Rajinder Raj
- 4Department of Laboratory Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 304833 Singapore
| | - Brenda Ang
- 1Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 304833 Singapore.,2National University of Singapore, 21 Lower Kent Ridge Road, Singapore, 119077 Singapore
| | - Partha Pratim De
- 4Department of Laboratory Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 304833 Singapore
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Lohr B, Pfeifer Y, Heudorf U, Rangger C, Norris DE, Hunfeld KP. High Prevalence of Multidrug-Resistant Bacteria in Libyan War Casualties Admitted to a Tertiary Care Hospital, Germany. Microb Drug Resist 2017; 24:578-584. [PMID: 29039717 DOI: 10.1089/mdr.2017.0141] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The ongoing Libyan conflict constantly causes victims among the military and civilian population. Cross-border transfer of patients represents a high risk of introducing multidrug-resistant organisms (MDROs), for example, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci, and carbapenem-resistant gram-negative organisms (CROs), into the country of destination. This study assessed the MDRO status in Libyan war casualties (n = 67) admitted to Northwest Medical Centre in Frankfurt/Main, Germany, from August 2016 till January 2017. Identified multidrug-resistant nonfermenters and Enterobacteriaceae were subjected to molecular detection of β-lactamases and further mechanisms of resistance. All isolates were typed by enzymatic macrorestriction and subsequent pulsed-field gel electrophoresis. MDROs were found in 40 (60%) patients, including 25 (37%) positive for at least one CRO and 11 (16%) patients with MRSA. A total of 37 isolates of Klebsiella pneumoniae, Acinetobacter baumannii, Escherichia coli, Enterobacter cloacae, and Serratia marcescens produced carbapenemases: NDM (n = 17), OXA-48 (n = 15), and OXA-23 (n = 9) in addition to other β-lactamases (with blaCTX-M-group-1 being most frequent) and plasmid-mediated quinolone resistance genes (qnrB, aac(6')Ib-cr). Bacterial strain typing revealed the presence of various clones. This high MDRO rate in Libyan war casualties demands awareness, appropriate screening, and containment measures for medical institutions involved in medical care to avoid patient-to-patient transmission.
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Affiliation(s)
- Benedikt Lohr
- 1 Institute for Laboratory Medicine , Microbiology & Infection Control, Northwest Medical Centre, Frankfurt/Main, Germany
| | - Yvonne Pfeifer
- 2 Nosocomial Pathogens and Antibiotic Resistance, Robert Koch-Institute , Wernigerode, Germany
| | - Ursel Heudorf
- 3 Division of Infectious Diseases and Hygiene, Public Health Department, Frankfurt/Main, Germany
| | - Christoph Rangger
- 4 Department for Orthopaedics and Trauma Surgery, Northwest Medical Centre , Frankfurt/Main, Germany
| | - Douglas E Norris
- 5 W. Harry Feinstone Department of Molecular Microbiology & Immunology, Bloomberg School of Public Health , Baltimore, Maryland
| | - Klaus-Peter Hunfeld
- 1 Institute for Laboratory Medicine , Microbiology & Infection Control, Northwest Medical Centre, Frankfurt/Main, Germany
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Mavroidi A, Katsiari M, Palla E, Likousi S, Roussou Z, Nikolaou C, Platsouka ED. Investigation of Extensively Drug-Resistant blaOXA-23-Producing Acinetobacter baumannii Spread in a Greek Hospital. Microb Drug Resist 2017; 23:488-493. [DOI: 10.1089/mdr.2016.0101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Angeliki Mavroidi
- Department of Microbiology, General Hospital of Nea Ionia, “Konstantopouleio-Patission,” Athens, Greece
| | - Maria Katsiari
- Intensive Care Unit, General Hospital of Nea Ionia, “Konstantopouleio-Patission,” Athens Greece
| | - Eleftheria Palla
- Department of Microbiology, General Hospital of Nea Ionia, “Konstantopouleio-Patission,” Athens, Greece
| | - Sofia Likousi
- Department of Microbiology, General Hospital of Nea Ionia, “Konstantopouleio-Patission,” Athens, Greece
| | - Zoi Roussou
- Department of Microbiology, General Hospital of Nea Ionia, “Konstantopouleio-Patission,” Athens, Greece
| | - Charikleia Nikolaou
- Intensive Care Unit, General Hospital of Nea Ionia, “Konstantopouleio-Patission,” Athens Greece
| | - Evangelia D. Platsouka
- Department of Microbiology, General Hospital of Nea Ionia, “Konstantopouleio-Patission,” Athens, Greece
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An JH, Kim YH, Moon JE, Jeong JH, Kim SH, Kang SJ, Park KH, Jung SI, Jang HC. Active surveillance for carbapenem-resistant Acinetobacter baumannii in a medical intensive care unit: Can it predict and reduce subsequent infections and the use of colistin? Am J Infect Control 2017; 45:667-672. [PMID: 28242072 DOI: 10.1016/j.ajic.2017.01.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/11/2017] [Accepted: 01/11/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Infection caused by carbapenem-resistant Acinetobacter baumannii (CRAB) has become a major problem in intensive care units (ICUs), with high incidence and mortality. This prospective study investigated the diagnostic value and influence of active surveillance, followed by isolation and enhanced contact precaution (IECP), on the subsequent CRAB infection and colistin use. METHODS The study prospectively enrolled 1,115 patients who were admitted to the medical ICU of Chonnam National University Hwasun Hospital between April 2011 and November 2014. Active surveillance cultures were obtained from the throat or trachea, skin, and urine. IECP was performed beginning April 2013. RESULTS Active surveillance detected CRAB in 168 (15%) patients and CRAB infection developed in 70 (6%) patients. Endotracheal tube was independently associated with both CRAB colonization and infection, whereas IECP was inversely associated with both CRAB colonization and infection in multivariate analysis (all P values <.001). The sensitivity, specificity, and positive and negative predictive values of active surveillance for subsequent CRAB infection were 84%, 90%, 47%, and 98%, respectively. The rate of CRAB acquisition, CRAB infection, and the use of colistin were significantly lower during the IECP period compared with the control period (6.5 vs 34.1, 2.6 vs 14.7, and 19.9 vs 65.5 per 1,000 patient-days, respectively; all P <.001). CONCLUSIONS Active surveillance has good specificity and negative predictive value for subsequent CRAB infection. Active surveillance followed by IECP was inversely associated with the acquisition of CRAB and subsequent CRAB infection, and was associated with a reduction in colistin use in ICU patients.
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Affiliation(s)
- Joon Hwan An
- Departments of Infectious Diseases, Chonnam National University Medical School, Gwang-ju, South Korea
| | - Yu-Hyoung Kim
- Infection Control Office, Hwasun Chonnam Nationality University Hospital, Hwasun, South Korea
| | - Jeong-Eun Moon
- Infection Control Office, Hwasun Chonnam Nationality University Hospital, Hwasun, South Korea
| | - Jong Hae Jeong
- Infection Control Office, Hwasun Chonnam Nationality University Hospital, Hwasun, South Korea
| | - Soo-Hyun Kim
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwang-ju, South Korea
| | - Seung-Ji Kang
- Departments of Infectious Diseases, Chonnam National University Medical School, Gwang-ju, South Korea
| | - Kyung-Hwa Park
- Departments of Infectious Diseases, Chonnam National University Medical School, Gwang-ju, South Korea
| | - Sook-In Jung
- Departments of Infectious Diseases, Chonnam National University Medical School, Gwang-ju, South Korea
| | - Hee-Chang Jang
- Departments of Infectious Diseases, Chonnam National University Medical School, Gwang-ju, South Korea; Infection Control Office, Hwasun Chonnam Nationality University Hospital, Hwasun, South Korea.
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44
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Kitazawa T, Seo K, Yoshino Y, Koga I, Ota Y. Co-Colonization with Neisseria species Is a Risk Factor for Prolonged Colonization with Multidrug-Resistant Acinetobacter baumannii in the Respiratory Tract. Jpn J Infect Dis 2017; 70:203-206. [PMID: 27357994 DOI: 10.7883/yoken.jjid.2016.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Multidrug-resistant Acinetobacter baumannii (MDRAB) colonization increases the risk of bacterial spread in the hospital setting. The impact of clinical factors, including antibiotic use, on prolongation of MDRAB colonization has not been investigated. Patients with respiratory tract MDRAB detected using culture were enrolled in this study. Long-term colonizers and short-term colonizers were defined as patients whose colonization periods were >30 days or ≤30 days, respectively. Clinical data were abstracted from medical records. MDRAB was isolated in 34 patients. There were 13 long-term colonizers and 9 short-term colonizers. Twelve patients were lost to follow-up and excluded from the study. There were no significant differences in average leukocyte counts, numbers of antibiotic classes administered, duration of antibiotic use in the 30 days following colonization, or rates of central catheterization or mechanical ventilation between the 2 groups. Long-term colonizers carried Neisseria species (spp.) more frequently in the 30 days following colonization than short-term colonizers (7/13 vs 1/9, p = 0.01); however, this was not the case prior to colonization with MDRAB (5/13 vs 1/9, p = 0.33). The 90-day MDRAB colonization rates for Neisseria-negative patients and Neisseria-positive patients were 10.0% and 83.3%, respectively (P < 0.01). Prolonged MDRAB colonization in the respiratory tract was associated with Neisseria spp. co-colonization.
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Gagnaire J, Gagneux-Brunon A, Pouvaret A, Grattard F, Carricajo A, Favier H, Mattei A, Pozzetto B, Nuti C, Lucht F, Berthelot P, Botelho-Nevers E. Carbapenemase-producing Acinetobacter baumannii: An outbreak report with special highlights on economic burden. Med Mal Infect 2017; 47:279-285. [PMID: 28343727 DOI: 10.1016/j.medmal.2017.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 05/31/2016] [Accepted: 02/20/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We aimed to describe the management of a carbapenemase-producing Acinetobacter baumannii (CP-AB) outbreak using the Outbreak Reports and Intervention Studies of Nosocomial Infection (ORION) statement. We also aimed to evaluate the cost of the outbreak and simulate costs if a dedicated unit to manage such outbreak had been set-up. METHODS We performed a prospective epidemiological study. Multiple interventions were implemented including cohorting measures and limitation of admissions. Cost estimation was performed using administrative local data. RESULTS Five patients were colonized with CP-AB and hospitalized in the neurosurgery ward. The index case was a patient who had been previously hospitalized in Portugal. Four secondary colonized patients were further observed within the unit. The strains of A. baumannii were shown to belong to the same clone and all of them produced an OXA-23 carbapenemase. The closure of the ward associated with the discharge of the five patients in a cohorting area of the Infectious Diseases Unit with dedicated staff put a stop to the outbreak. The estimated cost of this 17-week outbreak was $474,474. If patients had been managed in a dedicated unit - including specific area for cohorting of patients and dedicated staff - at the beginning of the outbreak, the estimated cost would have been $189,046. CONCLUSION Controlling hospital outbreaks involving multidrug-resistant bacteria requires a rapid cohorting of patients. Using simulation, we highlighted cost gain when using a dedicated cohorting unit strategy for such an outbreak.
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Affiliation(s)
- J Gagnaire
- Infection control unit, infectious diseases department, university hospital of Saint-Étienne, 42055 Saint-Étienne cedex 2, France
| | - A Gagneux-Brunon
- Infection control unit, infectious diseases department, university hospital of Saint-Étienne, 42055 Saint-Étienne cedex 2, France
| | - A Pouvaret
- Infection control unit, infectious diseases department, university hospital of Saint-Étienne, 42055 Saint-Étienne cedex 2, France
| | - F Grattard
- Laboratory of infectious agents and hygiene, university hospital of Saint-Étienne, 42055 Saint-Étienne cedex 2, France
| | - A Carricajo
- Laboratory of infectious agents and hygiene, university hospital of Saint-Étienne, 42055 Saint-Étienne cedex 2, France
| | - H Favier
- Infection control unit, infectious diseases department, university hospital of Saint-Étienne, 42055 Saint-Étienne cedex 2, France
| | - A Mattei
- Infection control unit, infectious diseases department, university hospital of Saint-Étienne, 42055 Saint-Étienne cedex 2, France
| | - B Pozzetto
- Laboratory of infectious agents and hygiene, university hospital of Saint-Étienne, 42055 Saint-Étienne cedex 2, France
| | - C Nuti
- Neurosurgery unit, university hospital of Saint-Étienne, 42055 Saint-Étienne cedex 2, France
| | - F Lucht
- Infection control unit, infectious diseases department, university hospital of Saint-Étienne, 42055 Saint-Étienne cedex 2, France
| | - P Berthelot
- Infection control unit, infectious diseases department, university hospital of Saint-Étienne, 42055 Saint-Étienne cedex 2, France; Laboratory of infectious agents and hygiene, university hospital of Saint-Étienne, 42055 Saint-Étienne cedex 2, France.
| | - E Botelho-Nevers
- Infection control unit, infectious diseases department, university hospital of Saint-Étienne, 42055 Saint-Étienne cedex 2, France
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Wenzler E, Goff DA, Humphries R, Goldstein EJC. Anticipating the Unpredictable: A Review of Antimicrobial Stewardship and Acinetobacter Infections. Infect Dis Ther 2017; 6:149-172. [PMID: 28260148 PMCID: PMC5446362 DOI: 10.1007/s40121-017-0149-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Indexed: 11/29/2022] Open
Abstract
Acinetobacter remains one of the most challenging pathogens in the field of infectious diseases owing primarily to the uniqueness and multiplicity of its resistance mechanisms. This resistance often leads to devastatingly long delays in time to appropriate therapy and increased mortality for patients afflicted with Acinetobacter infections. Selecting appropriate empiric and definitive antibacterial therapy for Acinetobacter is further complicated by the lack of reliability in commercial antimicrobial susceptibility testing devices and limited breakpoint interpretations for available agents. Existing treatment options for infections due to Acinetobacter are limited by a lack of robust efficacy and safety data along with concerns regarding appropriate dosing, pharmacokinetic/pharmacodynamic targets, and toxicity. Antimicrobial stewardship programs are essential to combat this unpredictable pathogen through use of infection prevention, rapid diagnostics, antibiogram-optimized treatment regimens, and avoidance of overuse of antimicrobials. The drug development pipeline includes several agents with encouraging in vitro activity against Acinetobacter, but their place in therapy and contribution to the armamentarium against this pathogen remain to be defined. The objective of this review is to highlight the unique challenge of treating infections due to Acinetobacter and summarize recent literature regarding optimal antimicrobial treatment for this pathogen. The drug development pipeline is also explored for future potentially effective treatment options.
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Affiliation(s)
- Eric Wenzler
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.
| | - Debra A Goff
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Romney Humphries
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Ellie J C Goldstein
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,R M Alden Research Laboratory, Santa Monica, CA, USA
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Surveillance culture for multidrug-resistant gram-negative bacteria: Performance in liver transplant recipients. Am J Infect Control 2017; 45:e40-e44. [PMID: 28254253 DOI: 10.1016/j.ajic.2016.12.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/13/2016] [Accepted: 12/13/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND The prevalence of infection with multidrug-resistant gram-negative bacteria (MDR-GNB) after solid-organ transplantation is increasing. Surveillance culture (SC) seems to be an important tool for MDR-GNB control. The goal of this study was to analyze the performance of SC for MDR-GNB among liver transplant (LT) recipients. METHODS This was a prospective cohort study involving patients who underwent LT between November 2009 and November 2011. We screened patients for extended spectrum β-lactamase-producing Escherichia coli, extended spectrum β-lactamase-producing Klebsiella pneumoniae, and carbapenem-resistant Enterobacteriaceae, carbapenem-resistant Pseudomonas aeruginosa (CRPA), and carbapenem-resistant Acinetobacter baumannii (CRAB). We collected SC samples immediately before LT and weekly thereafter, until hospital discharge. Samples were collected from the inguinal-rectal area, axilla, and throat. The performance of SC was evaluated through analysis of its sensitivity, negative predictive value, and accuracy. RESULTS During the study period, 181 patients were evaluated and 4,110 SC samples were collected. The GNB most often identified was CRAB, in 45.9% of patients, followed by CRKP in 40.3%. For all microorganisms, the positivity rate was highest among the inguinal-rectal samples. If only samples collected from this area were considered, the SC would fail to identify 34.9% of the cases of CRAB colonization. The sensitivity of SC for CRKP was 92.5%. The performance of SC was poorest for CRAB (sensitivity, 80.6%). CONCLUSIONS Our data indicate that SC is a sensitive tool to identify LT recipients colonized by MDR-GNB.
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Marchaim D, Levit D, Zigron R, Gordon M, Lazarovitch T, Carrico JA, Chalifa-Caspi V, Moran-Gilad J. Clinical and molecular epidemiology of Acinetobacter baumannii bloodstream infections in an endemic setting. Future Microbiol 2017; 12:271-283. [PMID: 28287300 DOI: 10.2217/fmb-2016-0158] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
AIM The transmission dynamics of Acinetobacter baumannii in endemic settings, and the relation between microbial properties and patients' clinical outcomes, are yet obscure and hampered by insufficient metadata. METHODS & RESULTS Of 20 consecutive patients with A. baumannii bloodstream infection that were thoroughly analyzed at a single center, at least one transmission opportunity was evident for 85% of patients. This implies that patient-to-patient transmission is the major mode of A. baumannii acquisitions in health facilities. Moreover, all patients who died immediately (<24 h of admission) were infected with a single clone (ST457; relative risk = 1.6; p = 0.05). CONCLUSION This preliminary analysis should prompt further investigation by mapping genomic virulence determinants among A. baumannii ST457 lineage compared with other strains.
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Affiliation(s)
- Dror Marchaim
- Unit of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Levit
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roy Zigron
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michal Gordon
- NIBN, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Tsillia Lazarovitch
- Clinical Microbiology Laboratory, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Joao A Carrico
- Instituto de Microbiologia & Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | | | - Jacob Moran-Gilad
- Public Health Services, Ministry of Health, Jerusalem, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,ESCMID Study Group for Genomic & Molecular Diagnostics (ESGMD), Basel, Switzerland
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Rabaan AA, Saunar JV, Bazzi AM, Raslan WF, Taylor DR, Al-Tawfiq JA. Epidemiology and detection of acinetobacter using conventional culture and in-house developed PCR based methods. J Infect Public Health 2017; 10:124-128. [DOI: 10.1016/j.jiph.2016.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 04/04/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022] Open
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50
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Nutman A, Lerner A, Schwartz D, Carmeli Y. Evaluation of carriage and environmental contamination by carbapenem-resistant Acinetobacter baumannii. Clin Microbiol Infect 2016; 22:949.e5-949.e7. [DOI: 10.1016/j.cmi.2016.08.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/14/2016] [Accepted: 08/15/2016] [Indexed: 10/21/2022]
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