Risk factors for and outcomes associated with clinical isolates of Escherichia coli and Klebsiella species resistant to extended-spectrum cephalosporins among patients admitted to Canadian hospitals

Extended Spectrum β-Lactamase-Producing Enterobacterales of Shrimp and Salmon Available for Purchase by Consumers in Canada-A Risk Profile Using the Codex Framework

The extended-spectrum β-lactamase (ESBL)-producing Enterobacterales (ESBL-EB) encompass several important human pathogens and are found on the World Health Organization (WHO) priority pathogens list of antibiotic-resistant bacteria. They are a group of organisms which demonstrate resistance to third-generation cephalosporins (3GC) and their presence has been documented worldwide, including in aquaculture and the aquatic environment. This risk profile was developed following the Codex Guidelines for Risk Analysis of Foodborne Antimicrobial Resistance with the objectives of describing the current state of knowledge of ESBL-EB in relation to retail shrimp and salmon available to consumers in Canada, the primary aquacultured species consumed in Canada. The risk profile found that Enterobacterales and ESBL-EB have been found in multiple aquatic environments, as well as multiple host species and production levels. Although the information available did not permit the conclusion as to whether there is a human health risk related to ESBLs in Enterobacterales in salmon and shrimp available for consumption by Canadians, ESBL-EB in imported seafood available at the retail level in Canada have been found. Surveillance activities to detect ESBL-EB in seafood are needed; salmon and shrimp could be used in initial surveillance activities, representing domestic and imported products.

Monitoring the antimicrobial susceptibility of Gram-negative organisms involved in intraabdominal and urinary tract infections recovered during the SMART study (Spain, 2016 and 2017)

OBJECTIVE

Continuous antimicrobial resistance surveillance is recommended by Public Health authorities. We up-dated data from the SMART (Study for Monitoring Antimicrobial Resistance Trends) surveillance study in Spain.

METHODS

The antimicrobial susceptibility data and extended-spectrum beta-lactamase (ESBL) production in isolates recovered from intra-abdominal (IAI) (n=1,429) and urinary tract (UTI) (n=937) infections during the 2016- 2017 SMART study in 10 Spanish hospitals were analysed.

RESULTS

Escherichia coli was the most frequently microorganism isolated (48.3% and 53.7%) followed by Klebsiella spp. (11.5% and 21.9%) in IAIs and UTIs, respectively. Figures for Pseudomonas aeruginosa were 9.0% and 6.1%, being more frequently recovered from patients with nosocomial infections. Overall, 9.9% (IAI) and 14.0% (UTI) of E. coli, Klebsiella spp. and Proteus mirabilis isolates were ESBL-producers, being Klebsiella pneumoniae (34.5%) from UTI of nosocomial origin the most frequent. ESBL-producers were higher in patients >60 years in both IAIs and UTIs. As in previous years, amikacin (96.3%-100% susceptibility), ertapenem (84.2%-100%) and imipenem (70.3%- 100%) were the most active antimicrobials tested among Enterobacterales species. The activity of amoxicillin-clavulanic, piperacillin-tazobactam, and ciprofloxacin susceptibility was lower, particularly among ESBL-producers. Ertapenem susceptibility (88.9%-100%) was retained in ESBL-E. coli isolates that were resistant to these antimicrobials but decreased (28.6%-100%) in similar isolates of K. pneumoniae.

CONCLUSIONS

Continuous antimicrobial resistance surveillance from the SMART study reveals overall maintenance of ESBL-producers in Spain, although with higher presence in isolates from UTIs than from IAIs. Moreover, ertapenem activity was high in E. coli irrespective of ESBL production but decreased in K. pneumoniae, particularly among ESBL-producers.

Mortality impact of empirical antimicrobial therapy in ESBL- and AmpC-producing Enterobacteriaceae bacteremia in an Australian tertiary hospital

BACKGROUND

Treatment of ESBL- and AmpC-producing Enterobacteriaceae bacteremia is often complicated by lack of appropriate antibiotics. We aimed to determine the predictors of mortality and impact of empirical antibiotics.

METHODS

A retrospective observational study was performed on consecutive adult cases of ESBL and AmpC bacteremia at the Alfred Hospital from 2014 through April 2018.

RESULTS

Among 110 patients with ESBL (88.2%) and AmpC (14.5%) bacteremia episodes, 96.4% had comorbidities such as hematological malignancy (30%). Approximately 45% were on immunosuppressive drugs, while 69% had recent antibiotic exposure. Over 84% of bacteremias were hospital acquired or healthcare associated. Urinary tract was the main source of infection (40%) with E. coli being the commonest organism (66.4%). The isolates were least resistant to gentamicin (21.8%), which was often appropriately used in empirical therapy. About 34% of patients presented with severe sepsis or shock. The 30-day mortality rate was 20% with no correlation with inappropriate empirical antibiotics (52%). There was no significant mortality difference between carbapenem use in empirical and definitive therapy. Respiratory source [OR 11.77, 95% CI 1.30-106.85; p = 0.03], severe sepsis or shock [OR 5.17, 95% CI 1.37-19.55; p = 0.02] and inappropriate definitive therapy [OR 27.93, 95%CI 3.69-211.35; p = 0.001] were independent predictors for mortality.

CONCLUSION

The choice and appropriateness of empirical therapy were not associated with mortality in ESBL and AmpC bacteremia. Prudent use of carbapenem is reasonable with gentamicin as alternative. Emphasis should be on prompt resuscitation in severe sepsis and early detection of ESBL and AmpC to facilitate appropriate switch to definitive therapy.

Risk Factors For and Outcomes of Multidrug-Resistant Escherichia coli Infections in Children

Introduction

The recent increase in multidrug-resistant (MDR) Escherichia coli infections is not well described in children. We determined the risk factors and outcomes of extraintestinal E. coli infections in children in our region.

Methods

We conducted a retrospective cohort study of children ≤18 years in Olmsted County, MN, USA, between January 1, 2012 and December 31, 2012. MDR isolates were defined as resistant to ≥3 antibiotic classes.

Results

A total of 368 children each contributed 1 isolate. Isolates were predominantly community-associated (82%) and from urine (90%), and outpatients (86%); 46 (13%) isolates were MDR. In multivariable analysis, genitourinary (GU) tract anomaly (OR 2.42, 95% CI 1.03–5.68), invasive devices (OR 3.48, 95% CI 1.37–8.83) and antibiotic use at presentation (OR 2.62, 95% CI 1.06–6.47) were associated with MDR E. coli. Children with MDR infections were more likely to have a complex infection (35% vs. 17%, P = 0.026), less likely to receive effective empiric antibiotics (47% vs. 74%, P < 0.001), had longer time to receipt of effective antibiotics (median 19.2 vs. 0.6 h, P < 0.001), and longer hospitalization (median 10 vs. 4 days, P = 0.029) than children with non-MDR infections.

Conclusion

Pediatric MDR E. coli infection was associated with GU tract anomaly, invasive devices, antibiotic use, delays in effective therapy and longer hospitalization.

Impact of infection with extended-spectrum β-lactamase-producing Escherichia coli or Klebsiella species on outcome and hospitalization costs

BACKGROUND

Extended-spectrum β-lactamase (ESBL)-producing bacteria are important sources of infection; however, Canadian data evaluating the impact of ESBL-associated infection are lacking.

AIM

To determine whether patients infected with ESBL-producing Escherichia coli or Klebsiella species (ESBL-EcKs) exhibit differences in clinical outcome, microbiological outcome, mortality, and/or hospital resource use compared to patients infected with non-ESBL-producing strains.

METHODS

A retrospective case-control study of 75 case patients with ESBL-EcKs matched to controls infected with non-ESBL-EcKs who were hospitalized from June 2010 to April 2013 was conducted. Patient-level cost data were provided by the institution's business office. Clinical data were collected using the electronic databases and paper charts.

FINDINGS

Median infection-related hospitalization costs per patient were greater for cases than controls (C$10,507 vs C$7,882; median difference: C$3,416; P = 0.04). The primary driver of increased costs was prolonged infection-related hospital length of stay (8 vs 6 days; P = 0.02) with patient location (ward, ICU) and indirect care costs (including costs associated with infection prevention and control) as the leading cost categories. Cases were more likely to experience clinical failure (25% vs 11%; P = 0.03), with a higher all-cause mortality (17% vs 5%; P = 0.04). Less than half of case patients were prescribed appropriate empiric antimicrobial therapy, whereas controls received adequate initial treatment in nearly all circumstances (48% vs 96%; P < 0.01).

CONCLUSION

Patients with infection caused by ESBL-EcKs are at increased risk for clinical failure and mortality, with additional cost to the Canadian healthcare system of C$3,416 per patient.

Prevalence of antimicrobial use in a network of Canadian hospitals in 2002 and 2009

BACKGROUND

Increasing antimicrobial resistance has been identified as an important global health threat. Antimicrobial use is a major driver of resistance, especially in the hospital sector. Understanding the extent and type of antimicrobial use in Canadian hospitals will aid in developing national antimicrobial stewardship priorities.

METHODS

In 2002 and 2009, as part of one-day prevalence surveys to quantify hospital-acquired infections in Canadian Nosocomial Infection Surveillance Program hospitals, data were collected on the use of systemic antimicrobial agents in all patients in participating hospitals. Specific agents in use (other than antiviral and antiparasitic agents) on the survey day and patient demographic information were collected.

RESULTS

In 2002, 2460 of 6747 patients (36.5%) in 28 hospitals were receiving antimicrobial therapy. In 2009, 3989 of 9953 (40.1%) patients in 44 hospitals were receiving antimicrobial therapy (P<0.001). Significantly increased use was observed in central Canada (37.4% to 40.8%) and western Canada (36.9% to 41.1%) but not in eastern Canada (32.9% to 34.1%). In 2009, antimicrobial use was most common on solid organ transplant units (71.0% of patients), intensive care units (68.3%) and hematology/oncology units (65.9%). Compared with 2002, there was a significant decrease in use of first-and second-generation cephalosporins, and significant increases in use of carbapenems, antifungal agents and vancomycin in 2009. Piperacillin-tazobactam, as a proportion of all penicillins, increased from 20% in 2002 to 42.8% in 2009 (P<0.001). There was a significant increase in simultaneous use of >1 agent, from 12.0% of patients in 2002 to 37.7% in 2009.

CONCLUSION

From 2002 to 2009, the prevalence of antimicrobial agent use in Canadian Nosocomial Infection Surveillance Program hospitals significantly increased; additionally, increased use of broad-spectrum agents and a marked increase in simultaneous use of multiple agents were observed.

Risk Factors for and Outcomes of Bacteremia Caused by Extended-Spectrum ß-Lactamase-Producing Escherichia coli and Klebsiella Species at a Canadian Tertiary Care Hospital

BACKGROUND

Antimicrobial resistance due to production of extended-spectrum ß-lactamases by Escherichia coli and Klebsiella species (ESBL-EK) is concerning. Previous studies have shown that bacteremia due to ESBL-producing organisms is associated with increases in length of stay and/or mortality rate. Rates of infection by ESBL-EK vary worldwide, and regional differences in the prevalence of risk factors are likely. Few Canadian studies assessing risk factors for ESBL-EK infections or the outcomes of empiric therapy have been published.

OBJECTIVES

To determine risk factors for and patient outcomes associated with ESBL-EK bacteremia. The appropriateness of empiric antibiotic therapy and the effect of inappropriate empiric therapy on these outcomes were also examined.

METHODS

In a retrospective, 1:1 case-control study conducted in a tertiary care hospital between 2005 and 2010, data for 40 patients with ESBL-EK bacteremia were compared with data for 40 patients who had non-ESBL-EK bacteremia.

RESULTS

Of all variables tested, only antibiotic use within the previous 3 months was found to be an independent risk factor for acquisition of ESBL-EK bacteremia (odds ratio 5.2, 95% confidence interval 1.6-16.9). A greater proportion of patients with non-ESBL-EK bacteremia received appropriate empiric therapy (88% [35/40] versus 15% [6/40], p < 0.001). Time to appropriate therapy was longer for those with ESBL-EK bacteremia (2.42 days versus 0.17 day, p < 0.001). Patient outcomes, including length of stay in hospital, admission to the intensive care unit (ICU), length of stay in the ICU (if applicable), and in-hospital mortality were not affected by the presence of ESBL-EK or the appropriateness of empiric therapy.

CONCLUSIONS

Previous antibiotic use was a significant, independent risk factor for acquiring ESBL-EK. Thus, prior antibiotic use is an important consideration in the selection of empiric antibiotic therapy and should increase the concern for resistant pathogens.

Outbreak of extended spectrum beta-lactamase-producing Klebsiella pneumoniae in an intensive care unit (Brest)

INTRODUCTION

We had for aim to describe control and investigation of an outbreak caused by a strain of Extended spectrum beta-lactamase producing Klebsiella pneumoniae in intensive care units of the Brest teaching hospital.

PATIENTS AND METHOD

The case definition was a patient infected by or carrying the epidemic strain. Control measures and investigations are presented. A case-control study was conducted in the surgical intensive care unit. Each case was matched with two controls based on admission times in the unit. The study focused on diagnostic and therapeutic procedures, and potential contacts with healthcare workers, in this context of cross transmission.

RESULTS

Between February and May 2011, nine cases were reported in the surgical ICU and two in the medical ICU. Eighteen controls were matched with the nine surgical ICU cases. Several factors were found to be statistically associated with infection or colonization by the epidemic strain: the surgical block in which patients had been operated and the ward of first hospitalization; the number of trans-esophageal and trans-thoracic echocardiographies, of central venous catheter insertions, and of surgical operations; intubation. The total number of invasive procedures was also found to be statistically higher among cases.

CONCLUSION

This study identified factors associated with colonization or infection by the epidemic strain. These factors might have been involved in the transmission tree, and be vulnerable elements for the prevention of nosocomial infections and colonisations, and their epidemic spread.

An observational study on bloodstream extended-spectrum beta-lactamase infection in critical care unit: incidence, risk factors and its impact on outcome

BACKGROUND

The incidence of nosocomial infections caused by extended-spectrum beta-lactamase (ESBL) producing microbes is increasing rapidly in the last few years. However, the clinical significance of infections caused by ESBL-producing bacteria in ICU patients remains unclear. We did a prospective study to look for incidence, risk factors and outcome of these infections in ICU patients.

METHODS

Consecutive isolates of Escherichia coli and Klebsiella pneumoniae in blood cultures were included for the analysis. Patients were divided into two groups based on the production of ESBL. Primary outcome measure was ICU mortality. Logistic regression analysis was done to identify risk factors for ESBL production.

RESULTS

Among the 95 isolates tested, 73 (76.8%) produced ESBL. Transfer from other hospitals or wards (OR 3.65; 95% CI: 1.3-10.1 and RR 1.35; 95% CI: 1.05-1.73) and previous history of antibiotics usage (OR 3.54; 95% CI: 1.04-11.97 and RR 1.5; 95% CI: 0.89-2.5) were risk factors for ESBL production. There was no significant difference in ICU mortality (p=0.588), need for organ support between two groups.

CONCLUSION

There is a high incidence of ESBL producing organisms causing blood stream infections in critically ill patients. Transfer from other hospitals and previous antibiotic usage are important risk factors for ESBL production. However ESBL production may not be associated with a poorer outcome if appropriate early antibiotic therapy is instituted.

Risk factors for extended-spectrum beta-lactamase-producing Escherichia coli infection in hospitalized patients

The incidence of nosocomial infection caused by extended-spectrum beta-lactamase (ESBL)-producing bacteria is increasing worldwide. Infections caused by ESBL producers have been associated with severe adverse clinical outcomes that have led to increased mortality, prolonged hospitalization, and rising medical costs. To avoid such adverse events and ineffective treatment, an appropriate use of drugs for infectious diseases is needed. To suppress the emergence and spread of drug-resistant bacteria in hospitals, it is important to be vigilant about ESBL-producing Escherichia coli (E. coli). In this study, we examined and compared seven items in a blood test between patients with ESBL-producing E. coli and non-ESBL-producing E. coli among febrile patients. We examined the levels of serum albumin, hemoglobin, and C-reactive protein (CRP), and the numbers of leucocytes, neutrophils, lymphocytes, and platelets in blood on the day of admission, the screening day during hospitalization, and the day immediately before discharge from the hospital. There were no significant differences in clinical background characteristics between the two groups of patients. In patients with invasive infections caused by ESBL-producing E. coli, serum albumin levels and the number of lymphocytes were significantly lower than those in patients not infected with ESBL producers. These values recovered to their baseline levels on the day of hospital discharge. This retrospective study suggests that serum albumin levels and the number of lymphocytes may serve as risk factors for infection by ESBL-producing E. coli, thereby supporting the appropriate use of antimicrobials in hospitals.

When and how to cover for resistant gram-negative bacilli in severe sepsis and septic shock

In the 80s and 90s, increasing antibiotic resistance was met by the introduction of new effective agents with broader antibacterial spectra for the empirical treatment of severe infections. In recent years, however, few novel antimicrobials have been developed, and this has critically weakened our strength in the fight against resistant bacteria, especially Gram-negative bacilli. It has been well proven that mortality increases if initial empirical antibiotic treatment for severe infection is inappropriate due to resistance of the pathogen. Physicians are already faced with the increasing challenge of untreatable or almost untreatable Gram-negative infections due to antibiotic resistance. Empirical treatment with broader spectra and high antibiotic pressure both in- and outside hospital is the driving force behind resistance. Since new efficient drugs against Gram-negative bacilli will not be available for some time, the best we can do to stop infections caused by multidrug-resistant bacteria is to improve infection control and choice of antibiotics, which should be based on surveillance of local antibiotic consumption and resistance. We must learn more about the revived antibacterial agents colistin and fosfomycin, and the few next generation Gram-negative antibiotics that have been developed. The aim of this review is to give an update on present therapeutic options in the fight against multidrug-resistant Gram-negative bacteria.