Risk factors and medical costs for healthcare-associated carbapenem-resistant Escherichia coli infection among hospitalized patients in a Chinese teaching hospital

Clinical risk factors and outcomes of carbapenem-resistant Escherichia coli nosocomial infections in a Chinese teaching hospital: a retrospective study from 2013 to 2020

The emergence of carbapenem-resistant Escherichia coli strains poses a considerable challenge to global public health, and little is known about carbapenemase-producing E. coli strains in Tianjin, China. This study aimed to investigate the risk factors for infections with carbapenem-resistant E. coli (CREC) strains. This retrospective case-control study was conducted at a tertiary teaching hospital. A total of 134 CREC clinical isolates were collected from the General Hospital of Tianjin Medical University between 2013 and 2020. The control group was selected at a ratio of 1:1 from patients with nosocomial carbapenem-susceptible E. coli infection. Risk factors for nosocomial CREC infection and clinical outcomes were analyzed using univariate and multivariate analyses. Multivariate analysis revealed that cephalosporin exposure (odd ratio OR = 2.01), carbapenem exposure (OR = 1.96), glucocorticoid exposure (OR = 32.45), and surgical history (OR = 3.26) were independent risk factors for CREC infection. The in-hospital mortality rate in the CREC group was 29.1%, and age >65 years (OR = 3.19), carbapenem exposure (OR = 3.54), and central venous catheter insertion (OR = 4.19) were independent risk factors for in-hospital mortality in patients with CREC infections. Several factors were identified in the development of nosocomial CREC infections. The CREC isolates were resistant to most antibiotics. Reducing CREC mortality requires a comprehensive consideration of appropriate antibiotic use, underlying diseases, and invasive procedures.IMPORTANCEEscherichia coli is an opportunistic pathogen that causes severe hospital-acquired infections. The spread of carbapenem-resistant E. coli is a global threat to public health, and only a few antibiotics are effective against these infections. Consequently, these infections are usually associated with poor prognosis and high mortality. Therefore, understanding the risk factors associated with the causes and outcomes of these infections is crucial to reduce their incidence and initiate appropriate therapies. In our study, several factors were found to be involved in nosocomial carbapenem-resistant E. coli (CREC) infections, and CREC isolates were resistant to most antibiotics. Reducing CREC mortality needs a comprehensive consideration of whether antibiotics are used appropriately, underlying diseases, and invasive interventions. These findings provide valuable evidence for the development of anti-infective therapy, infection prevention, and control of CREC-positive infections.

Containment of carbapenem-resistant Enterobacterales colonisations and infections: Results from an integrated infection control intervention in a large hospital trust of northern Italy

PURPOSE

We describe the results of an infection control intervention, implemented in 4 tertiary hospitals in Romagna, Italy, aiming at containing the spread of carbapenem-resistant Enterobacterales (CRE).

METHODS

The intervention consisted of rectal screening in patients at risk for CRE; pre-emptive contact precaution waiting for screening results; timely notification of CRE identification and concomitant computerized alert; contact precaution for confirmed CRE-positive patients. We performed an interrupted time series analysis to compare the incidence of CRE bacteraemia, of other CRE infections, and CRE-positive rectal swabs in the pre and postintervention period (January 2015-July 2017 and August 2017-June 2020, respectively).

RESULTS

4,332 CRE isolates were collected. Klebsiella pneumoniae was the most represented pathogen (n = 3,716, 85%); KPC production was the most common resistance mechanism (n = 3,896, 90%). The incidence rate of CRE bacteraemia significantly decreased from 0.554 to 0.447 episodes per 10.000 patient days in the early postintervention period (P = .001). The incidence rate of other CRE infections significantly decreased from 2.09 to 1.49 isolations per 10.000 patient days in the early postintervention period (P = .021). The monthly number of rectal swabs doubled in the postintervention period and there was a significant reduction trend of CRE-positive swabs, sustained over time (P < .001).

CONCLUSIONS

The infection control intervention was successful in containing the spread of CRE infections and colonisations.

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.

The impact of COVID-19 pandemic on hand hygiene compliance of healthcare workers in a tertiary hospital in East China

Introduction

Hand hygiene is a cost-effective measure to reduce healthcare-associated infections (HAIs) in healthcare facilities. The impact of the coronavirus disease 2019 (COVID-19) pandemic on hand hygiene performance (HHP) provided evidence for targeted hand hygiene intervention measures.

Methods

This study evaluated the HHP rate in a tertiary hospital before and after the COVID-19 outbreak. HHP was checked by infection control doctors or nurses every day, and they inputted the HHP rate to the full-time infection control staff every week. A random examination of HHP was conducted by a confidential worker every month. The HHP of healthcare workers (HCWs) was monitored in the outpatient department, inpatient ward, and operating room from January 2017 to October 2022. The influence of COVID-19 prevention and control strategies on HHP was elucidated by analyzing the results of HHP during the study period.

Results

The average HHP rate of HCWs was 86.11% from January 2017 to October 2022. The HHP rate of HCWs after the COVID-19 pandemic was statistically significantly higher than that before the pandemic (P < 0.001). The HHP rate was the highest (93.01%) in September 2022 when the local epidemic occurred. Among the different occupation categories, medical technicians showed the highest HHP rate (89.10%). The HHP rate was the highest after contact with body fluids or blood of patients (94.47%).

Conclusion

The HHP rate of HCWs in our hospital showed an increasing trend in the recent 6 years, especially during the COVID-19 pandemic, and the increase was most obvious during the local epidemic.

The economic burden of antibiotic resistance: A systematic review and meta-analysis

INTRODUCTION

Antibiotic resistance (ABR) has substantial global public health concerns. This systematic review aimed to synthesise recent evidence estimating the economic burden of ABR, characterised by study perspectives, healthcare settings, study design, and income of the countries.

METHODS

This systematic review included peer-reviewed articles from PubMed, Medline, and Scopus databases, and grey literature on the topic of the economic burden of ABR, published between January 2016 and December 2021. The study was reported in line with 'Preferred Reporting Items for Systematic Review and Meta-Analysis' (PRISMA). Two reviewers independently screened papers for inclusion first by title, then abstract, and then the full text. Study quality was assessed using appropriate quality assessment tools. Narrative synthesis and meta-analyses of the included studies were conducted.

RESULTS

A total of 29 studies were included in this review. Out of these studies, 69% (20/29) were conducted in high-income economies and the remainder were conducted in upper-and-middle income economies. Most of the studies were conducted from a healthcare or hospital perspective (89.6%, 26/29) and 44.8% (13/29) studies were conducted in tertiary care settings. The available evidence indicates that the attributable cost of resistant infection ranges from -US$2,371.4 to +US$29,289.1 (adjusted for 2020 price) per patient episode; the mean excess length of stay (LoS) is 7.4 days (95% CI: 3.4-11.4), the odds ratios of mortality for resistant infection is 1.844 (95% CI: 1.187-2.865) and readmission is 1.492 (95% CI: 1.231-1.807).

CONCLUSION

Recent publications show that the burden of ABR is substantial. There is still a lack of studies on the economic burden of ABR from low-income economies, and lower-middle-income economies, from a societal perspective, and in relation to primary care. The findings of this review may be of value to researchers, policymakers, clinicians, and those who are working in the field of ABR and health promotion.

SYSTEMATIC REVIEW REGISTRATION

CRD42020193886.

Rapid Detection of Carbapenem-Resistant Klebsiella pneumoniae Using Machine Learning and MALDI-TOF MS Platform

Background

Rapid detection of carbapenem-resistant Klebsiella pneumoniae (CRKP) is essential for specific antimicrobial therapy. Machine learning techniques combined with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) can be used as a rapid, reliable, sensitive, and low-cost species identification method.

Methods

Clinically collected K. pneumoniae were subjected to MALDI-TOF MS analysis. A random forest (RF) algorithm and non-linear support vector machine (SVM) were used to construct the RF, SVM, and dimension reduction (SVM-K) models, and their performance was assessed for accuracy, sensitivity, specificity, and area under the subject worker curve (AUC).

Results

The RF, SVM and SVM-K models showed good classification performance with 0.88, 0.88, and 0.91 accuracy, 0.82, 0.85, and 0.89 sensitivity, 0.93, 0.92, and 0.94 specificity with an AUC of 0.9013, 0.9298, and 0.9356, respectively. For the SVM-K model, the optimal dimension reduction was 105 to 153, and the average accuracy was >0.9. The top 10 peak features of significance according to the RF algorithm with 6515 Da appeared in 56.8% of CRKP isolates and 5.3% of CSKP isolates, which indicated the best classification performance.

Conclusion

The three RF, SVM, and SVM-K models showed excellent classification performance differentiating the CRKP from CSKP; the SVM-K model was the best. Data analysis with machine learning combined with MALDI-TOF MS can be employed as a rapid and inexpensive alternative to existing detection methods.

Carbapenem-resistant Escherichia coli from shrimp and salmon available for purchase by consumers in Canada: a risk profile using the Codex framework

Resistance to carbapenems in human pathogens is a growing clinical and public health concern. The carbapenems are in an antimicrobial class considered last-resort, they are used to treat human infections caused by multidrug-resistant Enterobacterales, and they are classified by the World Health Organization as 'High Priority Critically Important Antimicrobials'. The presence of carbapenem-resistant Enterobacterales (CREs) of animal-origin is of concern because targeted studies of Canadian retail seafood revealed the presence of carbapenem resistance in a small number of Enterobacterales isolates. To further investigate this issue, a risk profile was developed examining shrimp and salmon, the two most important seafood commodities consumed by Canadians and Escherichia coli, a member of the Enterobacterales order. Carbapenem-resistant E. coli (CREc) isolates have been identified in shrimp and other seafood products. Although carbapenem use in aquaculture has not been reported, several classes of antimicrobials are utilised globally and co-selection of antimicrobial-resistant microorganisms in an aquaculture setting is also of concern. CREs have been identified in retail seafood purchased in Canada and are currently thought to be uncommon. However, data concerning CRE or CREc occurrence and distribution in seafood are limited, and argue for implementation of ongoing or periodic surveillance.

Socioeconomic Burden of Bloodstream Infections Caused by Carbapenem-Resistant Enterobacteriaceae

Background

Although infection with carbapenem-resistant Enterobacteriaceae (CRE) has become an urgent public health threat worldwide, the socioeconomic burden of CRE bloodstream infection (BSI) remains to be clarified.

Methods

This retrospective study included all patients infected with Escherichia coli or Klebsiella pneumoniae who were hospitalized for BSI from 2013 to 2015. Socioeconomic burden, including direct and indirect economic burden, was compared in patients infected with carbapenem-sensitive Enterobacteriaceae (CSE) and CRE following 1:1 propensity score matching (PSM) to control for confounding variables.

Results

Data from 879 patients with Enterobacteriaceae BSI were evaluated, including 152 (17.3%) patients infected with CRE and 727 (82.7%) infected with CSE. PSM yielded 112 pairs of 224 patients. Median hospital length of stay did not differ significantly in the CRE and CSE groups (35 vs 29 days, P = 0.089), but in-hospital 28-day mortality rate was significantly higher in patients infected with CRE than with CSE (45.5% vs 32.1%, P = 0.040). Median direct economic burden was significantly greater in patients with CRE-BSI than with CSE-BSI during hospitalization ($24,940.1 vs 16,864.0, P = 0.017) but not during the period after infection ($10,403.4 vs 8498.0, P = 0.178). Drug expenditure accounted for the largest proportion of costs in both groups. The median disability-adjusted life year (DALY) was higher in CRE-BSI than in CSE-BSI patients, but the difference was not statistically significant (7.9 vs 6.7 years, P = 0.190). Median indirect economic burden did not differ significantly in these two groups ($3848.5 vs 1139.9, P = 0.304), although indirect economic burden increased significantly from 2013 to 2015 in patients with CRE-BSI.

Conclusion

Carbapenem resistance had a major impact on the clinical and socioeconomic burden of patients with Enterobacteriaceae BSI. The higher mortality rate in patients with CRE-BSI was associated with increased direct healthcare burden and indirect socioeconomic loss.

Impact of carbapenem resistance on mortality in patients infected with Enterobacteriaceae: a systematic review and meta-analysis

OBJECTIVES

To provide a comprehensive assessment of the impact of carbapenem resistance on mortality among patients infected with Enterobacteriaceae and to explore the source of heterogeneity across studies.

DESIGN

This systematic review was conducted following the guidelines of Cochrane Guidance and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

DATA SOURCES

We conducted a systematic literature search of the PubMed, Embase, Web of Science and Cochrane Library databases to identify relevant studies published between 1 January 1994 and 30 August 2020.

ELIGIBILITY CRITERIA

We included primary observational studies published in English that reported the mortality outcomes for hospitalised patients with confirmed infections due to carbapenem-resistant Enterobacteriaceae (CRE) and carbapenem-susceptible Enterobacteriaceae (CSE). Studies with no comparison group or with a comparison group of patients infected with unconfirmed CSE were excluded.

DATA EXTRACTION AND SYNTHESIS

Data extraction and assessment of risk bias were conducted independently by two reviewers. The pooled relative risk and risk difference were calculated as effect measures with 95% CIs using a random effects model. The heterogeneity across studies was assessed by Q-statistic and I² measures.

RESULTS

Of 10 304 studies initially identified, 50 studies were included in the meta-analyses. The results of the meta-analyses showed that carbapenem resistance has a significant positive effect on the probability of death for patients infected with Enterobacteriaceae for any type of mortality outcome. The results of the stratified analysis and meta-regression suggested that the effect of carbapenem resistance on the risk of death varied by infection type, sample size and year of publication.

CONCLUSIONS

Our results suggested that patients with CRE infection still face a greater risk of death than patients with CSE infection do, and an urgent need to develop new antibiotics and appropriate treatments to reduce the risk of death.

PROSPERO REGISTRATION NUMBER

CRD42020176808.

A retrospective study on risk factors and disease burden for hospital-acquired pneumonia caused by multi-drug-resistant bacteria in patients with intracranial cerebral hemorrhage

PURPOSE

Hospital-acquired pneumonia (HAP) is becoming a serious problem in China, especially caused by multi-drug resistant (MDR), which is a risk factor for poor prognosis of intracranial cerebral hemorrhage (ICH). We investigate the risk factors for HAP among patients with ICH and study the antibiotic use and medical costs of MDR infection.

METHODS

We performed a retrospective, case-control, parallel study in Xiangya Hospital. Patients included in this study and diagnosed with basal ganglia hemorrhage were admitted between January 2017 and December 2019.

RESULTS

Univariate analysis discovered some personal risk factors including gender (p = .002), age (p = .023), and underlying conditions such as diabetes (p = .036), coronary heart disease (p = .009), and renal insufficiency (p = .001). Invasive medical operations including endotracheal intubation, tracheotomy, ventilator use, lumbar puncture, urinary catheter insertion, and peripherally inserted central catheter (PICC) (p < .001 all) were also risk factors for HAP. Binary logistics regression indicated hospital duration, antibiotic exposure, and urinary catheter insertion explained 91.4% of the variance on HAP (p < 0.01). As for the antibiotic treatment, there were no difference in the duration of use days and total dose per patient between MDR and non-MDR group, except for Tigecycline. Antibiotic costs for the MDR group were significantly higher than those for the non-MDR group and no infection group (p < 0.001).

CONCLUSION

To better prevent HAP particularly caused by MDR bacteria, we emphasize the aseptic technique especially in the management of equipment in patient care.

Characterization of the genetic environment of blaKPC in Escherichia coli isolates from hospitals in China

Carbapenem resistance in Enterobacteriaceae members has become a major challenge, and the genetic environment of blaKPC, encoding Klebsiella pneumoniae carbapenemases, has not been fully clarified in China. In this study, we aimed to explore the genetic environment of blaKPC in 25 carbapenem-resistant E. coli isolates from hospitals in Hangzhou Province, China. Antimicrobial susceptibility against 22 common antimicrobial agents was tested. Polymerase chain reaction (PCR) analysis was performed for screening of the resistent genes, such as blaKPC, blaCTX-M, blaTEM, blaSHV, blaNDM, qnrA, qnrB, qnrS, aac(6')-Ib, armA and rmtB. The genetic environment of blaKPC were determinedin one isolate. blaKPC was detected by PCR in all the clinical E. coli isolates. There were no strains carrying blaNDM, qnrA and armA. The genetic environment of blaKPC showed that blaKPC dissemination is plasmid mediated and that it is located in the Tn3-Tn4401 transposon complex. Encoding of blaKPC-2 was responsible for carbapenem resistance in the 25 E. coli isolates. The genetic environment of blaKPC was characterized by the Tn3-Tn4401 complex. Our findings may provide a theoretical basis for clinical drug-resistance monitoring, anti-infection treatment and hospital infection control.

In vitro Activity of Meropenem-Vaborbactam versus Other Antibiotics Against Carbapenem-Resistant Escherichia coli from Southeastern China

Purpose

This study aimed to evaluate the in vitro activity of meropenem-vaborbactam (MVB) against a collection of carbapenem-resistant Escherichia coli (CREC) isolates and to compare the activity with other antibiotics with regard to different separation sites, carbapenem-resistant mechanisms, and sequence types (STs).

Methods

A total of 58 CREC strains were used as the experimental strains from the First Affiliated Hospital of Wenzhou Medical University in southeastern China. The minimum inhibitory concentrations of MVB, ceftazidime-avibactam, and tigecycline against all the experimental strains were determined by the microdilution broth method.

Results

MVB exhibited higher antimicrobial activity (83% susceptibility) than that of other antibiotics, except for colistin and tigecycline. The susceptibility of CREC strains towards MVB varied with regard to carbapenem-resistant mechanisms and STs, especially in Klebsiella pneumoniae carbapenemase (KPC)-positive isolates and ST8 isolates.

Conclusion

MVB exhibited considerably high activity against KPC-producing and ST8 CREC isolates. It has the great potential to be an alternative for the treatment of infections caused by CREC after determining the type of carbapenemase, the susceptibility to MVB and/or STs.

Developing a risk prediction model for multidrug-resistant bacterial infection in patients with biliary tract infection

BACKGROUND/AIMS

The aim of this study was to develop a tool to predict multidrug-resistant bacteria infections among patients with biliary tract infection for targeted therapy.

PATIENTS AND METHODS

We conducted a single-center retrospective descriptive study from January 2016 to December 2018. Univariate and multivariable logistic regression analysis were used to identify independent risk factors of multidrug-resistant bacterial infections. A nomogram was constructed according to multivariable regression model. Moreover, the clinical usefulness of the nomogram was estimated by decision curve analysis.

RESULTS

121 inpatients were randomly divided into a training cohort (n = 79) and validation cohort (n = 42). In multivariate analysis, 5 factors were associated with biliary tract infections caused by multidrug-resistant bacterial infections: aspartate aminotransferase (Odds ratio (OR), 13.771; 95% confidence interval (CI), 3.747-64.958; P < 0.001), previous antibiotic use within 90 days (OR, 4.130; 95% CI, 1.192-16.471; P = 0.032), absolute neutrophil count (OR, 3.491; 95% CI, 1.066-12.851; P = 0.046), previous biliary surgery (OR, 3.303; 95% CI, 0.910-13.614; P = 0.079), and hemoglobin (OR, 0.146; 95% CI, 0.030-0.576; P = 0.009). The nomogram model was constructed based on these variables, and showed good calibration and discrimination in the training set [area under the curve (AUC), 0.86] and in the validation set (AUC, 0.799). The decision curve analysis demonstrated the clinical usefulness of our nomogram. Using the nomogram score, high risk and low risk patients with multidrug-resistant bacterial infection could be differentiated.

CONCLUSIONS

This simple bedside prediction tool to predict multidrug-resistant bacterial infection can help clinicians identify low versus high risk patients as well as choose appropriate, timely initial empirical antibiotics therapy. This model should be validated before it is widely applied in clinical settings.

Epidemiology and molecular characteristics of the type VI secretion system in Klebsiella pneumoniae isolated from bloodstream infections

Background

The type VI secretion system (T6SS) has been identified as a novel virulence factor. This study aimed to investigate the prevalence of the T6SS genes in Klebsiella pneumoniae‐induced bloodstream infections (BSIs). We also evaluated clinical and molecular characteristics of T6SS‐positive K pneumoniae.

Methods

A total of 344 non‐repetitive K. pneumoniae bloodstream isolates and relevant clinical data were collected from January 2016 to January 2019. For all isolates, T6SS genes, capsular serotypes, and virulence genes were detected by polymerase chain reaction, and antimicrobial susceptibility was tested by VITEK® 2 Compact. MLST was being conducted for hypervirulent K. pneumoniae (HVKP).

Results

69 (20.1%) were identified as T6SS‐positive K. pneumoniae among 344 isolates recovered from patients with BSIs. The rate of K1 capsular serotypes and ten virulence genes in T6SS‐positive strains was higher than T6SS‐negative strains (P = .000). The T6SS‐positive rate was significantly higher than T6SS‐negative rate among HVKP isolates. (P = .000). The T6SS‐positive K. pneumoniae isolates were significantly more susceptible to cefoperazone‐sulbactam, ampicillin‐sulbactam, cefazolin, ceftriaxone, cefotan, aztreonam, ertapenem, amikacin, gentamicin, levofloxacin, and ciprofloxacin (P < 0.05). More strains isolated from the community and liver abscess were T6SS‐positive K. pneumoniae (P < .05). Multivariate regression analysis indicated that community‐acquired BSIs (OR 2.986), the carriage of wcaG (OR 10.579), iucA (OR 2.441), and p‐rmpA (OR 7.438) virulence genes, and biliary diseases (OR 5.361) were independent risk factors for T6SS‐positive K. pneumoniae‐induced BSIs.

Conclusion

The T6SS‐positive K. pneumoniae was prevalent in individuals with BSIs. T6SS‐positive K. pneumoniae strains seemed to be hypervirulent which revealed the potential pathogenicity of this emerging gene cluster.

Risk Factors for Subsequential Carbapenem-Resistant Klebsiella pneumoniae Clinical Infection Among Rectal Carriers with Carbapenem-Resistant Klebsiella pneumoniae

Purpose

Carbapenem-resistant Klebsiella pneumoniae (CRKP) infection has become a critical clinical concern for its high mortality. Rectal carriage of CRKP has been reported playing an important role in CRKP infection; however, the extent to which carrier develops clinical CRKP infection is unclear. This study aimed to identify risk factors for developing subsequential CRKP clinical infection in rectal carriers with CRKP.

Patients and Methods

Patients were screened for rectal carriage of CRKP in a tertiary university hospital; then, rectal CRKP carriers were divided into case group (those who developed subsequential clinical infection) and control group. Demographics, comorbid conditions, invasive procedures, antimicrobial exposure and other clinical parameters of those two groups were compared and analyzed using univariate and multivariate logistic regression analyses. Antimicrobial susceptibility profile and carbapenemase phenotype/genotype of those CRKP isolates were determined. MLST was applied to elucidate the molecular epidemiology of rectal CRKP isolates and clinical infection ones.

Results

Eight hundred and thirty-five patients were screened for rectal CRKP carriage. A total of 62 CRKP rectal carriers were identified; among them, 37.1% (23/62) developed CRKP clinical infection. CRKP isolates were resistant to most of the tested antimicrobial agents. ST11 was the dominant MLST type in rectal CRKP isolates (71.0%), and all the 23 clinical infection isolates were ST11. Multivariate analysis revealed that admission to the intensive care unit (ICU) (OR, 6.753; P=0.006), being in coma condition (OR, 11.085; P=0.015) and receiving central venous catheter (OR, 8.628; P=0.003) were independent risk factors for progressing to subsequential CRKP infection among those rectal carriers.

Conclusion

This study identified independent risk factors for developing subsequential CRKP clinical infection among CRKP rectal carriers, with being in coma condition as a new finding. It would help clinician target those high-risk rectal CRKP-colonized patients for prevention of subsequential clinical infection.

Antibiotic Resistance Profile and Diversity of Subtypes Genes in Escherichia coli Causing Bloodstream Infection in Northern Vietnam

BACKGROUND:

Evaluating the antibiotic susceptibility and resistance genes is essential in the clinical management of bloodstream infections (BSIs). But there are still limited studies in Northern Vietnam.

AIM:

The aim of the study was to determine the antibiotic resistance profile and characteristics of subtypes genes in Escherichia coli causing BSIs in Northern Vietnam.

METHODS:

The cross-sectional study was done in the period from December 2012 to June 2014 in two tertiary hospitals in Northern Vietnam. Tests were performed at the lab of the hospital.

RESULTS:

In 56 E. coli strains isolating 39.29 % produced ESBL. 100% of the isolates harbored blaTEM gene, but none of them had the blaPER gene. The prevalence of ESBL producers and ESBL non-producers in blaCTX-M gene was 81.82%, and 73.53%, in blaSHV gene was 18.18% and 35.29%. Sequencing results showed three blaTEM subtypes (blaTEM 1, 79, 82), four blaCTX-M subtypes (blaCTX-M-15, 73, 98, 161), and eight blaSHV subtypes (blaSHV 5, 7, 12, 15, 24, 33, 57, 77). Antibiotic resistance was higher in ampicillin (85.71%), trimethoprim/sulfamethoxazole (64.29%) and cephazolin (50%). Antibiotics were still highly susceptible including doripenem (96.43%), ertapenem (94.64%), amikacin (96.43%), and cefepime (89.29%).

CONCLUSION:

In Escherichia coli causing BSIs, antibiotic resistance was higher in ampicillin, trimethoprim/sulfamethoxazole and cephazolin. Antibiotics was highly susceptible including doripenem, ertapenem, amikacin, and cefepime.

In-hospital Medical Costs of Infections Caused by Carbapenem-resistant Klebsiella pneumoniae

Background

Carbapenem-resistant Klebsiella pneumoniae (CRKP) is a major health threat, but the economic impact of carbapenem resistance in K. pneumoniae infections remains largely uninvestigated.

Methods

We constructed a retrospective cohort of all patients hospitalized at West China Hospital in 2017 who had CRKP- or carbapenem-susceptible K. pneumoniae (CSKP)-positive clinical samples. Propensity score matching (PSM) was used to control the impact of potential confounding variables, including demographics, comorbidities, and treatment, and to observe the impact of factors other than length of stay (LOS). Patients who survived were subjected to subgroup analyses stratified by infection type.

Results

There were 267 patients with CRKP and 1328 with CSKP. Patients with CRKP had a higher crude in-hospital mortality rate (14.61% vs 5.65%, P < .05) and longer LOS (median, 31 vs 19 days; P < .05). PSM for demographics, comorbidities, and treatment generated 237 pairs. Patients with CRKP had higher medical costs than those with CSKP during the entire hospitalization (median, in US dollars, $22962 vs $11755, respectively; P < .05) and during the period after infection (median, $9215 vs $6904, respectively; P < .05). When LOS was matched, patients with CRKP still had high excess costs compared to those with CSKP (median, $22917 vs $13851, respectively, for the entire hospitalization, P < .05; $9101 vs $7001, respectively, after infection, P < .05). For infection type, the sample size generated sufficient power to compare only the patients with pneumonia. For surviving patients, high excess costs were observed in those with pneumonia caused by CRKP as compared to CSKP ($21890 vs $11698, respectively, for the entire hospitalization, P < .05; $9773 vs $5298, respectively, after infection, P < .05). Medicines other than antibacterial agents and nonmedicinal therapies contributed most (57.8%) of the excess costs associated with CRKP.

Conclusions

Carbapenem resistance in K. pneumoniae was associated with increased medical costs not accounted for by the cost of antimicrobial therapy.

Association between carbapenem-resistant Enterobacteriaceae and death: A systematic review and meta-analysis

BACKGROUND

Carbapenem-resistant Enterobacteriaceae (CRE) has emerged in health care facilities around the world. Several studies demonstrated data regarding clinical outcomes for CRE infections including death. This systematic review and meta-analysis summarized literature discussing association between CRE and mortality.

METHODS

A systematic literature review was performed by searching EMBASE, International Pharmaceutical Abstract databases, PubMed, and Scopus and to identify studies that assessed the association between CRE and death published from April 2012 to October 2017. A meta-analysis was performed using a random effect model. Heterogeneity was assessed using the I²-statistic.

RESULTS

Twenty-one studies were included in this meta-analysis. The underlying populations were moderately heterogeneous (I² = 60%; P = .01). Pooled risk estimates from 9 studies revealed a significant association between CRE and death (pooled-adjusted odds ratio: 2.85; 95% confidence interval: 1.88, 4.30). The unadjusted variable pooled from 18 studies demonstrated a significant association between CRE and death (pooled-unadjusted odds ratio: 3.73; 95% confidence interval: 2.02, 6.88).

DISCUSSION

The finding that CRE infection was positively associated with death agreed with the previous meta-analysis of studies published before April 2012.

CONCLUSIONS

This meta-analysis found that CRE was associated with increased risk of death. Our analysis implies a need for strict infection control measures.

Time series analysis of antibacterial usage and bacterial resistance in China: observations from a tertiary hospital from 2014 to 2018

Purpose

To describe trends and correlation between antibacterial exposure and bacterial resistance from hospitalized patients in a hospital in southern China.

Patients and methods

This study used hospital-wide data regarding antimicrobial resistance and consumption between January 1, 2014 and December 31, 2018. Antibacterial consumption was expressed as antimicrobial use density (AUD). The changes in trends and associations between antibacterial utilization and resistance were analyzed using linear regression and time series analysis.

Results

The total AUD of all antimicrobials decreased year by year (50.66 in 2014 vs 44.28 in 2018, P=0.03). The annual use of antimicrobials, such as penicillins, monobactams, aminoglycosides, macrolides, and lincosamides, significantly decreased (P<0.05), while the annual use of quinolones and tetracyclines significantly increased (P<0.05). Among the top ten isolated bacteria, antimicrobial resistance trends of Escherichia coli, Pseudomonas aeruginosa, Candida albicans, Staphylococcus aureus, and Staphylococcus epidermidis significantly decreased (P<0.05). Significant positive correlation was found between AUD of carbapenems and resistance rate of Acinetobacter baumannii to imipenem (β=32.87, P<0.01), as well as the correlation between AUD of quinolones and resistance rate of Enterococcus faecium to levofloxacin (β=104.40, P<0.01).

Conclusion

The consumption of antibiotics and antibiotic resistance has been significantly improved in this tertiary hospital. Additionally, the efforts of China’s antibiotic management may be suggested by the relationship between indicated antibiotic resistance and consumption. However, overall AUD levels and poor control of the use of antibiotics, such as quinolones and tetracyclines, still require strengthened management.

Economic burden of antibiotic resistance in ESKAPE organisms: a systematic review

Background

Antibiotic resistance (ABR) is one of the biggest threats to global health. Infections by ESKAPE (Enterococcus, S. aureus, K. pneumoniae, A. baumannii, P. aeruginosa, and E. coli) organisms are the leading cause of healthcare-acquired infections worldwide. ABR in ESKAPE organisms is usually associated with significant higher morbidity, mortality, as well as economic burden. Directing attention towards the ESKAPE organisms can help us to better combat the wide challenge of ABR, especially multi-drug resistance (MDR).

Objective

This study aims to systematically review and evaluate the evidence of the economic consequences of ABR or MDR ESKAPE organisms compared with susceptible cases or control patients without infection/colonization in order to determine the impact of ABR on economic burden.

Methods

Both English-language databases and Chinese-language databases up to 16 January, 2019 were searched to identify relevant studies assessing the economic burden of ABR. Studies reported hospital costs (charges) or antibiotic cost during the entire hospitalization and during the period before/after culture among patients with ABR or MDR ESKAPE organisms were included. The costs were converted into 2015 United States Dollars. Disagreements were resolved by a third reviewer.

Results

Of 13,693 studies identified, 83 eligible studies were included in our review. The most studied organism was S. aureus, followed by Enterococcus, A. baumannii, E. coli, E. coli or/and K. pneumoniae, P. aeruginosa, and K. pneumoniae. There were 71 studies on total hospital cost or charge, 12 on antibiotic cost, 11 on hospital cost or charge after culture, 4 on ICU cost, 2 on hospital cost or charge before culture, and 2 on total direct and indirect cost. In general, ABR or MDR ESKAPE organisms are significantly associated with higher economic burden than those with susceptible organisms or those without infection or colonization. Nonetheless, there were no differences in a few studies between the two groups on total hospital cost or charge (16 studies), antibiotic cost (one study), hospital cost before culture (one study), hospital cost after culture (one study). Even, one reported that costs associated with MSSA infection were higher than the costs for similar MRSA cases.

Conclusions

ABR in ESKAPE organisms is not always, but usually, associated with significantly higher economic burden. The results without significant differences may lack statistical power to detect a significant association. In addition, study design which controls for severity of illness and same empirical antibiotic therapy in the two groups would be expected to bias the study towards a similar, even negative result. The review also highlights key areas where further research is needed.

The Clinical and Economic Impact of Antibiotic Resistance in China: A Systematic Review and Meta-Analysis

Antibiotic resistance (ABR) is one of the biggest threats to global health, especially in China. This study aims to analyze the published literature on the clinical and economic impact of ABR or multi-drug resistant (MDR) bacteria compared to susceptible bacteria or non-infection, in mainland China. English and Chinese databases were searched to identify relevant studies evaluating mortality, hospital stay, and hospital costs of ABR. A meta-analysis of mortality was performed using a random effects model. The costs were converted into 2015 United States (US) dollars. Of 13,693 studies identified, 44 eligible studies were included. Twenty-nine investigated the impact of ABR on hospital mortality, 37 were focused on hospital stay, and 21 on hospital costs. Patients with ABR were associated with a greater risk of overall mortality compared to those with susceptibility or those without infection (odds ratio: 2.67 and 3.29, 95% confidence interval: 2.18–3.26 and 1.71–6.33, p < 0.001 and p < 0.001, respectively). The extra mean total hospital stay and total hospital cost were reported, ranging from 3 to 46 days, and from US$238 to US$16,496, respectively. Our study indicates that ABR is associated with significantly higher mortality. Moreover, ABR is not always, but usually, associated with significantly longer hospital stay and higher hospital costs.

Knowledge and practice of hand hygiene among hospitalised patients in a tertiary general hospital in China and their attitudes: a cross-sectional survey

OBJECTIVES

We aimed to gain a better understanding of patients' practice of hand hygiene (HH) and their knowledge and attitudes.

DESIGN

A cross-sectional survey.

SETTING

A 3500-bed university-affiliated medical hospital in China.

PARTICIPANTS

Inpatients and their family members or caregivers.

METHODS

An anonymous, self-reported questionnaire were used to collect data.

RESULTS

A total of 376 questionnaires were issued, and 310 respondents completed it. Of the 310 respondents, 47.4% had received HH education, and 13.5% had a completing understanding of HH. A majority of patients believed that handwashing was important for disease recovery, and that it could prevent infection development. A total of 62.3% of patients washed their hands <5 times a day and 49.0% spent <1 min every time. With regards to the seven steps of handwashing, 96.45% of the respondents adhered to the first step (washing the palms), but only 20.6% adhered to the fifth step (thumbs) and 17.7% to the sixth step (fingertips). Most respondents washed their hands only when visibly dirty. Few patients washed their hands before drinking fluids, and before and after interacting with visitors. HH compliance was lower among intensive care unit patients than medical patients.

CONCLUSIONS

In conclusion, this study demonstrated that patients had a positive attitude towards HH. However, their levels of knowledge and practice were unsatisfactory. A systematical education about patientHH is needed in future to correct this knowledge and behaviour.

The Attributable Direct Medical Cost of Healthcare Associated Infection Caused by Multidrug Resistance Organisms in 68 Hospitals of China

Healthcare associated infection (HAI) is known to increase the economic burden of patients while the medical cost due to MDRO HAI is even higher. Three hundred eighty-one multidrug resistance organisms (MDROs) healthcare associated infection (HAI) case-patients and three hundred eighty-one matched control-patients were identified between January and December in 2015. The average total hospitalization medical cost of the case group was $6127.65 and that of the control group was $2274.02. The difference between the case group and the control group was statistically significant (t = 21.07; P < 0.01). The attributable cost of MDRO HAI was $3853.63. The direct medical costs due to different MDRO infections were different. The increased medical costs of CR-AB, CR-KP, and CR-PA were significantly higher than that of MRSA, MRSE, ESBL E. coli, and ESBL Kp (P < 0. 05). Among the subitem expenses, the drug cost increased the most (the average cost was $1457.72), followed by the treatment fee and test fee; the differences were statistically significant (P < 0.01).

Assessing Molecular Epidemiology of Carbapenem-resistant Klebsiella pneumoniae (CR-KP) with MLST and MALDI-TOF in Central China

Carbapenem-resistant K. pneumoniae (CR-KP) posts significant public health challenge worldwide. The aim of this study is to assess clinical characteristics and molecular epidemiology of CR-KP infections with Multilocus sequence typing (MLST) and Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF) in Central China. A total of 71 CR-KP isolates were recovered in a teaching hospital from October 2014 to December 2015. Among all CR-KP isolates, 73.2% (52) produced K. pneumoniae carbapenemases-2 (KPC-2). Eighteen ST types were identified by MLST, among these ST types, forty-seven isolates belonged to ST11 type, which was the predominant outbreak strain in China, and most ST11 isolates produced KPC-2. Eleven mass spectrometry (MS) types were identified by MALDI-TOF MS analysis, 53.5% isolates were MS4 and MS6, which matched with ST11 in MLST analysis. CR-KP infection was associated with increased medical cost and longer hospitalization. Therefore, we found that KPC-2-producing ST11 (MS4 and MS6) CR-KP isolates were the predominant clone identified by MLST and MALDI-TOF, and CR-KP infection was associated with increased hospital costs and longer hospitalization.

Prevalence of pks gene cluster and characteristics of Klebsiella pneumoniae-induced bloodstream infections

BACKGROUND

The emerging pks-positive (pks⁺ ) strains have aroused great public concern recently. Colibactin, encoded by pks gene cluster, has been reported to be involved in DNA damage and increased virulence. Little is known about its prevalence among Klebsiella pneumoniae-induced bloodstream infections (BSIs). Therefore, the aim of this study was to investigate the prevalence of pks gene cluster, and molecular and clinical characteristics of K pneumoniae-induced BSIs.

METHODS

A total of 190 non-duplicate K pneumoniae bloodstream isolates were collected at a university hospital in China from March 2016 to March 2018. Molecular characteristics including capsular types, virulence, and pks genes were detected by polymerase chain reaction (PCR). Clinical characteristics and antimicrobial susceptibility were also investigated.

RESULTS

Overall, 21.6% (41/190) of K pneumoniae bloodstream isolates were hypervirulent K pneumoniae(hvKP). The prevalence of pks gene cluster was 26.8% (51/190). The positive rates of K1, K57, and genes associated with hypervirulence, that is, rmpA, wcaG, mrkD, allS, ybtS, kfu,and iucA, were significantly higher in the pks⁺ isolates than the pks-negative (pks^- ) isolates (P < 0.05), while the pks⁺ isolates were significantly less resistant to 11 antimicrobial agents than the pks^- isolates. Multivariate analysis showed diabetes mellitus, and K1 and K20 capsular types as independent risk factors for pks⁺ K pneumoniaebloodstream infections.

CONCLUSIONS

The pks⁺ K pneumoniae was prevalent in individuals with bloodstream infections in mainland China. The high rates of hypervirulent determinants among pks⁺ K pneumoniaerevealed the potential pathogenicity of this emerging gene cluster. Diabetes mellitus, and K1 and K20 capsular types were identified as independent risk factors associated with pks⁺ K pneumoniaebloodstream infections. This study highlights the significance of clinical awareness and epidemic surveillance of pks⁺ strains.

Risk Factors for Development of Carbapenem Resistance Among Gram-Negative Rods

Background

Infections due to carbapenem-resistant Gram-negative rods (CR-GNR) are increasing in frequency and result in high morbidity and mortality. Appropriate initial antibiotic therapy is necessary to reduce adverse consequences and shorten length of stay.

Methods

To determine risk factors for recovery on culture of CR-GNR, cases were retrospectively analyzed at a major academic hospital system from 2011 to 2016. Ertapenem resistance (ER-GNR) and antipseudomonal (nonertapenem) carbapenem resistance (ACR-GNR) patterns were analyzed separately. A total of 30951 GNR isolates from 12370 patients were analyzed, 563 of which were ER and 1307 of which were ACR.

Results

In multivariate analysis, risk factors for ER-GNR were renal disease, admission from another health care facility, ventilation at any point before culture during the index hospitalization, receipt of any carbapenem in the prior 30 days, and receipt of any anti-methicillin-resistant Staphylococcus aureus (anti-MRSA) agent in the prior 30 days (c-statistic, 0.74). Risk factors for ACR-GNR were male sex, admission from another health care facility, ventilation at any point before culture during the index hospitalization, receipt of any carbapenem in the prior 30 days, and receipt of any anti-MRSA agent in the prior 30 days (c-statistic, 0.76).

Conclusions

A straightforward scoring system derived from these models can be applied by providers to guide empiric antimicrobial therapy; it outperformed use of a standard hospital antibiogram in predicting infections with ER-GNR and ACR-GNR.

High excess costs of infections caused by carbapenem-resistant Gram-negative bacilli in an endemic region

The financial burden of antibiotic resistance is a serious concern worldwide. The aim of this study was to describe the excess costs associated with pneumonia, bacteraemia, surgical site infections and intra-abdominal infections (IAIs) caused by carbapenem-resistant Gram-negative bacilli in Medellín, Colombia, an endemic region for carbapenem resistance. A cohort study was conducted in a third-level hospital from 2014-2015. All patients with carbapenem-resistant and carbapenem-susceptible Gram-negative bacterial infections were included. Pharmaceutical, medical and surgical direct costs were described from the health system perspective. Excess costs were estimated from generalised linear models with gamma distribution and adjusted for variables that could affect the cost difference. A total of 218 patients were enrolled, 48 (22.0%) of whom were infected with carbapenem-resistant bacteria. IAIs were the most frequent. The adjusted total excess cost was US$3966 [95% confidence interval (CI) US$1684-6249], with a significantly higher cost for antibiotics, followed by hospital stay, laboratory tests and interconsultation. The highest excess cost was attributed mainly to the use of broad-spectrum antibiotics (US$1827, 95% CI US$1005-2648), followed by length of hospital stay (US$1015, 95% CI US$163-1867). The results of this study highlight the importance of designing antimicrobial stewardship programmes and infection control strategies in endemic regions to reduce the financial threat of antimicrobial resistance to health systems.

Factors associated with acquisition of carbapenem-resistant Enterobacteriaceae

Objective:

to identify possible risk factors for acquisition of Enterobacterial strains with a marker for resistance to carbapenems.

Methods:

exploratory case-control study performed in hospital settings. The study sample consisted of patients with biological specimens that tested positive for carbapenem-resistant Enterobacteriaceae (cases), with the disk diffusion test and Etest, and controls with biological samples testing negative for carbapenem-resistant Enterobacteriaceae. In all, 65 patients were included: 13 (20%) cases and 52 (80%) controls.

Results:

the microorganisms isolated were Serratia marcescens (6), Klebsiella pneumoniae (4), and Enterobacter cloacae (3). Univariate analysis revealed that length of hospitalization prior to sample collection (p=0.002) and having a surgical procedure (p=0.006) were statistically significant. In the multivariable logistic regression model, both were still significant, with odds ratios of 0.93 (p = 0.009; 95% CI: 0.89 to 0.98) for length of hospitalization prior to sample collection, and 9.28 (p = 0.05; 95% CI: 1.01 to 85.14) for having a surgical procedure.

Conclusion:

shorter hospitalization times and increased surveillance of patients undergoing surgery could play a decisive role in reducing the spread of carbapenem-resistant microorganisms in hospital settings.