Seasonal and temperature-associated increases in gram-negative bacterial bloodstream infections among hospitalized patients

The effect of climatic and seasonal factors on the microbial keratitis profile

PURPOSE

To compare retrospective data on microbial keratitis (MK) from two different climatic regions in Turkey over 11 years.

STUDY DESIGN

Retrospective cohort.

METHODS

This retrospective cohort study included patients diagnosed with presumed MK at two referral centers. Center A was located in the subtropical region of Turkey, whereas Center B was located in a continental temperate climate zone. Clinical and laboratory data were also recorded. The results were evaluated for seasonal variations.

RESULTS

This study included data from 665 patients with presumed MK (351 and 314 patients from centers A and B, respectively). The most common predisposing factors were ocular trauma in Center A, prior ocular surgery, and systemic disease in Center B. Severe keratitis was related to prior ocular surgery, presence of systemic disease, and fungal infection at presentation. The culture positivity rate was higher in spring and lower in summer at both centers. Gram-positive bacteria were the most commonly isolated bacteria in both centers in all seasons. The fungal and mixed keratitis ratios were higher in Center A than in Center B. In Center A, filamentous fungi were common pathogens that were found year-round, and peaks were observed in July and October.

CONCLUSION

The results of this study show that climatic and seasonal factors may affect the microbial profile of keratitis. Fungal keratitis appears to be a climatic disease. Understanding the regional profile of MK can aid clinicians in their disease management.

Does climate impact inflatable penile prosthesis infection (IPP) risk? Assessment of temperature and dew point on IPP infections

BACKGROUND

Variations in climate have been associated with a greater risk of surgical site infections, urinary tract infections, and changes in the skin microbiome; however, limited data exist on the impact of climate on inflatable penile prosthesis (IPP) infections.

AIM

We sought to evaluate the impact of climate on the risk of IPP infections in a large international, multicenter cohort.

METHODS

We performed a multi-institutional, retrospective study of patients undergoing IPP surgery. We then evaluated whether the month or season, during which surgery was performed, affected device infections. Implant infections were defined as infections requiring device explantation. A univariate logistic regression analysis was undertaken.

OUTCOMES

Our primary outcome was implant infection.

RESULTS

A total of 5289 patients with a mean age of 62.2 ± 10.8 years received IPP placement. There was a fairly even distribution of implants performed in each season. A total of 103 (1.9%) infections were recorded. There were 32 (31.1%) IPP infections in patients who underwent surgery in the summer, followed by 28 (27.2%) in the winter, 26 (25.2%) in the spring, and 17 (16.5%) in the fall. No statistically significant differences were recorded in terms of season (P = .19) and month (P = .29). The mean daily temperature (P = .43), dew point (P = .43), and humidity (P = .92) at the time of IPP placement was not associated with infection.

CLINICAL IMPLICATIONS

These findings provide reassurance to prosthetic urologists that infection reduction strategies do not need to be tailored to local climate.

STRENGTHS AND LIMITATIONS

Climate data were not directly recorded for each hospital, but rather based on the monthly averages in the city where the surgery was performed.

CONCLUSION

The climate at time of IPP placement and time of year of surgery is not associated with IPP infection risk.

Climate warming, environmental degradation and pollution as drivers of antibiotic resistance

Antibiotic resistance is a major challenge to public health, but human-caused environmental changes have not been widely recognized as its drivers. Here, we provide a comprehensive overview of the relationships between environmental degradation and antibiotic resistance, demonstrating that the former can potentially fuel the latter with significant public health outcomes. We describe that (i) global warming favors horizontal gene transfer, bacterial infections, the spread of drug-resistant pathogens due to water scarcity, and the release of resistance genes with wastewater; (ii) pesticide and metal pollution act as co-selectors of antibiotic resistance mechanisms; (iii) microplastics create conditions promoting and spreading antibiotic resistance and resistant bacteria; (iv) changes in land use, deforestation, and environmental pollution reduce microbial diversity, a natural barrier to antibiotic resistance spread. We argue that management of antibiotic resistance must integrate environmental goals, including mitigation of further increases in the Earth's surface temperature, better qualitative and quantitative protection of water resources, strengthening of sewage infrastructure and improving wastewater treatment, counteracting the microbial diversity loss, reduction of pesticide and metal emissions, and plastic use, and improving waste recycling. These actions should be accompanied by restricting antibiotic use only to clinically justified situations, developing novel treatments, and promoting prophylaxis. It is pivotal for health authorities and the medical community to adopt the protection of environmental quality as a part of public health measures, also in the context of antibiotic resistance management.

14-Year Epidemiologic study of Pseudomonas aeruginosa bloodstream infection incidence and resistance in the Veterans Health Administration system, 2009-2022

Background

Multidrug resistant Pseudomonas aeruginosa (PA) represents a serious threat to hospitalized patients. Characterizing the incidence of PA infection and degree of resistance can inform empiric treatment and preventative measures.

Objectives

We sought to describe trends in incidence and resistance characteristics of PA bloodstream infections (BSI) observed within the Veterans Health Administration (VHA) system and identify factors contributing to higher observed mortality within this population.

Methods

We characterized demographic and clinical features of unique patients among the VHA population presenting with their first episode of PA-BSI between 2009 and 2022 and summarized trends related to mortality and resistance phenotype based on year and geographical location. We additionally used logistic regression analysis to identify predictors of 30-day mortality among this cohort.

Results

We identified 8039 PA-BSIs during the study period, 32.7% of which were hospital onset. Annual PA-BSI cases decreased by 35.8%, and resistance among all antimicrobial classes decreased during the study period, while the proportion of patients receiving early active treatment based on susceptibility testing results increased. Average 30-day mortality rate was 23.3%. Higher Charlson Comorbidity Index, higher mAPACHE score, VHA facility complexity 1b and hospital-onset cases were associated with higher mortality, and early active treatment was associated with lower mortality.

Conclusions

PA-BSI resistance decreased across the VHA system during the study period. Further investigation of antimicrobial stewardship measures possibly contributing to the observed decreased resistance in this cohort and identification of measures to improve on the high mortality associated with PA-BSI in the VHA population is warranted.

Assessing the potential for improved predictive capacity of antimicrobial resistance in outpatient Staphylococcus aureus isolates using seasonal and spatial antibiograms

BACKGROUND

While the use of cumulative susceptibility reports, antibiograms, is recommended for improved empiric therapy and antibiotic stewardship, the predictive ability of antibiograms has not been well-studied. While enhanced antibiograms have been shown to better capture variation in susceptibility profiles by characteristics such as infection site or patient age, the potential for seasonal or spatial variation in susceptibility has not been assessed as important in predicting likelihood of susceptibility.

METHODS

Utilizing Staphylococcus aureus isolates obtained in outpatient settings from a nationwide provider of care, the Veterans Health Administration, and a local provider of care, the University of Iowa Hospitals and Clinics, standard, seasonal and spatial antibiograms were created for five commonly used antibiotic classes: cephalosporins, clindamycin, macrolides, tetracycline, trimethoprim/sulfamethoxazole.

RESULTS

A total of 338,681 S. aureus isolates obtained in VHA outpatient settings from 2010 to 2019 and 6,817 isolates obtained in UIHC outpatient settings from 2014 to 2019 were used to generate and test antibiograms. Logistic regression modeling determined the capacity of these antibiograms to predict isolate resistance to each antibiotic class. All models had low predictive capacity, with areas under the curve of < 0.7.

CONCLUSIONS

Standard antibiograms are poor in predicting S. aureus susceptibility to antibiotics often chosen by clinicians, and seasonal and spatial antibiograms do not provide an improved tool in anticipating non-susceptibility. These findings suggest that further refinements to antibiograms may be necessary to improve their utility in informing choice of effective antibiotic therapy.

Risk factors for bacteremia and mortality due to multidrug-resistant Acinetobacter baumannii: a retrospective study

This research aimed to determine the relationships between the risk factors for nosocomial multidrug-resistant Acinetobacter baumannii (MDRAB) bacteremia and associated mortality. We analyzed 144 patients treated for A. baumannii bacteremia, including 120 patients with MDRAB bacteremia, from March 2015 to March 2020, in this retrospective study. The overall bacteremia-related mortality rate was 48.6%. The mortality rates were 25.0% and 53.3% for non-MDRAB and MDRAB bacteremia, respectively. Risk factors for the development of MDRAB bacteremia were prior use of cephalosporins [odds ratio (OR): 8.62; P < .001], carbapenems (OR: 15.04; P < .001), or quinolones (OR: 5.02; P = .040); indwelling urinary catheters (OR: 21.38; P < .001); and respiratory tract as the source of bacteremia (OR: 75.33; P < .001). Patients with elective surgeries were inclined to develop non-MDRAB bacteremia (OR: 0.45; P = .029). High scores in the Acute Physiology and Chronic Health Evaluation II (OR: 1.321; P < .001) and Sequential Organ Failure Assessment (OR: 1.326; P < .001) were risk factors for mortality from MDRAB infection. In summary, higher mortality rates occur in patients with MDRAB bacteremia, and risk factors include prior use of cephalosporins, carbapenems, or quinolones. Urinary catheters and the respiratory tract as sources of the infection increase the risk of MDRAB bacteremia.

Heat stress enhances the occurrence of erythromycin resistance of Enterococcus isolates in mice feces

Heat stress is a common environmental factor in livestock breeding that has been shown to impact the development of antibiotic resistance within the gut microbiota of both human and animals. However, studies investigating the effect of temperature on antibiotic resistance in Enterococcus isolates remain limited. In this study, specific pathogen free (SPF) mice were divided into a control group maintained at normal temperature and an experimental group subjected to daily 1-h heat stress at 38 °C, respectively. Gene expression analysis was conducted to evaluate the activation of heat shock responsive genes in the liver of mice. Additionally, the antibiotic-resistant profile and antibiotic resistant genes (ARGs) in fecal samples from mice were analyzed. The results showed an upregulation of heat-inducible proteins HSP27, HSP70 and HSP90 following heat stress exposure, indicating successful induction of cellular stress within the mice. Furthermore, heat stress resulted in an increase in the proportion of erythromycin-resistant Enterococcus isolates, escalating from 0 % to 0.23 % over a 30-day duration of heat stress. The resistance of Enterococcus isolates to erythromycin also had a 128-fold increase in minimum inhibitory concentration (MIC) within the heated-stressed group compared to the control group. Additionally, a 2∼8-fold rise in chloramphenicol MIC was observed among these erythromycin-resistant Enterococcus isolates. The acquisition of ermB genes was predominantly responsible for mediating the erythromycin resistance in these Enterococcus isolates. Moreover, the abundance of macrolide, lincosamide and streptogramin (MLS) resistant-related genes in the fecal samples from the heat-stressed group exhibited a significant elevation compared to the control group, primarily driven by changes in bacterial community composition, especially Enterococcaceae and Planococcaceae, and the transfer of mobile genetic elements (MGEs), particularly insertion elements. Collectively, these results highlight the role of environmental heat stress in promoting antibiotic resistance in Enterococcus isolates and partly explain the increasing prevalence of erythromycin-resistant Enterococcus isolates observed among animals in recent years.

Nationwide epidemiology and clinical practice patterns of pediatric urinary tract infections: application of multivariate time-series clustering

BACKGROUND

The nationwide epidemiology and clinical practice patterns for younger children hospitalized with urinary tract infections (UTIs) were unclear.

METHODS

We conducted a retrospective observational study consisting of 32,653 children aged < 36 months who were hospitalized with UTIs from 856 medical facilities during fiscal years 2011-2018 using a nationally representative inpatient database in Japan. We investigated the epidemiology of UTIs and changes in clinical practice patterns (e.g., antibiotic use) over 8 years. A machine learning algorithm of multivariate time-series clustering with dynamic time warping was used to classify the hospitals based on antibiotic use for UTIs.

RESULTS

We observed marked male predominance among children aged < 6 months, slight female predominance among children aged > 12 months, and summer seasonality among children hospitalized with UTIs. Most physicians selected intravenous second- or third-generation cephalosporins as the empiric therapy for treating UTIs, which was switched to oral antibiotics during hospitalizations for 80% of inpatients. Whereas total antibiotic use was constant over the 8 years, broad-spectrum antibiotic use decreased gradually from 5.4 in 2011 to 2.5 days of therapy per 100 patient-days in 2018. The time-series clustering distinctively classified 5 clusters of hospitals based on antibiotic use patterns and identified hospital clusters that preferred to use broad-spectrum antibiotics (e.g., antipseudomonal penicillin and carbapenem).

CONCLUSIONS

Our study provided novel insight into the epidemiology and practice patterns for pediatric UTIs. Time-series clustering can be useful to identify the hospitals with aberrant practice patterns to further promote antimicrobial stewardship. A higher resolution version of the Graphical abstract is available as Supplementary information.

Distribution Patterns of Pathogens Causing Lower Respiratory Tract Infection Based on Metagenomic Next-Generation Sequencing

Purpose

Lower Respiratory Tract Infection (LRTI) is a leading cause of morbidity and mortality worldwide. In this study, the distribution patterns of causative pathogens in LRTI were evaluated within a city-level hospital by combining conventional microbiological tests (CMT) with metagenomic next-generation sequencing (mNGS).

Patients and Methods

This retrospective cohort study involved 160 patients suspected of having LRTI in a single center. Specimens, including bronchoalveolar lavage fluid (BALF), blood, tissue, sputum, and pus were utilized to identify pathogens. The seasonal prevalence of pathogens and co-pathogens involved in multiple infections was analyzed.

Results

A total of 137 patients with 156 samples were included in this study. Pseudomonas aeruginosa, Corynebacterium striatum, Klebsiella pneumoniae, Candida, and human herpesvirus were the top prevalent pathogens. We observed seasonal dynamic variation in the top prevalent bacteria (Pseudomonas aeruginosa and Klebsiella pneumoniae) and herpesvirus (Epstein-Barr virus and Human herpesvirus-7). The majority of patients had single bacterial infections, followed by instances of bacterial-viral co-infections, as well as mixed infections involving bacteria, fungi, and viruses. Notably, the spectrum of co-infecting pathogens was broader among the elderly population, and positive Spearman correlations were observed among these co-infecting pathogens.

Conclusion

Co-infections were prevalent among patients with LRTI, and the pathogens displayed distinct seasonal distribution patterns. The findings underscored the significance of comprehending pathogen distribution and epidemic patterns, which can serve as a basis for early etiological identification.

Emerging Antimicrobial Resistance

The burden of emerging antimicrobial resistance (AMR) in the United States is significant and even greater worldwide. Mitigation efforts have decreased the incidence and deaths from antimicrobial-resistant organisms in the United States. Yet more than 2.8 million antimicrobial-resistant infections occur every year and more than 35,000 patients die as a result. Infection prevention and control, data tracking, antimicrobial stewardship, vaccines, therapeutics, diagnostics, and sanitation are all required to decrease AMR threats. In 2019, in the second version of the Centers for Disease Control and Prevention (CDC) report on antibiotic-resistant threats, the agency categorized AMR threats as urgent, serious, concerning, or to be watched. This review will discuss the following aspects of each bacterium in the CDC report: estimated numbers of cases and deaths, identify the better known and impactful mechanisms of resistance, diagnostic testing and its limitations, and current and possible future therapies. This review also presents anatomical pathology case examples that highlight the altered morphology of antibiotic partially treated bacteria in tissues.

Acinetobacter baumannii Bloodstream Infections: A Nationwide Study in Israel

Acinetobacter baumannii (Ab) bloodstream infections (BSIs) are a major public health concern and associated with high mortality. We describe the nationwide incidence, antimicrobial resistance, and mortality of Ab-BSI in Israel using laboratory-based BSI surveillance data from January 2018 to December 2019. During the study period, there were 971 Ab-BSI events (508 in 2018 and 463 in 2019), with an average annual incidence of 8.08/100,000 population. The median age of patients was 72 (IQR 62-83), and 56.4% were males. Two-thirds of Ab-BSI events were hospital-onset (HO), with median day of onset 16 (IQR 9-30). HO-BSI incidence was 0.62/10,000 patient-days (rate per 10,000 patient-days: 2.78, 1.17, and 0.2 for intensive care, medical, and surgical wards, respectively). Carbapenem susceptibility was 23.4%; 41.4% and 14.9% in community and HO events, respectively. The 14-day, 30-day, and 1-year mortality were 51.2%, 59.3%, and 81.4%, respectively. Carbapenem-resistant Ab-BSI were associated with a significantly higher 14-day, 30-day, and 1-year mortality (p < 0.001 for all). In the multivariable model, age (aHR 1.02) and carbapenem resistance (aHR 3.21) were independent predictors of 30-day mortality. In conclusion, Ab-BSIs pose a significant burden with high mortality, especially associated with antimicrobial resistance. Attention should be focused on prevention and improving treatment.

The association between ambient temperature and antimicrobial resistance of Klebsiella pneumoniae in China: a difference-in-differences analysis

Introduction

Antimicrobial resistance (AMR) of Klebsiella pneumoniae (K. pneumoniae) poses a significant global public health threat and is responsible for a high prevalence of infections and mortality. However, knowledge about how ambient temperature influences the AMR of K. pneumoniae is limited in the context of global warming.

Methods

AMR data of 31 Chinese provinces was collected from the China Antimicrobial Resistance Surveillance System (CARSS) between 2014 and 2020. Socioeconomic and meteorological data were collected from the China Statistical Yearbook during the same period. A modified difference-in-differences (DID) approach was applied to estimate the association between ambient temperature and third-generation cephalosporin-resistant K. pneumoniae (3GCRKP) and carbapenem-resistant K. pneumoniae (CRKP). Furthermore, moderating effects of socioeconomic factors were also evaluated.

Results

Every 1°C increase in annual average temperature was associated with a 4.7% (relative risk (RR):1.047, 95% confidence intervals (CI): 1.031-1.082) increase in the detection rate of 3GCRKP, and a 10.7% (RR:1.107, 95% CI: 1.011-1.211) increase in the detection rate of CRKP. The relationships between ambient temperature and 3GCRKP and CRKP were found to be moderated by socioeconomic status (GDP per capita, income per capita, and consumption per capita; the interaction p-values <0.05), where higher economic status was found to strengthen the effects of temperature on the detection rate of 3GCRKP and weaken the effects on the detection rate of CRKP.

Discussion

Ambient temperature was found to be positively associated with AMR of K. pneumoniae, and this association was moderated by socioeconomic status. Policymakers should consider the impact of global warming and high temperatures on the spread of 3GCRKP and CRKP when developing strategies for the containment of AMR.

Late summer is a risk factor for periprosthetic joint infection after total joint arthroplasty: A retrospective cohort study

To explore whether season is a risk factor of periprosthetic joint infection (PJI) after total joint arthroplasty (TJA) and explain it with the theory of traditional Chinese medicine. This was a retrospective cohort study. Only patients who suffered from PJI within 1 month after TJA were included in the study. Occurrence of PJI was the outcome of this study. Chi-squared test and t test was used to assess differences for baseline characteristics. Chi-square test was used to analyze whether season was related to the occurrence of PJI. Logistic regression was used to evaluate the association between season and occurrence of PJI. The incidence of PJI in summer is significantly higher than that in winter, whether after total knee arthroplasty (Chi-square value = 6.455, P = .011) or total hip arthroplasty (Chi-square value = 6.141, P = .013). Summer was an independent risk factor for PJI (OR = 4.373, 95% confidence interval = 1.899-10.673, P = .004). To be more exact, compared to nonlate summer (19.51%), and PJI is mainly concentrated in late summer (80.49%). Late summer was an independent risk factor of PJI after TJA. The infection rate of PJI after TJA in late summer is higher than other seasons. A more thorough preoperative disinfection procedure is needed in late summer.

How Antimicrobial Resistance Is Linked to Climate Change: An Overview of Two Intertwined Global Challenges

Globally, antimicrobial resistance (AMR) and climate change (CC) are two of the top health emergencies, and can be considered as two interlinked public health priorities. The complex commonalities between AMR and CC should be deeply investigated in a One Health perspective. Here, we provided an overview of the current knowledge about the relationship between AMR and CC. Overall, the studies included pointed out the need for applying a systemic approach to planetary health. Firstly, CC increasingly brings humans and animals into contact, leading to outbreaks of zoonotic and vector-borne diseases with pandemic potential. Although it is well-established that antimicrobial use in human, animal and environmental sectors is one of the main drivers of AMR, the COVID-19 pandemic is exacerbating the current scenario, by influencing the use of antibiotics, personal protective equipment, and biocides. This also results in higher concentrations of contaminants (e.g., microplastics) in natural water bodies, which cannot be completely removed from wastewater treatment plants, and which could sustain the AMR spread. Our overview underlined the lack of studies on the direct relationship between AMR and CC, and encouraged further research to investigate the multiple aspects involved, and its effect on human health.

How Does Hospital Microbiota Contribute to Healthcare-Associated Infections?

Healthcare-associated infections (HAIs) are still a global public health concern, associated with high mortality and increased by the phenomenon of antimicrobial resistance. Causative agents of HAIs are commonly found in the hospital environment and are monitored in epidemiological surveillance programs; however, the hospital environment is a potential reservoir for pathogenic microbial strains where microorganisms may persist on medical equipment surfaces, on the environment surrounding patients, and on corporal surfaces of patients and healthcare workers (HCWs). The characterization of hospital microbiota may provide knowledge regarding the relatedness between commensal and pathogenic microorganisms, their role in HAIs development, and the environmental conditions that favor its proliferation. This information may contribute to the effective control of the dissemination of pathogens and to improve infection control programs. In this review, we describe evidence of the contribution of hospital microbiota to HAI development and the role of environmental factors, antimicrobial resistance, and virulence factors of the microbial community in persistence on hospital surfaces.

Air temperature and incidence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae

BACKGROUND

Higher outdoor temperature may be related to an increase in antibiotic resistant bacteria. We investigated the association between local outdoor air temperature and the incidence of extended-spectrum betalactamase (ESBL)-producing Enterobacteriaceae (ESBL-PE) correcting for known drivers of antibiotic resistance.

METHODS

We performed a time-series regression study using prospectively collected weekly surveillance data on all ESBL-PE isolated from in- and outpatients of the University Hospital Basel, a tertiary care center in Switzerland, between 01/2008-12/2017. Temperature was measured hourly at the meteorological institute of the University Basel next to our institution over this time period. A time-series approach using a Poisson regression model and different lag terms for delayed exposure effects was performed to assess associations between minimal, mean and maximal weekly temperature and the number of ESBL-PE recovered.

RESULTS

Over 10 years, recovery of ESBL-PE increased (annual incidence rate ratio [IRR] 1.14, 95%CI 1.13-1.16), while mean weekly temperature measures remained stable. In multivariable analyses, increasing temperature was associated with higher recovery rates of ESBL-PE after three to four weeks, correcting for potential confounders, such as the number of admissions, proportion of long-term nursing facility- and ICU-admissions, age, Charlson comorbidity index and consumption of antimicrobials (IRRs per 10 °C ranging from 1.14 to 1.22, 95%CIs 1.07-1.33). These trends remained when analyzing correlations between temperature with the proportion of extended spectrum cephalosporin resistance of all recovered Enterobacteriaceae.

CONCLUSIONS

Higher outdoor temperature may be associated with an increase of ESBL-PE-incidence, independent of important confounders, such as antimicrobial consumption and thus should be considered for future resistance-trajectories.

Microbiological characteristics and risk factors on prognosis associated with Acinetobacter baumannii bacteremia in general hospital: A single-center retrospective study

OBJECTIVE

Acinetobacter baumannii is one of the most important pathogenic bacteria causing nosocomial infections and has a high mortality rate. Assessment of the microbiological characteristics and risk factors on prognosis associated with A.baumannii is essential. In this study, we aimed to investigate the clinical characteristics and prognostic risk factors of patients with A.baumannii bacteremia.

PATIENTS AND METHODS

This study retrospectively analyzed the antibiotic resistance of pathogens based on the clinical data of A.baumannii bacteremia patients presented in a tertiary teaching hospital from 2017 to 2022. Logistic regression and decision tree identified the prognostic risk factors for patients with baumannemia. Kaplan-Meier method was used for survival analysis between MDR and Non-MDR groups. The area under receiver-operating characteristic curve (ROC curve) was used to compare the predictive value of the APACHE II score and Sequential Organ Failure Assessment (SOFA) score.

RESULTS

A total of 110 patients with positive A. Baumannii blood cultures were included. Most of the patients were from intensive care unit (ICU) wards. The drug sensitivity results showed that the resistance rate of A. baumannii to colistin was the lowest (1.1%), followed by tigecycline (3.6%).The survival time of MDR group was significantly shorter than that of Non-MDR group. Multivariate analysis showed that, APACHE II score and SOFA score were independent risk factors affecting the prognosis of 28 days of A.baumannii bacteremia. And both scores displayed excellent AUROCs (SOFA: 0.909, APACHE II: 0.895 in predicting 28-day mortality). The two scoring systems were highly correlated and predicted no significant difference (r 2 = 0.4410, P < 0.001). We found that SOFA > 7 and APACHE II > 21 are associated with significantly higher mortality rates.

CONCLUSION

A.baumannii bacteremia have the highest incidence in the ICU, with high drug resistance and mortality rates. The survival time of patients with MDR A. Baumannii bacteremia was significantly shortened. The SOFA score and APACHE II score can reflect the severity of A.baumannii bacteremia patients and evaluate the 28-day prognosis. In addition, for the convenience of calculation, the SOFA score may be more clinically useful than the APACHE II score in predicting the mortality rate of A.baumannii bacteremia.

Surveillance of bacterial load and multi-drug resistant bacteria on bedsheets in a primary health care unit

A patient is in close proximity to different types of textiles in hospital environment, which contribute to the transfer of drug-resistant bacteria in healthcare settings. This study was undertaken to estimate the temporal variations in bacterial load on bedsheets in a primary healthcare unit in Delhi. Data were collected for a period of 7 months. Antibiotic susceptibility testing of isolates was performed. The mean count of Acinetobacter spp. was highest (2.10 × 10² CFU/cm²), and Klebsiella spp. showed the least mean count (7.5 × 10¹ CFU/cm²). The mean bacterial count over the period showed maximum bacterial load for most microbial groups in June, and minimum in November. Enterococcus faecalis and Streptococcus spp. were highly resistant to different antibiotics, while Acinetobacter spp. and Group A Streptococcus showed the least resistance toward the antibiotics tested. Bacterial counts on bedsheets were found to vary with the time of the year, indicating that environmental factors affect bacterial load.

Association of PM2.5 and its components with lengths of hospital stay for hand foot and mouth disease in children

Hand foot and mouth disease (HFMD) is a widespread public health concern but the studies on air pollution and the lengths of hospital stay (LOS) of HFMD are scarce nevertheless. Clinic demographic features among 5135 hospitalized HFMD cases in Nanjing, China, had been characterized from 2012 to 2017. Then, we had analyzed the association between PM2.5 short-term exposure as well as its components (OM, BC, SO42-, NH4+, NIT, SOIL, and SS) and the LOS of HFMD. Among these cases that were involved in our study, 98.62% were aged 0-6 years old, and 3772 (73.46%) were hospitalized within 1 week or less. The LOS of HFMD patients was different in various age ranges, illness onset years, and illness onset seasons (P < 0.01). For per IQR increase in PM2.5 concentrations, LOS of HFMD increased by 0.52 (0.33, 0.71), 0.50 (95% CI, 0.31-0.69) and 0.46 (95% CI, 0.28-0.65) day in adjusted models at lag 3 days, lag 7 days, and lag 14 days, respectively. In addition, per IQR increase of BC, SO42-, NH4+, NIT, and SOIL was also significantly associated with the LOS of HFMD. Our findings corroborated that short-term PM2.5 exposure was associated with the increased LOS of HFMD, and its components (BC, SO42-, NH4+, NIT, and SOIL) of PM2.5 might play a key role in prolonged LOS of HFMD.

Bacteria isolated from equine uteri in The United Arab Emirates: A retrospective study

The United Arab Emirates (UAE) presents a unique environment in which to breed horses with a non-physiological breeding season coupled with high temperatures and humidity for much of the year. This study aimed to describe bacterial isolates from the uteri of mares in the UAE and compare them to those reported elsewhere in the world. Bacterial antibiotic resistance was also analysed to give a starting point for future monitoring. A total of 2022 swabs taken over 5 breeding seasons from the endometrium (n = 1350) or from uterine lavages (n = 672) were submitted for microbiological culture and antibiotic sensitivity testing. At 48h post inoculation 616/2022 (30.5%) of cultures showed microbial growth from which 690 isolates were identified. Most positive plates (548/616; 89%) grew one isolate; 68 cultures had two (62/616; 10.1%) or three (6/616; 1%) isolates. The most frequently isolated bacteria were β-haemolytic Streptococcus (36.5%; 252/690), E. coli (10.6%; 73/690), P. aeruginosa (10.1%; 70/690), K. pneumoniae (8.8%; 61/690) and Aeromonas hydrophila (4.1%; 28/690). The lowest level of antibiotic susceptibility for all isolates was shown by trimethoprim-sulphonamide (36.4%; 198/544), with amikacin showing the highest (76.1%; 271/356). A significant decrease in susceptibility to doxycycline, enrofloxacin and erythromycin, but a significant increase for amoxicillin with clavulanic acid, was seen for β-haemolytic Streptococcus. Decreasing susceptibility of trimethoprim-sulphonamide between two time periods was seen for E. coli. Compared to other studies UAE-based mares had a high incidence of P. aeruginosa and K. pneumoniae isolates, whereas E. coli was represented far less frequently as an isolate.

Influence of climatic factors on singlecenter peritoneal dialysisassociated peritonitis

OBJECTIVES

Peritoneal dialysis associated peritonitis (PDAP), one of the most common complications of peritoneal dialysis, is generally believed as an important factor causing technique failure and increasing hospital admission and fatality rate in peritoneal dialysis patients. Moreover, the prevention and treatment for PDAP have always been considered as an important link in clinical peritoneal dialysis. Thus, the study is performed to investigate the impact of climate factors on the incidence and prognosis of single-center PDAP in Hunan Province, China, which can provide a clinical basis for the prevention and treatment strategy for PDAP.

METHODS

A total of 885 patients on peritoneal dialysis, who were admitted to Department of Nephrology, Third Xiangya Hospital, Central South University (hereinafter referred to as our hospital) from January 1, 2009 to December 31, 2017, were enrolled as the subjects, and the demographic and clinical data for patients with PDAP from 2009 to 2017 as well as climate data of Hunan Province were collected.The patients were divided into different season groups, and the general information and clinical biochemical indicators in different season groups were compared. The incidence, the proportion of pathogenic bacteria and the clinical outcome of PDAP in the different season groups were compared. The risk factors of PDAP in different season groups were analyzed by using a multivariate logistic regression. Pearson's correlation analysis was used to analyze the correlations of the overall incidence of PDAP with the monthly mean temperature and the monthly mean humidity.

RESULTS

There were 448 cases of PDAP that occurred in the peritoneal dialysis center of our hospital from 2009 to 2017 (9 years), the incidence was 0.17 time/patient-years. The incidence of overall PDAP (0.246 time/patient-years) and the incidence of Gram-negative (G-) bacterial PDAP (0.048 time/patient-years) in the summer group were the highest compared with the other season groups, with significant difference (all P<0.05). Compared with the spring group (OR=0.321, 95% CI 0.144-0.713; P<0.01), the autumn group (OR=0.419, 95% CI 0.187, 0.937; P<0.05) and the winter group (OR=0.326; 95% CI 0.139, 0.763; P<0.05), the probability suffered from PDAP in the summer group were higher. The patients with low body mass index (BMI) in the spring group were more likely to suffer from PDAP in the summer group. The overall incidences of PDAP (r=0.258, P<0.05) and G- bacterial PDAP (r=0.278, P<0.05) were significantly positively correlated with the monthly mean temperature in Hunan Province, which was not correlated with the monthly average humidity. The overall cure rate of PDAP was 83%, and there was no difference in the treatment outcomes among the different season groups (all P>0.05).

CONCLUSIONS

The climate factors in Hunan, China have a significant impact on the incidence of PDAP in peritoneal dialysis patients in our hospital. Summer is the peak of PDAP, especially G- bacterial PDAP. Intestinal dysfunction and low BMI are risk factors for the onset of PDAP in summer. High temperature rather than high humidity is correlated with increased incidence of overall PDAP, especially for G- bacterial PDAP.

Gram-negative central line-associated bloodstream infection incidence peak during the summer: a national seasonality cohort study

Central line-associated bloodstream infections (CLABSI) cause increased morbidity, mortality, and hospital costs that are partially preventable. The phenomenon of seasonality among CLABSI rates has not been fully elucidated, but has implications for accurate surveillance and infection prevention trials. Longitudinal dynamic cohort of hospitals participating in hospital-wide and intensive care unit bloodstream infection surveillance for at least one full year over 2000 to 2014. Mixed-effects negative binomial regression analysis calculated the peak-to-low ratio between months as an adjusted CLABSI incidence rate ratio (IRR) with 95% confidence intervals (CI). Multivariate regression models examined the associations between CLABSI pathogens and ambient temperature and relative humidity. The study population included 104 hospital sites comprising 11,239 CLABSI. Regression analysis identified a hospital-wide increase in total CLABSI during July-August, with a higher gram-negative peak-to-low incidence rate ratio (IRR 2.52 [95% CI 1.92-3.30], p < 0.001) compared to gram-positive bacteria (IRR 1.29 [95% CI 1.11-1.48], p < 0.001). Subgroup analysis replicated this trend for CLABSI diagnosed in the intensive care unit. Only gram-negative CLABSI rates were associated with increased temperature (IRR + 30.3% per 5 °C increase [95% CI 17.3-43.6], p < 0.001) and humidity (IRR + 22.9% per 10% increase [95% CI 7.7-38.3), p < 0.001). The incidence and proportion of gram-negative CLABSI approximately doubled during the summer periods. Ambient temperature and humidity were associated with increases of hospital-acquired gram-negative infections. CLABSI surveillance, preventive intervention trials and epidemiological studies should consider seasonal variation and climatological factors when preparing study designs or interpreting their results.

A bundle of infection control measures reduces post-operative sternal wound infection due to Staphylococcus aureus but not Gram-negative bacteria: a retrospective analysis of 6,903 patient episodes

BACKGROUND

Prevention of cardiac surgical site infection has largely focused on reducing infection due to Staphylococcus aureus although other bacteria also play an important role in this complication.

AIM

We assess the impact of an evolving infection control program on the incidence of sternal wound infection (SWI) and the changing incidence of non-staphylococcal infections.

METHODS

We conducted a retrospective cohort study of all patients who underwent primary sternotomy at a single UK centre between September 2010 and May 2018. Data were collated from two-years prior to the stepwise introduction of a broad-ranging infection control program, including S. aureus decolonisation.

FINDINGS

6,903 primary sternotomies were performed of which 2.6% (n=178) were complicated by SWI. Gram-negative bacteria (GNB) and S. aureus were most commonly identified as causative pathogens (45.5% and 30.3% respectively). Following program introduction there was a reduction in the rate of SWI from 3.9 to 1.8 cases/100 patients/month. This was mainly due to a sustained reduction in S. aureus infected cases with no discernible impact on GNB. Multivariable logistic regression analysis identified coronary artery bypass grafting, procedural urgency and procedures performed in the 3rd quarter as independent risk factors for post-operative infection.

CONCLUSION

A multifaceted infection control program was successful at reducing the rate of SWI primarily due to a reduction in S. aureus infections. GNB also play an important role in SWI and traditional preventative measures fail to address these. Future intervention and impact assessments should consider Gram negative infection when measuring effectiveness.

Ambient temperature and hospital admissions for acute cholecystitis: a nationwide inpatient database study in Japan

BACKGROUND

The incidence of acute cholecystitis has a seasonal peak in summer. However, the reason for such seasonality remains unclear. This retrospective cohort study was performed to examine the association between ambient temperature and acute cholecystitis.

METHODS

We identified admissions for acute cholecystitis from January 2011 to December 2017 from a nationwide inpatient database in Japan. We performed a Poisson regression analysis to investigate the association between ambient temperature and admission for acute cholecystitis with adjustment for relative humidity, national holidays, day of the week, and year. We accounted for clustering of the outcome within prefectures using a generalized estimating equation.

RESULTS

We analyzed 601 665 admissions for acute cholecystitis. With an ambient temperature of 5.0 °C-9.9 °C as a reference, Poisson regression showed that the number of admissions increased significantly with increasing temperature (highest above 30 °C; relative risk, 1.35; 95% confidence interval, 1.34-1.37). An ambient temperature of <5.0 °C was also associated with higher admission for acute cholecystitis than an ambient temperature of 5.0 °C-9.9 °C (relative risk, 1.23; 95% confidence interval, 1.21-1.25).

CONCLUSION

The present nationwide Japanese inpatient database study showed that high temperature (≥10.0 °C) and low temperature (<5.0 °C) were associated with increased admission for acute cholecystitis.

Antimicrobial Resistance in Rivers: A Review of the Genes Detected and New Challenges

River ecosystems are very important parts of the water cycle and an excellent habitat, food, and drinking water source for many organisms, including humans. Antibiotics are emerging contaminants which can enter rivers from various sources. Several antibiotics and their related antibiotic resistance genes (ARGs) have been detected in these ecosystems by various research programs and could constitute a substantial problem. The presence of antibiotics and other resistance cofactors can boost the development of ARGs in the chromosomes or mobile genetic elements of natural bacteria in rivers. The ARGs in environmental bacteria can also be transferred to clinically important pathogens. However, antibiotics and their resistance genes are both not currently monitored by national or international authorities responsible for controlling the quality of water bodies. For example, they are not included in the contaminant list in the European Water Framework Directive or in the US list of Water-Quality Benchmarks for Contaminants. Although ARGs are naturally present in the environment, very few studies have focused on non-impacted rivers to assess the background ARG levels in rivers, which could provide some useful indications for future environmental regulation and legislation. The present study reviews the antibiotics and associated ARGs most commonly measured and detected in rivers, including the primary analysis tools used for their assessment. In addition, other factors that could enhance antibiotic resistance, such as the effects of chemical mixtures, the effects of climate change, and the potential effects of the coronavirus disease 2019 pandemic, are discussed. Environ Toxicol Chem 2022;41:687-714. © 2022 SETAC.

Influence of seasonal variability on orthopedic surgical outcomes in pediatric patients: a review of surgical site infections

Surgical site infections (SSIs) are challenging, with highly variable reported rates for children undergoing orthopedic surgery. It has been shown in adults that there is seasonal variability in SSI rates, with peak incidences in the summer months. We reviewed 8766 pediatric orthopedic procedures completed at a quaternary children's hospital over a 43-month period. Data collected included: age, sex, BMI, season of procedure, cultures, and other variables related to risks and treatment of SSIs. Of 4875 male and 3891 female pediatric patients undergoing orthopedic procedures, 47 patients (0.54%) with an average age of 11.3 years (range: 2.0-18.6) developed an SSI. Average time between surgery and diagnosis was 27.7 ± 19.8 days. Sixty percent of SSI patients had a BMI in the 85th percentile or above, and 49% of SSI patients had a BMI above the 95th percentile. Thirty-eight patients had positive cultures, with most common infections being due to methicillin-sensitive Staphylococcus aureus in 11 (29%) cases, polymicrobial in 9 (24%), pseudomonas in 5 (13%), and coagulase-negative Staphylococcus in 5 (13%). SSI rate in winter (0.18%) was significantly lower than in autumn (0.77%, P = 0.006) and summer (0.69%, P = 0.02). The difference did not reach statistical significance from the infection rate in spring (0.53%, P = 0.06). Twenty-nine (62%) SSI cases were considered elective in nature, and the other 18 (38%) cases were for acute traumatic injuries. There is a significantly higher SSI rate in summer and autumn than winter for pediatric patients undergoing orthopedic surgeries. Most patients with SSIs were overweight or obese.

A prospective multicentre screening study on multidrug-resistant organisms in intensive care units in the Dutch-German cross-border region, 2017 to 2018: the importance of healthcare structures

Background

Antimicrobial resistance poses a risk for healthcare, both in the community and hospitals. The spread of multidrug-resistant organisms (MDROs) occurs mostly on a local and regional level, following movement of patients, but also occurs across national borders.

Aim

The aim of this observational study was to determine the prevalence of MDROs in a European cross-border region to understand differences and improve infection prevention based on real-time routine data and workflows.

Methods

Between September 2017 and June 2018, 23 hospitals in the Dutch (NL)–German (DE) cross-border region (BR) participated in the study. During 8 consecutive weeks, patients were screened upon admission to intensive care units (ICUs) for nasal carriage of meticillin-resistant Staphylococcus aureus (MRSA) and rectal carriage of vancomycin-resistant Enterococcus faecium/E. faecalis (VRE), third-generation cephalosporin-resistant Enterobacteriaceae (3GCRE) and carbapenem-resistant Enterobacteriaceae (CRE). All samples were processed in the associated laboratories.

Results

A total of 3,365 patients were screened (median age: 68 years (IQR: 57–77); male/female ratio: 59.7/40.3; NL-BR: n = 1,202; DE-BR: n = 2,163). Median screening compliance was 60.4% (NL-BR: 56.9%; DE-BR: 62.9%). MDRO prevalence was higher in DE-BR than in NL-BR, namely 1.7% vs 0.6% for MRSA (p = 0.006), 2.7% vs 0.1% for VRE (p < 0.001) and 6.6% vs 3.6% for 3GCRE (p < 0.001), whereas CRE prevalence was comparable (0.2% in DE-BR vs 0.0% in NL-BR ICUs).

Conclusions

This first prospective multicentre screening study in a European cross-border region shows high heterogenicity in MDRO carriage prevalence in NL-BR and DE-BR ICUs. This indicates that the prevalence is probably influenced by the different healthcare structures.

Seasonal Relationship of Prosthetic Joint Infection Following Primary Total Joint Arthroplasty in a Subtropical Climate: A Retrospective Cohort Study

Background: One devastating complication that leads to increased morbidity and mortality rates after total joint arthroplasty (TJA) is prosthetic joint infection (PJI). Evidence on the relationship between climate, seasonality, and the risk of developing a PJI conflicts. The objective of this study was to investigate the effect of seasonality and climate change on the rate of PJI. Methods: We retrospectively reviewed data of patients undergoing primary TJA at a single institution in a subtropical climate location from 2012 to 2015. Only primary TJAs with a minimum of 1-year follow-up were included in the analysis. Patient demographics and complications were extracted from the database, and monthly average temperature, humidity, and precipitation were obtained. The primary endpoint was PJI requiring revision surgery within 1 year of the index procedure. Results: A total of 3,696 TJAs met the inclusion criteria, with 28 PJIs requiring a second surgery within 1 year (0.76%). We found no significant difference in age, sex, or body mass index in patients who developed a PJI (P=0.9450, P=0.0989, and P=0.7942, respectively). The highest incidence of PJI occurred in August (1.49%), but the incidence of PJI by month was not significant (P=0.8996). July and August were the hottest (91 °F) and most humid (79%) months, and June had the most average precipitation (8.06 inches); however, these climate variables were not significant contributors to the incidence of PJI (P=0.4996, P=0.4999, and P=0.4957, respectively). Conclusion: We found no association between temperature, humidity, and development of PJI in a North American subtropical climate. Surgeons can use this information to counsel patients when planning for TJA.

Seasonal Variation and Severity of Acute Abdomen in Japan: A Nine-Year Retrospective Analysis

The seasonal incidence of acute abdomens, such as appendicitis, is reportedly more common in summer but is reported less frequently in Asia. Additionally, seasonal variations in the severity of acute abdomens have been evaluated insufficiently. This study evaluated the seasonal variations in the incidence and severity of acute abdomens in Japan. This retrospective observational study used a multicenter database containing data from 42 acute hospitals in Japan. We included all patients diagnosed with acute appendicitis, diverticulitis, cholecystitis, and cholangitis between January 2011 and December 2019. Baseline patient data included admission date, sequential organ failure assessment score, presence of sepsis, and disseminated intravascular coagulation. We enrolled 24,708 patients with acute abdomen. Seasonal admissions for all four acute abdominal diseases were the highest in summer [acute appendicitis, (OR = 1.35; 95% CI = 1.28-1.43); diverticulitis, (OR = 1.23; 95% CI = 1.16-1.31; cholecystitis (OR = 1.23; 95% CI = 1.11-1.36); and cholangitis (OR = 1.23; 95% CI = 1.12-1.36)]. The proportion of patients with sepsis and disseminated intravascular coagulation as well as the total SOFA score for each disease, did not differ significantly across seasons. Seasonal variations in disease severity were not observed.

Trends in rates of incidence, fatality and antimicrobial resistance among isolates of Pseudomonas spp. causing bloodstream infections in England between 2009 and 2018. Results from a national voluntary surveillance scheme

BACKGROUND

This article provides baseline epidemiological data on Pseudomonas spp. BSI in England for comparison against future findings from the mandatory surveillance of this infection, beginning April 2017.

AIM

We report trends in incidence, thirty-day all-cause mortality and antimicrobial resistance of Pseudomonas spp. BSI in England between 2009 and 2018.

METHODS

Patients and antibiotic susceptibility data were obtained from Public Health England's voluntary surveillance database. Mortality information was linked from a central data repository.

FINDINGS

There were 39,322 Pseudomonas spp. BSI between 2009 and 2018. Regression analysis found that the incidence rate was greater by 18.5% (p< 0.01) in the summer (June to August) and by 16.2% (p< 0.01) in the autumn (September to November), compared with spring (March to May). The thirty-day all-cause case fatality rate (CFR) declined from 32.0% in 2009 to 23.8% in 2018 (p<0.001). In 2018, resistance to the key antibiotic agents were; ciprofloxacin (7.5%), ceftazidime (6.8%), piperacillin/tazobactam (6.6%), carbapenems (5.5%) and gentamicin (4.1%). The mortality rate per 100,000 population was greater by 25.7% (p< 0.01) in autumn and 23.6% (p< 0.01) in w. inter (December to February).

CONCLUSION

Despite an overall increase in the number of cases in recent years, the percentage of patients dying (from all causes) after a Pseudomonas spp. BSI has been declining. However, compared with other prominent healthcare-associated BSI, the CFRs are high, and it underscores the need for continued surveillance to support targeted infection control and prevention strategies, provide further understanding of patients' risks groups, and perhaps inform antimicrobial practices.

Seasonality and weather dependance of Acinetobacter baumannii complex bloodstream infections in different climates in Brazil

Recent studies report seasonality in healthcare-associated infections, especially those caused by Acinetobacter baumannii complex. We conducted an ecologic study aimed at analyzing the impact of seasons, weather parameters and climate control on the incidence and carbapenem-resistance in A. baumannii complex bloodstream infections (ABBSI) in hospitals from regions with different climates in Brazil. We studied monthly incidence rates (years 2006–2015) of ABBSI from hospitals in cities from different macro-regions in Brazil: Fortaleza (Ceará State, Northeast region), Goiânia (Goiás State, Middle-west) and Botucatu (São Paulo State, Southeast). Box-Jenkins models were fitted to assess seasonality, and the impact of weather parameters was analyzed in Poisson Regression models. Separate analyses were performed for carbapenem-resistant versus carbapenem-susceptible isolates, as well as for infections occurring in climate-controlled intensive care units (ICUs) versus non-climate-controlled wards. Seasonality was identified for ABSSI ICUs in the Hospitals from Botucatu and Goiânia. In the Botucatu hospital, where there was overall seasonality for both resistance groups, as well as for wards without climate control. In that hospital, the overall incidence was associated with higher temperature (incidence rate ratio for each Celsius degree, 1.05; 95% Confidence Interval, 1.01–1.09; P = 0.006). Weather parameters were not associated with ABBSI in the hospitals from Goiânia and Fortaleza. In conclusion, seasonality was found in the hospitals with higher ABBSI incidence and located in regions with greater thermal amplitude. Strict temperature control may be a tool for prevention of A. baumanii infections in healthcare settings.

Bacterial colonization dynamics and antibiotic resistance gene dissemination in the hospital environment after first patient occupancy: a longitudinal metagenetic study

BACKGROUND

Humans spend the bulk of their time in indoor environments. This space is shared with an indoor ecosystem of microorganisms, which are in continuous exchange with the human inhabitants. In the particular case of hospitals, the environmental microorganisms may influence patient recovery and outcome. An understanding of the bacterial community structure in the hospital environment is pivotal for the prevention of hospital-acquired infections and the dissemination of antibiotic resistance genes. In this study, we performed a longitudinal metagenetic approach in a newly opened ward at the Charité Hospital (Berlin) to characterize the dynamics of the bacterial colonization process in the hospital environment after first patient occupancy.

RESULTS

The sequencing data showed a site-specific taxonomic succession, which led to stable community structures after only a few weeks. This data was further supported by network analysis and beta-diversity metrics. Furthermore, the fast colonization process was characterized by a significant increase of the bacterial biomass and its alpha-diversity. The compositional dynamics could be linked to the exchange with the patient microbiota. Over a time course of 30 weeks, we did not detect a rise of pathogenic bacteria in the hospital environment, but a significant increase of antibiotic resistance determinants on the hospital floor.

CONCLUSIONS

The results presented in this study provide new insights into different aspects of the environmental microbiome in the clinical setting, and will help to adopt infection control strategies in hospitals and health care-related buildings. Video Abstract.

Seasonal variation of hospital-acquired bloodstream infections: A national cohort study

BACKGROUND

Hospital-acquired bloodstream infections (HABSIs) cause increased morbidity, mortality, and hospital costs that are partially preventable. HABSI seasonality has been described for gram-negative bacteria but has not been stratified per infection origin.

OBJECTIVE

To assess seasonality among all types of HABSIs and their associations with climate.

METHODS

Hospitals performing surveillance for at least 1 full calendar year between 2000 and 2014 were included. Mixed-effects negative binomial regression analysis calculated the peak-to-low monthly ratio as an adjusted HABSI incidence rate ratio (IRR) with 95% confidence intervals (CIs). Another regression model examined associations between HABSI rates and climate variables. These analyses were stratified by microorganism and infectious origin.

RESULTS

The study population included 104 hospitals comprising 44,111 HABSIs. Regression analysis identified an incidence rate ratio (IRR) peak in August for gram-negative HABSIs (IRR, 1.59; 95% CI, 1.49-1.71), CLABSIs (IRR, 1.49; 95% CI, 1.30-1.70), and urinary tract HABSI (IRR, 1.52; 95% CI, 1.34-1.74). The gram-negative incidence increased by 13.1% (95% CI, 9.9%-16.4%) for every 5°C increase in temperature. Seasonality was most present among E. coli, K. pneumoniae, E. cloacae, and the nonfermenters. Gram-positive and pulmonary HABSIs did not demonstrate seasonal variation.

CONCLUSIONS

Seasonality with summer spikes occurred among gram-negative bacteria, CLABSIs, and urinary tract HABSIs. Higher ambient temperature was associated with gram-negative HABSI rates. The preventable causative factors for seasonality, such as the nurse-to-patient ratio, indoor room temperature or device-utilization, need to be examined to assess areas for improving patient safety.

Iron Fortification and Supplementation: Fighting Anemia of Chronic Diseases or Fueling Obesity?

The significant worldwide increase in obesity has become a major health problem. Excess adiposity has been extensively linked to inflammation. Recently, studies have shown that dietary intake and microbiota dysbiosis can affect the health of the gut and lead to low-grade systemic inflammation, worsening the state of obesity and further exacerbating inflammation. The latter is shown to decrease iron status and potentially increase the risk of anemia by inhibiting iron absorption. Hence, anemia of obesity is independent of iron intake and does not properly respond to increased iron ingestion. Therefore, countries with a high rate of obesity should assess the health impact of fortification and supplementation with iron due to their potential drawbacks. This review tries to elucidate the relation between inflammation and iron status to better understand the etiology of anemia of obesity and chronic diseases and wisely design any dietary or medical interventions for the management of anemia and/or obesity.

Bacterial Contamination in Health Care Centers: Differences between Urban and Rural Settings

This study aims to assess the airborne bioburden of rural and urban Portuguese Primary Health Care Centers (PHCC) using active and passive sampling methods and identify the potential differences in airborne microbiota between both environments. The highest total aerobic mesophilic bacterial load in indoor air were found in the Vaccination Room (448 CFU.m−3) in the Rural PHCC and in the Waiting Room (420 CFU.m−3) for Urban PHCC. The total coliforms contamination level in indoor air was detected only in the Cleaning Supplies Room (4 CFU.m−3) in the Urban PHCC. The most frequent bacteria genera identified was Micrococcus (21% Rural PHCC; 31% Urban PHCC). The surface samples showed a highest total aerobic mesophilic bacterial contamination in the Treatment Room (86 × 103 CFU.m−2) from the Rural PHCC and in the Front Office (200 × 103 CFU.m−2) from the Urban PHCC. The electrostatic dust cloth (EDC) samples showed a highest bacterial load in the Urban PHCC. Total aerobic mesophilic bacterial load in settled dust and in the Heating, Ventilating and Air Conditioning (HVAC) filter samples in the Urban PHCC (8 CFU.g−1 and 6 × 103 CFU.m−2) presented higher values compared with the Rural PHCC (1 CFU.g−1 and 2.5 × 103 CFU.m−2). Urban PHCC presented higher bacterial airborne contamination compared with the Rural PHCC for the majority of sampling sites, and when compared with the indoor air quality (IAQ) Portuguese legislation it was the Rural PHCC in two sampling places who did not comply with the established criteria.

Atypical Microbiological Feature of Infectious Endophthalmitis on Jeju Island: A 10-Year Study at a Single Tertiary Referral Center

Background

To analyze the microbiological causes of infectious endophthalmitis on an isolated island over ten years.

Methods

A retrospective review of the medical records of 49 eyes clinically diagnosed with infectious endophthalmitis between January 2009 and December 2018 was done. The subjects were recruited from a single tertiary referral center on Jeju Island. The baseline characteristics of all subjects were investigated, and a culture examination was performed. The isolated pathogens were analyzed to determine how their microbiological features differed from those in regions with different geographical conditions.

Results

Of the 49 eyes, causative microorganisms were identified in 27 eyes (55.1%). Bacteria were found in 24 cases and fungi in 3 cases. Among the exogenous causes, Staphylococcus species (Staphylococcus aureus, S. epidermidis, and S. hominis) were the most common pathogens (7 cases). Achromobacter xylosoxidans was the second most common causative pathogen (4 cases) followed by Moraxella species (3 cases). The most frequent endogenous origin was due to Klebsiella pneumoniae (6 cases). The subjects were divided into two groups according to the treatment results and analyzed for predisposing factors related to visual outcomes. The presence of diabetes mellitus (P = 0.038) and initial visual acuity (P ≤ 0.001) were significant predisposing factors for visual outcomes.

Conclusion

The causative microorganisms of endogenous endophthalmitis on Jeju Island were not different from those reported previously. However, isolated exogenous microorganisms were different from those reported in other studies from inland areas. A high incidence and atypical clinical features of Achromobacter xylosoxidans and Moraxella in exogenous endophthalmitis were observed, reflective of the distinct climatic features of Jeju Island: high humidity and temperature. Therefore, considering the causative microorganisms of exogenous endophthalmitis, it may be assumed that the causative microorganisms of exogenous endophthalmitis and its clinical manifestations differ according to the region.

Bacteriological Profile and Antimicrobial Susceptibility Patterns of Bloodstream Infection at Kigali University Teaching Hospital

BACKGROUND

Worldwide, bacterial bloodstream infections (BSIs) constitute an important cause of morbidity and mortality in clinical settings. Due to the limited laboratory facilities in sub-Saharan Africa, poor diagnosis of BSIs results in poor clinical outcomes and leads to a risk of antimicrobial resistance. The present work was carried out to describe the microbiological features of BSIs using the data collected from Centre Hospitalier Universitaire de Kigali (CHUK).

METHODS

A retrospective study was carried out at CHUK. The blood culture results of 2,910 cases - from adults, children and infants - were reviewed in the Microbiology service from October 2017 to October 2018. The following variables were considered: age, gender, admitting department, blood culture results, and antimicrobials sensitivity test results. Data were entered and analyzed using Microsoft Excel 2013.

RESULTS

Twelve percent (341/2,910) of blood culture results reviewed were positive with 108 (31.7%) Gram positive bacteria and 233 (68.3%) Gram negative bacteria. The most prevalent pathogens were Klebsiella pneumoniae 108 (31.7%) and Staphylococcus aureus 100 (29.3%). This study revealed a high resistance to commonly prescribed antibiotics such as penicillin, trimethoprim sulfamethoxazole, and Ampicillin with 91.8, 83.3, and 81.8% of resistance, respectively. However, bacteria were sensitive to imipenem and vancomycin with 98.1 and 94.3% of sensitivity, respectively. The pediatrics and neonatology departments showed a high number of positive culture with 97/341 (28.4%), and 93/341 (27%) respectively. The overall prevalence of multidrug resistance was 77.1%.

CONCLUSION

The prevalence of bacterial pathogens in BSIs was found to be high. The antibiotic resistance to the commonly used antibiotics was high. Appropriate treatment of BSIs should be based on the current knowledge of bacterial resistance pattern. This study will help in formulating management of diagnostic guidelines and antibiotic policy.

Climate change and antibiotic resistance: a deadly combination

Climate change is driven primarily by humanity's use of fossil fuels and the resultant greenhouse gases from their combustion. The effects of climate change on human health are myriad and becomingly increasingly severe as the pace of climate change accelerates. One relatively underreported intersection between health and climate change is that of infections, particularly antibiotic-resistant infections. In this perspective review, the aspects of climate change that have already, will, and could possibly impact the proliferation and dissemination of antibiotic resistance are discussed.

Seasonal variation in acute post-cataract surgery endophthalmitis incidences in South Korea

PURPOSE

Previous studies have reported conflicting results on the influence of seasons on post-cataract surgery endophthalmitis incidences. This study aimed to investigate the seasonality associated with the incidence of postoperative endophthalmitis, and to evaluate its association with climate variables in South Korea.

SETTING

South Korea.

DESIGN

Retrospective cohort study.

METHODS

The postoperative endophthalmitis incidences were identified using the Health Insurance Review and Assessment Service claim data from July 2014 to June 2017. The monthly climate data were obtained from the Korea Meteorological Administration. The incidences of endophthalmitis were analyzed by the month of the year, and by the season. The association between postoperative endophthalmitis and the climatic variables, including mean temperature, relative humidity, precipitation, and hours of sunshine, was investigated.

RESULTS

The incidences were the highest in July, and they were the most prevalent during the summer months, although fewer cataract surgeries were performed in the summer months than during the rest of the year. The postoperative endophthalmitis incidences tended to increase with increasing relative humidity and increasing precipitation.

CONCLUSIONS

The incidences of post-cataract surgery endophthalmitis peaked during the hot and humid months. Understanding the seasonal and climatic influences on postoperative infection might help in risk stratification and outcome improvisation after the cataract surgery is performed.

The Association of Climatic Factors with Rates of Surgical Site Infections: 17 Years' Data From Hospital Infection Surveillance

BACKGROUND

Surgical site infections (SSI) are among the most common healthcare- associated infections. The aim of our explorative study was to determine how selected climatic factors are associated with SSI rates.

METHODS

SSI rates were calculated for operative procedures included in the surgi- cal site infection surveillance component (OP-KISS) of the German Nosocomial Infection Surveillance System (Krankenhaus-Infektions-Surveillance-System, KISS) during the years from 2000 to 2016. The surgeries were associated with department-related and patient-related data. Data of the German Meteorological Service (Deutscher Wetterdienst, DWD), including outdoor temperature and rainfall, were used to analyze the association between climatic factors and rates of SSI. Analyses focused on temperature which showed strong correlations with other climatic parameters. A descriptive analysis was performed, using the chi-squared test. Adjusted odds ratios (AORs) were calculated for SSI rates in relation to tem- perature, using a multivariable logistic regression model.

RESULTS

For the altogether 2 004 793 included operative procedures, 32 118 SSIs were documented. Temperatures ≥ 20 °C were associated with a significantly higher occurrence of SSI compared to temperatures <5 °C (AOR: 1.13; 95% confi- dence intervals [1.06; 1.20]). This increase was found for gram-positive pathogens (AOR: 1.13 [1.03; 1.23]) and, even more pronounced, for gram-negative pathogens (AOR: 1.20 [1.07; 1.35]). The association was strongest for superficial SSI caused by gram-negative pathogens (AOR: 1.38 [1.16; 1.64]).

CONCLUSION

An association between climatic factors and SSI rates was demon- strated. The predicted rise in global temperatures by up to 4 °C by the end of this century compared to preindustrial levels may increase the likelihood of SSI and should be taken into consideration in future preventive strategies.

Summer, sun and sepsis-The influence of outside temperature on nosocomial bloodstream infections: A cohort study and review of the literature

BACKGROUND

The incidence of many infections is seasonal e.g. surgical site infections, urinary tract infection and bloodstream infections. We questioned whether there is seasonal variation even in climate-controlled hospitalized patients, and analyzed the influence of climate parameters on nosocomial bloodstream infections.

METHODS AND FINDINGS

The retrospective cohort study is based on two databases: The German national surveillance system for nosocomial infections in intensive care units (ICU-KISS) from 2001 to 2015 and aggregated monthly climate data. Primary bloodstream infection (PBSI) is defined as a positive blood culture with one (or more) pathogen(s) which are not related to an infection on another site and which were not present at admission. Monthly infection data were matched with postal code, calendar month and corresponding monthly climate and weather data. All analyses were exploratory in nature. 1,196 ICUs reported data on PBSI to KISS. The ICUs were located in 779 hospitals and in 728 different postal codes in Germany. The majority of the 19,194 PBSI were caused by gram-positive bacteria. In total, the incidence density of BSI was 17% (IRR 1.168, 95%CI 1.076-1.268) higher in months with high temperatures (≥20°C) compared to months with low temperatures (<5°C). The effect was most prominent for gram-negatives; more than one third (38%) higher followed by gram-positives with 13%. Fungi reached their highest IRR at moderately warm temperatures between 15-20°C. At such temperatures fungi showed an increase of 33% compared to temperatures below 5°C. PBSI spiked in summer with a peak in July and August. PBSI differed by pathogen: The majority of bacteria increased with rising temperatures. Enterococci showed no seasonality. S. pneumoniae reached a peak in winter time. The association of the occurrence of PBSI and temperatures ≥20°C was stronger when the mean monthly temperature in the month prior to the occurrence of BSI was considered instead of the temperature in the month of the occurrence of BSI. High average temperatures ≥20°C increased the risk of the development of a PBSI by 16% compared with low temperatures <5°C.

CONCLUSIONS

Most nosocomial infections are endogenous in nature; the microbiome plays a crucial role in host health. If gut and skin microbiome varies with season, environmental parameters will contribute to the observed incidence patterns. Similarly, the impact of global warming on both local weather patterns and extreme weather events may influence the acquisition of pathogens. A better understanding of the etiology of these infections is needed to provide guidance for future infection control strategies.

Low-temperature laminar flow ward for the treatment of multidrug resistance Acinetobacter baumannii pneumonia

This study was designed to investigate the effect of low-temperature laminar flow ward (LTLFW) on the Acinetobacter baumannii pneumonia (MDR-ABP) in neurosurgical intensive care unit (NICU) patients. We evaluated whether patients in a LTLFW had significantly improved clinical outcomes as compared to those in nonconstant-temperature NICU (room temperature). The association of temperature with the prevalence of ABP and A. baumannii isolates (ABI) found in NICU patients was specifically investigated. In vitro microbiological experiments were conducted to measure the proliferation, antibiotic sensitivity, and genomic profiles of A. baumannii (AB) that grew in variable temperatures. MDR-ABP patients in LTLFW had significantly improved outcomes than those in the room temperature NICU. In addition, the numbers of ABI were positively associated with mean ambient outdoor temperatures (P = 0.002), with the incidence of ABP and average numbers of ABI among NICU patients being substantially lower in the winter as compared to other seasons. However, there were no significant seasonal variations in the other strains of the top five bacteria. Consistent with these clinical observations, AB growing at 20°C and 25°C had significantly reduced viability and antibiotic resistance compared to those growing at 35°C. The expression of genes related to AB survival ability, drug resistance, and virulence also differed between AB growing at 20°C and those at 35°C. LTLFW is effective in promoting the recovery of MDR-ABP patients because low temperatures reduced the density and virulence of AB and enhanced the efficacy of antibiotics, likely at the genetic level.

A systematic review of the global seasonality of infections caused by Acinetobacter species in hospitalized patients

BACKGROUND

Acinetobacter is a leading multidrug resistant pathogen in hospitals worldwide that has been seen to exhibit periodic surges during summer months. However, winter peaks and lack of seasonality have also been noted.

OBJECTIVES

To systematically collate and examine the evidence describing seasonal patterns in the incidence of Acinetobacter infection in hospitalized patients.

DATA SOURCES

MEDLINE/Ovid, EMBASE, Scopus and Web of Science.

STUDY ELIGIBILITY CRITERIA

Longitudinal observational studies investigating seasonal variation in the incidence of Acinetobacter infection.

PARTICIPANTS

Patients receiving hospital care.

INTERVENTIONS

Routine hospital care.

METHODS

Systematic review with narrative evidence synthesis structured around clinical and methodological heterogeneity and internal validity of retrieved studies, seasonal patterns and risk factors detected, and stated hypotheses of mechanisms underlying seasonality. To examine consistency in reported seasonal patterns across different conditions, monthly incidence data were extracted, standardised, weighted and presented graphically.

RESULTS

Twenty-five studies reporting 37006 cases of Acinetobacter infection or colonization during 1954 months of follow-up were reviewed. Standardised monthly incidence data pooled across studies exhibited a global seasonal pattern with an incidence peak in summer/warmer months and a trough in winter/colder months. This seasonal pattern remained consistent under different weighting schemes accounting for study size, length of follow-up and overall quality assessment rating. Seasonality persisted in different clinical settings and for different types and sources of infection. Nine studies provided consistent evidence of temperature-associated variation in Acinetobacter incidence, while there were controversial findings regarding other environmental variables. No study detected patient-related or clinical practice-related seasonal variation in Acinetobacter incidence.

CONCLUSIONS

Despite substantial clinical and methodological heterogeneity in retrieved studies, a consistent global seasonal pattern in Acinetobacter infection incidence was evident in this review. This merits attention when designing or evaluating infection control interventions in hospitals. Future research should focus on elucidating driving mechanisms underlying the observed seasonality.

Seasonal Variation in Acute Cholecystitis: An Analysis of Cholecystectomies Spanning Three Decades

BACKGROUND

Seasonal variation in the occurrence of medical illnesses reflects the effect of the environment, provides insight into pathogenesis, and can assist health care administrators in allocating resources accordingly. Seasonal variation has been reported in various infectious and surgical diseases, but has been rarely studied in acute cholecystitis. Our objective was to study seasonal variation in acute cholecystitis at our institution.

METHODS

We performed a retrospective analysis of patients who underwent cholecystectomy for acute cholecystitis from January 1988 to December 2018. Chi-square goodness-of-fit test was used to analyze seasonality of acute cholecystitis adjusting for variation in number of days between seasons. The number of days for seasons were taken as 92, 92, 91, and 90.25 for spring, summer, fall, and winter, respectively.

RESULTS

Overall, 3924 patients underwent cholecystectomy for acute cholecystitis during the study period. The frequency of cholecystectomies performed varied between months (minimum February n = 259, maximum July n = 372, P < 0.001) and seasons (minimum winter n = 789, maximum summer n = 1101 P < 0.001). Age and gender distribution across months and seasons was similar (P > 0.05).

CONCLUSIONS

Our findings confirm seasonal variation in occurrence of acute cholecystitis with summer season witnessing the most and the winter season encountering the least patients with acute cholecystitis. Validation of our findings through prospectively collected data at national level is the way forward.

The Epidemiology of Bloodstream Infections and Antimicrobial Susceptibility Patterns: A Nine-Year Retrospective Study at St. Dominic Hospital, Akwatia, Ghana

Background

Bloodstream infections are among the top causes of morbidity and mortality in people of all ages, especially in immunocompromised patients in sub-Saharan Africa. This study aimed at describing the epidemiology of bloodstream infections and antimicrobial susceptibility pattern over a nine-year period at St. Dominic Hospital, Akwatia, in the Eastern Region of Ghana.

Method

This study retrospectively analysed data from 4,489 patients who were referred to the Laboratory Department for blood culture and sensitivity testing from January 2009 to December 2017. Sociodemographic data included age, gender, and patients' department. Blood culture results were retrieved from archival records in the laboratory. The authorities of St. Dominic Hospital granted approval for the study.

Results

The incidence of bloodstream infection over the 9 years was 51.4 positive cultures per 100,000 hospital attendance. Staphylococcus aureus was the leading causative agent of bacteraemia for the first two scalar years (2009–2011 (38.9%) and 2012–2014 (42.2%)) while coagulase-negative staphylococcus (CoNS) (50.5%) was predominant for the last scalar year (2015–2017), followed by Staphylococcus aureus (169/587 (28.8%)). The highest incidence of bloodstream infections was recorded in the wet seasons (months of May (8.9 per 10,000 persons) and October (10.1 per 10,000 persons)). The bacterial isolates demonstrated high resistance to tetracyclines (390/531 (73.4%)), penicillins (1282/1669 (76.8%)), and sulphonamides (450/499 (90.2%)).

Conclusion

Bloodstream infection and antimicrobial resistance are high in patients seeking healthcare in Akwatia. This therefore calls for concerted efforts aimed at reducing the incidence in the study area.

Incidence and costs of ventilator-associated pneumonia in the adult intensive care unit of a tertiary referral hospital in Mexico

BACKGROUND

Ventilator-associated pneumonia (VAP) is defined as pneumonia that occurs after 48 hours of endotracheal intubation and initiation of mechanical ventilation. The aim of this work was to use a micro-costing method to calculate the costs generated in 2017 for the care of patients with VAP at the Hospital Juárez de México.

METHODS

We performed a cross-sectional, retrospective, analytical, and observational study of the databases of the registry of health care-associated infections (HAIs) in 2017, in addition to a micro-costing study.

RESULTS

We studied 48 VAP cases in an adult intensive care unit (AICU). In this period, 1668 ventilator days were identified, with an incidence rate of 28.8 per 1000 days. All cases were caused by multidrug-resistant (MDR) bacteria and the costs of their care exceeded the average costs for the use of antimicrobials. By calculating the profit on return as an association measure, we found that VAP caused by MDR bacteria confers 9 times the risk of increasing the costs of care above the expected average.

CONCLUSIONS

The cost for a case of VAP in the AICU is high and has an impact on the institutional budget. Control measures to prevent the spread of bacteria, particularly MDR bacteria, must be put into place in order to avoid increases in hospital stay costs and mortality.

Trends in resistant Enterobacteriaceae and Acinetobacter species in hospitalized patients in the United States: 2013-2017

BACKGROUND

Trends in antimicrobial resistance help inform infection control efforts. We examined trends in resistance for Enterobacteriaceae and Acinetobacter spp. from 2013 to 2017 in hospitalized US patients.

METHODS

We analyzed antimicrobial susceptibility of non-duplicate isolates in hospitalized patients (not limited to hospital-acquired infections) in the US BD Insights Research Database. Resistance profiles of interest were extended-spectrum beta-lactamase (ESBL)-producing, multidrug resistant (MDR), and carbapenem-nonsusceptible (Carb-NS) phenotypes of Enterobacteriaceae, and MDR and Carb-NS Acinetobacter spp. Time series models were used to evaluate the patterns of resistance trends in rate per 100 hospital admissions and proportion per isolates tested.

RESULTS

More than 1 million Enterobacteriaceae isolates were obtained from 411 hospitals; 12.05% were ESBL, 1.21% Carb-NS, and 7.08% MDR. Urine was the most common source. For Acinetobacter spp. (n = 19,325), 37.48% were Carb-NS, 47.66% were MDR, and the most common source was skin/wound cultures. Trend analyses showed that the rates of ESBL and Carb-NS Enterobacteriaceae per 100 hospital admissions increased significantly between 2013 and 2017. Rates of MDR Enterobacteriaceae and Carb-NS and MDR Acinetobacter spp. decreased during this time period. Trends in proportions of resistant isolates generally mirrored trends in rates per 100 hospital admissions. MDR Enterobacteriaceae and Carb-NS and MDR Acinetobacter spp. were more common in winter than summer.

CONCLUSIONS

In this large-scale study of patients in US hospitals, rates of ESBL and Carb-NS Enterobacteriaceae per 100 hospital admissions increased between 2013 and 2017. MDR Enterobacteriaceae and MDR and Carb-NS Acinetobacter spp. isolates decreased over this period. These data support continuing infection control and stewardship efforts and the development of new therapeutic options.