1
|
Mabena FC, Olwagen CP, Phosa M, Ngwenya IK, Van der Merwe L, Khan A, Mwamba TM, Mpembe R, Magobo RE, Govender NP, Velaphi SC, Madhi SA. Bacterial and Candida Colonization of Neonates in a Regional Hospital in South Africa. Pediatr Infect Dis J 2024; 43:263-270. [PMID: 38381956 DOI: 10.1097/inf.0000000000004177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND Neonatal colonization with multidrug-resistant (MDR) Enterobacter spp., Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterococcus faecium (ESKAPE) and Candida spp. often precedes invasive hospital-acquired infections. We investigated the prevalence and dynamics of neonatal ESKAPE and Candida spp. colonization from hospital admission until discharge (or death) and followed up for invasive disease. METHODS Prospective longitudinal surveillance for neonatal ESKAPE and Candida spp. colonization was conducted over 6 months at a South African regional hospital. Neonates enrolled at birth had swabs (nasal, 2× skin and rectal) collected within 24 hours and every 48-96 hours thereafter, until discharge or death. ESKAPE and Candida spp. were cultured for and antimicrobial susceptibility was performed on bacterial isolates. Whole-genome sequencing was undertaken on paired samples with the same bacterial species from colonizing and invasive disease episodes in the same child. RESULTS Of 102 enrolled neonates, 79% (n = 81) were colonized by ≥1 ESKAPE organism by time of discharge or death. Forty-four percent (36/81) were colonized within 24 hours of birth. Common colonizers were K. pneumoniae (70%; n = 57) and Enterobacter spp. (43%; n = 35). Almost all MDR organisms (93%) were Gram-negative. Forty-two (45%, 42/93) newborns acquired Candida spp. (skin only) colonization, commonly Candida parapsilosis (69%; n = 29). For 2 children with K. pneumoniae colonization and sepsis, the bloodstream and colonizing isolates were genetically different, whereas the single A. baumannii colonizing and blood isolate pair were genetically identical. CONCLUSIONS We report a high prevalence of MDR ESKAPE and Candida spp. colonization in a regional neonatal unit. Interventions to reduce the high incidence of hospital-acquired neonatal infections should include reducing high colonization rates.
Collapse
Affiliation(s)
- Fikile C Mabena
- From the Faculty of Health Science, South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand
- Department of Paediatrics and Child Health, University of the Witwatersrand
| | - Courtney P Olwagen
- From the Faculty of Health Science, South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand
| | - Matshie Phosa
- From the Faculty of Health Science, South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand
| | - Innocent K Ngwenya
- From the Faculty of Health Science, South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand
| | - Lara Van der Merwe
- From the Faculty of Health Science, South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand
| | - Aaliyah Khan
- From the Faculty of Health Science, South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand
| | - Tshiama M Mwamba
- Division of the National Health Laboratory Service, Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
| | - Ruth Mpembe
- Division of the National Health Laboratory Service, Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
| | - Rindidzani E Magobo
- Division of the National Health Laboratory Service, Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
| | - Nelesh P Govender
- Division of the National Health Laboratory Service, Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
- School of Pathology, University of the Witwatersrand
| | | | - Shabir A Madhi
- From the Faculty of Health Science, South Africa Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand
- Infectious Disease and Oncology Research Institute, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
2
|
de Oliveira ÉM, Beltrão EMB, Pimentel MIS, Lopes ACDS. Occurrence of high-risk clones of Klebsiella pneumoniae ST11, ST340, and ST855 carrying the blaKPC-2, blaNDM-1, blaNDM-5, and blaNDM-7 genes from colonized and infected patients in Brazil. J Appl Microbiol 2023; 134:lxad242. [PMID: 37880999 DOI: 10.1093/jambio/lxad242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/28/2023] [Accepted: 10/24/2023] [Indexed: 10/27/2023]
Abstract
AIMS Determine which sequence type (ST) clones were carrying the blaKPC, blaNDM, blaVIM, blaIMP, and blaGES genes and their variants in clinical isolates of multidrug-resistant Klebsiella pneumoniae. METHODS AND RESULTS Ten K. pneumoniae isolates were obtained from the colonized and infected patients in a public hospital in the city of Recife-PE, in northeastern Brazil, and were further analyzed. The detection of carbapenem resistance genes and the seven housekeeping genes [for multilocus sequence typing (MLST) detection] were done with PCR and sequencing. The blaKPC and blaNDM genes were detected concomitantly in all isolates, with variants being detected blaNDM-1, blaNDM-5, blaNDM-7, and blaKPC-2. The blaKPC-2 and blaNDM-1 combination being the most frequent. Molecular typing by MLST detected three types of high-risk ST clones, associated with the clonal complex 258, ST11/CC258 in eight isolates, and ST855/CC258 and ST340/CC258 in the other two isolates. CONCLUSIONS These findings are worrying, as they have a negative impact on the scenario of antimicrobial resistance, and show the high genetic variability of K. pneumoniae and its ability to mutate resistance genes and risk of dissemination via different ST clones.
Collapse
Affiliation(s)
- Érica Maria de Oliveira
- Departamento de Medicina Tropical, Universidade Federal de Pernambuco-UFPE, Recife, PE 50732-970, Brazil
| | | | | | | |
Collapse
|
3
|
Kontou A, Kourti M, Iosifidis E, Sarafidis K, Roilides E. Use of Newer and Repurposed Antibiotics against Gram-Negative Bacteria in Neonates. Antibiotics (Basel) 2023; 12:1072. [PMID: 37370391 DOI: 10.3390/antibiotics12061072] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Antimicrobial resistance has become a significant public health problem globally with multidrug resistant Gram negative (MDR-GN) bacteria being the main representatives. The emergence of these pathogens in neonatal settings threatens the well-being of the vulnerable neonatal population given the dearth of safe and effective therapeutic options. Evidence from studies mainly in adults is now available for several novel antimicrobial compounds, such as new β-lactam/β-lactamase inhibitors (e.g., ceftazidime-avibactam, meropenem-vaborbactam, imipenem/cilastatin-relebactam), although old antibiotics such as colistin, tigecycline, and fosfomycin are also encompassed in the fight against MDR-GN infections that remain challenging. Data in the neonatal population are scarce, with few clinical trials enrolling neonates for the evaluation of the efficacy, safety, and dosing of new antibiotics, while the majority of old antibiotics are used off-label. In this article we review data about some novel and old antibiotics that are active against MDR-GN bacteria causing sepsis and are of interest to be used in the neonatal population.
Collapse
Affiliation(s)
- Angeliki Kontou
- 1st Department of Neonatology and Neonatal Intensive Care Unit, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Maria Kourti
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Elias Iosifidis
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
- Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Kosmas Sarafidis
- 1st Department of Neonatology and Neonatal Intensive Care Unit, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Hippokration General Hospital, Thessaloniki 54642, Greece
- Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| |
Collapse
|
4
|
Harimanana A, Rakotondrasoa A, Rivoarilala LO, Criscuolo A, Opatowski L, Rakotomanana EFN, Herindrainy P, Collard JM, Crucitti T, Huynh BT. Neonatal acquisition of extended-spectrum beta-lactamase-producing Enterobacteriaceae in the community of a low-income country (NeoLIC): protocol for a household cohort study in Moramanga, Madagascar. BMJ Open 2022; 12:e061463. [PMID: 36153019 PMCID: PMC9511544 DOI: 10.1136/bmjopen-2022-061463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Data regarding the acquisition of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) in neonates at the community level are scarce in low-income and middle-income countries (LMICs), where the burden of neonatal sepsis is high.Our study aims at identifying and quantifying the role of the different routes of ESBL-PE transmission for neonates, which are still undefined in the community in LMICs. METHODS AND ANALYSIS In a semirural community in Madagascar, 60 mothers and their neonates will be recruited at delivery, during which a maternal stool sample and meconium of the newborn will be collected. Home visits will be planned the day of the delivery and next at days 3, 7, 14, 21 and 28. Stool samples from the newborn, the mother and every other household member will be collected at each visit, as well as samples from the environment in contact with the newborn (food, surfaces and objects). Sociodemographic data and factors which might drive ESBL-PE acquisition will also be collected.We will analyse the isolated ESBL-PE using DNA sequencing methods to characterise clones, resistance genes and plasmids of ESBL-PE. To analyse these data globally, we will develop novel analytical approaches combining mathematical modelling and statistics. Finally, mathematical simulations will be performed to test different strategies of control of ESBL-PE transmission to neonates.In complement, we will conduct an anthropological investigation to understand local environments and practices that would contribute to neonatal ESBL-PE acquisition. In-depth interviews with members of 16 households will be conducted and 4 mother-newborn pairs will be followed by a participants' observations methodology. ETHICS AND DISSEMINATION The study was approved by the ethical committee in Madagascar and by the institutional review board of Institut Pasteur, Paris, France.Findings will be reported to participating families, collaborators and local government; presented at national and international conferences and disseminated by peer-review publications.
Collapse
Affiliation(s)
| | | | | | - Alexis Criscuolo
- Institut Pasteur, Paris, Île-de-France, France
- Université de Paris, Paris, Île-de-France, France
| | - Lulla Opatowski
- Institut Pasteur, Paris, Île-de-France, France
- Institut National de la Santé et de la Recherche Médicale, Université de Versailles Saint-Quentin-en-Yvelines and Université Paris-Saclay, Montigny-Le-Bretonneux, Île-de-France, France
| | | | - Perlinot Herindrainy
- Infectious Disease Detection and Surveillance, ICF International, Antananarivo, Madagascar
| | - Jean-Marc Collard
- Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai, China
| | - Tania Crucitti
- Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - Bich-Tram Huynh
- Institut Pasteur, Paris, Île-de-France, France
- Institut National de la Santé et de la Recherche Médicale, Université de Versailles Saint-Quentin-en-Yvelines and Université Paris-Saclay, Montigny-Le-Bretonneux, Île-de-France, France
| |
Collapse
|
5
|
Bastidas-Caldes C, Romero-Alvarez D, Valdez-Vélez V, Morales RD, Montalvo-Hernández A, Gomes-Dias C, Calvopiña M. Extended-Spectrum Beta-Lactamases Producing Escherichia coli in South America: A Systematic Review with a One Health Perspective. Infect Drug Resist 2022; 15:5759-5779. [PMID: 36204394 PMCID: PMC9531622 DOI: 10.2147/idr.s371845] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/04/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Carlos Bastidas-Caldes
- One Health Research Group, Faculty of Engineering and Applied Sciences, Universidad de las Américas, Quito, Ecuador
- Doctoral Program in Public and Animal Health, Faculty of Veterinary Medicine, University of Extremadura, Cáceres, Spain
- Correspondence: Carlos Bastidas-Caldes, One Health Research Group, Faculty of Engineering and Applied Sciences, Universidad de las Américas, Quito, 170124, Ecuador, Tel +593 983 174949, Email
| | - Daniel Romero-Alvarez
- One Health Reserch Group, Faculty of Medicine, Universidad de las Américas, Quito, Ecuador
- Biodiversity Institute and Department of Ecology & Evolutionary Biology, The University of Kansas, Lawrence, KS, USA
| | - Victor Valdez-Vélez
- One Health Research Group, Faculty of Engineering and Applied Sciences, Universidad de las Américas, Quito, Ecuador
| | - Roberto D Morales
- One Health Research Group, Faculty of Engineering and Applied Sciences, Universidad de las Américas, Quito, Ecuador
| | - Andrés Montalvo-Hernández
- One Health Research Group, Faculty of Engineering and Applied Sciences, Universidad de las Américas, Quito, Ecuador
| | - Cicero Gomes-Dias
- Department of Basic Health Sciences, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Manuel Calvopiña
- One Health Reserch Group, Faculty of Medicine, Universidad de las Américas, Quito, Ecuador
| |
Collapse
|
6
|
Godijk NG, Bootsma MCJ, Bonten MJM. Transmission routes of antibiotic resistant bacteria: a systematic review. BMC Infect Dis 2022; 22:482. [PMID: 35596134 PMCID: PMC9123679 DOI: 10.1186/s12879-022-07360-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background Quantification of acquisition routes of antibiotic resistant bacteria (ARB) is pivotal for understanding transmission dynamics and designing cost-effective interventions. Different methods have been used to quantify the importance of transmission routes, such as relative risks, odds ratios (OR), genomic comparisons and basic reproduction numbers. We systematically reviewed reported estimates on acquisition routes’ contributions of ARB in humans, animals, water and the environment and assessed the methods used to quantify the importance of transmission routes. Methods PubMed and EMBASE were searched, resulting in 6054 articles published up until January 1st, 2019. Full text screening was performed on 525 articles and 277 are included. Results We extracted 718 estimates with S. aureus (n = 273), E. coli (n = 157) and Enterobacteriaceae (n = 99) being studied most frequently. Most estimates were derived from statistical methods (n = 560), mainly expressed as risks (n = 246) and ORs (n = 239), followed by genetic comparisons (n = 85), modelling (n = 62) and dosage of ARB ingested (n = 17). Transmission routes analysed most frequently were occupational exposure (n = 157), travelling (n = 110) and contacts with carriers (n = 83). Studies were mostly performed in the United States (n = 142), the Netherlands (n = 87) and Germany (n = 60). Comparison of methods was not possible as studies using different methods to estimate the same route were lacking. Due to study heterogeneity not all estimates by the same method could be pooled. Conclusion Despite an abundance of published data the relative importance of transmission routes of ARB has not been accurately quantified. Links between exposure and acquisition are often present, but the frequency of exposure is missing, which disables estimation of transmission routes’ importance. To create effective policies reducing ARB, estimates of transmission should be weighed by the frequency of exposure occurrence. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07360-z.
Collapse
Affiliation(s)
- Noortje G Godijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Martin C J Bootsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Mathematics, Faculty of Sciences, Utrecht University, Utrecht, The Netherlands
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
7
|
Flannery DD, Chiotos K, Gerber JS, Puopolo KM. Neonatal multidrug-resistant gram-negative infection: epidemiology, mechanisms of resistance, and management. Pediatr Res 2022; 91:380-391. [PMID: 34599280 PMCID: PMC8819496 DOI: 10.1038/s41390-021-01745-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/11/2021] [Accepted: 08/31/2021] [Indexed: 02/08/2023]
Abstract
Infants admitted to the neonatal intensive care unit, particularly those born preterm, are at high risk for infection due to the combination of an immature immune system, prolonged hospitalization, and frequent use of invasive devices. Emerging evidence suggests that multidrug-resistant gram-negative (MDR-GN) infections are increasing in neonatal settings, which directly threatens recent and ongoing advances in contemporary neonatal care. A rising prevalence of antibiotic resistance among common neonatal pathogens compounds the challenge of optimal management of suspected and confirmed neonatal infection. We review the epidemiology of MDR-GN infections in neonates in the United States and internationally, with a focus on extended-spectrum β-lactamase (ESBL)-producing Enterobacterales and carbapenem-resistant Enterobacterales (CRE). We include published single-center studies, neonatal collaborative reports, and national surveillance data. Risk factors for and mechanisms of resistance are discussed. In addition, we discuss current recommendations for empiric antibiotic therapy for suspected infections, as well as definitive treatment options for key MDR organisms. Finally, we review best practices for prevention and identify current knowledge gaps and areas for future research. IMPACT: Surveillance and prevention of MDR-GN infections is a pediatric research priority. A rising prevalence of MDR-GN neonatal infections, specifically ESBL-producing Enterobacterales and CRE, compounds the challenge of optimal management of suspected and confirmed neonatal infection. Future studies are needed to understand the impacts of MDR-GN infection on neonatal morbidity and mortality, and studies of current and novel antibiotic therapies should include a focus on the pharmacokinetics of such agents among neonates.
Collapse
Affiliation(s)
- Dustin D Flannery
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Kathleen Chiotos
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jeffrey S Gerber
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Karen M Puopolo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
8
|
Milic M, Siljic M, Cirkovic V, Jovicevic M, Perovic V, Markovic M, Martic J, Stanojevic M, Mijac V. Colonization with Multidrug-Resistant Bacteria in the First Week of Life among Hospitalized Preterm Neonates in Serbia: Risk Factors and Outcomes. Microorganisms 2021; 9:microorganisms9122613. [PMID: 34946217 PMCID: PMC8709168 DOI: 10.3390/microorganisms9122613] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/18/2021] [Accepted: 11/21/2021] [Indexed: 11/25/2022] Open
Abstract
The aim of this prospective cohort study was to determine the prevalence of gut colonization with multidrug-resistant (MDR) bacteria, risk factors for colonization, infection risk, and outcomes among preterm neonates hospitalized at a tertiary-care center in Serbia. During the period from December 2017 to April 2018, 103 neonates were screened for rectal carriage at admission and on the seventh day of life. Characterization of MDR strains was done by conventional microbiology and molecular methods. Out of 61 (59.2%) colonized neonates, 12 (11.6%) were found colonized at admission, while 49 (47.6%) became colonized at the study site. Among a total of 72 MDR isolates, extended-spectrum beta-lactamase (ESBL)-producing enterobacteria prevailed (56/72, 77%), followed by Acinetobacter baumannii (14/72, 19%). The majority of ESBL-producing strains carried multiple genes (blaTEM/blaCTX-M-15 or blaTEM/blaSHV). Longer previous hospitalization and delivery by cesarean section were associated with MDR colonization, while mechanical ventilation was a risk factor for colonization at the study site. Infections due to MDR bacteria were more frequent among colonized than non-colonized neonates, but not significantly, and mortality was low (1%) in the studied neonates. These results indicate that hospitalized preterm neonates in Serbia are rapidly colonized with a diversity of MDR species and resistance phenotypes/genotypes.
Collapse
Affiliation(s)
- Marija Milic
- Department of Neonatal Intensive Care, Institute of Neonatology, Kralja Milutina 50, 11000 Belgrade, Serbia;
| | - Marina Siljic
- Department of Bacteriology, Virology and Immunology, Institute of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000 Belgrade, Serbia; (M.S.); (V.C.); (M.J.); (V.P.); (M.S.)
| | - Valentina Cirkovic
- Department of Bacteriology, Virology and Immunology, Institute of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000 Belgrade, Serbia; (M.S.); (V.C.); (M.J.); (V.P.); (M.S.)
| | - Milos Jovicevic
- Department of Bacteriology, Virology and Immunology, Institute of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000 Belgrade, Serbia; (M.S.); (V.C.); (M.J.); (V.P.); (M.S.)
| | - Vladimir Perovic
- Department of Bacteriology, Virology and Immunology, Institute of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000 Belgrade, Serbia; (M.S.); (V.C.); (M.J.); (V.P.); (M.S.)
| | - Milos Markovic
- Department of Bacteriology, Virology and Immunology, Institute of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000 Belgrade, Serbia; (M.S.); (V.C.); (M.J.); (V.P.); (M.S.)
- Correspondence: (M.M.); (V.M.)
| | - Jelena Martic
- Department of Neonatology, Institute for Mother and Child Health Care of Serbia “Dr Vukan Cupic”, Faculty of Medicine, University of Belgrade, Radoja Dakica 6, 11070 Belgrade, Serbia;
| | - Maja Stanojevic
- Department of Bacteriology, Virology and Immunology, Institute of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000 Belgrade, Serbia; (M.S.); (V.C.); (M.J.); (V.P.); (M.S.)
| | - Vera Mijac
- Department of Bacteriology, Virology and Immunology, Institute of Microbiology and Immunology, Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000 Belgrade, Serbia; (M.S.); (V.C.); (M.J.); (V.P.); (M.S.)
- Correspondence: (M.M.); (V.M.)
| |
Collapse
|
9
|
Zakir A, Regasa Dadi B, Aklilu A, Oumer Y. Investigation of Extended-Spectrum β-Lactamase and Carbapenemase Producing Gram-Negative Bacilli in Rectal Swabs Collected from Neonates and Their Associated Factors in Neonatal Intensive Care Units of Southern Ethiopia. Infect Drug Resist 2021; 14:3907-3917. [PMID: 34588786 PMCID: PMC8476106 DOI: 10.2147/idr.s333603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/15/2021] [Indexed: 12/14/2022] Open
Abstract
Background Currently extended-spectrum β-lactamase (ESβL) and carbapenemase producing gram-negative bacteria are the greatest concern among the neonatal population with very limited therapeutic options. The aim of this study was to assess the prevalence of ESβL and carbapenemase producing gram-negative bacilli, associated factors and antimicrobial resistance patterns among neonates in intensive care units. Methods An institutional-based cross-sectional study was conducted from February to June 2021 on 212 neonates in intensive care units. Risk factors data were collected by using a well-designed questionnaire. A rectal swab sample was collected using a sterile cotton swab and inoculated on MacConkey agar. Bacterial isolates were identified using various biochemical tests. ESβL and carbapenemase were first screened by indicator cephalosporins (cefotaxime (30µg) and ceftazidine (30µg)) and carbapenem (meropenem and ertapenem), respectively. ESβL and carbapenemase were confirmed by a double-disk synergy test and modified carbapenem inactivation methods, respectively. SPSS version 21.0 was used for data analysis. A P-value ≤ 0.05 was considered as statistically significant. Results The overall prevalence of ESβL-producing gram-negative bacilli was 72/212 (34%). The predominant ESβL-producing isolate was Klebsiella pneumoniae 23/72 (31.9%) followed by Escherichia coli 17/72 (23.6%). Five (2.4%) carbapenemase-producing gram-negative bacilli were isolated. ESβL-producing isolates showed a high resistance against ampicillin 72/72 (100%), augmentin 69/72 (95.8%) and gentamycin 57/72 (79.2%). The majority 63/72 (87.5%) of isolated ESβL-producing gram-negative bacilli were multi-drug resistant (MDR). Rectal carriage of ESβL by neonates showed a statistically significant association with endotracheal intubation (p = 0.001; AOR = 4.2; 96% CI = (1.8–9.5)), treatment with ampicillin+gentamycin (p = 0.004; AOR = 3.3; 95% CI = (1.5–7.6)) and staying in a neonatal intensive care unit (NICU) between 11 and 20 days (p = 0.042; AOR = 2; 95% CI = (1.0–4.5)). Conclusion A high prevalence of ESβL-producing bacterial isolates was observed for commonly used antibiotics which needs further attention. Therefore, continuous and regular follow-ups of drug resistance patterns is important for the proper treatment and management of ESβL and carbapenemase producing gram-negative bacilli.
Collapse
Affiliation(s)
- Abdurezak Zakir
- Department of Medical Microbiology, Arba Minch University, Arba Minch, Ethiopia
| | | | - Addis Aklilu
- Department of Medical Microbiology, Arba Minch University, Arba Minch, Ethiopia
| | - Yisiak Oumer
- Department of Medical Microbiology, Arba Minch University, Arba Minch, Ethiopia
| |
Collapse
|
10
|
Arhoune B, El Fakir S, Himri S, Moutaouakkil K, El Hassouni S, Benboubker M, Hmami F, Oumokhtar B. Intense intestinal carriage and subsequent acquisition of multidrug-resistant enterobacteria in neonatal intensive care unit in Morocco. PLoS One 2021; 16:e0251810. [PMID: 34191805 PMCID: PMC8244853 DOI: 10.1371/journal.pone.0251810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/04/2021] [Indexed: 11/29/2022] Open
Abstract
This study was conducted in order to know the colonization rate of MDR enterobacteria in neonates during their hospitalization in neonatal intensive care unit (NICU). Furthermore, we investigated risk factors for potential colonization and molecular epidemiology of isolated resistant bacteria. This prospective study was carried out in the neonatology and intensive care unit department of the University Hospital of Fez (Morocco) from February 2013 to July 2015. All consecutive admitted newborns were screened for intestinal and nasal carriage of MDR enterobacteria at admission of the babies and during the hospitalization. During the study period, a total of 641 Enterobacteriaceae were isolated and Klebsiella pneumoniae was the predominated bacteria. Bacterial identification and antibiograms were performed according to the international standards. On admission, 455 newborns were screened. A median age of these newborns was 1 day with an extended 147 days and their average weight was 2612 ± 1023 grams. 22.4% of neonates were found colonized by an ESBL producing Enterobacteriaceae (ESBL-E), 8.7% by a carbapenemases producing Enterobacteriaceae (CPE). During hospitalization, 207 of newborns were included in the acquisition study. 59.4% of newborns acquired an ESBL-E during their stay, 12.5% has acquired CPE. The blaCTXM-15 gene was the most frequently detected (81.2%) among ESBL-E. While, all CPE has expressed the blaOXA-48 gene exclusively. Two risk factors have been significantly associated with MDR enterobacteria colonization at admission which are newborns admission from maternity of the university hospital (95% CI, 1.859-5.129, P = 0.000) and neurological distress (95% CI, 1.038 to 4.694, P = 0.040). During hospitalization, the none risk factor was significantly associated with the carriage of MDR-E. The high rate of colonization, the MDR enterobacteria and the resistance genes found represent good indicator of cross-transmission in the NICU. An active strategy to control the spread of MDR enterobacteria should be applied.
Collapse
Affiliation(s)
- Btissam Arhoune
- Laboratory of Microbiology and Molecular biology, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Samira El Fakir
- Laboratory of Epidemiology and Clinical Research, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Sara Himri
- Laboratory of Microbiology and Molecular biology, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Kaoutar Moutaouakkil
- Laboratory of Microbiology and Molecular biology, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Salma El Hassouni
- Laboratory of Microbiology and Molecular biology, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Moussa Benboubker
- Laboratory of Microbiology and Molecular biology, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| | - Fouzia Hmami
- Neonatal Intensive Care Unit, University Hospital Hassan II, Fez, Morocco
| | - Bouchra Oumokhtar
- Laboratory of Microbiology and Molecular biology, Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah University, Fez, Morocco
| |
Collapse
|
11
|
Saporito L, Graziano G, Mescolo F, Amodio E, Insinga V, Rinaudo G, Aleo A, Bonura C, Vitaliti M, Corsello G, Vitale F, Maida CM, Giuffrè M. Efficacy of a coordinated strategy for containment of multidrug-resistant Gram-negative bacteria carriage in a Neonatal Intensive Care Unit in the context of an active surveillance program. Antimicrob Resist Infect Control 2021; 10:30. [PMID: 33541419 PMCID: PMC7863509 DOI: 10.1186/s13756-021-00902-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 01/25/2021] [Indexed: 12/28/2022] Open
Abstract
Background Antimicrobial resistance in neonatal intensive care unit (NICU) patients is a threat, due to the frequent use of antimicrobial treatment and invasive devices in fragile babies. Since 2014 an active surveillance program of multidrug-resistant Gram-negative bacteria (MDR-GNB) carriage has been in place in the five NICUs of Palermo, Italy. In 2017 an increase in the prevalence of MDR-GNB, and in particular of extended-spectrum β-lactamases-producing Klebsiella pneumoniae (ESBL-KP), was observed in “Civico” hospital NICU. Aim To assess the impact of a coordinated intervention strategy in achieving long-lasting reduction of MDR-GNB prevalence in the NICU. Methods Rectal swabs were obtained monthly and processed to detect MDR-GNB using standard methods. MDR-GNB were characterized by pulsed-field gel electrophoresis (PFGE). Since November 2017 the following intervention measures were applied: (a) two-months intensification of sample collection; (b) stakeholders meetings; (c) improvement of prevention measures and antimicrobial policies. Findings During the intensified microbiological surveillance MDR-GNB and ESBL-KP were detected in rectal swabs (34.8%; 23.2%), nasal swabs (24.6%; 14.5%), oral swabs (14.5%; 5.4%), milk samples (32.1%; 17.9%), pacifiers swabs (30.8%; 17.9%) and from sub-intensive room surfaces. Thirteen ESBL-KP strains isolated from clinical and environmental samples showed identical PFGE patterns. The prevalence of MDR-GNB and ESBL-KP carriage significantly decreased in the year after intervention compared to the previous year (20.6% vs 62.2%; p < 0.001 and 11.1% vs 57.8%; p < 0.001). MDR-GNB were not detected at all for three months and ESBL-KP for five months. Multivariate analysis of the principal exposure variables showed that admission in the post-intervention period significantly reduced the risk of MDR-GNB carriage (adj-OR = 0.21, 95% CI = 0.076–0.629; p < 0.001). Conclusions MDR-GNB broadly circulate in NICU setting, they can colonize different body sites and spread through various vehicles. A coordinated strategy of multiple interventions with active cooperation between epidemiologists and clinicians in the NICU can effectively reduce their circulation and in particular the carriage of the most dangerous ESBL-KP strains.
Collapse
Affiliation(s)
- Laura Saporito
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy.
| | - Giorgio Graziano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Federica Mescolo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Emanuele Amodio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Vincenzo Insinga
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Grazia Rinaudo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Aurora Aleo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Celestino Bonura
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Marcello Vitaliti
- Neonatology and Neonatal Intensive Care Unit, ARNAS Civico - Di Cristina - Benfratelli, Palermo, Italy
| | - Giovanni Corsello
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Francesco Vitale
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Carmelo Massimo Maida
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Mario Giuffrè
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| |
Collapse
|
12
|
Ogunbosi BO, Moodley C, Naicker P, Nuttall J, Bamford C, Eley B. Colonisation with extended spectrum beta-lactamase-producing and carbapenem-resistant Enterobacterales in children admitted to a paediatric referral hospital in South Africa. PLoS One 2020; 15:e0241776. [PMID: 33156820 PMCID: PMC7647087 DOI: 10.1371/journal.pone.0241776] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/21/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION There are few studies describing colonisation with extended spectrum beta-lactamase-producing Enterobacterales (ESBL-PE) and carbapenem-resistant Enterobacterales (CRE) among children in sub-Saharan Africa. Colonisation often precedes infection and multi-drug-resistant Enterobacterales are important causes of invasive infection. METHODS In this prospective cross-sectional study, conducted between April and June 2017, 200 children in a tertiary academic hospital were screened by rectal swab for EBSL-PE and CRE. The resistance-conferring genes were identified using polymerase chain reaction technology. Risk factors for colonisation were also evaluated. RESULTS Overall, 48% (96/200) of the children were colonised with at least one ESBL-PE, 8.3% (8/96) of these with 2 ESBL-PE, and one other child was colonised with a CRE (0.5% (1/200)). Common colonising ESBL-PE were Klebsiella pneumoniae (62.5%, 65/104) and Escherichia coli (34.6%, 36/104). The most frequent ESBL-conferring gene was blaCTX-M in 95% (76/80) of the isolates. No resistance- conferring gene was identified in the CRE isolate (Enterobacter cloacae). Most of the Klebsiella pneumoniae isolates were susceptible to piperacillin/tazobactam (86.2%) and amikacin (63.9%). Similarly, 94.4% and 97.2% of the Escherichia coli isolates were susceptible to piperacillin/tazobactam and amikacin, respectively. Hospitalisation for more than 7 days before study enrolment was associated with ESBL-PE colonisation. CONCLUSION Approximately half of the hospitalised children in this study were colonised with ESBL-PE. This highlights the need for improved infection prevention and control practices to limit the dissemination of these microorganisms.
Collapse
Affiliation(s)
- Babatunde O. Ogunbosi
- Paediatric Infectious Diseases Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Clinton Moodley
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Preneshni Naicker
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - James Nuttall
- Paediatric Infectious Diseases Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Colleen Bamford
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Brian Eley
- Paediatric Infectious Diseases Unit, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
13
|
Kagia N, Kosgei P, Ooko M, Wafula L, Mturi N, Anampiu K, Mwarumba S, Njuguna P, Seale AC, Berkley JA, Bottomley C, Scott JAG, Morpeth SC. Carriage and Acquisition of Extended-spectrum β-Lactamase-producing Enterobacterales Among Neonates Admitted to Hospital in Kilifi, Kenya. Clin Infect Dis 2020; 69:751-759. [PMID: 30830952 PMCID: PMC6695508 DOI: 10.1093/cid/ciy976] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/30/2018] [Indexed: 12/18/2022] Open
Abstract
Background Infections caused by extended-spectrum β-lactamase–producing Enterobacterales (ESBL-E) among hospitalized neonates in sub-Saharan Africa pose significant clinical challenges. Data on prevalence and acquisition of ESBL-E carriage among hospitalized neonates in the region are few, and risk factors for transmission are not clearly defined. Methods In a cohort study of consecutive neonatal admissions to Kilifi County Hospital from July 2013 through August 2014, we estimated ESBL-E carriage prevalence on admission using rectal swab cultures and identified risk factors using logistic regression. Using twice-weekly follow-up swabs, we estimated the incidence and identified risk factors for ESBL-E acquisition in hospital using Poisson regression. Results The prevalence of ESBL-E carriage at admission was 10% (59/569). Cesarean delivery, older neonatal age, and smaller household size were significant risk factors. Of the 510 infants admitted without ESBL-E carriage, 238 (55%) acquired carriage during their hospital stay. The incidence of acquisition was 21.4% (95% confidence interval, 19.0%–24.0%) per day. The rate was positively associated with the number of known neonatal ESBL-E carriers and with the total number of neonates on the same ward. Conclusions Carriage of ESBL-E was common among neonates on admission, and in-hospital acquisition was rapid. The dissemination and selection of ESBL-E appears to be driven by hospital exposures, operative delivery, and neonatal ward patient density. Further attention to infection control, patient crowding, and carriage surveillance is warranted.
Collapse
Affiliation(s)
- Ngure Kagia
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Centre for Geographic Medicine Research- Coast, Kilifi
| | - Patrick Kosgei
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Centre for Geographic Medicine Research- Coast, Kilifi
| | - Michael Ooko
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Centre for Geographic Medicine Research- Coast, Kilifi
| | - Leonard Wafula
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Centre for Geographic Medicine Research- Coast, Kilifi
| | - Neema Mturi
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Centre for Geographic Medicine Research- Coast, Kilifi
| | - Kirimi Anampiu
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Centre for Geographic Medicine Research- Coast, Kilifi
| | - Salim Mwarumba
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Centre for Geographic Medicine Research- Coast, Kilifi
| | - Patricia Njuguna
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Centre for Geographic Medicine Research- Coast, Kilifi
| | - Anna C Seale
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Centre for Geographic Medicine Research- Coast, Kilifi.,Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
| | - James A Berkley
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Centre for Geographic Medicine Research- Coast, Kilifi.,Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - Christian Bottomley
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
| | - J Anthony G Scott
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Centre for Geographic Medicine Research- Coast, Kilifi.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Susan C Morpeth
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Centre for Geographic Medicine Research- Coast, Kilifi.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom.,Counties Manukau District Health Board, Auckland, New Zealand
| |
Collapse
|
14
|
Aklilu A, Manilal A, Ameya G, Woldemariam M, Siraj M. Gastrointestinal Tract Colonization Rate of Extended-Spectrum Beta-Lactamase- and Carbapenemase-Producing Enterobacteriaceae and Associated Factors Among Hospitalized Patients in Arba Minch General Hospital, Arba Minch, Ethiopia. Infect Drug Resist 2020; 13:1517-1526. [PMID: 32547121 PMCID: PMC7250175 DOI: 10.2147/idr.s239092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/07/2020] [Indexed: 11/23/2022] Open
Abstract
Background The incidence of hospital-acquired enterobacteria that produce extended-spectrum beta-lactamases (ESBLs) is on the rise worldwide. Colonization of gastrointestinal tract by extended-spectrum beta-lactamase Enterobacteriaceae, a prominent causative agent, results in life-threatening infections. Objective To determine the rate of gastrointestinal colonization by extended-spectrum beta-lactamase- and carbapenemase-producing Enterobacteriaceae and also to elucidate the antibiotic susceptibility profile and associated risk factors among hospitalized patients in Arba Minch General Hospital, Ethiopia. Methodology A facility-based cross-sectional study was conducted in Arba Minch General Hospital from May 2018 to July 2019. Sociodemographic data and associated factors were collected using a pre-tested-structured questionnaire. Stool specimens were collected using sterile stool cups. Each sample was then inoculated onto MacConkey agar. Bacterial isolates were identified using various biochemical tests. Screening and confirmatory tests for extended-spectrum beta-lactamase- and carbapenemase-producing Enterobacteriaceae were performed using the modified Kirby–Bauer disc diffusion technique. Statistical package for Social Science was used to analyze the data. The P-value ≤0.05 was considered as statistically significant. Results A total of 421 hospitalized patients were enrolled in this study of which there were 240 (57%) females. The mean age of the study participants was 28.8 with SD of 15.7. Majority of participants were in the age range of 25–40 years 179 (42.5%). About 146 (34.7%) participants were found to be colonized by extended-spectrum beta-lactamase-producing Enterobacteriaceae. The predominant ESBL-producing isolates were Escherichia coli 62 (42.46%) followed by Klebsiella pneumoniae 60 (41.09%). Six (1.43%) carbapenemase-producing K. pneumoniae were isolated. ESBL-producing Enterobacteriaceae showed higher resistance against tetracycline (91.1%) and cotrimoxazole (93.84%). Colonization of the gastrointestinal tract by ESBL showed statistically significant association with regard to chronic diseases (p<0.001) and the administration of oral antibiotics after admission (p=0.020). Conclusion The overall colonization rate of the gastrointestinal tract by extended-spectrum beta-lactamase-producing Enterobacteriaceae was prominent. The extended-spectrum beta-lactamase-producing isolates exhibited a higher level of resistance against the commonly used antibiotics which further needs greater attention.
Collapse
Affiliation(s)
- Addis Aklilu
- Arba Minch University, College of Medicine and Health Sciences, Department of Medical Laboratory Science, Arba Minch, Ethiopia
| | - Aseer Manilal
- Arba Minch University, College of Medicine and Health Sciences, Department of Medical Laboratory Science, Arba Minch, Ethiopia
| | - Gemechu Ameya
- Kotebe Metropolitan University, College of Health Sciences, Department of Medical Laboratory Science, Addis Ababa, Ethiopia
| | - Melat Woldemariam
- Arba Minch University, College of Medicine and Health Sciences, Department of Medical Laboratory Science, Arba Minch, Ethiopia
| | - Munira Siraj
- Arba Minch University, College of Medicine and Health Sciences, Department of Medical Laboratory Science, Arba Minch, Ethiopia
| |
Collapse
|
15
|
Baier C, Pirr S, Ziesing S, Ebadi E, Hansen G, Bohnhorst B, Bange FC. Prospective surveillance of bacterial colonization and primary sepsis: findings of a tertiary neonatal intensive and intermediate care unit. J Hosp Infect 2019; 102:325-331. [PMID: 30716339 DOI: 10.1016/j.jhin.2019.01.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 01/28/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Preterm infants and critically ill neonates are predisposed to nosocomial infections as sepsis. Moreover, these infants acquire commensal bacteria, which might become potentially harmful. On-ward transmission of these bacteria can cause outbreaks. AIM To report the findings of a prospective surveillance of bacterial colonization and primary sepsis in preterm infants and neonates. METHODS The results of the surveillance of bacterial colonization of the gut and the respiratory tract, targeting meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and Gram-negative bacteria from November 2016 to March 2018 were analysed. Bacterial colonization was compared to surveillance of sepsis. FINDINGS Six-hundred and seventy-one patients were admitted and 87.0 % (N=584) of the patients were screened; 48.3% (N=282) of the patients screened were colonized with at least one of the bacteria included in the screening; 26.2% of them (N=74) had multi-drug-resistant strains. A total of 534 bacterial isolates were found. The most frequently found species were Escherichia coli, Enterobacter cloacae, Klebsiella oxytoca and Klebsiella pneumoniae. Three MRSA but no VRE were detected. The surveillance detected a K. pneumoniae cluster involving nine patients. There were 23 blood-culture-confirmed sepsis episodes; 60.9% (N=14) were caused by staphylococci. Gram-negative bacteria (one Klebsiella aerogenes and two E. cloacae) caused three sepsis episodes which were preceded by colonization with the respective isolates. CONCLUSIONS Surveillance of colonization provided a comprehensive overview of species and antibiotic resistance patterns. It allowed early detection of a colonization cluster. Knowledge of colonization and surveillance of sepsis is useful for guiding infection control measures and antibiotic treatment.
Collapse
Affiliation(s)
- C Baier
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany.
| | - S Pirr
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - S Ziesing
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - E Ebadi
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - G Hansen
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - B Bohnhorst
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
| | - F-C Bange
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| |
Collapse
|
16
|
Herindrainy P, Rabenandrasana MAN, Andrianirina ZZ, Rakotoarimanana FMJ, Padget M, de Lauzanne A, Ndir A, Kermorvant-Duchemin E, Garin B, Piola P, Collard JM, Guillemot D, Huynh BT, Delarocque-Astagneau E. Acquisition of extended spectrum beta-lactamase-producing enterobacteriaceae in neonates: A community based cohort in Madagascar. PLoS One 2018; 13:e0193325. [PMID: 29494706 PMCID: PMC5832238 DOI: 10.1371/journal.pone.0193325] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 02/08/2018] [Indexed: 01/09/2023] Open
Abstract
In low and middle income countries (LMICs), where the burden of neonatal sepsis is the highest, the spread of extended spectrum beta-lactamase-producing enterobacteriaceae (ESBL-PE) in the community, potentially contributing to the neonatal mortality, is a public health concern. Data regarding the acquisition of ESBL-PE during the neonatal period are scarce. The routes of transmission are not well defined and particularly the possible key role played by pregnant women. This study aimed to understand the neonatal acquisition of ESBL-PE in the community in Madagascar. The study was conducted in urban and semi-rural areas. Newborns were included at birth and followed-up during their first month of life. Maternal stool samples at delivery and six stool samples in each infant were collected to screen for ESBL-PE. A Cox proportional hazards model was performed to identify factors associated with the first ESBL-PE acquisition. The incidence rate of ESBL-PE acquisition was 10.4 cases/1000 newborn-days [95% CI: 8.0–13.4 cases per 1000 newborn-days]. Of the 83 ESBL-PE isolates identified, Escherichia coli was the most frequent species (n = 28, 34.1%), followed by Klebsiella pneumoniae (n = 20, 24.4%). Cox multivariate analysis showed that independent risk factors for ESBL-PE acquisition were low birth weight (adjusted Hazard-ratio (aHR) = 2.7, 95% CI [1.2; 5.9]), cesarean-section, (aHR = 3.4, 95% CI [1.7; 7.1]) and maternal use of antibiotics at delivery (aHR = 2.2, 95% CI [1.1; 4.5]). Our results confirm that mothers play a significant role in the neonatal acquisition of ESBL-PE. In LMICs, public health interventions during pregnancy should be reinforced to avoid unnecessary caesarean section, unnecessary antibiotic use at delivery and low birth weight newborns.
Collapse
Affiliation(s)
| | | | | | | | - Michael Padget
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases Unit, Institut Pasteur, INSERM, UVSQ, Paris, France
| | - Agathe de Lauzanne
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Awa Ndir
- Epidemiology and Infectious Diseases Unit, Institut Pasteur de Dakar, Dakar, Senegal
| | - Elsa Kermorvant-Duchemin
- Paris Descartes University and AP-HP, Necker-Enfants Malades University Hospital, Department of Neonatology, Paris, France
| | - Benoit Garin
- Experimental Bacteriology Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - Patrice Piola
- Epidemiology Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - Jean-Marc Collard
- Experimental Bacteriology Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | - Didier Guillemot
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases Unit, Institut Pasteur, INSERM, UVSQ, Paris, France
| | - Bich-Tram Huynh
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases Unit, Institut Pasteur, INSERM, UVSQ, Paris, France
- * E-mail:
| | - Elisabeth Delarocque-Astagneau
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases Unit, Institut Pasteur, INSERM, UVSQ, Paris, France
| | | |
Collapse
|
17
|
Corbella M, Caltagirone M, Gaiarsa S, Mariani B, Sassera D, Bitar I, Muzzi A, Migliavacca R, Scudeller L, Stronati M, Cambieri P. Characterization of an Outbreak of Extended-Spectrum β-Lactamase-Producing Klebsiella pneumoniae in a Neonatal Intensive Care Unit in Italy. Microb Drug Resist 2018; 24:1128-1136. [PMID: 29368992 DOI: 10.1089/mdr.2017.0270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Here we report an outbreak of extended spectrum β-lactamase-producing Klebsiella pneumoniae that occurred in a neonatal intensive care unit in Northern Italy and involved 97 patients. Progressively tightened sets of containment measures were implemented but the epidemic event was stopped only 9 months later. The final, effective, containment strategy consisted of the application of strict geographic cohorting of colonized infants and their nursing staff, the suspension of any new admission and a rigorous daily sterilization protocol for all surfaces and fomites in the ward. A posteriori characterization of the outbreak strain was performed using both traditional microbiology and molecular biology techniques, and whole genome sequencing, allowing to compare outbreak isolates with other strains collected in the previous two years. The results allowed to determine that the outbreak strain had been circulating inside the ward since the year before. Genomic characterization revealed that the strain carried a wide array of virulence and antibiotic resistance determinants, including gene blaTEM-206, which had never been reported in a clinical isolate of K. pneumoniae before. The presence of such a high number of determinants for antibiotic resistance imposes significant therapeutic limitations on the treatment of infections, thus, further epidemiological investigations are needed to evaluate the prevalence of the newly described variant.
Collapse
Affiliation(s)
- Marta Corbella
- 1 U.O.C. Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo , Pavia, Italy .,2 Servizio Biometria ed Epidemiologia Clinica, Direzione Scientifica, Fondazione IRCCS Policlinico San Matteo , Pavia, Italy
| | - Mariasofia Caltagirone
- 3 Dipartimento di Scienze Clinico-Chirurgiche Diagnostiche e Pediatriche, Unità di Microbiologia e Microbiologia Clinica, Università di Pavia , Pavia, Italy
| | - Stefano Gaiarsa
- 1 U.O.C. Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo , Pavia, Italy .,4 Dipartimento di Bioscienze, Università degli Studi di Milano , Milano, Italy
| | - Bianca Mariani
- 1 U.O.C. Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo , Pavia, Italy
| | - Davide Sassera
- 5 Dipartimento di Biologia e Biotecnologie "L. Spallanzani," Università degli Studi di Pavia , Pavia, Italy
| | - Ibrahim Bitar
- 3 Dipartimento di Scienze Clinico-Chirurgiche Diagnostiche e Pediatriche, Unità di Microbiologia e Microbiologia Clinica, Università di Pavia , Pavia, Italy
| | - Alba Muzzi
- 6 U.O.C. Direzione Medica di Presidio, Fondazione IRCCS Policlinico San Matteo , Pavia, Italy
| | - Roberta Migliavacca
- 3 Dipartimento di Scienze Clinico-Chirurgiche Diagnostiche e Pediatriche, Unità di Microbiologia e Microbiologia Clinica, Università di Pavia , Pavia, Italy
| | - Luigia Scudeller
- 2 Servizio Biometria ed Epidemiologia Clinica, Direzione Scientifica, Fondazione IRCCS Policlinico San Matteo , Pavia, Italy
| | - Mauro Stronati
- 7 U.O.C. Neonatologia e Terapia Intensiva Neonatale, Fondazione IRCCS Policlinico San Matteo , Pavia, Italy
| | - Patrizia Cambieri
- 1 U.O.C. Microbiologia e Virologia, Fondazione IRCCS Policlinico San Matteo , Pavia, Italy
| |
Collapse
|
18
|
Soria Segarra C, Soria Baquero E, Cartelle Gestal M. High Prevalence of CTX-M-1-Like Enzymes in Urinary Isolates of Escherichia coli in Guayaquil, Ecuador. Microb Drug Resist 2018; 24:393-402. [PMID: 29298110 DOI: 10.1089/mdr.2017.0325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Escherichia coli is one of the major causes of urinary tract infections in primary healthcare, and treatment is more complicated due to the increase in antibiotic resistance. Extended-spectrum β-lactamases are the most common mechanism of resistance against third-generation cephalosporin, and CTX-M-like are among the most prevalent. The aim of our work is to investigate the prevalence of blaCTX-M in isolates of E. coli obtained from samples of patients without previous known contact with the hospital. Ninety-four E. coli isolates with resistance to third-generation cephalosporin were collected between 2008 and 2013 in Guayaquil, Ecuador. Polymerase chain reaction, followed by sequencing, was performed to identify the type of blaCTX-M-Like. Enterobacterial repetitive intergenic consensus (ERIC)-PCR was carried out to determine the clonal relationship between isolates. These results show an increase in resistance to third-generation cephalosporin from 10.58% to 23.96%. CTX-M-15 was the most prevalent mechanism of resistance being that the isolates were not clonal. Overall, these results show an increase in antibiotic resistance in the community over time, suggesting that more precise antibiotic stewardship needs to be implemented to control the dissemination of antibiotic-resistant bacteria in this region.
Collapse
Affiliation(s)
- Claudia Soria Segarra
- 1 Section of Bacteriology, Sosegar Clinical Laboratory , Guayaquil, Ecuador .,2 Faculty of Medical Sciences, University of Guayaquil , Guayaquil, Ecuador
| | | | - Monica Cartelle Gestal
- 3 Department of Infectious Diseases, Center for Vaccine and Immunology, University of Georgia , Athens, Georgia
| |
Collapse
|
19
|
ESBL-producing Escherichia coli
and Its Rapid Rise among Healthy People. Food Saf (Tokyo) 2017; 5:122-150. [PMID: 32231938 DOI: 10.14252/foodsafetyfscj.2017011] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 12/11/2017] [Indexed: 02/06/2023] Open
Abstract
Since around the 2000s, Escherichia coli (E. coli) resistant to both oxyimino-cephalosporins and fluoroquinolones has remarkably increased worldwide in clinical settings. The kind of E. coli is also identified in patients suffering from community-onset infectious diseases such as urinary tract infections. Moreover, recoveries of multi-drug resistant E. coli from the feces of healthy people have been increasingly documented in recent years, although the actual state remains uncertain. These E. coli isolates usually produce extended-spectrum β-lactamase (ESBL), as well as acquisition of amino acid substitutions in the quinolone-resistance determining regions (QRDRs) of GyrA and/or ParC, together with plasmid-mediated quinolone resistance determinants such as Qnr, AAC(6')-Ib-cr, and QepA. The actual state of ESBL-producing E. coli in hospitalized patients has been carefully investigated in many countries, while that in healthy people still remains uncertain, although high fecal carriage rates of ESBL producers in healthy people have been reported especially in Asian and South American countries. The issues regarding the ESBL producers have become very complicated and chaotic due to rapid increase of both ESBL variants and plasmids mediating ESBL genes, together with the emergence of various "epidemic strains" or "international clones" of E. coli and Klebsiella pneumoniae harboring transferable-plasmids carrying multiple antimicrobial resistance genes. Thus, the current state of ESBL producers outside hospital settings was overviewed together with the relation among those recovered from livestock, foods, pets, environments and wildlife from the viewpoint of molecular epidemiology. This mini review may contribute to better understanding about ESBL producers among people who are not familiar with the antimicrobial resistance (AMR) threatening rising globally.
Collapse
|
20
|
Aires CAM, Rybak MJ, Yim J, Pereira PS, Rocha-de-Souza CM, Albano RM, Cavalcanti VO, D'Alincourt Carvalho-Assef AP, Gomes MZR, Asensi MD. Genomic characterization of an extensively drug-resistant KPC-2-producing Klebsiella pneumoniae ST855 (CC258) only susceptible to ceftazidime-avibactam isolated in Brazil. Diagn Microbiol Infect Dis 2017; 89:324-327. [DOI: 10.1016/j.diagmicrobio.2017.08.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/05/2017] [Accepted: 08/21/2017] [Indexed: 02/01/2023]
|
21
|
Delerue T, de Pontual L, Carbonnelle E, Zahar JR. The potential role of microbiota for controlling the spread of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) in neonatal population. F1000Res 2017; 6:1217. [PMID: 28781766 PMCID: PMC5531162 DOI: 10.12688/f1000research.10713.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2017] [Indexed: 12/15/2022] Open
Abstract
The spread of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) in the hospital and also the community is worrisome. Neonates particularly are exposed to the risk of ESBL-PE acquisition and, owing to the immaturity of their immune system, to a higher secondary risk of ESBL-PE-related infection. Reducing the risk of acquisition in the hospital is usually based on a bundle of measures, including screening policies at admission, improving hand hygiene compliance, and decreasing antibiotic consumption. However, recent scientific data suggest new prevention opportunities based on microbiota modifications.
Collapse
Affiliation(s)
- Thibaud Delerue
- Département de Microbiologie Clinique et Unité de Contrôle et de Prévention du risque Infectieux, Groupe Hospitalier Paris Seine Saint-Denis, AP-HP, 125 rue de Stalingrad, 9300 Bobigny, France
| | - Loic de Pontual
- Service de pédiatrie, hôpital Jean-Verdier, Groupe Hospitalier Paris Seine Saint-Denis, Université Paris 13, AP-HP, 93140 Bondy, France
| | - Etienne Carbonnelle
- Département de Microbiologie Clinique et Unité de Contrôle et de Prévention du risque Infectieux, Groupe Hospitalier Paris Seine Saint-Denis, AP-HP, 125 rue de Stalingrad, 9300 Bobigny, France
- IAME, UMR 1137, Université Paris 13, Sorbonne Paris Cité, France
| | - Jean-Ralph Zahar
- Département de Microbiologie Clinique et Unité de Contrôle et de Prévention du risque Infectieux, Groupe Hospitalier Paris Seine Saint-Denis, AP-HP, 125 rue de Stalingrad, 9300 Bobigny, France
- IAME, UMR 1137, Université Paris 13, Sorbonne Paris Cité, France
| |
Collapse
|
22
|
Li X, Xu X, Yang X, Luo M, Liu P, Su K, Qing Y, Chen S, Qiu J, Li Y. Risk factors for infection and/or colonisation with extended-spectrum β-lactamase-producing bacteria in the neonatal intensive care unit: a meta-analysis. Int J Antimicrob Agents 2017; 50:622-628. [PMID: 28733213 DOI: 10.1016/j.ijantimicag.2017.06.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 06/16/2017] [Accepted: 06/24/2017] [Indexed: 01/11/2023]
Abstract
Extended-spectrum β-lactamase (ESBL)-producing bacteria are an important cause of healthcare-associated infections in the neonatal intensive care unit (NICU). The aim of this meta-analysis was to identify risk factors associated with infection and/or colonisation with ESBL-producing bacteria in the NICU. Electronic databases were searched for relevant studies published from 1 January 2000 to 1 July 2016. The literature was screened and data were extracted according to the inclusion and exclusion criteria. The Z-test was used to calculate the pooled odds ratio (OR) of the risk factors. ORs and their 95% confidence intervals were used to determine the significance of the risk. A total of 14 studies, including 746 cases and 1257 controls, were identified. Thirteen risk factors were determined to be related to infection and/or colonisation with ESBL-producing bacteria in the NICU: birthweight [standardised mean difference (SMD) = 1.17]; gestational age (SMD = 1.36); Caesarean delivery (OR = 1.76); parenteral nutrition (OR = 7.51); length of stay in the NICU (SMD = 0.72); mechanical ventilation (OR = 4.8); central venous catheter use (OR = 2.85); continuous positive airway pressure (OR = 5.0); endotracheal intubation (OR = 2.82); malformations (OR = 2.89); previous antibiotic use (OR = 6.72); ampicillin/gentamicin (OR = 2.31); and cephalosporins (OR = 6.0). This study identified risk factors for infection and/or colonisation with ESBL-producing bacteria in the NICU, which may provide a theoretical basis for preventive measures and targeted interventions.
Collapse
Affiliation(s)
- Xuan Li
- Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China
| | - Xuan Xu
- Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China
| | - Xianxian Yang
- Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China
| | - Mei Luo
- Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China
| | - Pin Liu
- Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China
| | - Kewen Su
- Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China
| | - Ying Qing
- Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China
| | - Shuai Chen
- Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China
| | - Jingfu Qiu
- Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China
| | - Yingli Li
- Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China.
| |
Collapse
|
23
|
Peretz A, Skuratovsky A, Khabra E, Adler A, Pastukh N, Barak S, Perlitz Y, Ben-Ami M, Kushnir A. Peripartum maternal transmission of extended-spectrum β-lactamase organism to newborn infants. Diagn Microbiol Infect Dis 2017; 87:168-171. [DOI: 10.1016/j.diagmicrobio.2016.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 11/07/2016] [Indexed: 10/20/2022]
|
24
|
High Gastrointestinal Colonization Rate with Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Hospitalized Patients: Emergence of Carbapenemase-Producing K. pneumoniae in Ethiopia. PLoS One 2016; 11:e0161685. [PMID: 27574974 PMCID: PMC5004900 DOI: 10.1371/journal.pone.0161685] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 08/10/2016] [Indexed: 11/19/2022] Open
Abstract
We investigated the gastrointestinal colonization rate and antibiotic resistance patterns of Extended-Spectrum Beta-Lactamase (ESBL)- producing Escherichia coli and Klebsiella pneumoniae in hospitalized patients admitted at Ethiopia's largest tertiary hospital. Fecal samples/swabs from 267 patients were cultured on chrome agar. ESBL. Bacterial species identification, verification of ESBL production and antibiotic susceptibility testing were done using Vitek 2 system (bioMérieux, France). Phenotype characterization of ESBL-E.coli and ESBL- K.pneumoniae was done using Neo-Sensitabs™. ESBL positivity rate was much higher in K. pneumoniae (76%) than E. coli (45%). The overall gastrointestinal colonization rate of ESBL producing Enterobacteriaceae (ESBL-E) in hospitalized patients was 52% (95%CI; 46%-58%) of which, ESBL-E. coli and K.pneumoniae accounted for 68% and 32% respectively. Fecal ESBL-E carriage rate in neonates, children and adults was 74%, 59% and 46% respectively. Gastrointestinal colonization rate of ESBL-E.coli in neonates, children and adults was 11%, 42% and 42% respectively. Of all E. coli strains isolated from adults, children and neonates, 44%, 49% and 22% were ESBL positive (p = 0.28). The prevalence of ESBL-K.pneumoniae carriage in neonates, children and adults was 68%, 22% and 7% respectively. All K. pneumoniae isolated from neonates (100%) and 88% of K. pneumoniae isolated from children were ESBL positive, but only 50% of K.pneumoniae isolated from adults were ESBL positive (p = 0.001). Thirteen patients (5%) were carriers of both ESBL-E.coli and ESBL-KP. The overall carrier rate of ESBL producing isolates resistant to carbapenem was 2% (5/267), all detected in children; three with E.coli HL cephalosporinase (AmpC), resistant to ertapenem and two with K. pneumoniae Carbapenemase (KPC) resistant to meropenem, ertapenem and impenem. We report a high gastrointestinal colonization rate with ESBL-E and the emergence of carbapenems-resistant K. pneumoniae in Ethiopia. Urgent implementation of infection control measures, and surveillance are urgently needed to limit the spread within healthcare facilities and further to the community.
Collapse
|
25
|
Delgado DYC, Barrigas ZPT, Astutillo SGO, Jaramillo APA, Ausili A. Detection and molecular characterization of β-lactamase genes in clinical isolates of Gram-negative bacteria in Southern Ecuador. Braz J Infect Dis 2016; 20:627-630. [PMID: 27479052 PMCID: PMC9427543 DOI: 10.1016/j.bjid.2016.07.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 07/09/2016] [Accepted: 07/12/2016] [Indexed: 12/30/2022] Open
Abstract
This work performed a phenotypic and genotypic characterization of 79 clinical isolates of Enterobacteriaceae and Pseudomonadaceae collected in hospitals of Southern Ecuadorin 2013. Our results showed a high incidence of β-lactamases and ESBLs with blaTEM and blaCTX-M as the prevalent genes, respectively. By direct sequencing of PCR amplicons, the different β-lactamases and variants of the genes were also distinguished. Our results revealed a predominance of TEM-1 β-lactamase and the presence of different CTX-M variants with a prevalence of CTX-M-15. Two infrequent CTX-M variants in South America were also identified. To the best of our knowledge, this is one of the first studies describing the genetic characteristics of β-lactamases in Ecuador.
Collapse
Affiliation(s)
| | | | | | | | - Alessio Ausili
- Universidad Técnica Particular de Loja (UTPL), Departamento de Ciencias de la Salud, Loja, Ecuador; Secretaría Nacional de Educación Superior, Ciencia, Tecnología e Innovación (SENESCYT), Quito, Ecuador.
| |
Collapse
|
26
|
Dautzenberg MJD, Haverkate MR, Bonten MJM, Bootsma MCJ. Epidemic potential of Escherichia coli ST131 and Klebsiella pneumoniae ST258: a systematic review and meta-analysis. BMJ Open 2016; 6:e009971. [PMID: 26988349 PMCID: PMC4800154 DOI: 10.1136/bmjopen-2015-009971] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Observational studies have suggested that Escherichia coli sequence type (ST) 131 and Klebsiella pneumoniae ST258 have hyperendemic properties. This would be obvious from continuously high incidence and/or prevalence of carriage or infection with these bacteria in specific patient populations. Hyperendemicity could result from increased transmissibility, longer duration of infectiousness, and/or higher pathogenic potential as compared with other lineages of the same species. The aim of our research is to quantitatively estimate these critical parameters for E. coli ST131 and K. pneumoniae ST258, in order to investigate whether E. coli ST131 and K. pneumoniae ST258 are truly hyperendemic clones. PRIMARY OUTCOME MEASURES A systematic literature search was performed to assess the evidence of transmissibility, duration of infectiousness, and pathogenicity for E. coli ST131 and K. pneumoniae ST258. Meta-regression was performed to quantify these characteristics. RESULTS The systematic literature search yielded 639 articles, of which 19 data sources provided information on transmissibility (E. coli ST131 n=9; K. pneumoniae ST258 n=10)), 2 on duration of infectiousness (E. coli ST131 n=2), and 324 on pathogenicity (E. coli ST131 n=285; K. pneumoniae ST258 n=39). Available data on duration of carriage and on transmissibility were insufficient for quantitative assessment. In multivariable meta-regression E. coli isolates causing infection were associated with ST131, compared to isolates only causing colonisation, suggesting that E. coli ST131 can be considered more pathogenic than non-ST131 isolates. Date of isolation, location and resistance mechanism also influenced the prevalence of ST131. E. coli ST131 was 3.2 (95% CI 2.0 to 5.0) times more pathogenic than non-ST131. For K. pneumoniae ST258 there were not enough data for meta-regression assessing the influence of colonisation versus infection on ST258 prevalence. CONCLUSIONS With the currently available data, it cannot be confirmed nor rejected, that E. coli ST131 or K. pneumoniae ST258 are hyperendemic clones.
Collapse
Affiliation(s)
- M J D Dautzenberg
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M R Haverkate
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M C J Bootsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands Faculty of Sciences, Department of Mathematics, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
27
|
Giuffrè M, Geraci DM, Bonura C, Saporito L, Graziano G, Insinga V, Aleo A, Vecchio D, Mammina C. The Increasing Challenge of Multidrug-Resistant Gram-Negative Bacilli: Results of a 5-Year Active Surveillance Program in a Neonatal Intensive Care Unit. Medicine (Baltimore) 2016; 95:e3016. [PMID: 26962817 PMCID: PMC4998898 DOI: 10.1097/md.0000000000003016] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Colonization and infection by multidrug-resistant gram-negative bacilli (MDR GNB) in neonatal intensive care units (NICUs) are increasingly reported.We conducted a 5-year prospective cohort surveillance study in a tertiary NICU of the hospital "Paolo Giaccone," Palermo, Italy. Our objectives were to describe incidence and trends of MDR GNB colonization and the characteristics of the most prevalent organisms and to identify the risk factors for colonization. Demographic, clinical, and microbiological data were prospectively collected. Active surveillance cultures (ASCs) were obtained weekly. Clusters of colonization by extended spectrum β-lactamase (ESBL) producing Escherichia coli and Klebsiella pneumoniae were analyzed by conventional and molecular epidemiological tools.During the study period, 1152 infants were enrolled in the study. Prevalences of colonization by MDR GNB, ESBL-producing GNB and multiple species/genera averaged, respectively, 28.8%, 11.7%, and 3.7%. Prevalence and incidence density of colonization by MDR GNB and ESBL-producing GNB showed an upward trend through the surveillance period. Rates of ESBL-producing E coli and K pneumoniae colonization showed wide fluctuations peaking over the last 2 years. The only independent variables associated with colonization by MDR GNB and ESBL-producing organisms and multiple colonization were, respectively, the days of NICU stay (odds ratio [OR] 1.041), the days of exposure to ampicillin-sulbactam (OR 1.040), and the days of formula feeding (OR 1.031). Most clusters of E coli and K pneumoniae colonization were associated with different lineages. Ten out of 12 clusters had an outborn infant as their index case.Our study confirms that MDR GNB are an increasing challenge to NICUs. The universal once-a-week approach allowed us to understand the epidemiology of MDR GNB, to timely detect new clones and institute contact precautions, and to assess risk factors. Collection of these data can be an important tool to optimize antimicrobials use and control the emergence and dissemination of resistances in NICU.
Collapse
Affiliation(s)
- Mario Giuffrè
- From the Department of Sciences for Health Promotion and Mother-Child Care "G. D'Alessandro," University of Palermo, Palermo, Italy; the Azienda Ospedaliera-Universitaria Policlinico "Paolo Giaccone" (MG, CB, VI, CM), Palermo, Italy; Department of Sciences for Health Promotion and Mother-Child Care "G. D'Alessandro" (DMG, AA), University of Palermo, Palermo, Italy; Post-Graduate Residency School in Hygiene and Preventive Medicine (LS, GG), University of Palermo, Palermo, Italy; Post-Graduate Residency School in Pediatrics (DV), University of Palermo, Palermo, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Lukac PJ, Bonomo RA, Logan LK. Extended-spectrum β-lactamase-producing Enterobacteriaceae in children: old foe, emerging threat. Clin Infect Dis 2015; 60:1389-97. [PMID: 25595742 DOI: 10.1093/cid/civ020] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 12/24/2014] [Indexed: 11/12/2022] Open
Abstract
Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae present an ever-growing burden in the hospital and community settings, across all ages and demographics. Infections due to ESBL-containing pathogens continue to be associated with significant morbidity and mortality worldwide. With widespread empiric broad-spectrum β-lactam use creating selective pressure, and the resultant emergence of stable, rapidly proliferating ESBL-producing clones with continued horizontal gene transfer across genera, addressing this issue remains imperative. Although well characterized in adults, the epidemiology, risk factors, outcomes, therapies, and control measures for ESBL-producing bacteria are less appreciated in children. This analysis provides a brief summary of ESBL-producing Enterobacteriaceae in children, with a focus on recent clinical and molecular data regarding colonization and infection in nonoutbreak settings.
Collapse
Affiliation(s)
| | - Robert A Bonomo
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center Department of Medicine Department of Pharmacology Department of Molecular Biology and Microbiology, Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Latania K Logan
- Department of Pediatrics Section of Pediatric Infectious Diseases, Rush University Medical Center, Rush Medical College, Chicago, Illinois Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center
| |
Collapse
|
29
|
Tijet N, Sheth PM, Lastovetska O, Chung C, Patel SN, Melano RG. Molecular characterization of Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae in Ontario, Canada, 2008-2011. PLoS One 2014; 9:e116421. [PMID: 25549365 PMCID: PMC4280202 DOI: 10.1371/journal.pone.0116421] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 12/09/2014] [Indexed: 12/25/2022] Open
Abstract
Due to the lack of detailed reports of Klebsiella pneumoniae carbapenemase (KPC)-producing enterobacteria in Ontario, Canada, we perform a molecular characterization of KPC-producing Enterobacteriaceae submitted to the provincial reference laboratory from 2008 to 2011. Susceptibility profiles were accessed by E-test. Molecular types of isolates were determined by pulse-field gel electrophoresis (PFGE) and multilocus sequence typing. Screening of ß-lactamase genes was performed by multiplex PCR and alleles were identified by DNA sequencing. The genetic platform of blaKPC gene was analyzed by PCR. Plasmid replicons were typed using PCR-based typing approach. KPC-plasmids were also evaluated by S1 nuclease-PFGE and Southern blot. Thirty unique clinical isolates (26 Klebsiella pneumoniae, 2 Enterobacter cloacae, 1 Citrobacter freundii and 1 Raoultella ornithinolytica) were identified as blaKPC positive: 4 in 2008, 3 in 2009, 10 in 2010 and 13 in 2011. The majority exhibited resistance to carbapenems, cephalosporins and fluoroquinolones and two isolates were also resistant to colistin. The isolates harbored blaKPC-2 (n = 23) or blaKPC-3 (n = 7). blaTEM-1 (n = 27) was commonly detected and occasionally blaOXA-1 (n = 3) and blaCTX-M-15 (n = 1). As expected, all K. pneumoniae isolates carried blaSHV-11. blaKPC genes were identified on Tn4401a (n = 20) or b (n = 10) isoforms, on plasmids of different sizes belonging to the incompatibility groups IncFIIA (n = 19), IncN (n = 3), IncI2 (n = 3), IncFrep (n = 2) and IncA/C (n = 1). The occurrence of KPC ß-lactamase in Ontario was mainly associated with the spread of the K. pneumoniae clone ST258.
Collapse
Affiliation(s)
- Nathalie Tijet
- Public Health Ontario Laboratories, Toronto, Ontario, Canada
| | - Prameet M. Sheth
- Department of Pathology and Molecular Medicine, Queen’s University, Kingston, Ontario, Canada
| | | | - Catherine Chung
- Public Health Ontario Laboratories, Toronto, Ontario, Canada
| | - Samir N. Patel
- Public Health Ontario Laboratories, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Roberto G. Melano
- Public Health Ontario Laboratories, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Department of Microbiology, Mt Sinai Hospital, Toronto, Ontario, Canada
- * E-mail:
| |
Collapse
|
30
|
Basu S. Neonatal sepsis: the gut connection. Eur J Clin Microbiol Infect Dis 2014; 34:215-22. [PMID: 25213719 DOI: 10.1007/s10096-014-2232-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 08/12/2014] [Indexed: 01/07/2023]
Abstract
Colonization of the neonatal gut takes place immediately after birth. Bacteria that get colonized are considered to be "normal" flora derived principally from the mother and the immediate environment. However, for some neonates, the colonization of the gut, particularly with potential pathogens, may lead to subsequent infections or sepsis. The immune system and the gut barrier in neonates is vulnerable, with decreased acid secretion, low levels of protective mucous, and decreased motility, particularly in those who are premature and of low birth weight. This makes the neonatal gut especially prone to colonization with aerobic Gram-negative bacilli (GNB). And these GNB may later, under circumstances favorable to them, cause disease in the neonates. In developing countries, it is the GNB that cause the majority of the infections. In addition, the use of antibiotics in the neonatal intensive care unit also triggers colonization with antibiotic-resistant bacteria. This review discusses various aspects of neonatal gut colonization, neonatal sepsis, and tries to gather support to understand the connection between the gut and subsequent sepsis in neonates.
Collapse
Affiliation(s)
- S Basu
- Division of Bacteriology, National Institute of Cholera and Enteric Diseases, P33, CIT Road, Scheme XM, Beliaghata, Kolkata, 700010, India,
| |
Collapse
|
31
|
Affiliation(s)
- Otto Cars
- ReAct, Action on Antibiotic Resistance, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| |
Collapse
|
32
|
Denkel LA, Schwab F, Kola A, Leistner R, Garten L, von Weizsäcker K, Geffers C, Gastmeier P, Piening B. The mother as most important risk factor for colonization of very low birth weight (VLBW) infants with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E). J Antimicrob Chemother 2014; 69:2230-7. [PMID: 24729603 DOI: 10.1093/jac/dku097] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES This study aimed to determine the prevalence of and risk factors for colonization with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) and methicillin-resistant Staphylococcus aureus (MRSA) in very low birth weight (VLBW; <1500 g) infants and their mothers. METHODS This investigation was conducted in the perinatal centre at the Charité Berlin between May 2012 and June 2013. VLBW infants and their mothers were screened for colonization with ESBL-E and MRSA. Demographic and clinical data were obtained from the German nationwide surveillance system for nosocomial infections in VLBW infants (NEO-KISS) and used to perform univariate and multivariate analyses. RESULTS Of 209 VLBW infants, 12 (5.7%) were colonized with ESBL-E. Eighteen of 209 (8.6%) ESBL-E-tested neonates were related to an ESBL-E-positive mother. Univariate analysis, strain typing and multivariate analysis (OR 7.4, 95% CI 2.1-26.7, P = 0.002) identified an ESBL-E-positive mother and maternal-neonatal transmission as a main source of colonization. The prevalence of MRSA was 2.3% (5 of 221) among VLBW infants. One of the 221 (0.5%) MRSA-tested neonates was related to an MRSA-positive mother. No risk factors for transmission of MRSA could be detected in this study. CONCLUSIONS Our study demonstrated that maternal-neonatal transmission of ESBL-E from mother to child is an important risk factor for colonization of VLBW infants. As a consequence, routine ESBL-E screening of neonates and mothers should be considered as a means of reducing neonatal morbidity and mortality.
Collapse
Affiliation(s)
- Luisa A Denkel
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, German National Reference Center for the Surveillance of Nosocomial Infections, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Frank Schwab
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, German National Reference Center for the Surveillance of Nosocomial Infections, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Axel Kola
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, German National Reference Center for the Surveillance of Nosocomial Infections, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Rasmus Leistner
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, German National Reference Center for the Surveillance of Nosocomial Infections, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Lars Garten
- Department of Neonatology, Charité University Medical Center Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - Katharina von Weizsäcker
- Department of Obstetrics, Charité University Medical Center Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - Christine Geffers
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, German National Reference Center for the Surveillance of Nosocomial Infections, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, German National Reference Center for the Surveillance of Nosocomial Infections, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Brar Piening
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, German National Reference Center for the Surveillance of Nosocomial Infections, Hindenburgdamm 27, D-12203 Berlin, Germany
| |
Collapse
|