High prevalence of multidrug resistant Enterobacteriaceae among residents of long term care facilities in Amsterdam, the Netherlands

Microbiological Species and Antibiotic Resistance in Diabetic and Nondiabetic Lower Extremity Wounds: A Comparative Cross-Sectional Study

Severe lower extremity wounds have an increased risk of complications and limb loss. The aim of this study was to evaluate and compare the microbiological profile and antibiotic resistance of wounds in diabetic and nondiabetic patients. A cross-sectional comparative study was carried out at a public hospital including 111 patients with moderate to severe wound infections. Tissue samples were collected during a surgical procedure. One hundred and four patients (94%) had positive cultures and 88 (79%) had a Gram-negative microorganism. Among the 185 cultured microorganisms, 133 (72%) were Gram-negative species. Pseudomonas aeruginosa (23 cases) was the most isolated Gram-negative species, and Enterococcus faecalis (26 cases) was the most prevalent Gram-positive species. Among 185 isolated species, 45 (24%) were extended-spectrum beta-lactamase producers, 23 (12%) were carbapenem-resistant, and 5 (3%) were methicillin-resistant Staphylococcus aureus. Findings revealed that there was no significant difference in the microbiological profile and antibiotic resistance among patients with lower extremity wounds whether they were diabetic or nondiabetic.

Educational interventions to prevent urinary infections in institutionalized elderly people. Quasi-experimental Study

Objective

To analyze the effectiveness of an educational intervention among nursing professionals and caregivers to prevent urinary tract infections in institutionalized elderly people.

Methods

this is a quasi-experimental study carried out with 20 people (7 nurses and 13 formal caregivers). A questionnaire was applied during the pre-intervention stage, then professional training was carried out and finally, the questionnaire was reapplied 6 months after the intervention. The prevalence profile and factors associated with urinary infections in 116 elderly people was evaluated before and after the educational interventions. Statistical analysis was performed using association and correlation tests, logistic regression model comparison and prevalence rates.

Results

The average number of correct answers by the nursing professionals and caregivers after the educational intervention increased from the pre to the post-test by 52% regarding signs of urinary infection, 32% regarding its symptoms, 72.5% regarding its treatment, 40% regarding personal/behavioral and morbidity-related risk factors, 59% regarding conditional factors and 43.8% regarding its preventive measures. The team of caregivers showed a greater gain in knowledge compared to the nursing team in almost every question (p<0.05). The length of time working in elderly care showed no positive correlation with any variable (R< p>0.05). The prevalence of urinary tract infection in the pre-intervention period was 33.62%, and 20% in the post-intervention period.

Conclusion

The educational intervention was effective in preventing urinary tract infections in the elderly. The increased knowledge acquired by nurses and caregivers was associated with a reduction in the infection rate and an improvement in the most prevalent modifiable factors for the development of this type of pathology.

Genetic epidemiology and plasmid-mediated transmission of mcr-1 by Escherichia coli ST155 from wastewater of long-term care facilities

Long-term care facilities (LTCFs) for older people play an important and unique role in multidrug-resistant organism transmission. Herein, we investigated the genetic characteristics of mobile colistin resistance gene (mcr-1)-carrying Escherichia coli strains isolated from wastewater of LTCFs in Shanghai. Antimicrobial susceptibility test was carried out by agar dilution methods. Whole-genome sequencing and plasmid sequencing were conducted, and resistance genes and sequence types of colistin in E. coli isolates were analyzed. Core genome multilocus sequence typing (cgMLST) analysis was performed by the Ridom SeqSphere+ software. Phylogenetic tree through the maximum likelihood method was constructed by MEGA X. Out of 306 isolates, only 1 E. coli named ECSJ33 was found, and the plasmid pECSJ33 from ECSJ33 harbored the mcr-1 gene that was located with 59,080 bp belonging to IncI2 type. The plasmid pECSJ33 was capable of conjugation with an efficiency of 2.9 × 10-2. Bioinformatic analysis indicated pECSJ33 shared backbone with the previously reported mcr-1-harboring pHNGDF93 isolated from fish source. Moreover, the cgMLST analysis revealed that ECSJ33 belongs to different lineages from those reported from previous E. coli strains but shared high similarity to NCTC11129 in cluster 11. The phylogenetic tree revealed MCR-1 of ECSJ33 in this study was mostly of animal food origin and that they were closely related. Our study firstly reports detection of genome sequence of a multidrug-resistant mcr-1-harboring E. coli ST155 from wastewater of LTCF source in China. The data may prove that the plasmid pECSJ33 belongs to food origin and help to understand the antimicrobial resistance mechanisms and genomic features of colistin resistance under One Health approach.IMPORTANCEOne Escherichia coli named ECSJ33 was found from wastewater of a long-term care facility (LTCF) and the plasmid pECSJ33 from ECSJ33 harbored the mobile colistin resistance gene (mcr-1) that was located with 59,080 bp belonging to IncI2 type, which was capable of conjugation with an efficiency of 2.9 × 10-2. This paper firstly reports an mcr-1-carrying E. coli strain ST155 isolated from LTCF in China. Comparative genomics analysis indicated pECSJ33 shared backbone with the previously reported mcr-1-harboring pHNGDF93 isolated from fish source. The phylogenetic tree revealed MCR-1 protein of ECSJ33 in this study was mostly of animal food origin and that they were closely related. Therefore, the pECSJ33 could be considered as food-origin transmission mcr-1-harboring plasmid.

Epidemiology and zoonotic transmission of mcr-positive and carbapenemase-producing Enterobacterales on German turkey farms

Introduction

The emergence of carbapenem-resistant bacteria causing serious infections may lead to more frequent use of previously abandoned antibiotics like colistin. However, mobile colistin resistance genes (mcr) can jeopardise its effectiveness in both human and veterinary medicine. In Germany, turkeys have been identified as the food-producing animal most likely to harbour mcr-positive colistin-resistant Enterobacterales (mcr-Col-E). Therefore, the aim of the present study was to assess the prevalence of both mcr-Col-E and carbapenemase-producing Enterobacterales (CPE) in German turkey herds and humans in contact with these herds.

Methods

In 2018 and 2019, 175 environmental (boot swabs of turkey faeces) and 46 human stool samples were analysed using a combination of enrichment-based culture, PCR, core genome multilocus sequence typing (cgMLST) and plasmid typing.

Results

mcr-Col-E were detected in 123 of the 175 turkey farms in this study (70.3%). mcr-Col-E isolates were Escherichia coli (98.4%) and Klebsiella spp. (1.6%). Herds that had been treated with colistin were more likely to harbour mcr-Col-E, with 82.2% compared to 66.2% in untreated herds (p = 0.0298). Prevalence also depended on husbandry, with 7.1% mcr-Col-E in organic farms compared to 74.5% in conventional ones (p < 0.001). In addition, four of the 46 (8.7%) human participants were colonised with mcr-Col-E. mcr-Col-E isolates from stables had minimum inhibitory concentrations (MICs) from 4 to ≥ 32 mg/l, human isolates ranged from 4 to 8 mg/l. cgMLST showed no clonal transmission of isolates. For one farm, plasmid typing revealed great similarities between plasmids from an environmental and a human sample. No CPE were found in turkey herds or humans.

Discussion

These findings confirm that mcr-Col-E-prevalence is high in turkey farms, but no evidence of direct zoonotic transmission of clonal mcr-Col-E strains was found. However, the results indicate that plasmids may be transmitted between E. coli isolates from animals and humans.

Single-use duodenoscopes compared with reusable duodenoscopes in patients carrying multidrug-resistant microorganisms: a break-even cost analysis

Background and study aims  Single-use duodenoscopes can prevent transmission of microorganisms through contaminated reusable duodenoscopes. Concerns regarding their economic and environmental impact impede the transition to single-use duodenoscopes. This study investigated the costs associated with two scenarios in which single-use duodenoscopes are used in patients carrying multidrug-resistant microorganisms (MDROs). Methods  Break-even costs for single-use duodenoscopes were calculated for two scenarios in which patients were screened for MDRO carriage before undergoing endoscopic retrograde cholangiopancreatography (ERCP). Only direct costs related to the endoscopy were taken into consideration. In Scenario 1, patients were screened through microbiological culturing with a lag time in receiving the test result. In Scenario 2, screening was performed using GeneXpert analysis providing a rapid read-out. Calculations were performed using data from a Dutch tertiary care center and also with US healthcare data. Results  In the Dutch situation, single-use duodenoscopes needed to be priced at a maximum of € 140 to € 250 to break-even. In the US analyses, break-even costs varied widely, depending on the duodenoscope-associated infection costs used, ERCP volume, and infection risk. The break-even costs in Scenario 1 ranged between $78.21 and $2,747.54 and in Scenario 2, between $248.89 and $2,209.23. Conclusions  This study showed that a crossover scenario in which single-use duodenoscopes are only used in patients carrying MDROs could be an economically viable alternative to a complete transition to single-use duodenoscopes. In the Dutch setting, single-use duodenoscopes need to be priced much lower than in the United States to reach a per-procedure cost that is comparable with a scenario using reusable duodenoscopes exclusively.

Risk factors for colonization by carbapenemase-producing bacteria in Spanish long-term care facilities: a multicentre point-prevalence study

BACKGROUND

The emergence of carbapenemase-producing bacteria (CPB) has become a major public health concern. Long-term care facilities (LTCF) are potential reservoirs for multidrug-resistant micro-organisms (MDRO). However, data on CPB is limited. The study aims to determine the prevalence of MDRO and risk factors for CPB colonization among residents of LTCFs.

METHODS

A point-prevalence study was conducted at 14 LTCFs in Tenerife (Spain) between October 2020 and May 2021. Nasal and rectal swabs were cultured for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), carbapenemase-producing Enterobacterales, MDR Acinetobacter baumannii (MDR-Ab) and MDR Pseudomonas aeruginosa. Antimicrobial susceptibility testing and molecular detection of resistance genes were performed. Risk factors for colonization by carbapenemase-producing bacteria (CPB) were determined by univariate and multivariate analysis.

RESULTS

A total of 760 LTCF residents were recruited. The prevalence of colonization by CPB was 9.3% (n = 71) with the following distribution: 35 (49.3%) K. pneumoniae, 26 (36.6%) MDR-Ab, 17 (23.9%) E. coli, and 1 (1.4%) C. koseri. In addition, the prevalence of colonization by MRSA was 28.1% (n = 215) and only one case of VRE was isolated. Multivariate analysis identified male sex (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.86-3.11; P = 0.01), having a high health requirement (OR, 6.32; 95% CI, 1.91-20.92; P = 0.003) and previous hospitalization (OR, 3.60; 95% CI, 1.59-8.15 P = 0.002) as independent risk factors for CPB rectal carriage.

CONCLUSIONS

LTCFs are an important reservoir for MDRO, including CPB. We have identified some predictors of colonization by CPB, which enable a more targeted management of high-risk residents. Antimicrobial stewardship programmes and infection control preventive measures are needed to stop acquisition and transmission of MDRO.

Occurrence of Healthcare-Associated Infections (HAIs) by Escherichia coli and Klebsiella spp. Producing Extended-Spectrum β-lactamases (ESBL) and/or Carbapenemases in Portuguese Long-Term Care Facilities

Extended-spectrum-β-lactamase (ESBL)- and carbapenemase-producing bacteria are widespread in hospitals, but the extent of this problem in long-term care facilities (LTCFs) is poorly understood. We aimed to elucidate, in the Portuguese regional clinical context, the relevance of LTCFs as a reservoir of Escherichia coli and Klebsiella spp. producing ESBL- and/or carbapenemases (Ec/Kp-ESBL/CARB). Fourteen LTCFs from Portugal, corresponding to units of convalescence (UC/n = 3), medium-term internment and rehabilitation (UMDR/ n = 5), or long-term internment and maintenance (ULDM/n = 6), were analyzed (2016–2019). All patients with Ec/Kp-ESBL/CARB infections acquired during LTCF stay were included, and detailed information was collected. Prevalence of patients with healthcare-associated infections (HAIs) by Ec/Kp-ESBL/CARB did not vary significantly over time (1.48% in 2016–2017, 1.89% in 2017–2018, and 1.90% in 2018–2019), but a statistically significant association with the LTCF typology (ULDM, UMDR) was observed. HAIs were caused by K. pneumoniae (n = 51/54.3%), E. coli (n = 41/43.6%), or both (n = 2/2.1%), producing ESBL (96%) or carbapenemases (4%). Prior colonization (n = 14/16%) corresponded to seven Kp-CARB and seven Ec/Kp-ESBL. The worrying prevalence of patients acquiring HAIs by Ec/Kp-ESBL/CARB, associated with the estimated rates of those already colonized at admission, highlights a relevant role for LTCFs as a reservoir of Ec/Kp-ESBL/CARB. Epidemiological surveillance should be extended to the national level, and colonization screening at LTCF admission implemented systematically.

A prospective matched case-control study on the genomic epidemiology of colistin-resistant Enterobacterales from Dutch patients

Background

Colistin is a last-resort treatment option for infections with multidrug-resistant Gram-negative bacteria. However, colistin resistance is increasing.

Methods

A six-month prospective matched case-control study was performed in which 22 Dutch laboratories with 32 associated hospitals participated. Laboratories were invited to send a maximum of five colistin-resistant Escherichia coli or Klebsiella pneumoniae (COLR-EK) isolates and five colistin-susceptible isolates (COLS-EK) to the reference laboratory, matched for patient location, material of origin and bacterial species. Epidemiological/clinical data were collected and included in the analysis. Characteristics of COLR-EK/COLS-EK isolates were compared using logistic regression with correction for variables used for matching. Forty-six ColR-EK/ColS-EK pairs were analysed by next-generation sequencing (NGS) for whole-genome multi-locus sequence typing and identification of resistance genes, including mcr genes. To identify chromosomal mutations potentially leading to colistin resistance, NGS reads were mapped against gene sequences of pmrAB, phoPQ, mgrB and crrB.

Results

In total, 72 COLR-EK/COLS-EK pairs (75% E. coli and 25% K. pneumoniae) were included. Twenty-one percent of COLR-EK patients had received colistin, in contrast to 3% of COLS-EK patients (OR > 2.9). Of COLR-EK isolates, five contained mcr-1 and two mcr-9. One isolate lost mcr-9 after repeated sub-culturing, but retained colistin resistance. Among 46 sequenced COLR-EK isolates, genetic diversity was large and 19 (41.3%) isolates had chromosomal mutations potentially associated with colistin resistance.

Conclusions

Colistin resistance is present but uncommon in the Netherlands and caused by the mcr gene in a minority of COLR-EK isolates. There is a need for surveillance of colistin resistance using appropriate susceptibility testing methods.

Multidrug-Resistant Bacteria on Healthcare Workers' Uniforms in Hospitals and Long-Term Care Facilities in Cyprus

Healthcare workers’ (HCW) clothing has been shown to harbor multidrug-resistant bacteria (MDRB) and may contribute to transmission. The aim of this study was to evaluate presence of MDRB on HCW uniforms in Cyprus. A cross-sectional study was carried out in 9 hospital wards and 7 long-term care facilities (LTCFs) in Nicosia, Cyprus, from April–August 2019. Sampling of HCW uniform pockets was conducted at the end of the first shift. Personal hygiene and other habits were recorded during personal interviews. Among 140 sampled HCW (69 from hospitals, 71 from LTCFs), 37 MDRB were identified, including 16 vancomycin-resistant enterococci (VRE), 15 methicillin-resistant Staphylococcus aureus (MRSA), 5 extended spectrum b-lactamase (ESBL)-producing bacteria, and 1 carbapenem-resistant Acinetobacter baumannii. Presence of MDRB was higher in LTCFs compared to hospitals (p = 0.03). Higher MDRB rates in uniforms were noted in HCWs that worked <1 year (41.7% vs. 21.1%) and in HCWs that opted for home laundering (23.5% vs. 12.5%) or visited the toilet during shifts (38.1% vs. 20.2%). Our findings indicate that HCW uniforms harbor MDRB and relevant interventions may reduce transmission risk. We identified LTCFs as an important area for targeted measures. Additional factors associated with HCW practices, characteristics, and attire laundering practices represent areas for improvement, particularly in LTCFs.

Prolonged carriage of ESBL-producing enterobacterales and potential cross-transmission among residents in geriatric long-term care facilities

Previous studies indicated residents in geriatric long-term care facilities (LTCFs) had much higher prevalence of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) carriage than the general population. Most ESBL-E carriers are asymptomatic. The study tested the hypothesis that residents with ESBL-E carriage may accumulate inside geriatric LTCFs through potential cross-transmission after exposure to residents with prolonged ESBL-E carriage. 260 residents from four Japanese LTCFs underwent ESBL-E testing of fecal specimens and were divided into two cohorts: Cohort 1,75 patients with ≥ 2 months residence at study onset; Cohort 2, 185 patients with < 2 months residence at study onset or new admission during the study period. Three analyses were performed: (1) ESBL-E carriage statuses in Cohort 1 and Cohort 2; (2) changes in ESBL-E carriage statuses 3-12 months after the first testing and ≥ 12 months after the second testing; and (3) lengths of positive ESBL-E carriage statuses. Compared with the residents in Cohort 1, a significantly larger proportion of residents in Cohort 2 were positive for ESBL-E carriage (28.0% in Cohort 1 vs 40.0% in Cohort 2). In the subsequent testing results, 18.3% of residents who were negative in the first testing showed positive conversion to ESBL-E carriage in the second testing, while no patients who were negative in the second testing showed positive conversion in the third testing. The maximum length of ESBL-E carriage was 17 months. The findings indicated that some residents acquired ESBL-E through potential cross-transmission inside the LTCFs after short-term residence. However, no residents showed positive conversion after long-term residence, which indicates that residents with ESBL-E carriage may not accumulate inside LTCFs. Practical infection control and prevention measures could improve the ESBL-E prevalence in geriatric LTCFs.

Barriers and facilitators to infection prevention and control in Dutch residential care facilities for people with intellectual and developmental disabilities: A theory-informed qualitative study

BACKGROUND

Care institutions are recognised to be a high-risk setting for the emergence and spread of infections and antimicrobial-resistant organisms, which stresses the importance of infection prevention and control (IPC). Accurate implementation is crucial for optimal IPC practice. Despite the wide promotion of IPC and research thereof in the hospital and nursing home setting, similar efforts are lacking in disability care settings. Therefore, this study aimed to assess perceived barriers and facilitators to IPC among professionals working at residential care facilities (RCFs) for people with intellectual and developmental disabilities (IDD), as well as to identify professional-reported recommendations to improve IPC.

METHODS

This qualitative study involved semi-structured interviews (before COVID-19) with twelve professionals from five Dutch RCFs for people with IDD. An integrated theoretical approach was used to inform data collection and analysis. Thematic analysis using inductive and deductive approaches was conducted. This study followed the COnsolidated criteria for REporting Qualitative research (COREQ) guidelines.

RESULTS

Our findings revealed barriers and facilitators at the guideline, client, professional, professional interaction, professional client interaction, client interaction, organisational, community, and societal level. Six main themes covering multiple barriers and facilitators were identified: (1) guidelines' applicability to (work)setting; (2) professionals' cognitions and attitude towards IPC (related to educational background); (3) organisational support and priority; (4) educational system; (5) time availability and staff capacity; and (6) task division and change coaches. The main professional-reported recommendations were the introduction of tailored and practical IPC guidelines, structural IPC education and training among all professionals, and client participation.

CONCLUSIONS

To promote IPC, multifaceted and multilevel strategies should be implemented, with a preliminary need for improvements on the guideline, professional, and organisational level. Given the heterogeneous character, i.e., different professionals, clients and care needs, there is a need for a tailored approach to implement IPC and sustain it successfully in disability care. Our findings can inform future IPC practice improvements.

Extended Spectrum Beta-Lactamase (ESBL) Produced by Gram-Negative Bacteria in Trinidad and Tobago

Gram-negative bacterial infections are a global health problem. The production of beta-lactamase is still the most vital factor leading to beta-lactam resistance. In Trinidad and Tobago, extended spectrum beta-lactamase (ESBL) production has been detected and reported mainly in the isolates of Klebsiella pneumoniae and Escherichia coli and constitutes a public health emergency that causes high morbidity and mortality in some patients. In this literature review, the authors cover vast information on ESBL frequency and laboratory detection using both conventional and molecular methods from clinical data. The aim is to make the reader reflect on how the actual knowledge can be used for rapid detection and understanding of the spread of antimicrobial resistance problems stemming from ESBL production among common Gram-negative organisms in the health care system.

Multiresistant Gram-Negative Pathogens—A Zoonotic Problem

BACKGROUND

Extended-spectrum-β-lactamase-producing, carbapenemase-producing, and colistin-resistant Enterobacteriaceae (ESBL-E, CPE, and Col-E) are multiresistant pathogens that are increasingly being encountered in both human and veterinary medicine. In this review, we discuss the frequency, sources, and significance of the zoonotic transmission of these pathogens between animals and human beings.

METHODS

This review is based on pertinent publications retrieved by a selective literature search. Findings for Germany are presented in the global context.

RESULTS

ESBL-E are common in Germany in both animals and human beings, with a 6-10% colonization rate in the general human population. A major source of ESBL-E is human-tohuman transmission, partly through travel. Some colonizations are of zoonotic origin (i.e., brought about by contact with animals or animal-derived food products); in the Netherlands, more than 20% of cases are thought to be of this type. CPE infections, on the other hand, are rare in Germany in both animals and human beings. Their main source in human beings is nosocomial transmission. Col-E, which bear mcr resistance genes, have been described in Germany mainly in food-producing animals and their meat. No representative data are available on Col-E in human beings in Germany; in Europe, the prevalence of colonization is less than 2%, with long-distance travel as a risk factor. The relevance of animals as a source of Col-E for human beings is not yet entirely clear.

CONCLUSION

Livestock farming and animal contact affect human colonization with the multiresistant Gram-negative pathogens CPE, ESBL-E and Col-E to differing extents. Improved prevention will require the joint efforts of human and veterinary medicine.

National point prevalence study on carriage of multidrug-resistant microorganisms in Dutch long-term care facilities in 2018

OBJECTIVES

Long-term care facilities (LTCFs) may act as a reservoir of ESBL-producing Enterobacterales (ESBL-E) and carbapenemase-producing Enterobacterales (CPE) for hospitals and the general population. In this study, we estimated the prevalence and molecular epidemiology of rectal carriage with ESBL-E and CPE in residents of Dutch LTCFs between March 2018 and December 2018.

METHODS

LTCFs were geographically selected across the country. For each LTCF, a random sample of residents were tested for ESBL-E and CPE in 2018. To identify risk factors for high carriage prevalence and/or individual carriage, characteristics of LTCFs and of a subset of the tested residents were collected. WGS was conducted on isolates from LTCFs with an ESBL-E prevalence of >10% and all CPE isolates to identify institutional clonal transmission.

RESULTS

A total of 4420 residents of 159 LTCFs were included. The weighted mean ESBL-E prevalence was 8.3% (95% CI: 6.8-10.0) and no CPE were found. In 53 LTCFs (33%), where ESBL-E prevalence was >10%, MLST using WGS (wgMLST) was performed. This included 264 isolates, the majority being Escherichia coli (n = 224) followed by Klebsiella pneumoniae (n = 30). Genetic clusters were identified in more than half (30/53; 57%) of high ESBL-positive LTCFs. Among the E. coli isolates, blaCTX-M-15 (92/224; 41%) and blaCTX-M-27 (40/224; 18%) were the most prevalent ESBL-encoding genes. For K. pneumoniae isolates, the most common was blaCTX-M-15 (23/30; 80%).

CONCLUSIONS

The estimated prevalence of ESBL-E rectal carriage in Dutch LTCFs is 8.3% and resistance is observed mainly in E. coli with predominance of blaCTX-M-15 and blaCTX-M-27. ESBL-E prevalence in LTCFs seems comparable to previously reported prevalence in hospitals and the general population.

Rectal Colonization by Drug Resistant Bacteria in Nursing Home Residents in Crete, Greece

(1) Background: In an area with a high prevalence of multi-drug resistant Gram-negative bacteria (MDR-GNB), we investigated the colonization of nursing home residents by such organisms. (2) Methods: A point prevalence study was performed in six nursing homes of the Heraklion area on the island of Crete. A rectal swab was taken and cultured from each participant, while additional risk factors such as recent hospitalization or antimicrobial usage were recorded and evaluated. (3) Results: A total of 137 nursing home residents were included in the study. Their mean age was 82.1 years and 19.7% were males. In total, cultures yielded 255 GNB; E. coli, K. pneumoniae and P. aeruginosa were the most common. Among the microorganisms cultured, 17.6% had the extended-spectrum beta-lactamase phenotype, while 18% were MDR. A statistically significant association was found between recent antimicrobial use and colonization by MDR-GNB; (4) Conclusions: Colonization by MDR-GNB was found to be highly prevalent in nursing home residents. Recent antimicrobial use was associated with MDR-GNB carriage.

Prevalence and Risk Factors for Multidrug-Resistant Organisms Colonization in Long-Term Care Facilities Around the World: A Review

Elderly people confined to chronic care facilities face an increased risk of acquiring infections by multidrug-resistant organisms (MDROs). This review presents the current knowledge of the prevalence and risk factors for colonization by MDROs in long-term care facilities (LTCF), thereby providing a useful reference to establish objectives for implementing successful antimicrobial stewardship programs (ASPs). We searched in PubMed and Scopus for studies examining the prevalence of MDROs and/or risk factors for the acquisition of MDROs in LTCF. One hundred and thirty-four studies published from 1987 to 2020 were included. The prevalence of MDROs in LTCF varies between the different continents, where Asia reported the highest prevalence of extended-spectrum ß-lactamase (ESBL) Enterobacterales (71.6%), carbapenem resistant (CR) Enterobacterales (6.9%) and methicillin-resistant Staphylococcus aureus (MRSA) (25.6%) and North America the highest prevalence to MDR Pseudomonas aeruginosa (5.4%), MDR Acinetobacter baumannii (15.0%), vancomycin-resistant Enterococcus spp. (VRE) (4.0%), and Clostridioides difficile (26.1%). Furthermore, MDRO prevalence has experienced changes over time, with increases in MDR P. aeruginosa and extended spectrum ß-lactamase producing Enterobacterales observed starting in 2015 and decreases of CR Enterobacterales, MDR A. baumannii, VRE, MRSA and C. difficile. Several risk factors have been found, such as male sex, chronic wounds, the use of medical devices, and previous antibiotic use. The last of these aspects represents one of the most important modifiable factors for reducing colonization with MDROs through implementing ASPs in LTCF.

Carbapenem-Resistant Enterobacterales in Long-Term Care Facilities: A Global and Narrative Review

The emergence of carbapenem-resistant Enterobacterales (CRE) has become a major public health concern. Moreover, its colonization among residents of long-term care facilities (LTCFs) is associated with subsequent infections and mortality. To further explore the various aspects concerning CRE in LTCFs, we conducted a literature review on CRE colonization and/or infections in long-term care facilities. The prevalence and incidence of CRE acquisition among residents of LTCFs, especially in California, central Italy, Spain, Japan, and Taiwan, were determined. There was a significant predominance of CRE in LTCFs, especially in high-acuity LTCFs with mechanical ventilation, and thus may serve as outbreak centers. The prevalence rate of CRE in LTCFs was significantly higher than that in acute care settings and the community, which indicated that LTCFs are a vital reservoir for CRE. The detailed species and genomic analyses of CRE among LTCFs reported that Klebsiella pneumoniae is the primary species in the LTCFs in the United States, Spain, and Taiwan. KPC-2-containing K. pneumoniae strains with sequence type 258 is the most common sequence type of KPC-producing K. pneumoniae in the LTCFs in the United States. IMP-11- and IMP-6-producing CRE were commonly reported among LTCFs in Japan. OXA-48 was the predominant carbapenemase among LTCFs in Spain. Multiple risk factors associated with the increased risk for CRE acquisition in LTCFs were found, such as comorbidities, immunosuppressive status, dependent functional status, usage of gastrointestinal devices or indwelling catheters, mechanical ventilation, prior antibiotic exposures, and previous culture reports. A high CRE acquisition rate and prolonged CRE carriage duration after colonization were found among residents in LTCFs. Moreover, the patients from LTCFs who were colonized or infected with CRE had poor clinical outcomes, with a mortality rate of up to 75% in infected patients. Infection prevention and control measures to reduce CRE in LTCFs is important, and could possibly be controlled via active surveillance, contact precautions, cohort staffing, daily chlorhexidine bathing, healthcare-worker education, and hand-hygiene adherence.

Microbiota-associated risk factors for asymptomatic gut colonisation with multi-drug-resistant organisms in a Dutch nursing home

Background

Nursing home residents have increased rates of intestinal colonisation with multidrug-resistant organisms (MDROs). We assessed the colonisation and spread of MDROs among this population, determined clinical risk factors for MDRO colonisation and investigated the role of the gut microbiota in providing colonisation resistance against MDROs.

Methods

We conducted a prospective cohort study in a Dutch nursing home. Demographical, epidemiological and clinical data were collected at four time points with 2-month intervals (October 2016–April 2017). To obtain longitudinal data, faecal samples from residents were collected for at least two time points. Ultimately, twenty-seven residents were included in the study and 93 faecal samples were analysed, of which 27 (29.0%) were MDRO-positive. Twelve residents (44.4%) were colonised with an MDRO at at least one time point throughout the 6-month study.

Results

Univariable generalised estimating equation logistic regression indicated that antibiotic use in the previous 2 months and hospital admittance in the previous year were associated with MDRO colonisation. Characterisation of MDRO isolates through whole-genome sequencing revealed Escherichia coli sequence type (ST)131 to be the most prevalent MDRO and ward-specific clusters of E. coli ST131 were identified. Microbiota analysis by 16S rRNA gene amplicon sequencing revealed no differences in alpha or beta diversity between MDRO-positive and negative samples, nor between residents who were ever or never colonised. Three bacterial taxa (Dorea, Atopobiaceae and Lachnospiraceae ND3007 group) were more abundant in residents never colonised with an MDRO throughout the 6-month study. An unexpectedly high abundance of Bifidobacterium was observed in several residents. Further investigation of a subset of samples with metagenomics showed that various Bifidobacterium species were highly abundant, of which B. longum strains remained identical within residents over time, but were different between residents.

Conclusions

Our study provides new evidence for the role of the gut microbiota in colonisation resistance against MDROs in the elderly living in a nursing home setting. Dorea, Atopobiaceae and Lachnospiraceae ND3007 group may be associated with protection against MDRO colonisation. Furthermore, we report a uniquely high abundance of several Bifidobacterium species in multiple residents and excluded the possibility that this was due to probiotic supplementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13073-021-00869-z.

Management of patients with multidrug-resistant organisms in rehabilitation facilities. Results of a survey in the Rhine-Main region, Germany, 2019

Introduction: Multidrug-resistant organisms (MDRO) are a problem in medical facilities, including rehabilitation facilities in Germany. The national recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) for prevention of and dealing with patients affected by MDRO are obligatory in rehabilitation facilities. A survey on the management of patients with MDRO in rehabilitation facilities in the Rhine-Main area is presented below. Materials and methods: The questions from a recently published survey in 45 rehabilitation facilities in 26 European countries (Doherty et al., 2019) were largely adopted unchanged: the type, size, and organization of the facility, availability of guidelines on MDRO, screening and (estimated) prevalence of MDRO, as well as special hygiene measures or restrictions for patients with MDRO. Results: 22 of the 43 institutions contacted participated (58%). All facilities had specific recommendations on how to deal with MDRO and more than 95% had adequate hygiene staff. The facilities encompassed 4,369 beds, with 3,909 (89%) of them in single-bed rooms, and only a few offered 3-bed rooms. About 20% of patients in general rehabilitation and 100% in early neurological rehabilitation are screened on admission. Six (27%) facilities refused to accept patients with MDRO. 40% of the facilities treated these patients in their own room and/or in a separate area. 27% of the facilities prohibited eating in the dining room and participating in hydrotherapy. Only 6 (27%) of the rehabilitation centers indicated that patients with MDRO are allowed to participate in full rehabilitation programs. Discussion: In accordance with the results of Doherty et al. (2019), there were many restrictions for rehabilitation patients with MDRO, indicating considerable need for improvement. Necessary hygiene recommendations to avoid the transmission of MDRO must not lead to rejection of inpatient rehabilitation or to less intensive rehabilitation.

Prevalence of Multidrug-Resistant Organisms and Risk Factors for Carriage among Patients Transferred from Long-Term Care Facilities

Background

Patient transport between acute care hospitals and long-term care facilities (LTCFs) plays a significant role in microbial migration. The study aimed to estimate the prevalence and risk factors associated with the colonization of multidrug-resistant organisms (MDROs) among patients transferred from LTCFs.

Materials and Methods

We retrospectively reviewed medical records to examine the colonization of MDROs. All patients who were transferred from LTCFs and admitted to an acute care hospital with 800 beds in Daejeon between March 2018 and February 2019 were included in the study. We surveyed rectal cultures and nasal swabs obtained for screening vancomycin-resistant Enterococcus (VRE), carbapenem-resistant Enterobacteriaceae (CRE), and methicillin-resistant Staphylococcus aureus (MRSA) at the time of hospitalization. We conducted a multivariable logistic regression to assess the association between clinical variables and the carriage of MDROs.

Results

Four hundred and fifteen patients from 86 LTCFs were enrolled. A total of 31.1% (130/415) of participants carried MDROs; VRE colonization was detected in 17.1% (71/415) of participants, and MRSA colonization was shown in 19.5% (81/415) of participants. No CRE was isolated. Previous use of antibiotics within three months [odds ratio (OR) 2.28; (95% confidence interval (CI) 1.30 - 4.00), P = 0.004], use of antibiotics for longer than two weeks [OR 2.16; (95% CI 1.03 - 4.53), P = 0.040], and previous colonization of MDROs within one year [OR 2.01; (95% CI 1.15 - 3.54), P = 0.015] were independently associated with increased risk for carriage of MDROs.

Conclusion

Our study showed that a third of patients transferred from LTCFs carried VRE or MRSA, and prior antibiotic therapy was highly associated with the carriage of MDROs, which suggested more efficient management approaches for high-risk patients.