Extended-spectrum β-Lactamase-producing Flora in Healthy Persons

Prevalence of faecal carriage of Carbapenemase Producing Enterobacteriaceae in healthy Indian subjects from the community

PURPOSE

Faecal carriage of carbapenemase-producing Enterobacterales (CPE) has been extensively investigated in hospitalized patients, but limited data is available on the carriage rate in healthy individuals in India.

METHODS

A total of 1000 stool samples were screened for CPE from healthy individuals in Chennai (n ​= ​50), Hyderabad (n ​= ​184) and Mumbai (n ​= ​766). Diluted stool samples were cultured on chromID CARBA SMART plates. Growing colonies were screened for CPE by RAPIDEC® CARBA NP Test and minimum inhibitory concentration (MIC) of imipenem by E-Test. PCR was performed for confirmation of CPE genes.

RESULTS

Out of the 1000 stool samples tested, 6.1% were positive for CPE. A total of 64 carbapenem resistant isolates (56 ​E.coli, 4 Klebsiella pneumoniae, 3 Enterobacter cloacae and 1 Citrobacter freundii) were recovered from ChromID CARBA SMART biplate. Carbapenemase production was identified in 57/64 isolates by RAPIDEC® CARBA NP test. PCR analysis showed 28 bla_NDM-1 and 33 bla_OXA48. Three remaining isolates (2 ​E.coli, 1 ​K.pneumoniae) were negative for the tested carbapenemase genes. Interestingly, out of these 61 PCR positive isolates, 49.1% displayed imipenem MIC within the susceptibility range on the basis of CLSI interpretative criteria.

CONCLUSIONS

Faecal carriage of CPE among healthy individuals was 6.1%. Comprehensive measures to improve the sanitation scenario and implementation of National AMR action plan are needed to prevent further generation and dissemination of carbapenem resistant Enterobacterales (CRE).

Local prevalence of extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae intestinal carriers at admission and co-expression of ESBL and OXA-48 carbapenemase in Klebsiella pneumoniae: a prevalence survey in a Spanish University Hospital

OBJECTIVE

To assess the prevalence of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae (ESBL-E) faecal carriers at admission in a University Hospital in Spain.

DESIGN

Prevalence survey.

SETTING

Pneumology, gastroenterology, urology and neurosurgery units at a university tertiary hospital in Madrid (Spain).

PARTICIPANTS

A total of 10 643 patients aged 18 and older admitted from March 2014 to April 2016 with a rectal swab taken at admission or as soon as possible within the first 48 hours.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of ESBL-E faecal carriers and prevalence of ESBL-E infections at admission.

RESULTS

The prevalance of ESBL-E carriers at admission was 7.69% (CI 95% 7.18 to 8.19). Most of the isolates were Escherichia coli (77.51%), followed by Klebsiella pneumoniae (20.71%). Eighty-eight (10.41%) of ESBL-E were simultaneous ESBL and carbapenemase (CP) producers, 1.83% in the case of E. coli and 42.86% among K. pneumoniae isolates. Of the ESBL typed, 52.15% belonged to the cefotaximases (CTX-M-15) type and 91.38% of the CP were oxacillinase (OXA-48) type. Only 0.43% patients presented an active infection by ESBL-E at admission.

CONCLUSIONS

The prevalence found in our study is very similar to that found in literature. However, we found a high percentage of simultaneous ESBL and CP producers, particularly in K. pneumoniae. Despite the high prevalence of colonised patients, the ESBL-infection rate at admission was very low.

Urinary tract infection in infants caused by extended-spectrum beta-lactamase-producing Escherichia coli: comparison between urban and rural hospitals

BACKGROUND

Community-acquired urinary tract infection (UTI) caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli is an emerging problem. Compared with urban infants, rural infants may encounter different distributions of community-acquired resistant strains and various barriers to efficient management.

METHODS

A retrospective survey and comparison was conducted for infants with UTI caused by ESBL-producing E. coli admitted to an urban hospital (n = 111) and a rural hospital (n = 48) in southern Taiwan from 2009 to 2012.

RESULTS

Compared with 2009 and 2010, the total number of cases at both hospitals significantly increased in 2011 and 2012 (p < 0.001). Compared with the rural patients, the urban patients were significantly younger, and they had fewer days of fever before and after admission, fewer presentations of poor activity and poor appetite, and a lower serum creatinine level. Most of the patients had no prior history of illness, and we could not identify any significant different risk factors for acquiring ESBL-producing E. coli, such as past antimicrobial use, hospitalization, UTI, and underlying renal diseases, between the urban and rural populations.

CONCLUSIONS

The increase in community-acquired UTI in infants caused by ESBL-producing E. coli was similar between the urban and rural populations. Our preliminary data suggest that the rural-urban disparities were probably related to easy access to health care by the urban population. ESBL complicates disease management, and the increase in the prevalence of ESBL producers is a major health concern and requires further healthy carrier and environmental surveillance.

Faecal carriage rate of extended-spectrum β-lactamase-producing Enterobacteriaceae in hospitalised patients and healthy asymptomatic individuals coming for health check-up

The prevalence of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) in hospitalised and community patients is of significant public health concern. The aim of this study was to estimate the faecal carriage rate of ESBL-PE in hospitalised patients and healthy asymptomatic individuals coming for health check-up. Non-repetitive, consecutive stool samples from 480 adults (260 healthy individuals and 220 hospitalised patients) aged ≥18 years from November 2011 to July 2013 were screened using MacConkey agar supplemented with ceftazidime. All screen-positive isolates were identified to species level and were tested for ESBL production. Representative ESBL-PE isolates were subjected to susceptibility testing and multiplex ESBL PCR. The faecal carriage rate of ESBL-PE was found to be 62.7% among hospitalised patients and 33.8% among healthy asymptomatic individuals. The most common ESBL-PE was Escherichia coli (70.3% and 78.4% in hospitalised patients and healthy individuals, respectively), followed by Klebsiella pneumoniae (26.8% and 17.0%). ESBL-PE showed the highest sensitivity to carbapenems (85% and 100%, respectively), followed by amikacin (67.2% and 98%), cefoperazone/sulbactam (27.8% and 88.2%) and piperacillin/tazobactam (18% and 74.5%). Ciprofloxacin exhibited a high level of resistance among both groups. Molecular analysis for ESBL genes showed a predominance of the CTX-M gene. In conclusion, the faecal carriage rate of ESBL-PE among hospitalised patients was almost double that of healthy individuals. Carriage of carbapenem-resistant isolates is emerging among hospitalised patients. The spread of these organisms in the community merits radical measures to improve sanitation and implement antibiotic stewardship.

Predictors and molecular epidemiology of community-onset extended-spectrum β-lactamase-producing Escherichia coli infection in a Midwestern community

OBJECTIVE

To identify predictors of community-onset extended-spectrum β-lactamase (ESBL)-producing Escherichia coli infection.

DESIGN

Prospective case-control study.

SETTING

Acute care hospitals and ambulatory clinics in the Chicago, Illinois, region.

PATIENTS

Adults with E. coli clinical isolates cultured in ambulatory settings or within 48 hours of hospital admission.

METHODS

Cases were patients with ESBL-producing E. coli clinical isolates cultured in ambulatory settings or within 48 hours of admission, and controls were patients with non-ESBL-producing E. coli isolates, matched to cases by specimen, location, and date. Clinical variables were ascertained through interviews and medical record review. Molecular methods were used to identify ESBL types, sequence type ST131, and aac(6')-Ib-cr.

RESULTS

We enrolled 94 cases and 158 controls. Multivariate risk factors for ESBL-producing E. coli infection included travel to India in the past year (odds ratio [OR], 14.40 [95% confidence interval (CI), 2.92-70.95]), ciprofloxacin use (OR, 3.92 [95% CI, 1.90-8.1]), and age (OR, 1.04 [95% CI, 1.02-1.06]). Case isolates exhibited high prevalence of CTX-M-15 (78%), ST131 (50%), and aac(6')-Ib-cr (66% of isolates with CTX-M-15).

CONCLUSIONS

Providers should be aware of the increased risk of ESBL-producing E. coli infection among returned travelers, especially those from India.

Extended-spectrum beta-lactamase-producing Gram-negative bacteria causing neonatal sepsis in India in rural and urban settings

Extended-spectrum β-lactamase (ESBL)-producing Gram-negative bacilli (GNB) are of increasing clinical concern in all age groups worldwide. Whilst sepsis continues to be the leading cause of morbidity and mortality in Indian neonates in the community, identification of microbiological attributes in this population is lacking. This population-based study enrolled 1738 infants with a diagnosis of clinical sepsis at four participating centres in India. Each study site conducted Bactec blood culture, identified bacterial species by API test and stored isolates at -70 °C. From 252 GNB isolates, 155 (113 Klebsiella species, 21 Escherichia coli and 21 other) were subjected to drug susceptibility testing, ESBL phenotyping and testing for clonal relatedness of ESBL strains by PFGE. The results demonstrated that Klebsiella species and E. coli are the most common GNB causes of neonatal sepsis in India, and over one-third are ESBL producers in both community and hospital settings. ESBL-producing strains exhibited frequent co-resistance to aminoglycosides and ciprofloxacin, but remained susceptible to imipenem. PFGE analysis revealed extensive genetic diversity within the ESBL-producing isolates, showing multiple profiles (total of 23). Over 40% of all ESBL-producing isolates formed three pulsed-field profiles (PFP I-III), with PFP-II being the largest cluster (>20% of all ESBL-producing isolates), sharing strains from two distant locations. Identification of a common clone at two geographically distant centres indicated that predominant clones with increased virulence may exist, even in the absence of any clear outbreak. The presence of ESBL-producing strains in community infants with no prior history of hospitalization or antibiotic use dictates heightened vigilance and further studies on the ecology of these organisms.

Community-onset genitourinary tract infection due to CTX-M-15-Producing Escherichia coli among travelers to the Indian subcontinent in New Zealand

A series of patients are described who presented to a New Zealand hospital with genitourinary tract infection due to CTX-M-15-producing Escherichia coli. All had a history of travel to the Indian subcontinent and lacked traditional risk factors for urinary tract infection due to a multidrug-resistant organism.

Molecular characteristics of travel-related extended-spectrum-beta-lactamase-producing Escherichia coli isolates from the Calgary Health Region

Extended-spectrum-beta-lactamase (ESBL)-producing Escherichia coli has recently emerged as a major risk factor for community-acquired, travel-related infections in the Calgary Health Region. Molecular characterization was done on isolates associated with infections in returning travelers using isoelectric focusing, PCR, and sequencing for bla(CTX-M)s, bla(TEM)s, bla(SHV)s, bla(OXA)s, and plasmid-mediated quinolone resistance determinants. Genetic relatedness was determined with pulsed-field gel electrophoresis using XbaI and multilocus sequence typing (MLST). A total of 105 residents were identified; 6/105 (6%) presented with hospital-acquired infections, 9/105 (9%) with health care-associated community-onset infections, and 90/105 (86%) with community-acquired infections. Seventy-seven of 105 (73%) of the ESBL-producing E. coli isolates were positive for bla(CTX-M) genes; 55 (58%) produced CTX-M-15, 13 (14%) CTX-M-14, six (6%) CTX-M-24, one (1%) CTX-M-2, one (1%) CTX-M-3, and one (1%) CTX-M-27, while 10 (10%) produced TEM-52, three (3%) TEM-26, 11 (11%) SHV-2, and four (4%) produced SHV-12. Thirty-one (30%) of the ESBL-producing E. coli isolates were positive for aac(6')-Ib-cr, and one (1%) was positive for qnrS. The majority of the ESBL-producing isolates (n = 95 [90%]) were recovered from urine samples, and 83 (87%) were resistant to ciprofloxacin. The isolation of CTX-M-15 producers belonging to clone ST131 was associated with travel to the Indian subcontinent (India, Pakistan), Africa, the Middle East, and Europe, while clonally unrelated strains of CTX-M-14 and -24 were associated with travel to Asia. Our study suggested that clone ST131 coproducing CTX-M-15, OXA-1, TEM-1, and AAC(6')-Ib-cr and clonally unrelated CTX-M-14 producers have emerged as important causes of community-acquired, travel-related infections.

High rate of intestinal colonization with extended-spectrum-beta-lactamase-producing organisms in household contacts of infected community patients

Fecal carriage of extended-spectrum-beta-lactamase (ESBL)-producing organisms was detected in 70% of index cases of patients (n = 40) with community-acquired infections due to ESBL producers and reached 16.7% in household contacts (n = 54). A total of 66% of ESBL-producing organisms from index cases were indistinguishable from isolates from household contacts by pulsed-field gel electrophoresis. Patients with community infections and members of their households represent a reservoir for ESBL producers, increasing dispersal of resistance in healthy people.