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Weber A, Neffe L, Diaz LAP, Thoma N, Aghdassi SJS, Denkel LA, Maechler F, Behnke M, Häussler S, Gastmeier P, Kola A. Analysis of transmission-related third-generation cephalosporin-resistant Enterobacterales by electronic data mining and core genome multi-locus sequence typing. J Hosp Infect 2023; 140:96-101. [PMID: 37562589 DOI: 10.1016/j.jhin.2023.07.020] [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: 05/16/2023] [Revised: 07/28/2023] [Accepted: 07/30/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND To contain intra-hospital transmission of third-generation cephalosporin-resistant Enterobacterales (3GCR-E), contact isolation precautions are recommended. AIM To quantify transmissions of 3GCR Escherichia coli and 3GCR Klebsiella pneumoniae within a hospital. METHODS An automated outbreak detection system (AODS) was used to identify clusters (N≥2) of 3GCR Enterobacterales for the years 2016, 2018 and 2020. Clusters were defined by phenotypic agreement of microbiological results and spatial and temporal relationship. Core genome multi-locus sequence typing (cgMLST) was used to confirm whether the cluster isolates were transmitted between patients. FINDINGS A total of 4343 3GCR E. coli and 1377 K. pneumoniae isolates were analysed. Among the 3GCR E. coli isolates, the AODS identified 304 isolates as cluster isolates, the median cluster size was two (range: 2-5). The cgMLST analysis revealed that a total of 23 (7.5%) 3GCR E. coli cluster isolates were transmission-associated, of which 20 isolates (87%) were detected in intensive care patients. Among the 3GCR K. pneumoniae isolates, the AODS identified 73 isolates as cluster isolates, the median cluster size was two (range: 2-4). CgMLST revealed that 35 (48%) 3GCR K. pneumoniae cluster isolates were transmission associated, of which 27 isolates (77%) were detected in intensive care patients. CONCLUSION For 3GCR K. pneumoniae, cgMLST confirmed the AODS results more frequently than for 3GCR E. coli. Therefore, contact isolation precautions for 3GCR K. pneumoniae may be appropriate on intensive care units, but only in certain circumstances, such as outbreaks, for Enterobacterales with lower transmissibility, such as E. coli.
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Affiliation(s)
- A Weber
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - L Neffe
- Helmholtz Centre for Infection Research, Department of Molecular Bacteriology, Braunschweig, Germany
| | - L A P Diaz
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - N Thoma
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - S J S Aghdassi
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Programme, Berlin, Germany
| | - L A Denkel
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - F Maechler
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - M Behnke
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - S Häussler
- Helmholtz Centre for Infection Research, Department of Molecular Bacteriology, Braunschweig, Germany; TWINCORE, Centre for Experimental and Clinical Infection Research, A Joint Venture of the HZI and the Hannover Medical School, Hannover, Germany
| | - P Gastmeier
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | - A Kola
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany.
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2
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Hagiya H, Otsuka F. Increased evidence for no benefit of contact precautions in preventing extended-spectrum β-lactamases-producing Enterobacteriaceae: Systematic scoping review. Am J Infect Control 2023; 51:1056-1062. [PMID: 36736903 DOI: 10.1016/j.ajic.2023.01.018] [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: 11/21/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Extended-spectrum β-lactamases-producing Enterobacteriaceae (ESBL-E) is a critical antimicrobial resistance pathogen, to which we need to pay the greatest attention. This study was aimed at uncovering the present evidence for the preventive effectiveness of contact precautions for patients colonized or infected with ESBL-E. METHODS According to the Preferred Reporting Items for Systemic Reviews and Meta-analyses (PRISMA) Extension for Scoping Reviews, we searched MEDLINE for articles with relevant keywords from the beginning of 2010 to October 18, 2022. RESULTS Of the 355 articles found, 9, including 8 observational studies and 1 randomized controlled trial, were selected. Safety of discontinuing contact precautions was evaluated mainly in acute-care and long-term care hospitals. Consistently, all authors concluded that contact precautions can be safely discontinued in patients colonized or infected with ESBL-E. CONCLUSION The clinical impact of discontinuing contact precautions for patients with ESBL-E is minimal and can be safely withdrawn at acute, noncritical, adult care wards. Relevant data from pediatric and geriatric wards, as well as intensive care units, were insufficient and should be investigated in future research.
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Affiliation(s)
- Hideharu Hagiya
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 7008558, Japan.
| | - Fumio Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 7008558, Japan
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3
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Brülisauer L, León-Sampedro R, Hall AR. Clinical antibiotic-resistance plasmids have small effects on biofilm formation and population growth in Escherichia coli in vitro. Plasmid 2023; 128:102706. [PMID: 37652194 DOI: 10.1016/j.plasmid.2023.102706] [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: 03/01/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 09/02/2023]
Abstract
Antimicrobial resistance (AR) mechanisms encoded on plasmids can affect other phenotypic traits in bacteria, including biofilm formation. These effects may be important contributors to the spread of AR and the evolutionary success of plasmids, but it is not yet clear how common such effects are for clinical plasmids/bacteria, and how they vary among different plasmids and host strains. Here, we used a combinatorial approach to test the effects of clinical AR plasmids on biofilm formation and population growth in clinical and laboratory Escherichia coli strains. In most of the 25 plasmid-bacterium combinations tested, we observed no significant change in biofilm formation upon plasmid introduction, contrary to the notion that plasmids frequently alter biofilm formation. In a few cases we detected altered biofilm formation, and these effects were specific to particular plasmid-bacterium combinations. By contrast, we found a relatively strong effect of a chromosomal streptomycin-resistance mutation (in rpsL) on biofilm formation. Further supporting weak and host-strain-dependent effects of clinical plasmids on bacterial phenotypes in the combinations we tested, we found growth costs associated with plasmid carriage (measured in the absence of antibiotics) were moderate and varied among bacterial strains. These findings suggest some key clinical resistance plasmids cause only mild phenotypic disruption to their host bacteria, which may contribute to the persistence of plasmids in the absence of antibiotics.
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Affiliation(s)
- Laura Brülisauer
- Institute of Integrative Biology, Department of Environmental Systems Science, ETH Zurich, Zurich, Switzerland.
| | - Ricardo León-Sampedro
- Institute of Integrative Biology, Department of Environmental Systems Science, ETH Zurich, Zurich, Switzerland; Centro de Investigación Biológica en Red, Epidemiología y Salud Pública- CIBERESP, Instituto de Salud Carlos III, Madrid, Spain
| | - Alex R Hall
- Institute of Integrative Biology, Department of Environmental Systems Science, ETH Zurich, Zurich, Switzerland
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4
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Gül E, Abi Younes A, Huuskonen J, Diawara C, Nguyen BD, Maurer L, Bakkeren E, Hardt WD. Differences in carbon metabolic capacity fuel co-existence and plasmid transfer between Salmonella strains in the mouse gut. Cell Host Microbe 2023; 31:1140-1153.e3. [PMID: 37348498 DOI: 10.1016/j.chom.2023.05.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/12/2023] [Accepted: 05/26/2023] [Indexed: 06/24/2023]
Abstract
Antibiotic resistance plasmids can be disseminated between different Enterobacteriaceae in the gut. Here, we investigate how closely related Enterobacteriaceae populations with similar nutrient needs can co-bloom in the same gut and thereby facilitate plasmid transfer. Using different strains of Salmonella Typhimurium (S.Tm SL1344 and ATCC14028) and mouse models of Salmonellosis, we show that the bloom of one strain (i.e., recipient) from very low numbers in a gut pre-occupied by the other strain (i.e., donor) depends on strain-specific utilization of a distinct carbon source, galactitol or arabinose. Galactitol-dependent growth of the recipient S.Tm strain promotes plasmid transfer between non-isogenic strains and between E. coli and S.Tm. In mice stably colonized by a defined microbiota (OligoMM12), galactitol supplementation similarly facilitates co-existence of two S.Tm strains and promotes plasmid transfer. Our work reveals a metabolic strategy used by Enterobacteriaceae to expand in a pre-occupied gut and provides promising therapeutic targets for resistance plasmids spread.
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Affiliation(s)
- Ersin Gül
- Institute of Microbiology, Department of Biology, ETH Zurich, 8093 Zurich, Switzerland.
| | - Andrew Abi Younes
- Institute of Microbiology, Department of Biology, ETH Zurich, 8093 Zurich, Switzerland
| | - Jemina Huuskonen
- Institute of Microbiology, Department of Biology, ETH Zurich, 8093 Zurich, Switzerland
| | - Cheickna Diawara
- Institute of Microbiology, Department of Biology, ETH Zurich, 8093 Zurich, Switzerland
| | - Bidong D Nguyen
- Institute of Microbiology, Department of Biology, ETH Zurich, 8093 Zurich, Switzerland
| | - Luca Maurer
- Institute of Microbiology, Department of Biology, ETH Zurich, 8093 Zurich, Switzerland
| | - Erik Bakkeren
- Institute of Microbiology, Department of Biology, ETH Zurich, 8093 Zurich, Switzerland
| | - Wolf-Dietrich Hardt
- Institute of Microbiology, Department of Biology, ETH Zurich, 8093 Zurich, Switzerland.
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5
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Morin-Le Bihan A, Le Neindre K, Dejoies L, Piau C, Donnio PY, Ménard G. Use of the quantitative antibiogram method for assessing nosocomial transmission of ESBL-producing Enterobacteriaceae in a French hospital. J Hosp Infect 2023; 135:132-138. [PMID: 36918068 DOI: 10.1016/j.jhin.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/19/2023] [Accepted: 01/24/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND ESBL-producing Enterobacteriaceae (eESBL) have a high prevalence in hospitals but real-time monitoring of nosocomial acquisition through conventional typing methods is challenging. Moreover, patient-to-patient transmission varies between the main species, namely Escherichia coli, and Klebsiella pneumoniae, then questioning the relevance of applying identical preventive measures. AIM To detect eESBL cross-transmission events (CTE) using combination of quantitative antibiogram with epidemiological data (combined-QA), and to rule on the effectiveness of standard or contact precautions for eESBL species. METHODS First, a validation set was used to confirm the relevance of the combined-QA by comparison to a combination of pulsed-field gel electrophoresis and epidemiological data (combined-PFGE). Secondly, a four-year retrospective analysis was conducted to detect eESBL-CTE in hospitalized patients. Two species were screened i.e. ESBL-E. coli (ESBL-Ec), and ESBL-K. pneumoniae (ESBL-Kp). During the study, only standard precautions were applied to ESBL-Ec patients whereas contact precautions were retained for ESBL-Kp. FINDINGS As a proof of concept, results between the two combined methods for the detection of CTE were identical for E. coli, and similar to at least 75% for K. pneumoniae. During the retrospective analysis, 722 patients with ESBL-Ec isolates and 280 with ESBL-Kp isolates were included. Nine CTE were identified for E. coli and 23 for K. pneumoniae, implying 20 (2.7%) and 36 (12.8%) patients, respectively. CONCLUSION The QA-combined method constitutes a rapid tool for epidemiological surveillance to detect CTE. In our hospital, standard precautions are sufficient to prevent acquisition of ESBL-Ec whereas contact precautions must be implemented to prevent acquisition of ESBL-Kp.
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Affiliation(s)
- Amélie Morin-Le Bihan
- CHU Rennes, SB2H (Service de Bactériologie-Hygiène Hospitalière), F-35000 Rennes, France
| | - Killian Le Neindre
- CHU Rennes, SB2H (Service de Bactériologie-Hygiène Hospitalière), F-35000 Rennes, France; INSERM, BRM (Bacterial RNAs and Medicine), University Rennes, UMR_S 1230, F-35000 Rennes, France
| | - Loren Dejoies
- CHU Rennes, SB2H (Service de Bactériologie-Hygiène Hospitalière), F-35000 Rennes, France; INSERM, BRM (Bacterial RNAs and Medicine), University Rennes, UMR_S 1230, F-35000 Rennes, France
| | - Caroline Piau
- CHU Rennes, SB2H (Service de Bactériologie-Hygiène Hospitalière), F-35000 Rennes, France
| | - Pierre-Yves Donnio
- CHU Rennes, SB2H (Service de Bactériologie-Hygiène Hospitalière), F-35000 Rennes, France; INSERM, BRM (Bacterial RNAs and Medicine), University Rennes, UMR_S 1230, F-35000 Rennes, France
| | - Guillaume Ménard
- CHU Rennes, SB2H (Service de Bactériologie-Hygiène Hospitalière), F-35000 Rennes, France; INSERM, BRM (Bacterial RNAs and Medicine), University Rennes, UMR_S 1230, F-35000 Rennes, France.
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6
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Huisman JS, Vaughan TG, Egli A, Tschudin-Sutter S, Stadler T, Bonhoeffer S. The effect of sequencing and assembly on the inference of horizontal gene transfer on chromosomal and plasmid phylogenies. Philos Trans R Soc Lond B Biol Sci 2022; 377:20210245. [PMID: 35989605 PMCID: PMC9393563 DOI: 10.1098/rstb.2021.0245] [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] [Indexed: 12/12/2022] Open
Abstract
The spread of antibiotic resistance genes on plasmids is a threat to human and animal health. Phylogenies of bacteria and their plasmids contain clues regarding the frequency of plasmid transfer events, as well as the co-evolution of plasmids and their hosts. However, whole genome sequencing data from diverse ecological or clinical bacterial samples are rarely used to study plasmid phylogenies and resistance gene transfer. This is partially due to the difficulty of extracting plasmids from short-read sequencing data. Here, we use both short- and long-read sequencing data of 24 clinical extended-spectrum β-lactamase (ESBL)-producing Escherichia coli to estimate chromosomal and plasmid phylogenies. We compare the impact of different sequencing and assembly methodologies on these phylogenies and on the inference of horizontal gene transfer. We find that chromosomal phylogenies can be estimated robustly with all methods, whereas plasmid phylogenies have more variable topology and branch lengths across the methods used. Specifically, hybrid methods that use long reads to resolve short-read assemblies (HybridSPAdes and Unicycler) perform better than those that started from long reads during assembly graph generation (Canu). By contrast, the inference of plasmid and antibiotic resistance gene transfer using a parsimony-based criterion is mostly robust to the choice of sequencing and assembly method. This article is part of a discussion meeting issue ‘Genomic population structures of microbial pathogens’.
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Affiliation(s)
- Jana S Huisman
- Department of Environmental Systems Science, ETH Zurich, 8092 Zurich, Switzerland.,Department of Biosystems Science and Engineering, ETH Zurich, 4058 Basel, Switzerland.,Swiss Institute of Bioinformatics, 1015 Lausanne, Switzerland
| | - Timothy G Vaughan
- Department of Biosystems Science and Engineering, ETH Zurich, 4058 Basel, Switzerland.,Swiss Institute of Bioinformatics, 1015 Lausanne, Switzerland
| | - Adrian Egli
- Division of Clinical Microbiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland.,Department of Biomedicine, University of Basel, Hebelstrasse 20, 4031 Basel, Switzerland
| | - Sarah Tschudin-Sutter
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland.,Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4031 Basel, Switzerland
| | - Tanja Stadler
- Department of Biosystems Science and Engineering, ETH Zurich, 4058 Basel, Switzerland.,Swiss Institute of Bioinformatics, 1015 Lausanne, Switzerland
| | - Sebastian Bonhoeffer
- Department of Environmental Systems Science, ETH Zurich, 8092 Zurich, Switzerland
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7
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Bakkeren E, Herter JA, Huisman JS, Steiger Y, Gül E, Newson JPM, Brachmann AO, Piel J, Regoes R, Bonhoeffer S, Diard M, Hardt WD. Pathogen invasion-dependent tissue reservoirs and plasmid-encoded antibiotic degradation boost plasmid spread in the gut. eLife 2021; 10:e69744. [PMID: 34872631 PMCID: PMC8651294 DOI: 10.7554/elife.69744] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 11/10/2021] [Indexed: 11/30/2022] Open
Abstract
Many plasmids encode antibiotic resistance genes. Through conjugation, plasmids can be rapidly disseminated. Previous work identified gut luminal donor/recipient blooms and tissue-lodged plasmid-bearing persister cells of the enteric pathogen Salmonella enterica serovar Typhimurium (S.Tm) that survive antibiotic therapy in host tissues, as factors promoting plasmid dissemination among Enterobacteriaceae. However, the buildup of tissue reservoirs and their contribution to plasmid spread await experimental demonstration. Here, we asked if re-seeding-plasmid acquisition-invasion cycles by S.Tm could serve to diversify tissue-lodged plasmid reservoirs, and thereby promote plasmid spread. Starting with intraperitoneal mouse infections, we demonstrate that S.Tm cells re-seeding the gut lumen initiate clonal expansion. Extended spectrum beta-lactamase (ESBL) plasmid-encoded gut luminal antibiotic degradation by donors can foster recipient survival under beta-lactam antibiotic treatment, enhancing transconjugant formation upon re-seeding. S.Tm transconjugants can subsequently re-enter host tissues introducing the new plasmid into the tissue-lodged reservoir. Population dynamics analyses pinpoint recipient migration into the gut lumen as rate-limiting for plasmid transfer dynamics in our model. Priority effects may be a limiting factor for reservoir formation in host tissues. Overall, our proof-of-principle data indicates that luminal antibiotic degradation and shuttling between the gut lumen and tissue-resident reservoirs can promote the accumulation and spread of plasmids within a host over time.
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Affiliation(s)
- Erik Bakkeren
- Institute of Microbiology, Department of Biology, ETH ZurichZurichSwitzerland
| | | | - Jana Sanne Huisman
- Swiss Institute of BioinformaticsLausanneSwitzerland
- Institute of Integrative Biology, Department of Environmental Systems Science, ETH ZurichZurichSwitzerland
| | - Yves Steiger
- Institute of Microbiology, Department of Biology, ETH ZurichZurichSwitzerland
| | - Ersin Gül
- Institute of Microbiology, Department of Biology, ETH ZurichZurichSwitzerland
| | | | | | - Jörn Piel
- Institute of Microbiology, Department of Biology, ETH ZurichZurichSwitzerland
| | - Roland Regoes
- Institute of Integrative Biology, Department of Environmental Systems Science, ETH ZurichZurichSwitzerland
| | - Sebastian Bonhoeffer
- Institute of Integrative Biology, Department of Environmental Systems Science, ETH ZurichZurichSwitzerland
| | - Médéric Diard
- Botnar Research Centre for Child HealthBaselSwitzerland
- Biozentrum, University of BaselBaselSwitzerland
| | - Wolf-Dietrich Hardt
- Institute of Microbiology, Department of Biology, ETH ZurichZurichSwitzerland
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8
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Plasmid- and strain-specific factors drive variation in ESBL-plasmid spread in vitro and in vivo. THE ISME JOURNAL 2021; 15:862-878. [PMID: 33149210 PMCID: PMC8026971 DOI: 10.1038/s41396-020-00819-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/15/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023]
Abstract
Horizontal gene transfer, mediated by conjugative plasmids, is a major driver of the global rise of antibiotic resistance. However, the relative contributions of factors that underlie the spread of plasmids and their roles in conjugation in vivo are unclear. To address this, we investigated the spread of clinical Extended Spectrum Beta-Lactamase (ESBL)-producing plasmids in the absence of antibiotics in vitro and in the mouse intestine. We hypothesised that plasmid properties would be the primary determinants of plasmid spread and that bacterial strain identity would also contribute. We found clinical Escherichia coli strains natively associated with ESBL-plasmids conjugated to three distinct E. coli strains and one Salmonella enterica serovar Typhimurium strain. Final transconjugant frequencies varied across plasmid, donor, and recipient combinations, with qualitative consistency when comparing transfer in vitro and in vivo in mice. In both environments, transconjugant frequencies for these natural strains and plasmids covaried with the presence/absence of transfer genes on ESBL-plasmids and were affected by plasmid incompatibility. By moving ESBL-plasmids out of their native hosts, we showed that donor and recipient strains also modulated transconjugant frequencies. This suggests that plasmid spread in the complex gut environment of animals and humans can be predicted based on in vitro testing and genetic data.
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9
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Contact isolation versus standard precautions to decrease acquisition of extended-spectrum β-lactamase-producing Enterobacterales in non-critical care wards: a cluster-randomised crossover trial. THE LANCET. INFECTIOUS DISEASES 2020; 20:575-584. [PMID: 32087113 DOI: 10.1016/s1473-3099(19)30626-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 09/02/2019] [Accepted: 10/25/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND The effectiveness of contact isolation for decreasing the spread of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) has been questioned. The aim of this study was to establish the benefits of contact isolation over standard precautions for reducing the incidence density of ESBL-E colonisation and infection in adult medical and surgical wards with an active surveillance culture programme. METHODS We did a cluster-randomised crossover trial in adult wards in four European university hospitals. Medical, surgical, or combined medical-surgical wards without critical care were randomised to continue standard precautions alone or implement contact isolation alongside standard precautions for 12 months, followed by a 1 month washout period and 12 months of the alternate strategy. Randomisation was done via a computer-generated sequence, with a block size of two consecutive wards. Only laboratory technicians and data analysts were masked to allocation. Patients were screened for ESBL-E carriage within 3 days of admission, once a week thereafter, and on discharge. The primary outcome was the incidence density of ESBL-E, defined as the acquisition rate per 1000 patient-days at risk at the ward level and assessed in the per-protocol population, which included all patients screened at least twice with a length of stay of more than 1 week for each intervention period. No specific safety measures were assessed given the minimal risk of adverse events. The trial is registered, ISRCTN57648070. FINDINGS We enrolled 20 wards from four hospitals in Germany (eight wards), the Netherlands (four wards), Spain (four wards), and Switzerland (four wards). Between Jan 6, 2014, and Aug 31, 2016, 38 357 patients were admitted to these wards. Among 15 184 patients with a length of stay of more than 1 week, 11 368 patients (75%) were screened at least twice. The incidence density of ward-acquired ESBL-E was 6·0 events per 1000 patient-days at risk (95% CI 5·4-6·7) during periods of contact isolation and 6·1 (5·5-6·7) during periods of standard precautions (p=0·9710). Multivariable analysis adjusted for length of stay, percentage of patients screened, and prevalence in first screening cultures yielded an incidence rate ratio of 0·99 (95% CI 0·80-1·22; p=0·9177) for care under contact isolation compared with standard precautions. INTERPRETATION Contact isolation showed no benefit when added to standard precautions for controlling the spread of ESBL-E on non-critical care wards with extensive surveillance screening. FUNDING European Commission.
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10
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Biehl LM, Vehreschild MJGT. Contact precautions: no benefits, no indication. THE LANCET. INFECTIOUS DISEASES 2020; 20:516-517. [PMID: 32087117 DOI: 10.1016/s1473-3099(20)30017-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 01/09/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Lena M Biehl
- Department I of Internal Medicine, Faculty of Medicine; and University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany; German Centre of Infection Research (partner site Bonn-Cologne), Cologne, Germany.
| | - Maria J G T Vehreschild
- Department I of Internal Medicine, Faculty of Medicine; and University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany; German Centre of Infection Research (partner site Bonn-Cologne), Cologne, Germany; Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
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11
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Thompson P, Teter J, Atrubin K. Incidence of health care-associated extended-spectrum β-lactamase-positive patients before and after discontinuation of contact precautions. Am J Infect Control 2020; 48:52-55. [PMID: 31358415 DOI: 10.1016/j.ajic.2019.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Isolation of patients with multidrug-resistant organisms has been recommended in several guidelines. Recent evidence has suggested potential negative effects of isolation on patient well-being and facility throughput. Published literature shows a difference in transmission risk of extended-spectrum β-lactamase (ESBL)-producing organisms, suggesting that contact precautions may not be necessary for all ESBL-positive organisms. METHODS Incidence rates of health care-associated ESBL organisms were measured before and after eliminating the use of contact precautions for patients with only ESBL-positive organisms. The National Healthcare Safety Network surveillance methodology was used to measure incidence. Surgical site infections and carbapenem-resistant Enterobacteriaceae were excluded from the surveillance incidence. RESULTS The incidence of health care-associated ESBL infections from January 2014 through November 2015 was 3.71 per 10,000 patient days. The incidence from December 2015 through August 2017 was 3.00 per 10,000 patient days. This rate change was statistically significant (P = .022) CONCLUSIONS: This study found that discontinuing the use of contact precautions for patients colonized or infected with ESBL-positive organisms did not lead to an increased rate of health care-associated ESBL-positive infections or colonization.
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12
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Lucet JC, Zahar JR. Simplified control measures for ESBL-producing Enterobacteriacae? THE LANCET. INFECTIOUS DISEASES 2019; 19:1036-1037. [PMID: 31451422 DOI: 10.1016/s1473-3099(19)30412-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/09/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Jean-Christophe Lucet
- Université de Paris, Infection, Antimicrobiens, Modélisation, Évolution (IAME), Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, France; *Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bichat, Infection Control Unit, F-75018 Paris, France.
| | - Jean-Ralph Zahar
- AP-HP, Hôpital Avicenne, Infection Control Unit, Bobigny, France
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Kluytmans-van den Bergh MFQ, Bruijning-Verhagen PCJ, Vandenbroucke-Grauls CMJE, de Brauwer EIGB, Buiting AGM, Diederen BM, van Elzakker EPM, Friedrich AW, Hopman J, Al Naiemi N, Rossen JWA, Ruijs GJHM, Savelkoul PHM, Verhulst C, Vos MC, Voss A, Bonten MJM, Kluytmans JAJW. Contact precautions in single-bed or multiple-bed rooms for patients with extended-spectrum β-lactamase-producing Enterobacteriaceae in Dutch hospitals: a cluster-randomised, crossover, non-inferiority study. THE LANCET. INFECTIOUS DISEASES 2019; 19:1069-1079. [PMID: 31451419 DOI: 10.1016/s1473-3099(19)30262-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/24/2019] [Accepted: 05/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Use of single-bed rooms for control of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae is under debate; the added value when applying contact precautions has not been shown. We aimed to assess whether an isolation strategy of contact precautions in a multiple-bed room was non-inferior to a strategy of contact precautions in a single-bed room for preventing transmission of ESBL-producing Enterobacteriaceae. METHODS We did a cluster-randomised, crossover, non-inferiority study on medical and surgical wards of 16 Dutch hospitals. During two consecutive study periods, either contact precautions in a single-bed room or contact precautions in a multiple-bed room were applied as the preferred isolation strategy for patients with ESBL-producing Enterobacteriaceae cultured from a routine clinical sample (index patients). Eligible index patients were aged 18 years or older, had no strict indication for barrier precautions in a single-bed room, had a culture result reported within 7 days of culture and before discharge, and had no wardmate known to be colonised or infected with an ESBL-producing Enterobacteriaceae isolate of the same bacterial species with a similar antibiogram. Hospitals were randomly assigned in a 1:1 ratio by computer to one of two sequences of isolation strategies, stratified by university or non-university hospital. Allocation was masked for laboratory technicians who assessed the outcomes but not for patients, treating doctors, and infection-control practitioners enrolling index patients. The primary outcome was transmission of ESBL-producing Enterobacteriaceae to wardmates, which was defined as rectal carriage of an ESBL-producing Enterobacteriaceae isolate that was clonally related to the index patient's isolate in at least one wardmate. The primary analysis was done in the per-protocol population, which included patients who were adherent to the assigned room type. A 10% non-inferiority margin for the risk difference was used to assess non-inferiority. This study is registered with Nederlands Trialregister, NTR2799. FINDINGS 16 hospitals were randomised, eight to each sequence of isolation strategies. All hospitals randomised to the sequence single-bed room then multiple-bed room and five of eight hospitals randomised to the sequence multiple-bed room then single-bed room completed both study periods and were analysed. From April 24, 2011, to Feb 27, 2014, 1652 index patients and 12 875 wardmates were assessed for eligibility. Of those, 693 index patients and 9527 wardmates were enrolled and 463 index patients and 7093 wardmates were included in the per-protocol population. Transmission of ESBL-producing Enterobacteriaceae to at least one wardmate was identified for 11 (4%) of 275 index patients during the single-bed room strategy period and for 14 (7%) of 188 index patients during the multiple-bed room strategy period (crude risk difference 3·4%, 90% CI -0·3 to 7·1). INTERPRETATION For patients with ESBL-producing Enterobacteriaceae cultured from a routine clinical sample, an isolation strategy of contact precautions in a multiple-bed room was non-inferior to a strategy of contact precautions in a single-bed room for preventing transmission of ESBL-producing Enterobacteriaceae. Non-inferiority of the multiple-bed room strategy might change the current single-bed room preference for isolation of patients with ESBL-producing Enterobacteriaceae and, thus, broaden infection-control options for ESBL-producing Enterobacteriaceae in daily clinical practice. FUNDING Netherlands Organisation for Health Research and Development.
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Affiliation(s)
- Marjolein F Q Kluytmans-van den Bergh
- Department of Infection Control, Amphia Hospital, Breda, Netherlands; Amphia Academy Infectious Disease Foundation, Amphia Hospital, Breda, Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands.
| | - Patricia C J Bruijning-Verhagen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
| | - Christina M J E Vandenbroucke-Grauls
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Anton G M Buiting
- Laboratory for Medical Microbiology and Immunology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Bram M Diederen
- Regional Laboratory of Public Health, Haarlem, Netherlands; Microvida Laboratory for Microbiology, Bravis Hospital, Roosendaal, Netherlands
| | | | - Alex W Friedrich
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Joost Hopman
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nashwan Al Naiemi
- Department of Medical Microbiology and Infection Control, Ziekenhuisgroep Twente, Almelo/Hengelo, Netherlands
| | - John W A Rossen
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Gijs J H M Ruijs
- Laboratory for Microbiology and Infectious Diseases, Isala Clinics, Zwolle, Netherlands
| | - Paul H M Savelkoul
- Department of Medical Microbiology and Infection Control, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands; Department of Medical Microbiology, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Carlo Verhulst
- Microvida Laboratory for Microbiology, Amphia Hospital, Breda, Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, Rotterdam, Netherlands
| | - Andreas Voss
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, Netherlands; Department of Medical Microbiology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
| | - Jan A J W Kluytmans
- Department of Infection Control, Amphia Hospital, Breda, Netherlands; Microvida Laboratory for Microbiology, Amphia Hospital, Breda, Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
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Duval A, Obadia T, Boëlle PY, Fleury E, Herrmann JL, Guillemot D, Temime L, Opatowski L. Close proximity interactions support transmission of ESBL-K. pneumoniae but not ESBL-E. coli in healthcare settings. PLoS Comput Biol 2019; 15:e1006496. [PMID: 31145725 PMCID: PMC6542504 DOI: 10.1371/journal.pcbi.1006496] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 04/08/2019] [Indexed: 11/19/2022] Open
Abstract
Antibiotic-resistance of hospital-acquired infections is a major public health issue. The worldwide emergence and diffusion of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, including Escherichia coli (ESBL-EC) and Klebsiella pneumoniae (ESBL-KP), is of particular concern. Preventing their nosocomial spread requires understanding their transmission. Using Close Proximity Interactions (CPIs), measured by wearable sensors, and weekly ESBL-EC-and ESBL-KP-carriage data, we traced their possible transmission paths among 329 patients in a 200-bed long-term care facility over 4 months. Based on phenotypically defined resistance profiles to 12 antibiotics only, new bacterial acquisitions were tracked. Extending a previously proposed statistical method, the CPI network's ability to support observed incident-colonization episodes of ESBL-EC and ESBL-KP was tested. Finally, mathematical modeling based on our findings assessed the effect of several infection-control measures. A potential infector was identified in the CPI network for 80% (16/20) of ESBL-KP acquisition episodes. The lengths of CPI paths between ESBL-KP incident cases and their potential infectors were shorter than predicted by chance (P = 0.02), indicating that CPI-network relationships were consistent with dissemination. Potential ESBL-EC infectors were identified for 54% (19/35) of the acquisitions, with longer-than-expected lengths of CPI paths. These contrasting results yielded differing impacts of infection control scenarios, with contact reduction interventions proving less effective for ESBL-EC than for ESBL-KP. These results highlight the widely variable transmission patterns among ESBL-producing Enterobacteriaceae species. CPI networks supported ESBL-KP, but not ESBL-EC spread. These outcomes could help design more specific surveillance and control strategies to prevent in-hospital Enterobacteriaceae dissemination.
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Affiliation(s)
- Audrey Duval
- Equipe PheMI, unité B2PHI, Inserm, Université de Versailles Saint Quentin, Institut Pasteur,Paris, France
| | - Thomas Obadia
- Malaria: Parasites & Hosts Unit, Department of Parasites & Insect Vectors, Institut Pasteur,Paris, France
- Institut Pasteur—Bioinformatics and Biostatistics Hub—C3BI, USR 3756 IP CNRS—Paris, France
| | - Pierre-Yves Boëlle
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, PARIS France
| | - Eric Fleury
- Univ Lyon, Cnrs, ENS de Lyon, Inria, UCB Lyon 1, LIP UMR 5668, Lyon, FRANCE
| | - Jean-Louis Herrmann
- INSERM U1173, UFR Simone Veil, Versailles-Saint-Quentin University, Saint-Quentin en Yvelines, France AP-HP, Service de Microbiologie, Hôpital Raymond Poincaré, Garches, France
| | - Didier Guillemot
- Equipe PheMI, unité B2PHI, Inserm, Université de Versailles Saint Quentin, Institut Pasteur,Paris, France
| | - Laura Temime
- Laboratoire MESuRS, Conservatoire national des Arts et Métiers, Paris, France
- Institut Pasteur, Cnam, unité PACRI, Paris, France
| | - Lulla Opatowski
- Equipe PheMI, unité B2PHI, Inserm, Université de Versailles Saint Quentin, Institut Pasteur,Paris, France
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Impact of single-room contact precautions on hospital-acquisition and transmission of multidrug-resistant Escherichia coli: a prospective multicentre cohort study in haematological and oncological wards. Clin Microbiol Infect 2019; 25:1013-1020. [PMID: 30641228 DOI: 10.1016/j.cmi.2018.12.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 12/15/2018] [Accepted: 12/23/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Colonization and infection with third-generation cephalosporin-resistant Escherichia coli (3GCR-EC) are frequent in haematological and oncological patients. In this high-risk setting, German guidelines recommend single-room contact precautions (SCP) for patients with 3GCR-EC that are non-susceptible to fluoroquinolones (F3GCR-EC). However, this recommendation is controversial, as evidence is limited. METHODS We performed a prospective, multicentre cohort study at four haematology and oncology departments assessing the impact of SCP on hospital-acquired colonization or bloodstream infection (BSI) with F3GCR-EC. Two sites performed SCP for F3GCR-EC patients including single rooms, gloves and gowns (SCP sites), and two did not (NCP sites). Active screening for 3GCR-EC was performed and isolates were characterized with molecular typing methods including whole genome sequencing and core genome multiple locus sequence typing to assess patient-to-patient transmission. Potential confounders were assessed by competing-risk regression analysis. RESULTS Within 12 months, 1386 patients at NCP sites and 1582 patients at SCP sites were included. Hospital-acquisition of F3GCR-EC was observed in 22/1386 (1.59%) and 16/1582 (1.01%) patients, respectively (p 0.191). There were 3/1386 (0.22%) patients with BSI caused by F3GCR-EC at NCP sites and 4/1582 (0.25%) at SCP sites (p 1.000). Patient-to-patient transmission occurred in three cases at NCP and SCP sites each (p 1.000). The number of patients needed to screen in order to prevent one patient-to-patient transmission of F3GCR-EC was determined to be 3729. CONCLUSIONS Use of SCP had no significant impact on hospital-acquisition or patient-to-patient transmission of F3GCR-EC in this high-risk setting.
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Gysin DV, Cookson B, Saenz H, Dettenkofer M, Widmer AF. Variability in contact precautions to control the nosocomial spread of multi-drug resistant organisms in the endemic setting: a multinational cross-sectional survey. Antimicrob Resist Infect Control 2018; 7:81. [PMID: 30002821 PMCID: PMC6038251 DOI: 10.1186/s13756-018-0366-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 06/04/2018] [Indexed: 12/19/2022] Open
Abstract
Background Definitions and practices regarding use of contact precautions and isolation to prevent the spread of gram-positive and gram-negative multidrug-resistant organisms (MDRO) are not uniform. Methods We conducted an on-site survey during the European Congress on Clinical Microbiology and Infectious Diseases 2014 to assess specific details on contact precaution and implementation barriers. Results Attendants from 32 European (EU) and 24 non-EU countries participated (n = 213). In EU-respondents adherence to contact precautions and isolation was high for Methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Enterobacteriaceae, and MDR A. baumannii (84.7, 85.7, and 80%, respectively) whereas only 68% of EU-respondents considered any contact precaution measures for extended-spectrum-beta-lactamase (ESBL) producing non-E. coli. Between 30 and 45% of all EU and non-EU respondents did not require health-care workers (HCW) to wear gowns and gloves at all times when entering the room of a patient in contact isolation. Between 10 and 20% of respondents did not consider any rooming specifications or isolation for gram-positive MDRO and up to 30% of respondents abstain from such interventions in gram-negative MDRO, especially non-E. coli ESBL. Understaffing and lack of sufficient isolation rooms were the most commonly encountered barriers amongst EU and non-EU respondents. Conclusion The effectiveness of contact precautions and isolation is difficult to assess due to great variation in components of the specific measures and mixed levels of implementation. The lack of uniform positive effects of contact isolation to prevent transmission may be explained by the variability of interpretation of this term. Indications for contact isolation require a global definition and further sound studies. Electronic supplementary material The online version of this article (10.1186/s13756-018-0366-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Danielle Vuichard Gysin
- 1Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, 4051 Basel, Switzerland.,Present address: Department of Internal Medicine, Cantonal Hospital Thurgau, Muensterlingen, Switzerland
| | - Barry Cookson
- 2Division of Infection and Immunity, University College London, London, UK
| | - Henri Saenz
- 3ESCMID Executive Office, Basel, Switzerland
| | - Markus Dettenkofer
- Institute of Hospital Hygiene and Infection Prevention, Gesundheitsverbund Landkreis Konstanz, Radolfzell, Germany
| | - Andreas F Widmer
- 1Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, 4051 Basel, Switzerland
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Discontinuing contact precautions for multidrug-resistant organisms: A systematic literature review and meta-analysis. Am J Infect Control 2018; 46:333-340. [PMID: 29031432 DOI: 10.1016/j.ajic.2017.08.031] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/24/2017] [Accepted: 08/25/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Several single-center studies have suggested that eliminating contact precautions (CPs) for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) control in nonoutbreak settings has no impact on infection rates. We performed a systematic literature review and meta-analysis on the impact of discontinuing contact precautions in the acute care setting. METHODS We searched PubMed, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Embase through December 2016 for studies evaluating discontinuation of contact precautions for multidrug-resistant organisms. We used random-effect models to obtain pooled risk ratio estimates. Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic. Pooled risk ratios for MRSA and VRE were assessed separately. RESULTS Fourteen studies met inclusion criteria and were included in the final review. Six studies discontinued CPs for both MRSA and VRE, 3 for MRSA only, 2 for VRE only, 2 for extended-spectrum β-lactamase-producing Escherichia coli, and 1 for Clostridium difficile infection. When study results were pooled, there was a trend toward reduction of MRSA infection after discontinuing CPs (pooled risk ratio, 0.84; 95% confidence interval, 0.70-1.02; P = .07) and a statistically significant reduction in VRE infection (pooled risk ratio, 0.82; 95% confidence interval, 0.72-0.94; P = .005). CONCLUSIONS Discontinuation of CPs for MRSA and VRE has not been associated with increased infection rates.
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Zahar JR, Blot S. Dilemmas in infection control in the intensive care unit. Intensive Crit Care Nurs 2018; 46:1-3. [PMID: 29395569 DOI: 10.1016/j.iccn.2018.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Jean-Ralph Zahar
- IAME, UMR 1137, Université Paris 13, Sorbonne Paris Cité; Département de Microbiologie Clinique, Unité de Contrôle et de Prévention du risque Infectieux, Groupe Hospitalier Paris Seine Saint-Denis, AP-HP, 125 rue de Stalingrad, 9300 Bobigny, France
| | - Stijn Blot
- Department of Internal Medicine, Ghent University, Flanders, Belgium; Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia.
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Dettenkofer M, Frank U, Just HM, Lemmen S, Scherrer M. Isolierungsmaßnahmen. PRAKTISCHE KRANKENHAUSHYGIENE UND UMWELTSCHUTZ 2018. [PMCID: PMC7123004 DOI: 10.1007/978-3-642-40600-3_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Die Kenntnis des infektionsspezifischen Übertragungsweges einer Erkrankung ist die entscheidende Voraussetzung zur Festlegung sinnvoller, d. h. effektiver Präventionsmaßnahmen, zu denen auch heute noch die räumliche Isolierung von Patienten gehört. Die in der Vergangenheit empfohlenen pauschalen Maßnahmen, die weder den Übertragungsweg noch die Virulenz eines Infektionserregers angemessen berücksichtigten, führten oftmals zu erkennbarer Überisolierung, mit der Folge, dass in der täglichen Praxis notwendige Isolierungsmaßnahmen eher nachlässig gehandhabt wurden. Die Konsequenzen waren vermeidbare Kontaktinfektionen in Kliniken. Andererseits birgt die Unterbringung in einem Isolierzimmer die Gefahr einer schlechteren medizinischen wie pflegerischen Versorgung und damit einer Gefährdung des Patienten. Erreger- und maßnahmenbezogene Isolierkriterien mit disziplinierter Befolgung erforderlicher Verhaltensregeln seitens aller Beschäftigten, der isolierten Patienten und ihrer Besucher sind die Voraussetzung einer erfolgreichen Vermeidung von Infektionsübertragungen. Die Vermeidung unnötiger Isolierungsmaßnahmen spart erhebliche Kosten, reduziert die Belastung von Ärzten wie Pflegekräften und damit die Gefahr der Noncompliance bei essenziellen Präventionsmaßnahmen wie Händedesinfektion und andere Maßnahmen der Basishygiene.
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Affiliation(s)
- Markus Dettenkofer
- Gesundheitsverbund Landkreis Konstanz, Institut für Krankenhaushygiene & Infektionsprävention, Radolfzell, Germany
| | - Uwe Frank
- Sektion Krankenhaus- und Umwelthygiene, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | - Sebastian Lemmen
- Zentralbereich für Krankenhaushygiene, Universitätsklinikum Aachen, Aachen, Germany
| | - Martin Scherrer
- Stabsstelle Techn. Krankenhaushygiene, Universitätsklinikum Heidelberg, Heidelberg, Germany
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Quantifying Hospital-Acquired Carriage of Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae Among Patients in Dutch Hospitals. Infect Control Hosp Epidemiol 2017; 39:32-39. [DOI: 10.1017/ice.2017.241] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUNDExtended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-E) are emerging worldwide. Contact precautions are recommended for known ESBL-E carriers to control the spread of ESBL-E within hospitals.OBJECTIVEThis study quantified the acquisition of ESBL-E rectal carriage among patients in Dutch hospitals, given the application of contact precautions.METHODSData were used from 2 cluster-randomized studies on isolation strategies for ESBL-E: (1) the SoM study, performed in 14 Dutch hospitals from 2011 through 2014 and (2) the R-GNOSIS study, for which data were limited to those collected in a Dutch hospital in 2014. Perianal cultures were obtained, either during ward-based prevalence surveys (SoM), or at admission and twice weekly thereafter (R-GNOSIS). In both studies, contact precautions were applied to all known ESBL-E carriers. Estimates for acquisition of ESBL-E were based on the results of admission and discharge cultures from patients hospitalized for more than 2 days (both studies) and a Markov chain Monte Carlo (MCMC) model, applied to all patients hospitalized (R-GNOSIS).RESULTSThe absolute risk of acquisition of ESBL-E rectal carriage ranged from 2.4% to 2.9% with an ESBL-E acquisition rate of 2.8 to 3.8 acquisitions per 1,000 patient days. In addition, 28% of acquisitions were attributable to patient-dependent transmission, and the per-admission reproduction number was 0.06.CONCLUSIONSThe low ESBL-E acquisition rate in this study demonstrates that it is possible to control the nosocomial transmission of ESBL in a low-endemic, non-ICU setting whereEscherichia coliis the most prevalent ESBL-E and standard and contact precautions are applied for known ESBL-E carriers.TRIAL REGISTRATIONNederlands Trialregister, NTR2799,http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2799; ISRCTN Registry, ISRCTN57648070,http://www.isrctn.com/ISRCTN57648070Infect Control Hosp Epidemiol2018;39:32–39
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Impact of Discontinuing Contact Precautions for MRSA and ESBLE in an Intensive Care Unit: A Prospective Noninferiority Before and After Study. Infect Control Hosp Epidemiol 2017; 38:1342-1350. [DOI: 10.1017/ice.2017.196] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVETo compare incidence densities of methicillin-resistant Staphylococcus aureus (MRSA) or extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBLE) acquisition in the intensive care unit (ICU) before and after discontinuation of contact precautions (CP) and application of standard precautions (SP).DESIGNProspective noninferiority before-and-after study comparing 2 periods: January 1, 2012, to January 31, 2014 (the CP period) and February 1, 2014, to February 29, 2016 (the SP period).SETTINGA 16-bed polyvalent ICU in France with only single-bed rooms with dedicated equipment and reusable medical devices.PATIENTSAll patients admitted to the ICU during the CP and SP periods were included: 1,547 and 1,577 patients, respectively.METHODSIncidence densities of ICU-acquired MRSA or ESBLE were determined per 1,000 patient days. Other studied factors included (1) patient characteristics, (2) incidence densities of MRSA or ESBLE carried at admission, (3) compliance with hand hygiene protocols, and (4) antibiotic consumption.RESULTSIncidence densities of ICU-acquired MRSA were 0.82 (95% confidence interval [CI], 0.31–1.33) and 0.79 (95% CI, 0.30–1.29) per 1,000 patient days during the CP and SP periods, respectively. For ESBLE, values were 2.7 (95% CI, 1.78–3.62) and 2.06 (95% CI, 1.27–2.86) per 1,000 patient days. These rates were significantly nonsuperior during the SP period compared to CP period, with a margin of 1 per 1,000 patient days for both MRSA (P=.002) and ESBLE (P=.004). Other factors were comparable during the 2 periods. Only ESBLE carried at admission was inferior during the SP period. We observed a high level of compliance to hand hygiene protocols.CONCLUSIONSDiscontinuing CP did not increase acquired MRSA and ESBLE in our ICU with single rooms with dedicated equipment, strict application of hand hygiene, medical and paramedical leadership, and good antibiotic stewardship.Infect Control Hosp Epidemiol 2017;38:1342–1350
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Cessation of Contact Precautions for Extended-Spectrum Beta-Lactamase (ESBL)–Producing Escherichia coli Seems to be Safe in a Nonepidemic Setting. Infect Control Hosp Epidemiol 2017; 38:1379-1381. [DOI: 10.1017/ice.2017.198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Repessé X, Artiguenave M, Paktoris-Papine S, Espinasse F, Dinh A, Charron C, El Sayed F, Geri G, Vieillard-Baron A. Epidemiology of extended-spectrum beta-lactamase-producing Enterobacteriaceae in an intensive care unit with no single rooms. Ann Intensive Care 2017; 7:73. [PMID: 28674848 PMCID: PMC5495817 DOI: 10.1186/s13613-017-0295-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 06/19/2017] [Indexed: 01/28/2023] Open
Abstract
Background The transmission of extended-spectrum beta-lactamase-producing enterobacteriaceae (ESBL) is prevented by additional contact precautions, mainly relying on isolation in a single room and hand hygiene. Contact isolation cannot be achieved in our 12-bed ICU, which has only double rooms. We report the epidemiology of ESBL imported, acquired and transmitted in an ICU with no single rooms. Methods We prospectively conducted an observational and non-interventional study in a French 12-bed ICU. Inclusion criteria were patients >18 years of age treated by at least two successive nursing teams. Patient characteristics at admission and clinical data during hospital stay were collected prospectively. ESBL carriage was monitored using rectal swabs collected at admission and once weekly during the ICU stay. Potential cross-transmission was studied (1) by identifying index patients defined as possible ESBL sources for transmission, (2) by classifying each ESBL strain according to the cefotaximase München (CTXM) 1 and 9 groups and (3) by gene sequencing for remaining cases of possible transmission. Results From June 2014 to April 2015, of 550 patients admitted to the ICU, 470 met the inclusion criteria and 221 had at least two rectal swabs. The rate of ESBL colonization, mainly by Escherichia coli, at admission was 13.2%. The incidence of ESBL acquisition, mainly with E. coli too, was 4.1%. Mortality did not differ between ESBL carriers and non-carriers. In univariate analysis, ESBL acquisition was associated with male gender, SAPS II, SOFA, chronic kidney disease at admission, duration of mechanical ventilation, need for catecholamine and the ICU LOS. In multivariate analysis, SAPS II at admission was the only risk factor for ESBL acquisition. We confirmed cross-transmission, emanating from the same index patient, in two of the nine patients with ESBL acquisition (0.8%, 2/221). No case of cross-transmission in the same double room was observed. Discussion and conclusion Prevalence of ESBL colonization in our ICU was 13.2%. Despite the absence single rooms, the incidence of ESBL acquisition was 4.1% and cross-transmission was proven in only two cases, resulting from the same index patient who was not hospitalized in the same double room. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0295-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xavier Repessé
- Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 9, Avenue Charles-de-Gaulle, 92100, Boulogne-Billancourt, France
| | - Margaux Artiguenave
- Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 9, Avenue Charles-de-Gaulle, 92100, Boulogne-Billancourt, France
| | - Sophie Paktoris-Papine
- Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 9, Avenue Charles-de-Gaulle, 92100, Boulogne-Billancourt, France
| | - Florence Espinasse
- Infection Control Unit, Section Biology Pathology and Health Products, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France
| | - Aurélien Dinh
- Infectious Diseases Department, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France
| | - Cyril Charron
- Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 9, Avenue Charles-de-Gaulle, 92100, Boulogne-Billancourt, France
| | - Faten El Sayed
- Microbiology Unit, Section Biology Pathology and Health Products, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France
| | - Guillaume Geri
- Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 9, Avenue Charles-de-Gaulle, 92100, Boulogne-Billancourt, France.,Faculty of Medicine Paris Ile-de-France Ouest, University of Versailles Saint-Quentin en Yvelines, 78280, Saint-Quentin-en-Yvelines, France.,INSERM U-1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), UVSQ, 94807, Villejuif, France
| | - Antoine Vieillard-Baron
- Intensive Care Unit, Section Thorax-Vascular Disease-Abdomen-Metabolism, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 9, Avenue Charles-de-Gaulle, 92100, Boulogne-Billancourt, France. .,Faculty of Medicine Paris Ile-de-France Ouest, University of Versailles Saint-Quentin en Yvelines, 78280, Saint-Quentin-en-Yvelines, France. .,INSERM U-1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), UVSQ, 94807, Villejuif, France.
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Tschudin-Sutter S, Lucet JC, Mutters NT, Tacconelli E, Zahar JR, Harbarth S. Contact Precautions for Preventing Nosocomial Transmission of Extended-Spectrum β Lactamase–Producing Escherichia coli: A Point/Counterpoint Review. Clin Infect Dis 2017; 65:342-347. [DOI: 10.1093/cid/cix258] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/29/2017] [Indexed: 01/10/2023] Open
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25
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Fitzpatrick F, Perencevich EN. Putting contact precautions in their place. J Hosp Infect 2017; 96:99-100. [PMID: 28262434 DOI: 10.1016/j.jhin.2017.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 02/10/2017] [Indexed: 11/26/2022]
Affiliation(s)
- F Fitzpatrick
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland.
| | - E N Perencevich
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA; Center for Comprehensive Access and Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
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