Transmission Chains of Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae at the Companion Animal Veterinary Clinic-Household Interface

Raw meat diets are a major risk factor for carriage of third-generation cephalosporin-resistant and multidrug-resistant E. coli by dogs in the UK

Introduction

Raw-meat diets (RMD) for dogs, comprising unprocessed or non-heat-treated animal material, are increasingly popular. However, RMDs have been demonstrated to be contaminated with antimicrobial resistant (AMR) bacteria, and there is concern that such diets may pose a zoonotic disease risk. Additionally, dogs fed RMD may shed more AMR- fecal bacteria compared to those fed conventional cooked diets. Data from the UK remain limited; the present study investigated the presence of AMR-Escherichia coli in the feces of RMD and non-RMD (NRMD)-fed dogs in the UK, the E. coli AMR gene complement, and the lifestyle risk factors associated with AMR- E. coli carriage.

Methods

Fecal samples from UK-owned dogs (N = 193 RMD, N = 239 NRMD) and questionnaires discussing lifestyle factors, were obtained between October 2020-August 2021. Samples underwent culture and antimicrobial susceptibility testing to determine the presence of AMR-E. coli. Whole genome sequencing determined AMR gene carriage. Risk factors for the presence of AMR-E. coli were determined by multivariable modeling.

Results

RMD dogs carried significantly more fecal AMR E. coli (p < 0.001), including third-generation cephalosporin resistant, extended-spectrum beta-lactamase (ESBL) producing, and multidrug resistant isolates and multivariable modeling confirmed raw-meat diets to be a significant risk factor. The bla CTX-M-15 gene was the most frequently identified bla ESBL gene. The bla CTX-M-55 and bla SHV-66 genes were also prevalent and were only found in RMD dogs. The mobile colistin resistance gene, mcr-4 was identified in one ESBL-producing E. coli isolate from a NRMD-fed dog.

Conclusion

This study has shown that dogs fed RMD in the UK are significantly more likely to shed E. coli which is resistant to highest priority critically important antibiotics, and multidrug resistant E. coli, than dogs fed NRMD. Additionally, AMR-E. coli isolates from RMD-fed dogs harbor multiple, diverse, and novel AMR genes. Therefore, provision of RMD to dogs could pose an important potential threat to human and animal health, especially given the close nature of the relationship many owners share with their pets. Awareness of these findings should be shared with pet owners, veterinary and medical professionals, pet food manufacturers and public health to mitigate potential risks.

International travel increases risk of urinary tract infection caused by extended-spectrum beta-lactamase-producing Enterobacterales-three-arm case-control study

BACKGROUND

Extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-PE) have worldwide become increasingly prevalent as pathogens causing urinary tract infections (UTIs), posing challenges in their treatment. Of particular concern are travellers to low- and middle-income countries (LMICs), a substantial proportion of whom become colonized by ESBL-PE, with UTIs as the most common clinical manifestation. Seeking tools for preventing ESBL-PE UTI, we explored factors associated with (i) any UTI (versus control), (ii) ESBL-PE UTI (versus control) and (iii) ESBL-PE versus non-ESBL-PE UTI.

METHODS

During 2015-20, we recruited patients with recent ESBL-PE or non-ESBL-PE UTIs, and controls with no UTI to fill in questionnaires covering potential (ESBL-PE-)UTI risk factors.

RESULTS

Of our 430 participants, 130 had ESBL-PE UTI and 187 non-ESBL-PE UTI; 113 were controls. Our three comparisons showed several risk factors as exemplified for any UTI versus controls by female sex, lower education, age, diabetes, antibiotic use, diarrhoea; for ESBL-PE UTI versus controls by travel to LMICs, antibiotic use, swimming; and ESBL-PE versus non-ESBL-PE UTI by male sex, higher education, LMIC travel (participant/household member), pets and antibiotic use. Weekly fish meals appeared protective against both UTI and ESBL-PE UTI.

CONCLUSIONS

Of the numerous factors predisposing to UTI and/or ESBL-PE UTI, our study highlights antibiotic use and LMIC travel. Household members' LMIC travel appears to pose a risk of ESBL-PE UTI, pointing to household transmission of travel-acquired uropathogens. As predisposing factors to multidrug-resistant UTI, international travel and antibiotic use constitute practical targets for prevention efforts.

Evidence for the transmission of antimicrobial resistant bacteria between humans and companion animals: A scoping review

Objective

Transmission of antimicrobial resistant bacteria between people and household pets, such as dogs and cats, is an emerging global public health problem. This scoping review synthesized existing evidence of human-pet bacteria transmission to understand the magnitude and breadth of this issue.

Methods

The search included specific and generic terms for bacteria, resistance, transmission, pets, and humans. Searches were conducted through PubMed, Scopus, Web of Science, CABI Global Health, Networked Digital Library of Theses and Dissertations, Google Scholar. All studies published in English and Mandarin that isolated bacteria from pets (cats and dogs) and humans who had contact with the pets, and reported phenotypic or genotypic antimicrobial sensitivity test results, were included in this review. In cases of bacterial species that are commonly associated with pets, such as Staphylococcus pseudintermedius and Pasteurella multocida, we also included studies that only isolated bacteria from humans.

Results

After removing duplication, the search captured 9355 studies. A total of 1098 papers were screened in the full-text review, and 562 studies were identified as eligible according to our inclusion criteria. The primary reason for exclusion was the lack of sensitivity testing. The included studies were published between 1973 and 2021. The most common study location was the United States (n = 176, 31.3%), followed by the United Kingdom (n = 53, 9.4%), Japan (n = 29, 5.2%), and Canada (n = 25, 4.4%). Most of the included studies were case reports (n = 367, 63.4%), cross-sectional/prevalence studies (n = 130, 22.4%), and case series (n = 51, 8.8%). Only few longitudinal studies (n = 14, 2.4%), case-control studies (n = 12, 2.1%), and cohort studies (n = 5, 0.9%) were included in our review. Most studies focused on Pasteurella multocida (n = 221, 39.3%), Staphylococcus aureus (n = 81, 14.4%), and Staphylococcus pseudintermedius (n = 52, 8.9%). For the 295 studies that used strain typing methods to compare bacteria from humans and pets, most used DNA banding pattern-based methods (n = 133, 45.1%) and DNA sequencing-based methods (n = 118, 40.0%).

Conclusion

Transmission of bacteria could occur in both directions: pets to humans (e.g., S. pseudintermedius and P. multocida) and humans to pets (e.g., S. aureus). The majority of studies provided a low level of evidence of transmission (e.g., case reports), suggesting that more rigorous longitudinal, cohort, or case-control studies are needed to fully understand the risk of human-pet resistant bacterial transmission.

Educational intervention to improve infection prevention and control practices in four companion animal clinics in Switzerland

BACKGROUND

Infection prevention and control (IPC) practices vary among companion animal clinics, and outbreaks with carbapenemase-producing Enterobacterales (CPE) have been described.

AIM

To investigate the effect of an IPC intervention (introduction of IPC protocols, IPC lectures, hand hygiene campaign) in four companion animal clinics.

METHODS

IPC practices, environmental and hand contamination with antimicrobial-resistant micro-organisms (ARM) and hand hygiene (HH) were assessed at baseline, and 1 and 5 months after the intervention.

RESULTS

Median IPC scores (% maximum score) improved from 57.8% (range 48.0-59.8%) to 82.9% (range 81.4-86.3%) at 1-month follow-up. Median cleaning frequency assessed by fluorescent tagging increased from 16.7% (range 8.9-18.9%) to 30.6% (range 27.8-52.2%) at 1-month follow-up and 32.8% (range 32.2-33.3%) at 5-month follow-up. ARM contamination was low in three clinics at baseline and undetectable after the intervention. One clinic showed extensive contamination with ARM including CPE before and after the intervention (7.5-16.0% ARM-positive samples and 5.0-11.5% CPE-positive samples). Mean HH compliance improved from 20.9% [95% confidence interval (CI) 19.2-22.8%] to 42.5% (95% CI 40.4-44.7%) at 1-month follow-up and 38.7% (95% CI 35.7-41.7%) at 5-month follow-up. Compliance was lowest in the pre-operative preparation area at baseline (11.8%, 95% CI 9.3-14.8%) and in the intensive care unit after the intervention (28.8%, 95% CI 23.3-35.1%). HH compliance was similar in veterinarians (21.5%, 95% CI 19.0-24.3%) and nurses (20.2%, 95% CI 17.9-22.7%) at baseline, but was higher in veterinarians (46.0%, 95% CI 42.9-49.1%) than nurses (39.0%, 95% CI 36.0-42.1%) at 1-month follow-up.

CONCLUSION

The IPC intervention improved IPC scores, cleaning frequency and HH compliance in all clinics. Adapted approaches may be needed in outbreak situations.

ESBL-Positive Enterobacteriaceae from Dogs of Santiago and Boa Vista Islands, Cape Verde: A Public Health Concern

Antimicrobial resistance is a public health threat with an increasing expression in low- and middle-income countries such as Cape Verde. In this country, there is an overpopulation of dogs, which may facilitate the spread of resistant bacteria, including extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae. To clarify the role of dogs as reservoirs for the dissemination of this bacterial group, 100 rectal swab samples were collected from confined (n = 50) and non-confined (n = 50) dogs in Santiago and Boa Vista Islands, Cape Verde. These were analyzed using conventional bacteriological techniques for the detection of ESBL-producing Enterobacteriaceae and characterization of their pathogenic and resistance profiles. Twenty-nine samples displayed ESBL-positive bacteria, from which 48 ESBL-producing isolates were obtained and mostly identified as Escherichia coli. Multiple antimicrobial resistance indexes ranged from 0.18 to 0.70 and half of the isolates were classified as multidrug-resistant. Isolates were capable of producing relevant virulence factors, including biofilm, showing virulence indexes between 0.29 and 0.71. As such, dogs in Cape Verde may act as reservoirs of resistant bacteria, including pathogenic and zoonotic species, representing a public health concern. Although further investigation is needed, this study proposes the periodical analysis of dogs’ fecal samples to monitor resistance dissemination in the country, in a One-Health perspective.

Virulence Profile, Antibiotic Resistance, and Phylogenetic Relationships among Escherichia coli Strains Isolated from the Feces and Urine of Hospitalized Patients

Extra-intestinal pathogenic Escherichia coli (ExPEC) may inhabit the human gut microbiota without causing disease. However, if they reach extra-intestinal sites, common cystitis to bloodstream infections may occur, putting patients at risk. To examine the human gut as a source of endogenous infections, we evaluated the E. coli clonal diversity of 18 inpatients' guts and their relationship with strains isolated from urinary tract infection (UTI) in the same hospital. Random amplified polymorphic DNA evaluated the clonal diversity, and the antimicrobial susceptibility was determined by disk diffusion. One isolate of each clone detected was sequenced, and their virulome and resistome were determined. Overall, 177 isolates were screened, among which 32 clones were identified (mean of two clones per patient), with ExPEC strains found in over 75% of the inpatients' guts. Endogenous infection was confirmed in 75% of the cases. ST10, ST59, ST69, ST131, and ST1193 clones and critical mobile drug-resistance encoding genes (bla_CTX-M-15, bla_OXA-1, bla_DHA-1, aac(6')-lb-cr, mcr-1.26, qnrB4, and qnrB19) were identified in the gut of inpatients. The genomic analysis highlighted the diversity of the fecal strains, colonization by lactose-negative E. coli, the high frequency of ExPEC in the gut of inpatients without infections, and the presence of β-lactamase producing E. coli in the gut of inpatients regardless of the previous antibiotics' usage. Considering that we found more than one ExPEC clone in the gut of several inpatients, surveillance of inpatients' fecal pathogens may prevent UTI caused by E. coli in the hospital and dissemination of risk clones.

Human pandemic K27-ST392 CTX-M-15 extended-spectrum-β-lactamase-positive Klebsiella pneumoniae: A one health clone threatening companion animals

Extended spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae is a medically important pathogen that commonly causes human nosocomial infections. Since veterinary emergency and critical care services have also significantly progressed over the last decades, there are increasing reports of ESBL-producing K. pneumoniae causing hospital-associated infections in companion animals. We present microbiological and genomic analysis of a multidrug-resistant ESBL-positive K. pneumoniae (LCKp01) isolated from a fatal infection in a dog admitted to a veterinary intensive care unit. LCKp01 strain belonged to the sequence type ST392 and displays a KL27 (wzi-187) and O-locus 4 (O4). A broad resistome and presence of the bla_CTX-M-15 ESBL gene were predicted. SNP-based phylogenomic analysis, using an international genome database, clustered LCKp01 (60–80 SNPs differences) with K. pneumoniae ST392 from human and animal infections, isolated at 4-year interval, whereas phylogeographical analysis confirmed successful expansion of ST392 as a global clone of One Health concern.

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A fatal infection by a multidrug-resistant K. pneumoniae in dog was investigated.

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Identification of human pandemic K. pneumoniae ST392/CTX-M-15 clone is highlighted.

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Phylogenomic analysis revealed clonal relatedness with nosocomial lineages.

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Phylogeographical analysis confirmed expansion of ST392 as global One Health clone.

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Dissemination of K. pneumoniae ST392 at the human-animal interface is discussed.

Detection of NDM-5 and MCR-1 antibiotic resistance encoding genes in Enterobacterales in long-distance migratory bird species Ciconia ciconia, Algeria

β-lactams and colistin resistance in Enterobacterales is a global public health issue. In this study we aimed to investigate the occurrence and genetic determinants of Extended-Spectrum β-lactamases, carbapenemases and mcr-encoding-genes in Enterobacterales isolates recovered from the migratory bird species Ciconia ciconia in an Algerian city. A total of 62 faecal samples from white storks were collected. Samples were then subjected to selective isolation of β-lactams and colistin-resistant-Enterobacterales. The representative colonies were identified using Matrix-Assisted Laser Desorption-Ionisation Time-of-Flight Mass Spectrometry. Susceptibility testing was performed using the disk-diffusion method. ESBL, carbapenemases, and colistin resistance determinants were searched for by PCR and sequencing. The clonality relationships of the obtained isolates were investigated by multilocus sequence typing assays. Mating experiments were carried out to evaluate the transferability of the carbapenemase and mcr-genes. Forty-two isolates were identified as follows: Escherichia coli (n = 33), Klebsiella pneumoniae (n = 4), Proteus mirabilis (n = 4) and Citrobacter freundii (n = 1). Molecular analysis showed that twelve isolates carried the bla_ESBL genes alone, fifteen E. coli isolates were positive for the bla_OXA-48 gene, six isolates were NDM-5-carriers (two P. mirabilis, two K. pneumoniae and two E. coli) and eight E. coli strains were positive for the mcr-1 gene. MLST results showed a high clonal diversity, where NDM-5-producing strains were assigned to two sequence types (ST167 for E. coli and ST198 for K. pneumoniae), whereas the mcr-1 positive E. coli isolates belonged to ST58, ST224, ST453, ST1286, ST2973, ST5542, ST9815 and the international high-risk resistant lineage ST101. To the best of our knowledge, this is the first report of bla_NDM-5 gene in white storks and also the first describing the mcr-1 gene in white storks in Algeria. This study underlines the important role of migratory white storks as carriers of high-level drug-resistant bacteria, allowing their possible implication as indicators and sentinels for antimicrobial resistance surveillance.

Characterisation of and risk factors for extended-spectrum β-lactamase producing Enterobacterales (ESBL-E) in an equine hospital with a special reference to an outbreak caused by Klebsiella pneumoniae ST307:CTX-M-1

Background

Extended-spectrum β-lactamase producing Enterobacterales (ESBL-E) are important causative agents for infections in humans and animals. At the Equine Veterinary Teaching Hospital of the University of Helsinki, the first infections caused by ESBL-E were observed at the end of 2011 leading to enhanced infection surveillance. Contact patients were screened for ESBL-E by culturing infection sites and rectal screening. This study was focused on describing the epidemiology and microbiological characteristics of ESBL-E from equine patients of the EVTH during 2011–2014, and analysing putative risk factors for being positive for ESBL-E during an outbreak of Klebsiella pneumoniae ST307.

Results

The number of ESBL-E isolations increased through 2012–2013 culminating in an outbreak of multi-drug resistant K. pneumoniae ST307:bla_CTX-M-1:bla_TEM:bla_SHV during 04–08/2013. During 10/2011–05/2014, altogether 139 ESBL-E isolates were found from 96 horses. Of these, 26 were from infection-site specimens and 113 from rectal-screening swabs. A total of 118 ESBL-E isolates from horses were available for further study, the most numerous being K. pneumoniae (n = 44), Escherichia coli (n = 31) and Enterobacter cloacae (n = 31). Hospital environmental specimens (N = 47) yielded six isolates of ESBL-E. Two identical E. cloacae isolates originating from an operating theatre and a recovery room had identical or highly similar PFGE fingerprint profiles as five horse isolates. In the multivariable analysis, mare–foal pairs (OR 4.71, 95% CI 1.57–14.19, P = 0.006), length of hospitalisation (OR 1.62, 95% CI 1.28–2.06, P < 0.001) and passing of a nasogastric tube (OR 2.86, 95% CI 1.03–7.95, P = 0.044) were associated with being positive for ESBL-E during the K. pneumoniae outbreak.

Conclusions

The occurrence of an outbreak caused by a pathogenic ESBL-producing K. pneumoniae ST307 strain highlights the importance of epidemiological surveillance of ESBL-E in veterinary hospitals. Limiting the length of hospitalisation for equine patients may reduce the risk of spread of ESBL-E. It is also important to acknowledge the importance of nasogastric tubing as a potential source of acquiring ESBL-E. As ESBL-E were also found in stomach drench pumps used with nasogastric tubes, veterinary practices should pay close attention to appropriate equipment cleaning procedures and disinfection practices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13028-022-00621-6.

Massive Spread of OXA-48 Carbapenemase-Producing Enterobacteriaceae in the Environment of a Swiss Companion Animal Clinic

Background: Companion animal clinics contribute to the spread of antimicrobial resistant microorganisms (ARM) and outbreaks with ARM of public health concern have been described. Methods: As part of a project to assess infection prevention and control (IPC) standards in companion animal clinics in Switzerland, a total of 200 swabs from surfaces and 20 hand swabs from employees were collected during four days in a medium-sized clinic and analyzed for extended spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E), carbapenemase-producing Enterobacteriaceae (CPE), vancomycin-resistant enterococci (VRE), and methicillin-resistant staphylococci (MRS). Results: A total of 22 (11.0%) environmental specimen yielded CPE, 14 (7.0%) ESBL-E, and 7 (3.5%) MRS; MR Staphylococcus aureus were isolated from two (10.0%) hand swabs. The CPE isolates comprised Escherichia coli, Klebsiella pneumoniae, Enterobacter hormaechei, Citrobacter braakii, and Serratia marcescens. Whole genome sequencing revealed that all CPE carried closely related bla_OXA-48 plasmids, suggesting a plasmidic spread within the clinic. The clinic exhibited major deficits in surface disinfection, hand hygiene infrastructure, and hand hygiene compliance. CPE were present in various areas, including those without patient contact. The study documented plasmidic dissemination of bla_OXA-48 in a companion animal clinic with low IPC standards. This poses a worrisome threat to public health and highlights the need to foster IPC standards in veterinary clinics to prevent the spread of ARM into the community.

Hand Hygiene Evaluation Using Two Different Evaluation Tools and Hand Contamination of Veterinary Healthcare Workers in a Swiss Companion Animal Clinic

Hand hygiene (HH) is the most important measure to prevent nosocomial infections. HH compliance in companion animal clinics has been reported to be poor. The present study compared an online application with the WHO evaluation form to assess the WHO five moments of HH in a Swiss companion animal clinic. In 202 hand swabs from 87 staff members, total viable count (TVC) before and after patient contact was evaluated and the swabs were tested for selected antimicrobial resistant microorganisms of public health importance. HH compliance (95% confidence interval) was 36.6% (33.8–39.5%) and was similar when assessed with the two evaluation tools. HH differed between hospital areas (p = 0.0035) and HH indications (p < 0.0001). Gloves were worn in 22.0% (18.0–26.6%) of HH observations and were indicated in 37.2% (27.3–48.3%) of these observations. Mean TVC before patient contact was lower (0.52 log CFU/cm²) than after patient contact (1.02 log CFU/cm²) but was similar before patient contact on gloved and ungloved hands. Three hand swabs (1.5% (0.4–4.3%)) were positive for methicillin-resistant Staphylococcus aureus. Gloving should not be regarded as a substitute for HH. Overall, HH in companion animal medicine should urgently be fostered.