Reduction of Multidrug-Resistant (MDR) Bacterial Infections during the COVID-19 Pandemic: A Retrospective Study

Clinical and microbiological profile of health care-associated infections in a tertiary hospital: Comparison between a cohort of hospitalized patients during prepandemic and COVID-19 pandemic periods

BACKGROUND

During the COVID-19 pandemic, health service practices underwent significant changes, impacting the occurrence of health care-associated infections (HAIs). This study presents the epidemiology of bacterial infections and compares clinical data on nosocomial infections in hospitalized patients before and during the pandemic.

METHODS

A unicentric, observational, retrospective cohort study was conducted with descriptive analyses on the microorganism identification and resistance profile. Patient's clinical data who had hospital-acquired infection (HAI), during their hospitalization in a tertiary hospital before and during the COVID-19 pandemic was compared by descriptive and inferential analyses.

RESULTS

A total of 1,581 bacteria were isolated from 1,183 hospitalized patients. Among patients coinfected with COVID-19, there was a statistically significant increase in HAI-related deaths (P < .001) and HAI caused by multidrug-resistant organisms (P < .001), mainly by Acinetobacter baumannii and Staphylococcus aureus. A higher odds ratio of HAI-related deaths compared to the prepandemic period was observed (odds ratio 6.98 [95% confidence interval 3.97-12.64]).

CONCLUSIONS

The higher incidence of multidrug-resistant bacteria and increased deaths due to HAI, especially in patients with COVID-19 coinfection, might be related to various factors such as increased workload, broad-spectrum antibiotic use, and limited resources. The pandemic has changed the profile of circulating bacteria and antimicrobial resistance. Prevention strategies should be considered to reduce the impact of these infections.

A scoping review of bacterial resistance among inpatients amidst the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic disrupted antimicrobial stewardship and infection prevention operations worldwide, raising concerns for an acceleration of antimicrobial resistance (AMR). Therefore, we aimed to define the scope of peer reviewed research comparing AMR in inpatient bacterial clinical cultures before and after the start of the COVID-19 pandemic.

METHODS

We conducted a scoping review and searched PubMed, Scopus, and Web of Science through 15 June 2023. Our inclusion criteria were: (1) English language, (2) primary evidence, (3) peer-reviewed, (4) clinical culture data from humans, (5) AMR data for at least one bacterial order/species, (6) inpatient setting, (7) use of statistical testing to evaluate AMR data before and during the COVID-19 pandemic. Reviewers extracted country, study design, type of analysis, study period, setting and population, number of positive cultures or isolates, culture type(s), method of AMR analysis, organisms, and AMR results. Study results were organised by organism and antibiotic class or resistance mechanism. AMR results are also summarised by individual study and across all studies.

RESULTS

In total, 4805 articles were identified with 55 papers meeting inclusion criteria. Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus were the most commonly studied organisms. There were 464 bacterial AMR results across all studies with 82 (18%) increase, 71 (15%) decrease, and 311 (67%) no change results.

CONCLUSIONS

The literature examining the impact of COVID-19 on AMR among inpatients is diverse with most results reflecting no change pre/post pandemic. Ongoing inquiry is needed into evolving patterns in AMR post COVID-19.

The impact of COVID-19 on antibiotic resistance and clinical outcomes among critically ill patients

BACKGROUND

There is conflicting evidence regarding the impact of the Coronavirus 2019 (COVID-19) pandemic on antimicrobial resistance, with few studies conducted in low- and middle-income countries. We investigated the impact of the COVID-19 pandemic on multidrug resistant organisms (MDROs) among critically ill patients and their clinical outcomes.

METHODS

This was a retrospective observational study of patients admitted to the medical Intensive Care Unit at Jordan University Hospital and had blood, urine, or bronchoalveolar bacterial cultures taken during 2 time periods: prepandemic (ie, 1/2016 to 1/2019) and pandemic (ie, 1/2020 to 1/2023). We compared the clinical outcomes (ie, in-hospital deaths, the need for O2 devices, intubation, the length of hospital stay, and the occurrence of complications) and prevalence of MDROs between the 2 periods and conducted multivariate analyses.

RESULTS

There were 1,254 patients (479 prepandemic and 775 postpandemic. The percentage of patients who had MDROs was significantly higher among patients with a culture taken during the pandemic (82.4%) compared to before it (17.6%) (P-value=.000). Multivariate analysis demonstrated that patients cultured during the pandemic were more than 3 times as likely to have an MDRO (odds ratio = 3.210; 95% confidence interval: 2.236-4.609).

CONCLUSIONS

The increase in MDROs during the COVID-19 pandemic is an alarming threat to public health; thus, investigating the antibiotic resistance situation as the pandemic subsides is crucial.

Genomic surveillance of carbapenem-resistant Klebsiella pneumoniae reveals a prolonged outbreak of extensively drug-resistant ST147 NDM-1 during the COVID-19 pandemic in the Apulia region (Southern Italy)

OBJECTIVES

The recent worldwide spread of New Delhi metallo-beta-lactamase-producing Klebsiella pneumoniae (NDM-KP) in health-care settings remains a concern. The aim of the study was to describe an outbreak of extensively drug-resistant ST147 NDM-1-KP in the Apulia region of Southern Italy that occurred between 2020 and 2022 through genomic surveillance of carbapenem-resistant Enterobacterales.

METHODS

A total of 459 carbapenem-resistant KP isolates collected from patients hospitalised with bloodstream infections were tested using a commercial multiplex real-time polymerase chain reaction to identify carbapenemase genes. A subset of 27 isolates was subjected to whole-genome sequencing. Core-genome multilocus sequence typing was performed by analysing a panel of 4884 genes.

RESULTS

Molecular testing revealed that 104 (22.6%) isolates carried the carbapenemase NDM gene. Phylogenetic analysis of the 27 isolates subjected to whole-genome sequencing revealed high genetic relatedness among strains. All isolates were resistant to all first-line antibiotics. Virulome analysis identified the ybt locus, the two well-recognised virulence factors iucABCDiutA and rmpA, and the genes encoding the type 3 pilus virulence factor. Plasmids IncFIB(pkPHS1), IncFIB(pNDM-Mar), IncFIB(pQil), IncHI1B(pNDM-MAR), IncR, and Col(pHAD28) were identified in all isolates. Moreover, further analysis identified the IncFIB-type plasmid carrying the NDM-1 genes.

CONCLUSION

The increasing circulation of extensively drug-resistant NDM-1 ST147 KP strains in Southern Italy in recent years is worrisome, because these clones pose a real risk, particularly in hospital settings. Genomic surveillance is a crucial tool for early identification of emerging threats such as the spread of high-risk pathogens. Rapid infection control measures and antimicrobial stewardship are key to preventing further spread of hypervirulent KP strains.

Post-Coronavirus Disease 2019 Pandemic Antimicrobial Resistance

BACKGROUND AND AIM

Antimicrobial resistance (AMR) is a chronic issue of our Westernized society, mainly because of the uncontrolled and improper use of antimicrobials. The coronavirus disease 2019 (COVID-19) pandemic has triggered and expanded AMR diffusion all over the world, and its clinical and therapeutic features have changed. Thus, we aimed to review evidence from the literature on the definition and causative agents of AMR in the frame of the COVID-19 post-pandemic era.

METHODS

We conducted a search on PubMed and Medline for original articles, reviews, meta-analyses, and case series using the following keywords, their acronyms, and their associations: antibiotics, antimicrobial resistance, severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), COVID-19 pandemic, personal protective equipment.

RESULTS

AMR had a significant rise in incidence both in in-hospital and outpatient populations (ranging from 5 up to 50%) worldwide, but with a variegated profile according to the germ and microorganism considered. Not only bacteria but also fungi have developed more frequent and diffuse AMR. These findings are explained by the increased use and misuse of antibiotics and preventive measures during the first waves of the SARS-CoV2 pandemic, especially in hospitalized patients. Subsequently, the reduction in and end of the lockdown and the use of personal protective equipment have allowed for the indiscriminate circulation of resistant microorganisms from low-income countries to the rest of the world with the emergence of new multi- and polyresistant organisms. However, there is not a clear association between COVID-19 and AMR changes in the post-pandemic period.

CONCLUSIONS

AMR in some microorganisms has significantly increased and changed its characteristics during and after the end of the pandemic phase of COVID-19. An integrated supranational monitoring approach to this challenge is warranted in the years to come. In detail, a rational, personalized, and regulated use of antibiotics and antimicrobials is needed.

The Impact of COVID-19 on Multidrug-Resistant Bacteria at a Slovenian Tertiary Medical Center

The COVID-19 pandemic has strained healthcare systems globally. Shortages of hospital beds, reassignment of healthcare workers to COVID-19-dedicated wards, an increased workload, and evolving infection prevention and control measures have potentially contributed to the spread of multidrug-resistant bacteria (MDRB). To determine the impact of the COVID-19 pandemic at the University Medical Center Ljubljana, a tertiary teaching hospital, we analyzed the monthly incidence of select bacterial species per patient from 2018 to 2022. The analysis was performed for all isolates and for MDRB isolates. The data were analyzed separately for isolates from all clinical samples, from blood culture only, and from clinical and surveillance samples. Our findings revealed an increased incidence density of patients with Enterococcus faecium, Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa isolates from clinical samples during the COVID-19 period in the studied hospital. Notably, the incidence density of MDRB isolates-vancomycin-resistant E. faecium, extended-spectrum betalactamase-producing K. pneumoniae, and betalactam-resistant P. aeruginosa-from clinical samples increased during the COVID-19 period. There were no statistically significant differences in the incidence density of patients with blood culture MDRB isolates. We observed an increase in the overall MDRB burden (patients with MDRB isolates from both clinical and surveillance samples per 1000 patient days) in the COVID-19 period in the studied hospital for vancomycin-resistant E. faecium, carbapenem-resistant K. pneumoniae, and betalactam-resistant P. aeruginosa and a decrease in the methicillin-resistant S. aureus burden.

Impact of the COVID-19 pandemic on the incidence and type of infections in hospitalized patients with cirrhosis: a retrospective study

Infections are a major cause of morbidity and mortality in cirrhosis, especially those caused by multi-drug resistant bacteria. During the COVID-19 pandemic, the incidence and type of infection in these patients may have been influenced by the restrictive measures implemented. We aimed to compare the infections in patients with cirrhosis hospitalized before the COVID-19 pandemic versus those hospitalized during the pandemic. We retrospectively compared infections in patients with cirrhosis hospitalized in the hepatology unit during the pre-pandemic period (3/2019-2/2020) with infections in patients hospitalized during the pandemic (3/2020-2/2021). Baseline characteristics, type of infections, type of bacteria, antimicrobial resistance and mortality were evaluated. There were 251 hospitalizations in 170 patients during the pre-pandemic period and 169 hospitalizations in 114 patients during the pandemic period. One or more infections were identified in 40.6% of hospitalizations during the pre-pandemic period and 43.8% of hospitalizations during the pandemic, P = 0.52. We found 131 infections in the pre-pandemic period and 75 infections during the pandemic. The percentage of nosocomial infections decreased in the pandemic period (25.3% vs. 37.4% in the pre-pandemic period, P = 0.06). We found a non-significant trend to a higher incidence of infections by multi-drug resistant organisms (MDRO) in the pandemic period than in the pre-pandemic period (6.5% vs. 4%). The incidence of infections was similar in both periods. However, during the pandemic, we observed a trend to a lower incidence of nosocomial infections with a higher incidence of MDRO infections.

A COVID-19 Silver Lining-Decline in Antibiotic Resistance in Ischemic Leg Ulcers during the Pandemic: A 6-Year Retrospective Study from a Regional Tertiary Hospital (2017-2022)

Antibiotic resistance (AR) associated with chronic limb-threatening ischemia (CLTI) poses additional challenges for the management of ischemic leg ulcers, increasing the likelihood of severe outcomes. This study assessed AR prevalence in bacteria isolated from CLTI-associated leg ulcers before (1 January 2017-10 March 2020; n = 69) and during (11 March 2020-31 December 2022; n = 59) the COVID-19 pandemic from patients admitted with positive wound cultures to a regional hospital in Chiang Mai (Thailand). There was a marked reduction in AR rates from 78% pre-pandemic to 42% during the pandemic (p < 0.0001), with rates of polymicrobial infections 22 percentage points lower (from 61% to 39%, respectively; p = 0.014). There were reduced AR rates to amoxicillin/clavulanate (from 42% to 4%; p < 0.0001) and ampicillin (from 16% to 2%; p = 0.017), as well as multidrug resistance (19% to 8%; p = 0.026). Factors associated with increased AR odds were polymicrobial infections (adjusted odds ratio (aOR) 5.6 (95% CI 2.1, 15.0); p = 0.001), gram-negative bacteria (aOR 7.0 (95% CI 2.4, 20.5); p < 0.001), and prior use of antibiotics (aOR 11.9 (95% CI 1.1, 128.2); p = 0.041). Improvements in infection control measures and hygiene practices in the community during the pandemic were likely key factors contributing to lower AR rates. Thus, strategic public health interventions, including community education on hygiene and the informed use of antibiotics, may be crucial in mitigating the challenges posed by AR in CLTI. Further, advocating for more judicious use of empirical antibiotics in clinical settings can balance effective treatment against AR development, thereby improving patient outcomes.

Impact of the COVID-19 pandemic on prevalence of highly resistant microorganisms in hospitalised patients in the Netherlands, March 2020 to August 2022

BackgroundThe COVID-19 pandemic resulted in adaptation in infection control measures, increased patient transfer, high occupancy of intensive cares, downscaling of non-urgent medical procedures and decreased travelling.AimTo gain insight in the influence of these changes on antimicrobial resistance (AMR) prevalence in the Netherlands, a country with a low AMR prevalence, we estimated changes in demographics and prevalence of six highly resistant microorganisms (HRMO) in hospitalised patients in the Netherlands during COVID-19 waves (March-June 2020, October 2020-June 2021, October 2021-May 2022 and June-August 2022) and interwaves (July-September 2020 and July-September 2021) compared with pre-COVID-19 (March 2019-February 2020).MethodsWe investigated data on routine bacteriology cultures of hospitalised patients, obtained from 37 clinical microbiological laboratories participating in the national AMR surveillance. Demographic characteristics and HRMO prevalence were calculated as proportions and rates per 10,000 hospital admissions.ResultsAlthough no significant persistent changes in HRMO prevalence were detected, some relevant non-significant patterns were recognised in intensive care units. Compared with pre-COVID-19 we found a tendency towards higher prevalence of meticillin-resistant Staphylococcus aureus during waves and lower prevalence of multidrug-resistant Pseudomonas aeruginosa during interwaves. Additionally, during the first three waves, we observed significantly higher proportions and rates of cultures with Enterococcus faecium (pooled 10% vs 6% and 240 vs 120 per 10,000 admissions) and coagulase-negative Staphylococci (pooled 21% vs 14% and 500 vs 252 per 10,000 admissions) compared with pre-COVID-19.ConclusionWe observed no substantial changes in HRMO prevalence in hospitalised patients during the COVID-19 pandemic.

Early coronavirus disease 2019 (COVID-19) pandemic effects on individual-level risk for healthcare-associated infections in hospitalized patients

OBJECTIVE

We compared the individual-level risk of hospital-onset infections with multidrug-resistant organisms (MDROs) in hospitalized patients prior to and during the coronavirus disease 2019 (COVID-19) pandemic. We also quantified the effects of COVID-19 diagnoses and intrahospital COVID-19 burden on subsequent MDRO infection risk.

DESIGN

Multicenter, retrospective, cohort study.

SETTING

Patient admission and clinical data were collected from 4 hospitals in the St. Louis area.

PATIENTS

Data were collected for patients admitted between January 2017 and August 2020, discharged no later than September 2020, and hospitalized ≥48 hours.

METHODS

Mixed-effects logistic regression models were fit to the data to estimate patients' individual-level risk of infection with MDRO pathogens of interest during hospitalization. Adjusted odds ratios were derived from regression models to quantify the effects of the COVID-19 period, COVID-19 diagnosis, and hospital-level COVID-19 burden on individual-level hospital-onset MDRO infection probabilities.

RESULTS

We calculated adjusted odds ratios for COVID-19-era hospital-onset Acinetobacter spp., P. aeruginosa and Enterobacteriaceae spp infections. Probabilities increased 2.64 (95% confidence interval [CI], 1.22-5.73) times, 1.44 (95% CI, 1.03-2.02) times, and 1.25 (95% CI, 1.00-1.58) times relative to the prepandemic period, respectively. COVID-19 patients were 4.18 (95% CI, 1.98-8.81) times more likely to acquire hospital-onset MDRO S. aureus infections.

CONCLUSIONS

Our results support the growing body of evidence indicating that the COVID-19 pandemic has increased hospital-onset MDRO infections.

Is there a correlation between antibiotic use and the severity or post-infection conditions of COVID-19 and other viral infections?

Antibiotics are one of the most frequently prescribed medications in modern medicine; besides treating bacterial infections, they may often be utilized for prophylactic purposes, including during select viral infections. It has been shown that 74.9% of COVID-19 patients received antibiotics as a part of their treatment regimen during the pandemic. However, studies suggest that the actual incidence of bacterial coinfection was relatively uncommon with a mere 3.5% of overall cases reported. A recent study revealed that antibiotic administration would not improve disease progression or shorten the length of hospitalization in COVID-19 patients; additionally, some antibiotics, such as linezolid, promote the production of free radicals that might be responsible for exacerbated clinical symptoms during and post-infection. Notably, antibiotic use disturbs the normal gut microbiome, and this interference impedes antiviral immune response enhancing severity and susceptibility to a list of viral infections. Thus, resultant augmented severity of these infections may be a consequence of higher susceptibility to respiratory viral co-infection.

Comparative De Novo and Pan-Genome Analysis of MDR Nosocomial Bacteria Isolated from Hospitals in Jeddah, Saudi Arabia

Multidrug-resistant (MDR) bacteria are one of the most serious threats to public health, and one of the most important types of MDR bacteria are those that are acquired in a hospital, known as nosocomial. This study aimed to isolate and identify MDR bacteria from selected hospitals in Jeddah and analyze their antibiotic-resistant genes. Bacteria were collected from different sources and wards of hospitals in Jeddah City. Phoenix BD was used to identify the strains and perform susceptibility testing. Identification of selected isolates showing MDR to more than three classes on antibiotics was based on 16S rRNA gene and whole genome sequencing. Genes conferring resistance were characterized using de novo and pan-genome analyses. In total, we isolated 108 bacterial strains, of which 75 (69.44%) were found to be MDR. Taxonomic identification revealed that 24 (32%) isolates were identified as Escherichia coli, 19 (25.3%) corresponded to Klebsiella pneumoniae, and 17 (22.67%) were methicillin-resistant Staphylococcus aureus (MRSA). Among the Gram-negative bacteria, K. pneumoniae isolates showed the highest resistance levels to most antibiotics. Of the Gram-positive bacteria, S. aureus (MRSA) strains were noticed to exhibit the uppermost degree of resistance to the tested antibiotics, which is higher than that observed for K. pneumoniae isolates. Taken together, our results illustrated that MDR Gram-negative bacteria are the most common cause of nosocomial infections, while MDR Gram-positive bacteria are characterized by a wider antibiotic resistance spectrum. Whole genome sequencing found the appearance of antibiotic resistance genes, including SHV, OXA, CTX-M, TEM-1, NDM-1, VIM-1, ere(A), ermA, ermB, ermC, msrA, qacA, qacB, and qacC.

Clinical characteristics and mortality risk factors of mixed bacterial infections in hematopoietic stem cell transplantation recipients

Background and objective

Mixed bacterial infections (MBI) is one of the complications after hematopoietic stem cell transplantation (HSCT) and increases the risk of patient death. However, there are few reports specifically on this topic. The purpose of this study was to investigate the clinical characteristics and mortality risk factors of MBI in HSCT recipients.

Methods

The electronic medical records of patients undergoing HSCT were collected. The epidemiological features and antibiotic resistance of patients with and without MBI were compared. Logistic regression and Cox regression were used to identify the risk factors for MBI acquisition and death. R language was used to construct a prediction model for the overall survival of HSCT recipients with MBI.

Results

The cumulative incidence of MBI was 6.3% and the mortality was 48.8%. Time interval from diagnosis to transplantation > 180 days (HR=2.059, 95% CI 1.042-4.069, P=0.038) and ICU admission after transplantation (HR=2.271, 95% CI 1.053-4.898, P=0.036) were independent risk factors for MBI acquisition. Engraftment period > 20 days (HR=2.273, 95% CI 1.028-5.027, P=0.043), continuous renal replacement therapy (HR=5.755, 95% CI 1.691-19.589, P=0.005) and septic shock (HR=4.308, 95% CI 2.085-8.901, P=0.000) were independent risk factors associated with mortality.

Conclusions

MBI has become a serious problem that cannot be ignored after HSCT. It is urgent for clinicians to pay high attention to it and formulate reasonable monitoring and treatment plans to improve the prognosis of patients.

Metaproteomic Analysis of Nasopharyngeal Swab Samples to Identify Microbial Peptides in COVID-19 Patients

During the COVID-19 pandemic, impaired immunity and medical interventions resulted in cases of secondary infections. The clinical difficulties and dangers associated with secondary infections in patients necessitate the exploration of their microbiome. Metaproteomics is a powerful approach to study the taxonomic composition and functional status of the microbiome under study. In this study, the mass spectrometry (MS)-based data of nasopharyngeal swab samples from COVID-19 patients was used to investigate the metaproteome. We have established a robust bioinformatics workflow within the Galaxy platform, which includes (a) generation of a tailored database of the common respiratory tract pathogens, (b) database search using multiple search algorithms, and (c) verification of the detected microbial peptides. The microbial peptides detected in this study, belong to several opportunistic pathogens such as Streptococcus pneumoniae, Klebsiella pneumoniae, Rhizopus microsporus, and Syncephalastrum racemosum. Microbial proteins with a role in stress response, gene expression, and DNA repair were found to be upregulated in severe patients compared to negative patients. Using parallel reaction monitoring (PRM), we confirmed some of the microbial peptides in fresh clinical samples. MS-based clinical metaproteomics can serve as a powerful tool for detection and characterization of potential pathogens, which can significantly impact the diagnosis and treatment of patients.

Impact of the COVID-19 Pandemic on Epidemiology of Antibiotic Resistance in an Intensive Care Unit (ICU): The Experience of a North-West Italian Center

The SARS-CoV-2 pandemic caused an increase in intensive care unit (ICU) hospitalizations with a rise in morbidity and mortality; nevertheless, there is still little evidence on the impact of the pandemic on antibiotic resistance in ICUs. This is a retrospective, monocentric epidemiological study. The aim of the study was to describe and analyze the impact of the SARS-CoV-2 pandemic on ICU bacterial resistance patterns. All bacteria isolated from all patients admitted to the E.O. Galliera ICU from January 2018 to December 2022 were included. Antibiotic resistance (AR) profiles were evaluated. A total of 1021 microorganisms were identified, of which 221 (12.47%) had a resistance pattern (resistant organisms; ROs). In this time, there were 1679 patients with a total of 12,030 hospitalization days. The majority of microorganisms were Gram-negative (79.66% in 2018, 77.29% in 2019, 61.83% in 2020, 62.56% in 2021, and 60.75% in 2022), but an increase in Gram-positive microorganisms was observed (20.34 to 39.25% between 2018 and 2022). The prevalence of AR was 19.44% in 2018, 11.54% in 2019, 38.04% in 2020, 34.15% in 2021, and 39.29% in 2022 for Gram-positive microorganisms and 19.86% in 2018, 13.56% in 2019, 18.12% in 2020, 12.41% in 2021, and 12.31% in 2012 for Gram-negative microorganisms. The incidence of ROs showed a COVID-19-related increase in 2020-2021, followed by a lowering trend since 2021, and a new increase in 2022. Possible explanations are antibiotic overtreatment and a decrease in containment measures. An interesting finding was the cumulative lowering trend of carbapenem-resistant K. pneumoniae and P. aeruginosa, probably due to different patient features.

A Systematic Review of Antimicrobial Resistance During the COVID-19 Pandemic

Antimicrobial-resistant pathogens, or "superbugs," cause more than 35 000 deaths and more than 2.8 million antibiotic-resistant infections in the US each year. Worldwide, antimicrobial resistance (AMR) has claimed at least 700 000 lives per year, including 230 000 from multi-drug resistant (MDR) tuberculosis. AMR-related deaths are projected to increase to 10 million by the year 2050. The use of biocides, improper prescribing of antibiotics for viral infections, prolonged hospital stays, and other issues contribute to AMR. The purpose of this study was to determine whether the COVID-19 pandemic has had an impact on the rates of AMR globally. While it is still early for the results of research studies, 4 articles indicated an increase, 2 found a decrease, and 2 had mixed results. It is possible that this pandemic may be contributing to an increase of medication-resistant infections.

The Impact of COVID-19 Pandemic on ESBL-Producing Enterobacterales Infections: A Scoping Review

Several studies have reported an increased frequency of colonization and/or infection with antibiotic-resistant bacteria (ARB) during the COVID-19 pandemic. Extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-PE) are a group of bacteria with intrinsic resistance to multiple antibiotics, including penicillins, cephalosporins, and monobactams. These pathogens are easy to spread and can cause difficult-to-treat infections. Here, we summarize the available evidence on the impact of the COVID-19 pandemic on infections caused by ESBL-PE. Using specific criteria and keywords, we searched PubMed, MEDLINE, and EMBASE for articles published up to 30 March 2023 on potential changes in the epidemiology of ESBL-E since the beginning of the COVID-19 pandemic. We identified eight studies that documented the impact of COVID-19 on ESBL-E. Five studies were focused on assessing the frequency of ESBL-PE in patient-derived specimens, and three studies investigated the epidemiological aspects of ESBL-PE infections in the context of the COVID-19 pandemic. Some of the studies that were focused on patient specimens reported a decrease in ESBL-PE positivity during the pandemic, whereas the three studies that involved patient data (1829 patients in total) reported a higher incidence of ESBL-PE infections in patients hospitalized for COVID-19 compared with those with other conditions. There are limited data on the real impact of the COVID-19 pandemic on the epidemiology of ESBL-PE infections; however, patient-derived data suggest that the pandemic has exacerbated the spread of these pathogens.

Isolation of Carbapenem and Colistin Resistant Gram-Negative Bacteria Colonizing Immunocompromised SARS-CoV-2 Patients Admitted to Some Libyan Hospitals

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had a devastating effect, globally. We describe, for the first time, the occurrence of carbapenem-resistant bacteria colonizing SARS-CoV-2 patients who developed hospital-associated infections with carbapenemase-producing, Gram-negative bacteria at some isolation centers of SARS-CoV-2 in the eastern part of Libya. In total, at first, 109 samples were collected from 43 patients, with the samples being recovered from oral (n = 35), nasal (n = 45), and rectal (n = 29) cavities. Strain identification was performed via matrix assisted laser desorption ionization-time of flight (MALDI-TOF). Antibiotic susceptibility testing was carried out on Mueller-Hinton agar, using the standard disk diffusion method. MIC determination was confirmed via E-TEST and microdilution standard methods. A molecular study was carried out to characterize the carbapenem and colistin resistance in Gram-negative bacterial strains. All of the positive results were confirmed via sequencing. Klebsiella pneumoniae (n = 32), Citrobacter freundii (n = 21), Escherichia coli (n = 7), and Acinetobacter baumannii (n = 21) were the predominant isolated bacteria. Gram-negative isolates were multidrug-resistant and carried different carbapenem resistance-associated genes, including NDM-1 (56/119; 47.05%), OXA-48 (15/119; 12.60%), OXA-23 (19/119; 15.96%), VIM (10/119; 8.40%), and the colistin resistance mobile gene mcr-1 (4/119; 3.36%). The overuse of antimicrobials, particularly carbapenem antibiotics, during the SARS-CoV-2 pandemic has led to the emergence of multidrug-resistant bacteria, mainly K. pneumoniae, A. baumannii, and colistin-resistant E. coli strains. Increased surveillance as well as the rational use of carbapenem antibiotics and, recently, colistin are required to reduce the propagation of multidrug-resistant strains and to optimally maintain the efficacy of these antibiotics. IMPORTANCE In this work, we describe, for the first time, the occurrence of carbapenem-resistant bacteria colonizing COVID-19 patients who developed hospital-associated infections with carbapenemase-producing, Gram-negative bacteria at some isolation centers of COVID-19 in the eastern part of Libya. Our results confirmed that the overuse of antimicrobials, such as carbapenem antibiotics, during the COVID-19 pandemic has led to the emergence of multidrug-resistant bacteria, mainly K. pneumoniae and A. baumannii, as well as colistin resistance.

Antimicrobial Activity of Biogenic Metal Oxide Nanoparticles and Their Synergistic Effect on Clinical Pathogens

The rising prevalence of antibiotic-resistance is currently a grave issue; hence, novel antimicrobial agents are being explored and developed to address infections resulting from multiple drug-resistant pathogens. Biogenic CuO, ZnO, and WO3 nanoparticles can be considered as such agents. Clinical isolates of E. coli, S. aureus, methicillin-resistant S. aureus (MRSA), and Candida albicans from oral and vaginal samples were treated with single and combination metal nanoparticles incubated under dark and light conditions to understand the synergistic effect of the nanoparticles and their photocatalytic antimicrobial activity. Biogenic CuO and ZnO nanoparticles exhibited significant antimicrobial effects under dark incubation which did not alter on photoactivation. However, photoactivated WO3 nanoparticles significantly reduced the number of viable cells by 75% for all the test organisms, thus proving to be a promising antimicrobial agent. Combinations of CuO, ZnO, and WO3 nanoparticles demonstrated synergistic action as a significant increase in their antimicrobial property (>90%) was observed compared to the action of single elemental nanoparticles. The mechanism of the antimicrobial action of metal nanoparticles both in combination and in isolation was assessed with respect to lipid peroxidation due to ROS (reactive oxygen species) generation by measuring malondialdehyde (MDA) production, and the damage to cell integrity using live/dead staining and quantitating with the use of flow cytometry and fluorescence microscopy.

Multidrug-Resistant (MDR) Urinary Tract Infections Associated with Gut Microbiota in CoV and Non-CoV Patients in a Urological Clinic during the Pandemic: A Single Center Experience

The aim of the study was to compare the profile of COVID-19 (CoV)-infected patients with non-COVID-19 (non-CoV) patients who presented with a multidrug-resistant urinary tract infection (MDR UTI) associated with gut microbiota, as well as analyze the risk factors for their occurrence, the types of bacteria involved, and their spectrum of sensitivity.

METHODS

We conducted a case-control study on patients admitted to the urology clinic of the "Parhon" Teaching Hospital in Iasi, Romania, between March 2020 and August 2022. The study group consisted of 22 CoV patients with MDR urinary infections associated with gut microbiota. For the control group, 66 non-CoV patients who developed MDR urinary infections associated with gut microbiota were selected. Electronic medical records were analyzed to determine demographics, characteristics, and risk factors. The types of urinary tract bacteria involved in the occurrence of MDR urinary infections and their sensitivity spectrum were also analyzed.

RESULTS

Patients in both groups studied were over 60 years of age, with no differences in gender, environment of origin, and rate of comorbidities. Patients in the CoV group had a higher percentage of urosepsis (54.5% versus 21.2%, p < 0.05) and more hospitalization days (9.27 versus 6.09, p < 0.05). Regarding risk factors, the two groups had similar percentages of previous urologic interventions (95.45% versus 96.97%, p > 0.05), antibiotic therapy (77.3% versus 87.9%, p > 0.05), and the presence of permanent urinary catheters (77.27% versus 84.85%, p > 0.05). Escherichia coli (31.8% versus 42.4%, p > 0.05), Klebsiella spp. (22.7% versus 34.8%, p > 0.05), and Pseudomonas aeruginosa (27.3% versus 9.1%, p > 0.05) were the most common urinary tract bacteria found in the etiology of MDR urinary infections in CoV and non-CoV patients. A high percentage of the involved MDR urinary tract bacteria were resistant to quinolones (71.4-76.2% versus 80.3-82%, p > 0.05) and cephalosporins (61.9-81% versus 63.9-83.6%, p > 0.05), both in CoV and non-CoV patients.

CONCLUSIONS

Patients with urological interventions who remain on indwelling urinary catheters are at an increased risk of developing MDR urinary infections associated with gut microbiota resistant to quinolones and cephalosporins. Patients with MDR UTIs who have CoV-associated symptoms seem to have a higher rate of urosepsis and a longer hospitalization length.

The Hidden Cost of COVID-19: Focus on Antimicrobial Resistance in Bloodstream Infections

Antibiotic resistance is one of the greatest growing public health threats and a worldwide priority. According to the WHO, drug-resistant diseases may cause 10 million deaths a year by 2050 and have a substantial impact on the global economy, driving up to 24 million people into poverty. The ongoing COVID-19 pandemic has exposed the fallacies and vulnerability of healthcare systems worldwide, displacing resources from existing programs and reducing funding for antimicrobial resistance (AMR) fighting efforts. Moreover, as already seen for other respiratory viruses, such as flu, COVID-19 is often associated with superinfections, prolonged hospital stays, and increased ICU admissions, further aggravating healthcare disruption. These events are accompanied by widespread antibiotic use, misuse, and inappropriate compliance with standard procedures with a potential long-term impact on AMR. Still, COVID-19-related measures such as increasing personal and environmental hygiene, social distancing, and decreasing hospital admissions could theoretically help the AMR cause. However, several reports have shown increased antimicrobial resistance during the COVID-19 pandemic. This narrative review focuses on this "twindemic", assessing the current knowledge of antimicrobial resistance in the COVID-19 era with a focus on bloodstream infections and provides insights into the lessons learned in the COVID-19 field that could be applied to antimicrobial stewardship initiatives.

Antibiotic resistance associated with the COVID-19 pandemic: a systematic review and meta-analysis

BACKGROUND

COVID-19 and antimicrobial resistance (AMR) are two intersecting global public health crises.

OBJECTIVE

We aimed to describe the impact of the COVID-19 pandemic on AMR across health care settings.

DATA SOURCE

A search was conducted in December 2021 in WHO COVID-19 Research Database with forward citation searching up to June 2022.

STUDY ELIGIBILITY

Studies evaluating the impact of COVID-19 on AMR in any population were included and influencing factors were extracted. Reporting of enhanced infection prevention and control and/or antimicrobial stewardship programs was noted.

METHODS

Pooling was done separately for Gram-negative and Gram-positive organisms. Random-effects meta-analysis was performed.

RESULTS

Of 6036 studies screened, 28 were included and 23 provided sufficient data for meta-analysis. The majority of studies focused on hospital settings (n = 25, 89%). The COVID-19 pandemic was not associated with a change in the incidence density (incidence rate ratio 0.99, 95% CI: 0.67-1.47) or proportion (risk ratio 0.91, 95% CI: 0.55-1.49) of methicillin-resistant Staphylococcus aureus or vancomycin-resistant enterococci cases. A non-statistically significant increase was noted for resistant Gram-negative organisms (i.e. extended-spectrum beta-lactamase, carbapenem-resistant Enterobacterales, carbapenem or multi-drug resistant or carbapenem-resistant Pseudomonas aeruginosa or Acinetobacter baumannii, incidence rate ratio 1.64, 95% CI: 0.92-2.92; risk ratio 1.08, 95% CI: 0.91-1.29). The absence of reported enhanced infection prevention and control and/or antimicrobial stewardship programs initiatives was associated with an increase in gram-negative AMR (risk ratio 1.11, 95% CI: 1.03-1.20). However, a test for subgroup differences showed no statistically significant difference between the presence and absence of these initiatives (p 0.40).

CONCLUSION

The COVID-19 pandemic may have hastened the emergence and transmission of AMR, particularly for Gram-negative organisms in hospital settings. But there is considerable heterogeneity in both the AMR metrics used and the rate of resistance reported across studies. These findings reinforce the need for strengthened infection prevention, antimicrobial stewardship, and AMR surveillance in the context of the COVID-19 pandemic.

Impact of COVID-19 pandemic on multidrug resistant gram positive and gram negative pathogens: A systematic review

BACKGROUND

There is paucity of data describing the impact of COVID-19 pandemic on antimicrobial resistance. This review evaluated the changes in the rate of multidrug resistant gram negative and gram positive bacteria during the COVID-19 pandemic.

METHODS

A search was conducted in PubMed, Science Direct, and Google Scholar databases to identify eligible studies. Studies that reported the impact of COVID-19 pandemic on carbapenem-resistant Acinetobacter baumannii (CRAB), carbapenem-resistant Enterobacteriaceae (CRE), extended-spectrum beta-lactamase inhibitor (ESBL)-producing Enterobacteriaceae, vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Pseudomonas aeruginosa (CPE) were selected. Studies published in English language from the start of COVID-19 pandemic to July 2022 were considered for inclusion.

RESULTS

Thirty eligible studies were selected and most of them were from Italy (n = 8), Turkey (n = 3) and Brazil (n = 3). The results indicated changes in the rate of multidrug resistant bacteria, and the changes varied between the studies. Most studies (54.5%) reported increase in MRSA infection/colonization during the pandemic, and the increase ranged from 4.6 to 170.6%. Five studies (55.6%) reported a 6.8-65.1% increase in VRE infection/colonization during the pandemic. A 2.4-58.2% decrease in ESBL E. coli and a 1.8-13.3% reduction in ESBL Klebsiella pneumoniae was observed during the pandemic. For CRAB, most studies (58.3%) reported 1.5-621.6% increase in infection/colonization during the pandemic. Overall, studies showed increase in the rate of CRE infection/colonization during the pandemic. There was a reduction in carbapenem-resistant E. coli during COVID-19 pandemic, and an increase in carbapenem-resistant K. pneumoniae. Most studies (55.6%) showed 10.4 - 40.9% reduction in the rate of CRPA infection during the pandemic.

CONCLUSION

There is an increase in the rate of multidrug resistant gram positive and gram negative bacteria during the COVID-19 pandemic. However, the rate of ESBL-producing Enterobacteriaceae and CRPA has decrease during the pandemic. Both infection prevention and control strategies and antimicrobial stewardship should be strengthen to address the increasing rate of multidrug resistant gram positive and gram negative bacteria.

The Clash of the Titans: COVID-19, Carbapenem-Resistant Enterobacterales, and First mcr-1-Mediated Colistin Resistance in Humans in Romania

(1) Background: Antibiotic resistance and coronavirus disease-19 (COVID-19) represent a dual challenge in daily clinical practice, inducing a high burden on public health systems. Hence, we aimed to dynamically evaluate the impact of COVID-19 on patients with carbapenem-resistant Enterobacterales (CRE) urinary tract infections (UTIs), as well as the antibiotic resistance trends after the onset of the pandemic. (2) Methods: We conducted a prospective study including patients with CRE UTIs who were enrolled both pre- and during the pandemic from 2019 to 2022. We further performed a standardized and comparative clinical, paraclinical, and microbiological assessment between patients with and without COVID-19. (3) Results: A total of 87 patients with CRE UTIs were included in this study (46 pre-pandemic and 41 during the pandemic, of which 21 had associated Severe Acute Respiratory Syndrome Coronavirus-2 infection). Klebsiella pneumoniae was the main etiological agent of the UTIs, with the majority of strains (82.7%) being carbapenemase producers (mainly OXA-48 producers), while five of the 34 colistin-resistant isolates were harboring the mobile colistin resistance-1 (mcr-1) gene. COVID-19 patients presented a significantly worse outcome with higher rates of intensive care unit (ICU) admissions (66.7% for COVID patients vs. 18.2% for non-COVID patients, p < 0.001), while the fatality rates were also considerably higher among patients with concomitant viral infection (33.3% vs. 12.1%, p < 0.001). Besides COVID-19, additional risk factors associated with increased mortality were urinary catheterization, sepsis with K. pneumoniae, impaired liver and kidney function, and an inappropriate initial empiric antibiotic therapy. (4) Conclusions: COVID-19 showed a pronounced negative impact on patients with CRE UTIs, with significantly longer hospitalizations and higher ICU admissions and mortality rates.

Impact of coronavirus disease 2019 (COVID-19) pandemic in hospital-acquired infections and bacterial resistance at an oncology hospital

Objective

Hospital-acquired infection (HAI) rates were negatively affected by the the coronavirus disease 2019 (COVID-19) pandemic. We describe the incidence of HAIs, main pathogens, and multidrug-resistant organisms (MDROs) isolated in cancer patients before and during the pandemic.

Design

This retrospective, comparative study included patients with HAIs. We compared 2 periods: the prepandemic period (2018, 2019, and the first 3 months of 2020) with the pandemic period (April-December 2020 and all of 2021).

Setting

Instituto Nacional de Cancerología, a tertiary-care oncology public hospital in Mexico City, Mexico.

Methods

Patients with the following HAIs were included: nosocomial pneumonia, ventilator-associated pneumonia (VAP), secondary bloodstream infection (BSI), central-line-associated bloodstream infection (CLBSI), and Clostridioides difficile infection (CDI). Demographic data, clinical characteristics, pathogens isolated, and MDRO data were included.

Results

We identified 639 HAIs: 381 (7.95 per 100 hospital discharges) in the prepandemic period and 258 (7.17 per 100 hospital discharges) in the pandemic period. Hematologic malignancy was documented in 263 (44.3%) patients; 251 (39.2%) were in cancer progression or relapse. Nosocomial pneumonia was more frequent during the pandemic period (40.3% vs 32.3%; P = .04). Total episodes of VAP were not different between the 2 periods (28.1% vs 22.1%; P = .08), but during the pandemic period, the VAP rate was higher among COVID-19 patients than non-COVID-19 patients (72.2% vs 8.8%; P < .001). Escherichia coli, Stenotrophomonas maltophilia, and Staphylococcus aureus bacteremia cases were more frequent in the pandemic period. Extended-spectrum β-lactamases (ESBL)-E. coli was the only MDRO that occurred more frequently during the pandemic period.

Conclusions

In cancer patients, nosocomial pneumonia was more frequent during the pandemic period. We did not observe a significant impact on other HAIs. MDROs did not significantly increase during the pandemic.

Bacterial coinfection and antibiotic resistance in hospitalized COVID-19 patients: a systematic review and meta-analysis

Background

There were a few studies on bacterial coinfection in hospitalized COVID-19 patients worldwide. This systematic review aimed to provide the pooled prevalence of bacterial coinfection from published studies from 2020 to 2022.

Methods

Three databases were used to search the studies, and 49 studies from 2,451 identified studies involving 212,605 COVID-19 patients were included in this review.

Results

The random-effects inverse-variance model determined that the pooled prevalence of bacterial coinfection in hospitalized COVID-19 patients was 26.84% (95% CI [23.85-29.83]). The pooled prevalence of isolated bacteria for Acinetobacter baumannii was 23.25% (95% CI [19.27-27.24]), Escherichia coli was 10.51% (95% CI [8.90-12.12]), Klebsiella pneumoniae was 15.24% (95% CI [7.84-22.64]), Pseudomonas aeruginosa was 11.09% (95% CI [8.92-13.27]) and Staphylococcus aureus (11.59% (95% CI [9.71-13.46])). Meanwhile, the pooled prevalence of antibiotic-resistant bacteria for extended-spectrum beta-lactamases producing Enterobacteriaceae was 15.24% (95% CI [7.84-22.64]) followed by carbapenem-resistant Acinetobacter baumannii (14.55% (95% CI [9.59-19.52%])), carbapenem-resistant Pseudomonas aeruginosa (6.95% (95% CI [2.61-11.29])), methicillin-resistant Staphylococcus aureus (5.05% (95% CI [3.49-6.60])), carbapenem-resistant Enterobacteriaceae (4.95% (95% CI [3.10-6.79])), and vancomycin-resistant Enterococcus (1.26% (95% CI [0.46-2.05])).

Conclusion

All the prevalences were considered as low. However, effective management and prevention of the infection should be considered since these coinfections have a bad impact on the morbidity and mortality of patients.

The impact of COVID-19 on multidrug-resistant organisms causing healthcare-associated infections: a narrative review

Coronavirus disease 2019 (COVID-19) changed healthcare across the world. With this change came an increase in healthcare-associated infections (HAIs) and a concerning concurrent proliferation of MDR organisms (MDROs). In this narrative review, we describe the impact of COVID-19 on HAIs and MDROs, describe potential causes of these changes, and discuss future directions to combat the observed rise in rates of HAIs and MDRO infections.

Patient Safety in Anesthesia: Hand Hygiene and Perioperative Infection Control

Purpose of Review

This review highlights the importance of the anesthesia team in minimizing perioperative infection risks and prevention of surgical site infection. Due to the immense financial and patient care burden that results from perioperative infection, a foundational knowledge in preventive measures is essential.

Recent Findings

Perioperative infection control, the role of the anesthesia team in reducing infection risk, and more specifically the outsized importance of hand hygiene in this space have become increasingly apparent. Maintenance of workspace cleanliness along with hand hygiene forms the cornerstone of preventing microbial transmission. Unfortunately, improvements around perioperative infection control are lacking.

Summary

The importance of the anesthesia team in maintaining proper hand hygiene, a clean work environment, and appropriate patient conditions to minimize risk of perioperative infection cannot be overstated. Poor clinical outcomes, economic burden, and external pressure from payers highlight the need for anesthesia providers to have an up-to-date knowledge of best practices in this area. In this article, we will review the current recommendations for hand hygiene practices and perioperative infection prevention.

Hypervirulence and Multiresistance to Antibiotics in Klebsiella pneumoniae Strains Isolated from Patients with Hospital- and Community-Acquired Infections in a Mexican Medical Center

Klebsiella pneumoniae is a pathogenic bacterium associated with different infectious diseases. This study aimed to establish the different association profiles of virulence genes related to the hypermucoviscous phenotype (HM), capsular serotypes, biofilm formation, and multidrug resistance in K. pneumoniae strains from patients with hospital- and community-acquired infections. K. pneumoniae virulence genes and capsular serotypes were identified by PCR, antibiotic susceptibility by the Kirby-Bauer method, HM by the string test, and biofilm formation by measurement in polystyrene microtiter plates. Of a total of 150 strains from patients with hospital- (n = 25) and community-acquired infections (n = 125), 53.3% (80/150) were HM-positive and 46.7% (70/150) were HM-negative. HM-positive (68/80) and HM-negative (67/70) strains were biofilm-forming. Moreover, 58.7% (47/80) HM-positive and 57.1% (40/70) HM-negative strains were multidrug-resistant. Among HM-positive, HM-negative, and serotypes K1 (25/150), K2 (48/150), and non-K1/K2 strains, (77/150) the frequently detected adhesion genes were fimH, mrkD, ycfM, and kpn; entB, irp2, irp1, and ybtS, for iron acquisition; and rmpA for protectins. The gene association pattern fimH/kpn/mrkD/ycfM/entB/irp1/irp2/ybtS/fyuA (18/150) was frequent among the strains. K. pneumoniae strains from patients with hospital- and community-acquired infections demonstrated a wide diversity of virulence gene profiles related to phenotype (hypermucoviscosity, multidrug resistance, and biofilm formation) and serotypes.

Stay-at-home and face mask policy intentions inconsistent with incidence and fatality during the US COVID-19 pandemic

During the COVID-19 pandemic, many states imposed stay-at-home (SAH) and mandatory face mask (MFM) orders to supplement the United States CDC recommendations. The purpose of this study was to characterize the relationship between SAH and MFM approaches with the incidence and fatality of COVID-19 during the pandemic period until 23 August 2020 (about 171 days), the period with no vaccines or specific drugs that had passed the phase III clinical trials yet. States with SAH orders showed a potential 50-60% decrease in infection and fatality during the SAH period (about 45 days). After normalization to population density, there was a 44% significant increase in the fatality rate in no-SAH + no-MFM states when compared to SAH + MFM. However, many results in this study were inconsistent with the intent of public health strategies of SAH and MFM. There were similar incidence rates (1.41, 1.81, and 1.36%) and significant differences in fatality rates (3.40, 2.12, and 1.25%; p < 0.05) and mortality rates (51.43, 34.50, and 17.42 per 100,000 residents; p < 0.05) among SAH + MFM, SAH + no-MFM, and no-SAH + no-MFM states, respectively. There were no significant differences in total positive cases, average daily new cases, and average daily fatality when normalized with population density among the three groups. This study suggested potential decreases in infection and fatality with short-term SAH order. However, SAH and MFM orders from some states' policies probably had limited effects in lowering transmission and fatality among the general population. At the policy-making level, if contagious patients would not likely be placed in strict isolation and massive contact tracing would not be effective to implement, we presume that following the CDC's recommendations with close monitoring of healthcare capacity could be appropriate in helping mitigate the COVID-19 disaster while limiting collateral socioeconomic damages.

The effect of immunosuppressive therapy on the development of ventilator-associated pneumonia in patients with COVID-19

Aim: It remains unclear whether immunosuppressive treatments such as corticosteroids and IL-6 receptor blockers have an effect on the development of ventilator-associated pneumonia (VAP). The aim of this study was to investigate the effect of immunosuppressive therapy on the development of VAP in critically ill patients with COVID-19. Material and Method: Two hundred thirty five patients with critically ill patients with COVID-19, who were treated in the intensive care unit (ICU) and received mechanical ventilator support, were evaluated retrospectively. VAP development, secondary infections, microorganisms isolated, and resistance patterns were compared between the groups that received and did not receive immunosuppressive therapy, and also the groups that did not receive immunosuppressive therapy, received only corticosteroid, received only tocilizumab, and received corticosteroid plus tocilizumab were compared in the subgroup analysis. Results: In the immunosuppressive treatment group, VAP development (40.2% vs. 21.2%; p=0.001), secondary infection development (48.4% vs. 29.2%; p=0.003), at least one drug resistant bacteria growth (46.7% vs. 27.4%; p=0.001), extensively-drug resistant (XDR) microorganism growth (89.8% vs. 72.7%; p=0.033) were higher than the group that did not receive immunosuppressive treatment. VAP (53.3%; p=0.004), secondary infection (73.3%; p=0.0002), the growth of bacteria resistant to at least one drug (70%; p=0.0003) were highest in the corticosteroid plus tocilizumab group in the subgroup analysis. In addition, XDR (95.5% vs. 72.7%; p=0.032) and pan-drug resistant (PDR) microorganism growth (31.8% vs. 9.1% p=0.032) were higher in the corticosteroid plus tocilizumab group than the no immunosuppressive therapy group. There was no difference between the groups in terms of mortality (p>0.05). Conclusion: Immunosuppressive therapy has been found to potentially enhance the risk of VAP and secondary infections in critically ill patients with COVID-19 pneumonia as well as the growth of bacteria resistant to at least one drug, the length of stay in hospital and ICUs. In addition, it has been evaluated that there may be an increase in the growth of XDR and PDR microorganisms when corticosteroid and tocilizumab are used together. Although there was no difference in mortality, using immunosuppressive therapy may require careful use of targeted antibiotics and longer-term antimicrobial therapy.

Antimicrobial resistance pattern in clinical Escherichia coli and Pseudomonas aeruginosa isolates obtained from a secondary-care hospital prior to and during the COVID-19 pandemic in Kuwait

Introduction

The study objective was to compare the prevalence of antimicrobial resistance (AMR) in clinical Escherichia coli and Pseudomonas aeruginosa isolates obtained from a secondary-care hospital prior to and during the COVID-19 pandemic in Kuwait.

Methods

A retrospective descriptive study was conducted based on AMR profiles of clinical Escherichia coli and Pseudomonas aeruginosa isolates. The AMR data represented isolates from five specimen types (body fluids; blood; respiratory; wound, bone, or other tissues; and urine) of patients admitted to four wards (surgical, medical, pediatric, and maternal-postnatal). Tested isolates between January 2019 and February 2020 represented the pre-COVID-19 pandemic period in Kuwait, whereas those from February 2020 until April 2021 represented the 'during COVID-19' period.

Results

A total of 1,303 isolates (57.2% E. coli and 42.8% P. aeruginosa) were analyzed. For ceftazidime, ertapenem and meropenem, the prevalence of AMR in E. coli was significantly (p<0.05) lower in pre-COVID-19 wards compared to that during COVID-19, whereas for other antibiotics (i.e., cefepime, gentamicin, and trimethoprim/sulfamethoxazole), the prevalence of AMR in pre-COVID-19 was significantly higher than that during COVID-19. The prevalence of AMR to gentamicin in P. aeruginosa isolates from non-COVID-19 wards (52.8%) was significantly higher (p<0.001) than that from COVID-19 wards (35.0%) and from the pre-COVID-19 period (32.9%). The multidrug-resistance (MDR) prevalence was 37.4% for E. coli and 32.1% for P. aeruginosa isolates. The odds of MDR in E. coli isolates from the COVID-19 medical wards were significantly lower (OR=0.27, [95%CI: 0.09-0.80], p=0.018) compared to the pre-COVID-19 wards. The odds of MDR E. coli and P. aeruginosa isolates by COVID-19 status stratified by specimen type were not different (p>0.05).

Conclusions

No major differences in AMR in E. coli and P. aeruginosa prevalence by specimen type and wards prior to and during the COVID-19 pandemic was observed at this hospital. The high reported MDR prevalence calls for better infection control and prevention.

Controlling an Unprecedented Outbreak with Vancomycin-Resistant Enterococcus faecium in Germany, October 2015 to November 2019

Hospital outbreaks with vancomycin-resistant enterococci (VRE) pose a serious health threat and a challenge to infection prevention and control (IPC). We herein report on a VRE outbreak of unprecedented extent in Southern Germany (October 2015-November 2019). We used descriptive epidemiology and whole-genome sequencing (WGS) for a detailed outbreak investigation. Of the 2905 cases, 2776 (95.3%) were colonized, whereas from 127 (3.7%), VRE could be isolated from otherwise sterile body fluids or sites unlikely for enterococci colonization. Cases had a median age of 78 years (IQR 68-84) and 1339/2905 (46%) were female. The majority of isolates sequenced belonged to the clonal lineage ST80/CT1013 (212/397, 53%). Nosocomial transmission was observed as well as the constant import of VRE into the hospital. Extensive IPC measures were implemented and terminated the outbreak in late 2019, eventually. Our study shows that the combination of epidemiological and genomic analyses is indispensable for comprehensive outbreak investigations. The adaptation of IPC measures to these findings, their timely implementation, and strict execution also allow containment of large VRE outbreaks in hospital settings.

Bacterial Resistance to Antibiotics and Clonal Spread in COVID-19-Positive Patients on a Tertiary Hospital Intensive Care Unit, Czech Republic

This observational retrospective study aimed to analyze whether/how the spectrum of bacterial pathogens and their resistance to antibiotics changed during the worst part of the COVID-19 pandemic (1 November 2020 to 30 April 2021) among intensive care patients in University Hospital Olomouc, Czech Republic, as compared with the pre-pandemic period (1 November 2018 to 30 April 2019). A total of 789 clinically important bacterial isolates from 189 patients were cultured during the pre-COVID-19 period. The most frequent etiologic agents causing nosocomial infections were strains of Klebsiella pneumoniae (17%), Pseudomonas aeruginosa (11%), Escherichia coli (10%), coagulase-negative staphylococci (9%), Burkholderia multivorans (8%), Enterococcus faecium (6%), Enterococcus faecalis (5%), Proteus mirabilis (5%) and Staphylococcus aureus (5%). Over the comparable COVID-19 period, a total of 1500 bacterial isolates from 372 SARS-CoV-2-positive patients were assessed. While the percentage of etiological agents causing nosocomial infections increased in Enterococcus faecium (from 6% to 19%, p < 0.0001), Klebsiella variicola (from 1% to 6%, p = 0.0004) and Serratia marcescens (from 1% to 8%, p < 0.0001), there were significant decreases in Escherichia coli (from 10% to 3%, p < 0.0001), Proteus mirabilis (from 5% to 2%, p = 0.004) and Staphylococcus aureus (from 5% to 2%, p = 0.004). The study demonstrated that the changes in bacterial resistance to antibiotics are ambiguous. An increase in the frequency of ESBL-positive strains of some species (Serratia marcescens and Enterobacter cloacae) was confirmed; on the other hand, resistance decreased (Escherichia coli, Acinetobacter baumannii) or the proportion of resistant strains remained unchanged over both periods (Klebsiella pneumoniae, Enterococcus faecium). Changes in pathogen distribution and resistance were caused partly due to antibiotic selection pressure (cefotaxime consumption increased significantly in the COVID-19 period), but mainly due to clonal spread of identical bacterial isolates from patient to patient, which was confirmed by the pulse field gel electrophoresis methodology. In addition to the above shown results, the importance of infection prevention and control in healthcare facilities is discussed, not only for dealing with SARS-CoV-2 but also for limiting the spread of bacteria.

Disinfecting Action of Gaseous Ozone on OXA-48-Producing Klebsiella pneumoniae Biofilm In Vitro

Klebsiella pneumoniae is an emerging multidrug-resistant pathogen that can contaminate hospital surfaces in the form of a biofilm which is hard to remove with standard disinfectants. Because of biofilm resistance to conservative disinfectants, the application of new disinfection technologies is becoming more frequent. Ozone gas has antimicrobial activity but there is lack of data on its action against K. pneumoniae biofilm. The aim of this study was to investigate the effects and mechanisms of action of gaseous ozone on the OXA-48-procuding K. pneumoniae biofilm. A 24 h biofilm of K. pneumoniae formed on ceramic tiles was subsequently exposed to different concentrations of ozone during one and two hours to determine the optimal ozone concentration. Afterwards, the total bacteria count, total biomass and oxidative stress levels were monitored. A total of 25 ppm of gaseous ozone was determined to be optimal ozone concentration and caused reduction in total bacteria number in all strains of K. pneumoniae for 2.0 log₁₀ CFU/cm², followed by reduction in total biomass up to 88.15%. Reactive oxygen species levels significantly increased after the ozone treatment at 182% for the representative K. pneumoniae NCTC 13442 strain. Ozone gas in the concentration of 25 ppm caused significant biofilm reduction but did not completely eradicate the K. pneumoniae biofilm formed on ceramics. In conclusion, ozone gas has great potential to be used as an additional hygiene measure in joint combat against biofilm in hospital environments.

Challenges of Antimicrobial Resistance and Stewardship in Solid Organ Transplant Patients

Purpose of Review

Without effective antimicrobials, patients cannot undergo transplant surgery safely or sustain immunosuppressive therapy. This review examines the burden of antimicrobial resistance in solid organ transplant recipients and identifies opportunities for antimicrobial stewardship.

Recent Findings

Antimicrobial resistance has been identified to be the leading cause of death globally. Multidrug-resistant pathogens are associated with significant morbidity and mortality in transplant recipients. Methicillin-resistant S. aureus affects liver and lung recipients, causing bacteremia, pneumonia, and surgical site infections. Vancomycin-resistant enterococci is a nosocomial pathogen primarily causing bacteremia in liver recipients. Multidrug-resistant Gram-negative pathogens present urgent and serious threats to transplant recipients. Extended-spectrum beta-lactamase-producing E. coli and K. pneumoniae commonly cause bacteremia and intra-abdominal infections in liver and kidney recipients. Carbapenemase-producing Enterobacterales, mainly K. pneumoniae, are responsible for infections early-post transplant in liver, lung, kidney, and heart recipients. P. aeruginosa and A. baumannii continue to be critical threats. While there are new antimicrobial agents targeting resistant pathogens, judicious prescribing is crucial to minimize emerging resistance. The full implications of the COVID-19 global pandemic on antimicrobial resistance in transplant recipients remain to be understood. Currently, there are no established standards on the implementation of antimicrobial stewardship interventions, but strategies that leverage existing antimicrobial stewardship program structure while tailoring to the needs of transplant recipients may help to optimize antimicrobial use.

Summary

Clinicians caring for transplant recipients face unique challenges tackling emerging antimcirobial resistance. Coordinated antimicrobial stewardship interventions in collaboration with appropriate expertise in transplant and infectious diseases may mitigate against such threats.

The Clinical Manifestation of SARS-CoV-2 in Critically Ill Patients with Klebsiella pneumoniae NDM Hospitalized in the ICU of a Modular Hospital during the Third Wave of the Pandemic in Poland—An Observational Cohort Study

There is limited information on the clinical characteristics of critically ill patients infected with SARS-CoV-2 and Klebsiella pneumoniae NDM. The objective of this study was to describe such a group of patients hospitalised in the intensive care unit of a large academic hospital during the third wave of the COVID-19 pandemic in Poland. Between 1 March and 30 June 2021, 103 patients were hospitalised, of whom 23 (22.3%) were positive for K. pneumoniae NDM; 14 (61%) of those patients died. Their hospitalisation time varied between 9 and 47 days. Five of the 23 patients (21.7%) were otherwise healthy. In contrast, the others suffered from cardiovascular problems (11, 47.8%), obesity (6, 26.1%), diabetes (5, 21.7%), neurological problems (4, 17.4%), or kidney disease (1, 4.3%); 4 (17.4%) were heavy smokers, and 1 (4.3%) had a history of alcohol abuse. K. pneumoniae NDM was isolated from urine samples of all patients. In 17 patients (73.9%), it was also isolated from other sources: from the respiratory tract in 10 (43.8%), from the blood in 2 (8.7%), and the central venous catheter was contaminated in 1 case (4.3%). Fourteen of the patients (60.9%) were colonised K. pneumoniae NDM. In four patients (17.4%), bacterial and fungal coinfection occurred. In one case (4.4%), two fungal species, Candida albicans and Candida glabrata, were isolated simultaneously. The most frequently administered antimicrobial agent was colistin (60.9%), followed by meropenem (47.8%), vancomycin (47.8%), ceftriaxone (34.8%), linezolid (30.4%), piperacillin/tazobactam (30.4%), and trimethoprim/sulfamethoxazole (30.4%). Other less-frequently administered agents included amikacin, amoxicillin/clavulanate, tigecycline, ciprofloxacin, fosfomycin, clindamycin, and cloxacillin. Fluconazole was administered in 14 patients (60.7%) and micafungin was administered in 2 (8.7%).

Outbreak of MRSA in a Gynecology/Obstetrics Department during the COVID-19 Pandemic: A Cautionary Tale

Since March 2020, the COVID-19 pandemic forced hospitals worldwide to intensify their infection control measures to prevent health care-associated transmission of SARS-CoV-2. The correct use of personal protective equipment, especially the application of masks, was quickly identified as priority to reduce transmission with this pathogen. Here, we report a nosocomial cluster of methicillin-resistant Staphylococcus aureus (MRSA) that occurred during the COVID-19 pandemic in a gynecology/obstetrics department, despite these intensified contact precautions. Five MRSA originating from clinical samples after surgical intervention led to an outbreak investigation. Firstly, this included environmental sampling of the operation theatre (OT) and, secondly, a point prevalence screening of patients and health care workers (HCW). All detected MRSA were subjected to whole genome sequencing (WGS) and isolate relatedness was determined using core genome multilocus sequence typing (cgMLST). WGS revealed one MRSA cluster with genetically closely related five patient and two HCW isolates differing in a single cgMLST allele at maximum. The outbreak was terminated after implementation of infection control bundle strategies. Although contact precaution measures, which are also part of MRSA prevention bundle strategies, were intensified during the COVID-19 pandemic, this MRSA outbreak could take place. This illustrates the importance of adherence to classical infection prevention strategies.

Antimicrobial resistance (AMR) in COVID-19 patients: a systematic review and meta-analysis (November 2019-June 2021)

Background

Pneumonia from SARS-CoV-2 is difficult to distinguish from other viral and bacterial etiologies. Broad-spectrum antimicrobials are frequently prescribed to patients hospitalized with COVID-19 which potentially acts as a catalyst for the development of antimicrobial resistance (AMR).

Objectives

We conducted a systematic review and meta-analysis during the first 18 months of the pandemic to quantify the prevalence and types of resistant co-infecting organisms in patients with COVID-19 and explore differences across hospital and geographic settings.

Methods

We searched MEDLINE, Embase, Web of Science (BioSIS), and Scopus from November 1, 2019 to May 28, 2021 to identify relevant articles pertaining to resistant co-infections in patients with laboratory confirmed SARS-CoV-2. Patient- and study-level analyses were conducted. We calculated pooled prevalence estimates of co-infection with resistant bacterial or fungal organisms using random effects models. Stratified meta-analysis by hospital and geographic setting was also performed to elucidate any differences.

Results

Of 1331 articles identified, 38 met inclusion criteria. A total of 1959 unique isolates were identified with 29% (569) resistant organisms identified. Co-infection with resistant bacterial or fungal organisms ranged from 0.2 to 100% among included studies. Pooled prevalence of co-infection with resistant bacterial and fungal organisms was 24% (95% CI 8–40%; n = 25 studies: I² = 99%) and 0.3% (95% CI 0.1–0.6%; n = 8 studies: I² = 78%), respectively. Among multi-drug resistant organisms, methicillin-resistant Staphylococcus aureus, carbapenem-resistant Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa and multi-drug resistant Candida auris were most commonly reported. Stratified analyses found higher proportions of AMR outside of Europe and in ICU settings, though these results were not statistically significant. Patient-level analysis demonstrated > 50% (n = 58) mortality, whereby all but 6 patients were infected with a resistant organism.

Conclusions

During the first 18 months of the pandemic, AMR prevalence was high in COVID-19 patients and varied by hospital and geography although there was substantial heterogeneity. Given the variation in patient populations within these studies, clinical settings, practice patterns, and definitions of AMR, further research is warranted to quantify AMR in COVID-19 patients to improve surveillance programs, infection prevention and control practices and antimicrobial stewardship programs globally.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01085-z.

Hospital-acquired infections in a tertiary hospital in Iran before and during the COVID-19 pandemic

Infection prevention protocols are the accepted standard to control nosocomial infections. These protective measures intensified after the coronavirus 2019 (COVID-19) pandemic to reduce the risk of viral transmission. It is the rationale that this practice reduces nosocomial infections. We evaluated the impact of these protective measures on nosocomial infections in our center with more than 20,000 records of annual patient admission. In a retrospective study, we evaluated the incidence of nosocomial infections in Sina hospital for 9 months (April–December 2020) during the COVID-19 period and compared it with the 8 months in the pre-COVID period (April–November 2019). Despite decreasing the number of admissions during the COVID era (hospitalizations showed a reduction of 43.79%), the total hospital nosocomial infections remained unchanged; 4.73% in the pre-COVID period versus 4.78% during the COVID period. During the COVID period the infection percentages increased in the cardiovascular care unit (p-value = 0.002) and intensive care units (p-value = 0.045), and declined in cardiology (p-value = 0.046) and neurology (p-value = 0.019) wards. This study showed that intensifying the infection prevention protocols is important in decreasing the nosocomial infections in some wards (cardiology and neurology). Still, we saw increased nosocomial infection in some wards, e.g., the intensive care unit (ICU) and coronary care unit (CCU). Thus, enhanced infection prevention protocols implemented in hospitals to prevent the spread of a pandemic infection may not always decrease rates of other hospital-acquired infections during a pandemic. Due to limited resources, transfer of staff, and staff shortage due to quarantine measures may prohibit improved prevention procedures from effectively controlling nosocomial infections.

First Outbreak of NDM-1-Producing Klebsiella pneumoniae ST11 in a Portuguese Hospital Centre during the COVID-19 Pandemic

New Delhi metallo-β-lactamase (NDM) carbapenemase has been considered a global threat due to its worldwide widespread in recent years. In Portugal, a very low number of infections with NDM-producing Enterobacterales has been reported. A total of 52 strains from 40 patients and 1 environmental sample isolated during COVID-19 pandemic were included in this study. Wholegenome sequencing (WGS) was performed on 20 carbapenemase-producing strains, including 17 NDM-1-producing Klebsiella pneumoniae ST11-KL105 lineage strains, one NDM-1-producing Escherichia coli ST58 strain and one KPC-3-producing K. pneumoniae ST147 strain, recovered from a total of 19 patients. Of interest, also one NDM-1-producing K. pneumoniae ST11-KL105 was collected from the hospital environment. Genome-wide phylogenetic analysis revealed an ongoing dissemination of NDM-1-producing K. pneumoniae ST11 strains (n = 18) with the same genetic features seen across multiple wards. Furthermore, the ST58 E. coli strain, collected from a patient rectal swab that was also colonised with a K. pneumoniae strain, also showed the IncFIA plasmid replicon and the bla_NDM-1 gene (preceded by IS30 and followed by genes ble_MBL, trpF, dsbC, cutA, groES and groEL). The bla_NDM-1 is part of Tn125-like identical to those reported in Poland, Italy and India. The bla_KPC-3 K. pneumoniae ST147-KL64 strain has the genetic environment Tn4401d isoform. In conclusion, herein we report the molecular epidemiology, resistome, virulome and mobilome of the first NDM-1 carbapenemase outbreak caused by K. pneumoniae ST11-KL105 lineage during the COVID-19 pandemic in Portugal. Moreover, the outbreak strains characterised included seventeen different patients (infected and colonised) and one environmental sample which also emphasises the role of commensal and hospital environment strains in the dissemination of the outbreak.

Effects of the Enhanced Public Health Intervention during the COVID‐19 Epidemic on Respiratory and Gastrointestinal Infectious Diseases in China

The public health interventions to mitigate coronavirus disease 2019 (COVID‐19) could also potentially reduce the global activity of influenza. However, this strategy's impact on other common infectious diseases is unknown. We collected data of 10 respiratory infectious (RI) diseases, influenza‐like illnesses (ILIs), and seven gastrointestinal infectious (GI) diseases during 2015–2020 in China and applied two proportional tests to check the differences in the yearly incidence and mortality, and case‐fatality rates (CFRs) over the years 2015–2020. The results showed that the overall RI activity decreased by 7.47%, from 181.64 in 2015–2019 to 168.08 per 100 000 in 2020 (p < 0.001); however, the incidence of influenza was seen to have a 16.08% escalation (p < 0.001). In contrast, the average weekly ILI percentage and positive influenza virus rate decreased by 6.25% and 61.94%, respectively, in 2020 compared to the previous 5 years (all p < 0.001). The overall incidence of GI decreased by 45.28%, from 253.73 in 2015–2019 to 138.84 in 2020 per 100 000 (p < 0.001), and with the greatest decline seen in hand, foot, and mouth disease (HFMD) (64.66%; p < 0.001). The mortality and CFRs from RI increased by 128.49% and 146.95%, respectively, in 2020, compared to 2015–2019 (p < 0.001). However, the mortality rates and CFRs of seven GI decreased by 70.56% and 46.12%, respectively (p < 0.001). In conclusion, China's COVID‐19 elimination/containment strategy is very effective in reducing the incidence rates of RI and GI, and ILI activity, as well as the mortality and CFRs of GI diseases.

COVID‐19 elimination strategy in China decreased the activity of respiratory infectious diseases (RI) and influenza‐like illnesses.

A 16.08% escalation was seen in influenza in 2020 compared to 2015–2019.

The mortality of RI increased slightly in 2020 compared to 2015–2019.

COVID‐19 elimination strategy in China decreased dramatically the activity and mortality of gastrointestinal infectious diseases.

Multidrug Resistance (MDR): A Widespread Phenomenon in Pharmacological Therapies

Multidrug resistance is a leading concern in public health. It describes a complex phenotype whose predominant feature is resistance to a wide range of structurally unrelated cytotoxic compounds, many of which are anticancer agents. Multidrug resistance may be also related to antimicrobial drugs, and is known to be one of the most serious global public health threats of this century. Indeed, this phenomenon has increased both mortality and morbidity as a consequence of treatment failures and its incidence in healthcare costs. The large amounts of antibiotics used in human therapies, as well as for farm animals and even for fishes in aquaculture, resulted in the selection of pathogenic bacteria resistant to multiple drugs. It is not negligible that the ongoing COVID-19 pandemic may further contribute to antimicrobial resistance. In this paper, multidrug resistance and antimicrobial resistance are underlined, focusing on the therapeutic options to overcome these obstacles in drug treatments. Lastly, some recent studies on nanodrug delivery systems have been reviewed since they may represent a significant approach for overcoming resistance.

How Does COVID-19 Pandemic Impact on Incidence of Clostridioides difficile Infection and Exacerbation of Its Gastrointestinal Symptoms?

Coronavirus disease 2019 (COVID-19) has rapidly spread all over the world with a very high rate of mortality. Different symptoms developed by COVID-19 infection and its impacts on various organs of the human body have highlighted the importance of both coinfections and superinfections with other pathogens. The gastrointestinal (GI) tract is vulnerable to infection with COVID-19 and can be exploited as an alternative transmission route and target for virus entry and pathogenesis. The GI manifestations of COVID-19 disease are associated with severe disease outcomes and death in all age groups, in particular, elderly patients. Empiric antibiotic treatments for microbial infections in hospitalized patients with COVID-19 in addition to experimental antiviral and immunomodulatory drugs may increase the risk of antibiotic-associated diarrhea (AAD) and Clostridioides difficile infection (CDI). Alterations of gut microbiota are associated with depletion of beneficial commensals and enrichment of opportunistic pathogens such as C. difficile. Hence, the main purpose of this review is to explain the likely risk factors contributing to higher incidence of CDI in patients with COVID-19. In addition to lung involvement, common symptoms observed in COVID-19 and CDI such as diarrhea, highlight the significance of bacterial infections in COVID-19 patients. In particular, hospitalized elderly patients who are receiving antibiotics might be more prone to CDI. Indeed, widespread use of broad-spectrum antibiotics such as clindamycin, cephalosporins, penicillin, and fluoroquinolones can affect the composition and function of the gut microbiota of patients with COVID-19, leading to reduced colonization resistance capacity against opportunistic pathogens such as C. difficile, and subsequently develop CDI. Moreover, patients with CDI possibly may have facilitated the persistence of SARS-CoV-2 viral particles in their feces for approximately one month, even though the nasopharyngeal test turned negative. This coinfection may increase the potential transmissibility of both SARS-CoV-2 and C. difficile by fecal materials. Also, CDI can complicate the outcome of COVID-19 patients, especially in the presence of comorbidities or for those patients with prior exposure to the healthcare setting. Finally, physicians should remain vigilant for possible SARS-CoV-2 and CDI coinfection during the ongoing COVID-19 pandemic and the excessive use of antimicrobials and biocides.

Multiple Secondary Healthcare-Associated Infections Due to Carbapenem-Resistant Organisms in a Critically Ill COVID-19 Patient on Extensively Prolonged Venovenous Extracorporeal Membrane Oxygenation Support-A Case Report

Patients with severe Coronavirus disease 2019 (COVID-19) are at high risk for secondary infection with multidrug-resistant organisms (MDROs). Secondary infections contribute to a more severe clinical course and longer intensive care unit (ICU) stays in patients with COVID-19. A man in his 60s was admitted to the ICU at a university hospital for severe COVID-19 pneumonia requiring mechanical ventilation. His respiratory condition worsened further due to persistent bacteremia caused by imipenem-non-susceptible Klebsiella aerogenes and he required VV-ECMO. Subsequently, he developed a catheter-related bloodstream infection (CRBSI) due to Candida albicans, ventilator-associated pneumonia (VAP) due to multidrug-resistant Pseudomonas aeruginosa (MDRP), and a perianal abscess due to carbapenem-resistant K. aerogenes despite infection control procedures that maximized contact precautions and the absence of MDRO contamination in the patient’s room environment. He was decannulated from VV-ECMO after a total of 72 days of ECMO support, and was eventually weaned off ventilator support and discharged from the ICU on day 138. This case highlights the challenges of preventing, diagnosing, and treating multidrug-resistant organisms and healthcare-associated infections (HAIs) in the critical care management of severe COVID-19. In addition to the stringent implementation of infection prevention measures, a high index of suspicion and a careful evaluation of HAIs are required in such patients.

Factors associated with preventive practices of COVID-19 among health care workers in Dilla University Hospital, Southern Ethiopia

Implementation of prevention measures is essential for decreasing COVID-19 morbidity and mortality. In health care settings, wearing face masks, avoiding handshakes and spitting, and thoroughly washing hands with soap and water or using an alcohol-based hand rub have been recommended as preventive measures to reduce the risk of COVID-19 transmission. Therefore, this study aimed to assess factors associated with COVID-19 prevention practices among health care workers at Dilla university hospital in Southern Ethiopia. An institutional-based cross-sectional study was conducted among 238 health care workers in Dilla university hospital from June 13, 2021- July 12, 2021. A stratified random sampling techniques were used to select study participants. Data were collected by using pre-tested structured self-administered questionnaires. A binary logistic regression analysis was used to identify factors related to COVID-19 prevention practice among health care professionals. For statistical significance factors with p-value less than 0.05, an Adjusted Odds Ratio (AOR) with a 95% Confidence Interval (CI) was calculated and interpreted. One hundred thirty-four participants [56.3%, 95% CI: 50 - 60.3%] had good COVID-19 prevention practices. Being a frontline worker [AOR=12.6, 95% CI: 3.9-41.6], being female [AOR= 0.7, 95% CI: 0.35-0.84], being a nurse [AOR= 8, 95% CI: 2.4-27], and implementation of Infection Prevention and Control (IPC) guideline [AOR = 4.0, 95% CI: 1.56-10.08] were all factors associated with good COVID-19 prevention practice. COVID-19 prevention practices were low among healthcare professionals in the study settings. Being frontline worker, being a nurse, being female, and implementation of IPC guidelines were all associated with COVID-19 preventive measures practices among health care workers. Health care workers may need to improve the way and habit of practicing prevention methods towards COVID-19.

The interface between COVID-19 and bacterial healthcare-associated infections

BACKGROUND

A wide range of bacterial infections occur in coronavirus disease 2019 (COVID-19) patients, particularly in those with severe coronaviral disease. Some of these are community-acquired co-infections.

OBJECTIVE

To review recent data that indicate the occurrence of hospital-onset bacterial infections, including with antibiotic-resistant isolates, in COVID-19 patients.

SOURCES

Using PubMed, the literature was searched using terms including: 'COVID-19'; 'SARS-CoV-2'; 'bacterial infection'; 'healthcare-associated infection'; 'antibiotic resistance'; 'antimicrobial resistance'; 'multi-drug resistance'; 'Streptococcus'; 'Staphylococcus'; 'Pseudomonas'; 'Escherichia'; 'Klebsiella'; 'Enterococcus'; 'Acinetobacter'; 'Haemophilus'; 'MRSA'; 'VRE'; 'ESBL'; 'NDM-CRE'; 'CR-Ab'; 'VRSA'; 'MDR'.

CONTENT

There is a growing number of reports of bacterial infections acquired by patients with severe COVID-19 after hospital admission. Antibiotic-resistant pathogens found to cause healthcare-associated infections (HAIs) in COVID-19 patients include methicillin-resistant Staphylococcus aureus, New Delhi metallo-β-lactamase-producing carbapenem-resistant Enterobacterales, carbapenem-resistant Acinetobacter baumannii, extended-spectrum β-lactamase Klebsiella pneumoniae and vancomycin-resistant enterococci. COVID-19 has impacted bacterial HAIs in a number of ways with an increase in the incidence of New Delhi metallo-β-lactamase-producing carbapenem-resistant Enterobacterales and carbapenem-resistant A. baumannii reported at some hospital sites compared with before the pandemic. Recommended guidelines for antimicrobial stewardship in COVID-19 patient treatment are discussed regarding minimization of empiric broad-spectrum antibiotic use. Other studies have reported a decrease in methicillin-resistant S. aureus and vancomycin-resistant enterococci cases, which has been attributed to enhanced infection prevention and control practices introduced to minimize intra-hospital spread of COVID-19.

IMPLICATIONS

Poorer outcomes have been observed in hospitalized COVID-19 patients with an antibiotic-resistant infection. Although heightened IPC measures have been accompanied by a reduction in some HAIs at specific sites, in other situations, COVID-19 has been associated with an increase in bacterial HAI incidence. Further research is needed to define the cost-benefit relationship of maintaining COVID-19-related infection prevention and control protocols beyond the pandemic to reduce the burden of HAIs. In addition, the longer-term impact of high usage of certain broad-spectrum antibiotics during the COVID-19 pandemic requires evaluation.