Defining Multidrug Resistance of Gram-Negative Bacteria in the Dutch-German Border Region-Impact of National Guidelines

Prevalence and characterization of quinolone resistance and integrons in clinical Gram-negative isolates from Gaza strip, Palestine

BACKGROUND

Gram-negative bacteria with quinolone resistance and extended-spectrum beta-lactamases (ESBLs) present significant treatment challenges. This study evaluated the prevalence and characteristics of quinolone resistance in Gram-negative strains, investigating the relationship between plasmid-mediated quinolone resistance (PMQR), ESBLs, and integrons.

METHODS AND RESULTS

We collected 146 Gram-negative isolates from patients in three Palestinian hospitals. For quinolone resistance isolates, the presence and characterization of PMQR, β-lactamase genes and integrons were studied by PCR and sequencing. Out of 146 clinical isolates, 64 (43.8%) were resistant to quinolones, with 62 (97%) being multidrug-resistant (MDR) and 33 (51.5%) ESBL-producers. PMQR-encoding genes were present in 45 (70.3%) isolates, including aac(6')-Ib-cr (26.6%), qnrA (18.8%), qnrS1 (20.8%), and qnrB (6.4%). BlaCTX-M genes were detected in 50% (32/64) of isolates, with blaCTX-M-15 being the most common. BlaTEM-1, blaSHV-1 and blaVIM genes were found in 13, 6, and 4 isolates, respectively. Class I integrons were found in 31/64 (48%) of isolates, with 14 containing gene cassettes conferring resistance to trimethoprim (dhfr17, dfrA12, dfrA1) and aminoglycosides resistance genes (aadA1, aadA2, aadA5, and aadA6).

CONCLUSIONS

This study found a high rate of quinolone resistance, ESBL and integrons in clinical Gram-negative isolates from our hospitals. Urgent measures are crucial, including implementing an antimicrobial resistance surveillance system, to control and continuously monitor the development of antimicrobial resistance.

Molecular Detection of blaSHV-la Gene in Klebsiella pneumonia Isolated from Urinary Tract Infections, Najaf, Iraq

Klebsiella pneumoniae is a gram-negative bacterium that causes serious illnesses, including pneumonia, liver abscess, meningitis, bloodstream infections, and urinary tract infections (UTIs). This study aimed to isolate and diagnose K. pneumoniae from clinical specimens of urine from patients with UTIs and perform molecular detection of the bla_SHV-la gene in K. pneumonia in the Najaf Province, Iraq. The study included 100 clinical specimens from October 2021 to March 2022. As an initial diagnosis, K. pneumoniae isolates were diagnosed based on culture and biochemical features. Apart from the usage of polymerase chain reaction (PCR) technology to identify the bla_SHV-la gene, the final diagnostic was achieved by the automated Vitek-2 compact system. The biochemical findings revealed that 40 out of every 100 isolates tested positive for K. pneumoniae. These results were validated by Vitek, which revealed that 40/100 of the samples tested positive for K. pneumoniae, and by PCR utilizing the bla_SHV-la gene, which showed that 13/40 of the samples tested positive for K. pneumoniae isolated from the urine of patients with UTIs. In conclusion, the results indicated that the use of the Vitek-2 technique was required to confirm the accurate identification of the pathogen. Klebsiella pneumoniae clinical isolates showed multidrug resistance to antibiotics commonly used to treat UTIs. The blaSHV gene encoded for Extended-spectrum beta-lactam antibiotic was found almost in K. pneumoniae isolates.

A prospective multicentre screening study on multidrug-resistant organisms in intensive care units in the Dutch-German cross-border region, 2017 to 2018: the importance of healthcare structures

Background

Antimicrobial resistance poses a risk for healthcare, both in the community and hospitals. The spread of multidrug-resistant organisms (MDROs) occurs mostly on a local and regional level, following movement of patients, but also occurs across national borders.

Aim

The aim of this observational study was to determine the prevalence of MDROs in a European cross-border region to understand differences and improve infection prevention based on real-time routine data and workflows.

Methods

Between September 2017 and June 2018, 23 hospitals in the Dutch (NL)–German (DE) cross-border region (BR) participated in the study. During 8 consecutive weeks, patients were screened upon admission to intensive care units (ICUs) for nasal carriage of meticillin-resistant Staphylococcus aureus (MRSA) and rectal carriage of vancomycin-resistant Enterococcus faecium/E. faecalis (VRE), third-generation cephalosporin-resistant Enterobacteriaceae (3GCRE) and carbapenem-resistant Enterobacteriaceae (CRE). All samples were processed in the associated laboratories.

Results

A total of 3,365 patients were screened (median age: 68 years (IQR: 57–77); male/female ratio: 59.7/40.3; NL-BR: n = 1,202; DE-BR: n = 2,163). Median screening compliance was 60.4% (NL-BR: 56.9%; DE-BR: 62.9%). MDRO prevalence was higher in DE-BR than in NL-BR, namely 1.7% vs 0.6% for MRSA (p = 0.006), 2.7% vs 0.1% for VRE (p < 0.001) and 6.6% vs 3.6% for 3GCRE (p < 0.001), whereas CRE prevalence was comparable (0.2% in DE-BR vs 0.0% in NL-BR ICUs).

Conclusions

This first prospective multicentre screening study in a European cross-border region shows high heterogenicity in MDRO carriage prevalence in NL-BR and DE-BR ICUs. This indicates that the prevalence is probably influenced by the different healthcare structures.

A decade of trends in the distribution and antimicrobial susceptibility of prevalent uropathogens among pediatric patients from Tehran, Iran during 2005-2016

Objectives

To determine changes in the distribution of uropathogens and their antimicrobial resistance in pediatric patients in a children's hospital from 2005 to 2016.

Methods

A cross-sectional analysis of uropathogens and their antimicrobial resistance within inpatient children was performed over the 11-year period, 2005 to 2016, in Ali Asghar children's hospital. The rate of antibiotic resistance among patients was evaluated according to demographic data including age, sex, urinary tract abnormities and history of antibiotic consumption.

Results

In total, 958 female and 349 male positive cultures were analyzed. Escherichia coli (E. coli) (77.6%) was the most common causative agent of urinary tract infection (UTI) in children and Klebsiella pneumoniae (10.4%), Pseudomonas aeruginosa (2.4%), and Enterococcus spp (2.4%) were less frequent isolated bacteria. The resistance rates of E. coli isolates were increased against amikacin, ceftriaxone, ceftazidime, ciprofloxacin, cotrimoxazole and imipenem from 2005 to 2010. However, we observed a decreasing trend for some of antibiotics including amikacin, gentamicin, imipenem, ceftazidime and cotrimoxazole during 2014–2016. The rate of antibiotic resistance was greater in boys than in girls against many antibiotics. The rate of resistance to amikacin, gentamicin, nitrofurantoin and cotrimoxazole in patients aged <1 year was higher than other age groups (p<0.001). A higher antibiotic resistance rate was observed in patients with anatomical abnormality and those who have had a history of antibiotic consumption.

Conclusion

The study indicated the significant decrease in E. coli antibiotic resistance in the last 3 years. An effective empirical treatment regime should be based on local epidemiology and antimicrobial susceptibility testing.

Rates of bacterial co-infections and antimicrobial use in COVID-19 patients: a retrospective cohort study in light of antibiotic stewardship

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide. Bacterial co-infections are associated with unfavourable outcomes in respiratory viral infections; however, microbiological and antibiotic data related to COVID-19 are sparse. Adequate use of antibiotics in line with antibiotic stewardship (ABS) principles is warranted during the pandemic. We performed a retrospective study of clinical and microbiological characteristics of 140 COVID-19 patients admitted between February and April 2020 to a German University hospital, with a focus on bacterial co-infections and antimicrobial therapy. The final date of follow-up was 6 May 2020. Clinical data of 140 COVID-19 patients were recorded: The median age was 63.5 (range 17-99) years; 64% were males. According to the implemented local ABS guidelines, the most commonly used antibiotic regimen was ampicillin/sulbactam (41.5%) with a median duration of 6 (range 1-13) days. Urinary antigen tests for Legionella pneumophila and Streptococcus peumoniae were negative in all cases. In critically ill patients admitted to intensive care units (n = 50), co-infections with Enterobacterales (34.0%) and Aspergillus fumigatus (18.0%) were detected. Blood cultures collected at admission showed a diagnostic yield of 4.2%. Bacterial and fungal co-infections are rare in COVID-19 patients and are mainly prevalent in critically ill patients. Further studies are needed to assess the impact of antimicrobial therapy on therapeutic outcome in COVID-19 patients to prevent antimicrobial overuse. ABS guidelines could help in optimising the management of COVID-19. Investigation of microbial patterns of infectious complications in critically ill COVID-19 patients is also required.

Cross-border comparison of antimicrobial resistance (AMR) and AMR prevention measures: the healthcare workers' perspective

Background

Cross-border healthcare may promote the spread of multidrug-resistant microorganisms (MDRO) and is challenging due to heterogeneous antimicrobial resistance (AMR) prevention measures (APM). The aim of this article is to compare healthcare workers (HCW) from Germany (DE) and The Netherlands (NL) on how they perceive and experience AMR and APM, which is important for safe patient exchange and effective cross-border APM cooperation.

Methods

A survey was conducted amongst HCW (n = 574) in hospitals in DE (n = 305) and NL (n = 269), using an online self-administered survey between June 2017 and July 2018. Mann-Whitney U tests were used to analyse differences between answers of German and Dutch physicians (n = 177) and German and Dutch nurses (n = 397) on 5-point Likert Items and Scales.

Results

Similarities between DE and NL were a high awareness about the AMR problem and the perception that the possibility to cope with AMR is limited (30% respondents perceive their contribution to limit AMR as insufficient). Especially Dutch nurses scored significantly lower than German nurses on their contribution to limit AMR (means 2.6 vs. 3.1, p ≤ 0.001). German HCW were more optimistic about their potential role in coping with AMR (p ≤ 0.001), and scored higher on feeling sufficiently equipped to perform APM (p ≤ 0.003), although the mean scores did not differ much between German and Dutch respondents.

Conclusions

Although both German and Dutch HCW are aware of the AMR problem, they should be more empowered to contribute to limiting AMR through APM (i.e. screening diagnostics, infection diagnosis, treatment and infection control) in their daily working routines. The observed differences reflect differences in local, national and cross-border structures, and differences in needs of HCW, that need to be considered for safe patient exchange and effective cross-border APM.

Community- and Hospital-Acquired Klebsiella pneumoniae Urinary Tract Infections in Portugal: Virulence and Antibiotic Resistance

Klebsiella pneumoniae is a clinically relevant pathogen and a frequent cause of hospital-acquired (HA) and community-acquired (CA) urinary tract infections (UTI). The increased resistance of this pathogen is leading to limited therapeutic options. To investigate the epidemiology, virulence, and antibiotic resistance profile of K. pneumoniae in urinary tract infections, we conducted a multicenter retrospective study for a total of 81 isolates (50 CA-UTI and 31 HA-UTI) in Portugal. The detection and characterization of resistance and virulence determinants were performed by molecular methods (PCR, PCR-based replicon typing, and multilocus sequence typing (MLST)). Out of 50 CA-UTI isolates, six (12.0%) carried β-lactamase enzymes, namely bla_TEM-156 (n = 2), bla_TEM-24 (n = 1), bla_SHV-11 (n = 1), bla_SHV-33 (n = 1), and bla_CTX-M-15 (n = 1). All HA-UTI were extended-spectrum β-lactamase (ESBL) producers and had a multidrug resistant profile as compared to the CA-UTI isolates, which were mainly resistant to ciprofloxacin, levofloxacin, tigecycline, and fosfomycin. In conclusion, in contrast to community-acquired isolates, there is an overlap between virulence and multidrug resistance for hospital-acquired UTI K. pneumoniae pathogens. The study is the first to report different virulence characteristics for hospital and community K. pneumoniae pathogens, despite the production of β-lactamase and even with the presence of CTX-M-15 ESBL, a successful international ST15 clone, which were identified in both settings. This highlights that a focus on genomic surveillance should remain a priority in the hospital environment.

Control of hospital acquired infections and antimicrobial resistance in Europe: the way to go

One of the major challenges for modern medicine is our ageing society and an increased level of immunocompromised hosts. More invasive and intensive medical interventions will increase the number of healthcare-associated infections (HCAI), which means infection that occur because of or in concomitance, but in any case, during or after healthcare interventions. Such infections are caused usually endogenously from microbial components of the patient's own microbiome. Usually, the microorganisms of the microbiome show a natural resistance against a few antibiotics. Due to selection processes and epidemic transmission of specific clones, microorganisms that have become resistant to multiple antibiotics become part of the patient's microbiome and can subsequently cause infections that are difficult or even impossible to treat. The kind of infections that will occur depends on diverse factors. Already today, according to Cassini et al., 2,609,911 new cases of HCAI occur every year in the European Union and European Economic Area (EU/EEA). The cumulative burden of the six HAIs was estimated at 501 disability-adjusted life years (DALYs) per 100,000 general population each year in the EU/EEA. In a recent publication, 426,277 healthcare-associated infections caused by antimicrobial resistant microorganisms were calculated to occur in the EU every year. Attributable deaths in the EU due to antimicrobial resistant microorganisms were estimated to be 33,110 per year. We know that we cannot prevent all HCAI. Because medical innovations will allow for an increased number of novel treatments that will comprise abiotic materials, microorganisms will adapt to this environment and enhance the risk for new HCAI. The challenge for the future will not be to try to prevent all infections, as some of them will remain unavoidable, but to prevent the occurrence of non-treatable microorganisms that would make unavoidable infections additionally untreatable. That means that we need to reflect on how we organize infection prevention, diagnostics and control. While patients with classical infectious diseases present with infectious diseases (ID)-specific symptoms, patients with HCAI present usually with another underlying disease. HCAI are therefore perceived as a secondary damage not following classical clinical and epidemiological rules. However, more recently we have to consider how we should react to HCAI and antimicrobial resistance (AMR) as they are quite different in epidemiology and transmission behavior than classical infectious diseases. Today, the prevalence of AMR is rising all over Europe. Although good success has been seen in many countries, methicillin-resistant Staphylococcus aureus (MRSA) remains an important challenge for many countries. In addition to MRSA, multidrug-resistant Escherichia coli and carbapenem-resistant Enterobacteriaceae are becoming a problem of public health importance. Furthermore, we need to focus more on implementation of known infection prevention measures than trying to solve the problem by observing and describing it. However, in addition to medical factors such as antibiotic use, hand hygiene etc., we tend to forget that there are factors behind these factors that have a major influence and are found in the structures of our different healthcare systems. We need to look more at the context before we try to implement prevention measures and need to learn from each other. A common goal to tackle carbapenem-resistant Enterobacteriaceae (CRE) by 2030 would be an important step to foster collaboration across Europe. As the current funding and remmuneration system does not sufficiently support prevention of HCAI and AMR, it is time for the development of a less production- but more prevention-economic financing system for clinical microbiology and infection control.

Draft Genome Sequence of the Extensively Drug-Resistant Pseudomonas aeruginosa Clinical Isolate TUEPA7472

Pseudomonas aeruginosa TUEPA7472 is extensively drug resistant (XDR) and is a representative Gram-negative rod that is multiresistant toward 4 classes of clinically relevant antibiotics (4MRGN). The 6.8-Mb draft genome sequence of this strain provides insight into these resistance mechanisms and the potential of the strain to produce virulence factors.

Pseudomonas aeruginosa TUEPA7472 is extensively drug resistant (XDR) and is a representative Gram-negative rod that is multiresistant toward 4 classes of clinically relevant antibiotics (4MRGN). The 6.8-Mb draft genome sequence of this strain provides insight into these resistance mechanisms and the potential of the strain to produce virulence factors.

Prevalence of Plasmid-Mediated Quinolone Resistance in Multidrug-Resistant Gram Negative Bacilli in Egypt

Resistance to quinolone has increased significantly and one of the most reasons is plasmid-mediated quinolone resistance (PMQR). The aim of this study is to detect the prevalence of PMQR in multidrug-resistant (MDR) Gram negative bacilli and to characterize these resistance genes. A total of 420 Gram negative bacilli clinical isolates were collected from patients attending Misr children hospital. Isolates were identified by biochemical reactions, while antimicrobial susceptibility testingwas done by Kirby-Bauer disk diffusion method. Minimum inhibitory concentrations (MIC) of ciprofloxacin were detected by E-test, whereas combined test method was used to detect extended-spectrum β-lactamase (ESBL) production. QnrA, qnrB, and qnrS genes were determined by multiplex polymerase chain reaction (PCR). MDRGram negative bacilli represented 68% (268/420); most of them were recovered from blood culture specimens (21%).Among these MDR isolates21%(60/268) were ciprofloxacin resistant; with MICs >32µg/ml in 95% of the isolates.ESBL production was detected in 11.7% of the studied isolates. The qnr genes were detected in 60%. QnrS and qnrB were the detected genes in 77.8% and 16.7% of the isolates respectively. Both qnrB and qnrS genes were determined simultaneously in 5.5%.QnrB gene was found alone in only one isolate (14.3%) that was ESBL-producer. The most MDR isolates were recovered from blood culture; this confirms the occurrence of these superbugs and their ability to cause life threatening infections. The prevalence of quinolone resistant Gram negative bacilli clinical isolates is high. The mostly prevalent PMQR gene is qnrS followed by qnrB.

High prevalence of MRSA and multi-resistant gram-negative bacteria in refugees admitted to the hospital-But no hint of transmission

With high numbers of refugees arriving in Europe uncertainty exists as to whether multidrug-resistant organisms are imported into the healthcare system. In our study, we identified 383 refugee-inpatients admitted to the University Hospital Münster, Germany between September 2015 and September 2016. For this patient cohort screening for Methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant Gram-negative bacteria (MDR-GNB) and Vancomycin-resistant enterococci (VRE) was recommended in our institution. Until May 2016 pre-emptive isolation was applied to all refugee-inpatients until the exclusion of these multidrug-resistant organisms. MRSA were found in 34 refugee-patients (9.8%), MDR-GNB in 25 refugee-patients (12.9%) and VRE in none of the refugee patients. We did not find any strains carrying carbapenemases. Whole genome sequencing (WGS) data demonstrated that the respective isolates were genetically heterogeneous and revealed no transmission of refugee-patient isolates to other patients. We therefore omitted pre-emptive isolation as an infection control measure for this group of patients. Furthermore, molecular typing did not show evidence for nosocomial transmission from refugee-patients to other patients. Standard hygiene measures successfully prevented the transmission of refugee-patient isolates to other patients and as a result introduction into the healthcare system. This underlines that any multidrug-resistant organisms present within this cohort are not of any extraordinary concern for health systems.