New Delhi metallo-β-lactamase and extended spectrum β-lactamases co-producing isolates are high in community-acquired urinary infections in Assam as detected by a novel multiplex polymerase chain reaction assay

A systematic review and meta-analysis to develop a landscape map of antibiotic resistance for six WHO priority pathogens in east and north-east India from 2011 to 2022

BACKGROUND

Determining regional patterns of antimicrobial resistance in bacterial infections in the healthcare setting (AMR) identifies surveillance gaps and informs policies for mitigation. We estimated the prevalence of AMR for six WHO priority pathogens in diagnostic and surveillance samples in the twelve east and north-east Indian states from 2011 to 2022 (PROSPERO ID: CRD42021278961).

METHODS

Studies were searched on Medline, Scopus, and Web of Science. Observational, descriptive, and cross-sectional studies, reporting AMR based on laboratory diagnostics, in individuals from east and north-east India from 2011 to 2022 were included. Four reviewers in pairs conducted abstract, full-text screening, and data extraction. We estimated the prevalence of resistance in fifty-four pathogen-antibiotic combinations, and six antibiotic resistance patterns. Pooled estimates of prevalence (Ɵ), heterogeneity (I2), and 95 % confidence intervals were calculated using the random effects model.

RESULTS

Fifty-five studies were included. Information was available for nine states, none from Arunachal Pradesh, Mizoram, and Nagaland. E. coli was most frequently isolated (59.2 %, 95 % CI: 48.8-69.6 %), followed by S. aureus (36.2 %, 95 % CI: 20.2-52.2 %), Enterococcus (27.5 %, 95 % CI: 11.2-43.7 %), Klebsiella (25 %, 95 % CI: 15-35 %), Acinetobacter (15.7 %, 95 % CI: 2.3-29.1 %), and Pseudomonas aeruginosa (15.7 %, 95 % CI: 4.1-27.3 %). There was high prevalence of ESBL (45 %, 95 % CI: 35-55 %) and carbapenem resistance (30 %, 95 % CI: 22-38 %). AmpC (23 %, 95 % CI: 9-37 %) and colistin resistance was lower (10 %, 95 % CI: 0-22 %) but supporting data was limited. Overall prevalence of MRSA was 26 % (95 % CI: 14-39 %), and VRE was 9 % (95 % CI: 0-17 %).

CONCLUSION

High prevalence of resistance was seen to all first-line antibiotics. Gram positive bacteria had high resistance to penicillins, and Gram negatives to third-generation cephalosporins, beta-lactam/beta-lactamase inhibitors, and carbapenems. Aminoglycoside, fluoroquinolone, and trimethoprim-sulphamethoxazole resistance was common across all genera. Critical regional AMR information gaps exist.

Molecular Characterization of Extended Spectrum β-Lactamase Producing Escherichia coli and Klebsiella pneumoniae Isolates and Their Antibiotic Resistance Profile in Health Care-Associated Urinary Tract Infections in North India

Background Healthcare-associated urinary tract infections (HAUTIs) caused by gram-negative pathogens have emerged as a global concern. So far, little is known about the epidemiology of extended-spectrum β lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae in HAUTIs in India. The study was carried to determine the antibiotic resistance pattern and ESBL-producing genes in E. coli and K. pneumoniae strains isolated from HAUTIs in a tertiary institute in North India.

Methods A total of 200 consecutive, nonduplicate clinical isolates of E. coli and 140 isolates of K. pneumoniae from hospitalized patients with UTI were collected during a period of 1 year. Strains were studied for the presence of ESBL genes (blaCTX-M1, blaCTX-M2, blaCTX-M9, blaCTX-M15, blaSHV, blaTEM, blaOXA-1, blaVEB, blaPER-2, and blaGES) by multiplex polymerase chain reaction using gene-specific primers.

Results ESBL was detected in 82.5% (165 out of 200) isolates of E. coli and 74.3% (104 out of 140) isolates of K. pneumoniae by phenotypic confirmatory testing. From 269 phenotypically positive ESBL isolates, blaTEM (49.4%) was the most common genotype followed by blaCTX-M1 (31.97%), blaOXA-1 (30.1%), and blaSHV(11.9%) either alone or in combination. In the present study, blaCTX-M-15 (84.89%) was the most common blaCTX-M1-type ESBL. In total, 2.6 and 5.2% of the isolates were positive for PER-2 and VEB genes, respectively.

Conclusion To the best of our knowledge, this is the first study on ESBL resistance patterns and ESBL-producing genes in HAUTIs in North India. Our study reports high occurrence with ESBL types CTX-M-1, CTX-M-15, TEM, and SHV. Minor ESBL variants OXA-1, VEB-type, and PER-2-type β-lactamase are also emerging in HAUTIs infections in North India.

V. S, K. C. S, Chaudhuri S, Pundir S, Kocher D, Gautam H, Sood S, Das BK, Kapil A, Hari P, Kumar A, Kumari R, Kalaivani M, R. A, Salve HR, Malhotra S, Kant S. Prevalence and resistance pattern of uropathogens from community settings of different regions: an experience from India

Introduction

Urinary tract infection (UTI) is one of the most common infections in clinical practice worldwide in both healthcare and community settings causing significant morbidity and mortality. It is one of the major conditions at the community level treated empirically and regarded as a potential cause of emergence of antimicrobial resistance (AMR). Limited information is available regarding community-acquired UTI (CA-UTI) from India.

Methodology

This is a first of its kind, multicentric-cross-sectional study at the community level targeting patients attending the out-patient department (OPD) of the community health centre (CHC) from four geographical regions (North, South, West and East) of India. The study had been designed to determine the epidemiology, antibiogram profile and identification of extended-spectrum beta-lactamase (ESBL) producer and carbapenem resistant (CR) uropathogens. Samples were collected prospectively from UTI suspected patients coming at CHC and processed at the tertiary healthcare centres using a common standard operating procedure. Clinical history of all the patients exhibiting significant bacteriuria was collected and data was analysed.

Result

Overall, 250 out of a total of 2459 (10.1 %) urine samples were positive for bacteria with significant bacteriuria (adult: paediatrics, 6.7 : 1). Females were predominantly affected (male: female, 1 : 2.9). History of recent episode of UTI was observed as the commonest risk factor followed by diabetes mellitus. Altogether, 86 % of total cases were caused by Escherichia coli (68 %) and Klebsiella pneumoniae (17.6 %) together. Among the commonly used oral antibiotics for the Gram-negative bacilli (GNB), the highest resistance was observed against beta-lactams, first- and second-generation cephalosporins, fluoroquinolones and co-trimoxazole. Overall, the prevalence of ESBL producer and CR isolates were 44.8, and 4.3 %, respectively. However, the ESBL production, CR and nitrofurantoin resistance among the uropathogenic E. coli (UPEC) isolates was 52.8, 5.1 and 14 %, respectively. No resistance was found against fosfomycin among the UPEC isolates.

Conclusion

The current study highlights the increasing incidence of AMR among uropathogens at the community-settings of India. A significant percentage of ESBL producers among the isolated UPEC and K. pneumoniae were observed. The currently available evidence supports the clinical recommendation of fosfomycin and nitrofurantoin for empiric therapy in CA-UTI in India.

Antibiotic-resistance genes in E. coli strains in GCC countries: A meta-analysis

Background:

Antimicrobial resistance (AMR) in Escherichia coli is an alarming issue worldwide, including in the Gulf Cooperation Council (GCC) countries, yet the prevailing gene patterns have not recently been reviewed. This study was conducted to determine and report on the dominant E. coli antimicrobial resistant gene patterns in GCC countries.

Method:

A scoping review identified the predominant AMR genes in GCC countries: CTX M, TEM, SHV, NDM, OXA, and VIM genes. For the systematic review, two authors independently searched Scopus, PubMed, Google Scholar, Science Direct, and Web of Science for interventional, clinical, or observational studies on the chosen AMR-conferring genes in E. coli published from GCC countries between January 2013 and June 2019, when the last search was carried out. The search strategy followed the PRISMA guidelines. The risk of bias was assessed using a 6-item standardized checklist. Random-effects modeling was used for all analyses.

Results:

A total 32 studies were included in the final synthesis of evidence. Overall, CTX-M (53.8%) was the most prevalent gene in the region followed TEM (40.6%), NDM-1 (28.4%), OXA (24.3%), VIM (8.5%), and SHV (7.8%). Most included studies were from Saudi Arabia: CTX-M was again most common with a prevalence of 46.8% from 5442 isolates.

Conclusion:

The risk of bias analysis showed a mean quality score of 4.25 ± 0.75, indicating high-quality in studies included in this meta-analysis. This review found that CTX-M gene is the most common AMR-conferring gene in E. coli strains from most GCC countries.

Drug resistance phenotypes and genotypes in Mexico in representative gram-negative species: Results from the infivar network

Aim

This report presents phenotypic and genetic data on the prevalence and characteristics of extended-spectrum β-lactamases (ESBLs) and representative carbapenemases-producing Gram-negative species in Mexico.

Material and methods

A total of 52 centers participated, 43 hospital-based laboratories and 9 external laboratories. The distribution of antimicrobial resistance data for Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae complex, Acinetobacter baumannii complex, and Pseudomonas aeruginosa in selected clinical specimens from January 1 to March 31, 2020 was analyzed using the WHONET 5.6 platform. The following clinical isolates recovered from selected specimens were included: carbapenem-resistant Enterobacteriaceae, ESBL or carbapenem-resistant E. coli, and K. pneumoniae, carbapenem-resistant A. baumannii complex, and P. aeruginosa. Strains were genotyped to detect ESBL and/or carbapenemase-encoding genes.

Results

Among blood isolates, A. baumannii complex showed more than 68% resistance for all antibiotics tested, and among Enterobacteria, E. cloacae complex showed higher resistance to carbapenems. A. baumannii complex showed a higher resistance pattern for respiratory specimens, with only amikacin having a resistance lower than 70%. Among K. pneumoniae isolates, bla_TEM, bla_SHV, and bla_CTX were detected in 68.79%, 72.3%, and 91.9% of isolates, respectively. Among E. coli isolates, bla_TEM, bla_SHV, and bla_CTX were detected in 20.8%, 4.53%, and 85.7% isolates, respectively. For both species, the most frequent genotype was bla_CTX-M-15. Among Enterobacteriaceae, the most frequently detected carbapenemase-encoding gene was bla_NDM-1 (81.5%), followed by bla_OXA-232 (14.8%) and bla_oxa-181(7.4%), in A. baumannii was bla_OXA-24 (76%) and in P. aeruginosa, was bla_IMP (25.3%), followed by bla_GES and bla_VIM (13.1% each).

Conclusion

Our study reports that NDM-1 is the most frequent carbapenemase-encoding gene in Mexico in Enterobacteriaceae with the circulation of the oxacillinase genes 181 and 232. KPC, in contrast to other countries in Latin America and the USA, is a rare occurrence. Additionally, a high circulation of ESBL bla_CTX-M-15 exists in both E. coli and K. pneumoniae.

Impact of an antimicrobial stewardship and monitoring of infection control bundle in a surgical intensive care unit of a tertiary-care hospital in India

OBJECTIVES

Antimicrobial stewardship (AMS) in resource-limited settings lacks models that can be readily adapted to their settings. Here we discuss the impact of a combined strategy of AMS and monitoring of infection control practices in a tertiary-care centre of a developing country.

METHODS

This study was undertaken in the surgical unit of a tertiary-care hospital over an 8-month period. In the first 2 months (baseline phase), prospective audit and feedback alone was undertaken, while in the next 6 months (intervention phase) this was supplemented with strategies such as antimicrobial timeout, correction of doses and bundle approach for prevention of hospital-acquired infections.

RESULTS

A total of 337 patients were included (94 in the baseline phase and 243 in the intervention phase). There was a decrease in days of therapy per 1000 patient-days (1000PD) (1112.3 days vs. 1048.6 days), length of therapy per 1000PD (956 days vs. 936.3 days) and defined daily doses (DDD) per 1000PD for most antimicrobials. A decrease in double cover for Gram-negative infections (9.6% vs. 2.9%) but an increase in double anaerobic cover (4.2% vs. 7.4%) was observed. There was a decrease in the incidence of ventilator-associated pneumonia per 1000 ventilator-days in the intervention phase (46.4 vs. 35.4), whereas central line-associated bloodstream infections per 1000 central line-days remained the same (14.7 vs. 14.8).

CONCLUSION

This study shows that implementation of routine AMS activities with monitoring of infection control practices can help decrease overall antimicrobial use. With furtherance of measures to control infection, antimicrobial use may be further curtailed.

The spectrum of bacteria and mechanisms of resistance identified from the casualties treated in the Israeli field hospital after the earthquake in Nepal, 2015: A retrospective analysis

BACKGROUND

On the April 25, 2015, a 7.8 magnitude earthquake struck Nepal. Soon-after, the Israel Defense Force (IDF) dispatched a tertiary field-hospital to Kathmandu. The field-hospital was equipped with a clinical laboratory with microbiology capabilities. Limited data exists regarding the spectrum of bacteria isolated from earthquake casualties. We aimed to identify the spectrum of bacteria and their mechanisms of resistance in-order to allow preparedness of antibiotic treatment protocols for future disaster scenarios.

METHODS

- The field-laboratory phenotypically processed cultures from sterile and non-sterile sites as needed clinically. Later-on, the isolates were brought to Israel for quality control, definite identification and molecular characterization including mechanisms of resistance.

RESULTS

A total of 82 clinical pathogens were isolated from 56 patients; 68% of them were Gram negative bacilli. The most common isolates were Enterobacteriaceae (55%) -36% carried bla-_NDM and 33% produced Extended-spectrum beta-lactamase (ESBL), mostly bla_CTX-M-15. Enterococcus spp were the main Gram positive bacteria isolated (22 isolates), yet, none were vancomycin resistant. The overall level of resistance was 27% MDR and 23% extensively drug resistant (XDR) bacteria.

CONCLUSIONS

- Gram negative bacteria were the predominant organism cultured from the casualties, of them 77% were MDR or XDR. NDM was the most common resistance mechanism. The Antibiotic inventory of a field-hospital should be set to cover a wide and unexpected spectrum of bacteria, including resistant organisms. This report adds important information to the scarce reports of bacterial resistance in Nepal.

Indian consensus on the management of CRE infection in critically ill patients (ICONIC) - India

Background: The increasing burden of carbapenem-resistant Enterobacteriaceae (CRE) carriage and infection in different patient settings in India has created an acute need for guidance for clinicians regarding optimal strategies for the management of CRE infection in critically ill patients. Research design and methods: A multidisciplinary panel of 11 Indian experts in CRE infection assembled for comprehensive discussion and consensus development. The experts developed clinical statements through a systematic review of key literature. Main outcome measures: The panel voted anonymously on 60 clinically relevant questions, through a modified Delphi process. Results: Forty-six key clinical consensus statements (CCS) were proposed. The panel reached a consensus on several important issues, providing recommendations on surveillance, diagnosis, prevention, pharmacokinetic challenges, combination therapy, and cornerstone molecules in CRE infections. The panel also proposed a treatment algorithm for NDM-prevalent settings. Conclusion: These consensus statements may offer clinicians expert guidance on the management of CRE infections. There is a dearth of high-/moderate-level evidence on managing CRE infections; the recommendations presented herein are based on expert opinion.

Antimicrobial Resistance: Its Surveillance, Impact, and Alternative Management Strategies in Dairy Animals

Antimicrobial resistance (AMR), one among the most common priority areas identified by both national and international agencies, is mushrooming as a silent pandemic. The advancement in public health care through introduction of antibiotics against infectious agents is now being threatened by global development of multidrug-resistant strains. These strains are product of both continuous evolution and un-checked antimicrobial usage (AMU). Though antibiotic application in livestock has largely contributed toward health and productivity, it has also played significant role in evolution of resistant strains. Although, a significant emphasis has been given to AMR in humans, trends in animals, on other hand, are not much emphasized. Dairy farming involves surplus use of antibiotics as prophylactic and growth promoting agents. This non-therapeutic application of antibiotics, their dosage, and withdrawal period needs to be re-evaluated and rationally defined. A dairy animal also poses a serious risk of transmission of resistant strains to humans and environment. Outlining the scope of the problem is necessary for formulating and monitoring an active response to AMR. Effective and commendably connected surveillance programs at multidisciplinary level can contribute to better understand and minimize the emergence of resistance. Besides, it requires a renewed emphasis on investments into research for finding alternate, safe, cost effective, and innovative strategies, parallel to discovery of new antibiotics. Nevertheless, numerous direct or indirect novel approaches based on host-microbial interaction and molecular mechanisms of pathogens are also being developed and corroborated by researchers to combat the threat of resistance. This review places a concerted effort to club the current outline of AMU and AMR in dairy animals; ongoing global surveillance and monitoring programs; its impact at animal human interface; and strategies for combating resistance with an extensive overview on possible alternates to current day antibiotics that could be implemented in livestock sector.

Carbapenem-Resistant Enterobacteriaceae

Carbapenem-resistant Enterobacteriaceae (CRE) have emerged as a major threat. Commonly used antibiotics are generally inactive against CRE. Therefore, timely detection of CRE is of paramount importance. Among CRE, those producing carbapenem-hydrolyzing β-lactamase enzymes (carbapenemase-producing Enterobacteriaceae) are particularly of concern because they tend to spread, and treatment is difficult. The carbapenemase groups most commonly encountered include KPC, NDM, and OXA-48. Treatment options are limited and include combinations of polymyxins, tigecycline, aminoglycosides, or carbapenems; newer agents with activity against CRE and better safety profiles are becoming available and will likely emerge as the preferred therapy.

The global epidemiology of carbapenemase-producing Enterobacteriaceae

Carbapenemase-producing Enterobacteriaceae (CPE) are an important and increasing threat to global health. Both clonal spread and plasmid-mediated transmission contribute to the ongoing rise in incidence of these bacteria. Among the 4 classes of β-lactamases defined by the Ambler classification system, the carbapenemases that confer carbapenem resistance in Enterobacteriaceae belong to 3 of them: Class A (K. pneumoniae carbapenemases, KPC), Class B (metallo-β-lactamases, MBL including New Delhi metallo-β-lactamases, NDM) and Class D (OXA-48-like carbapenemases). KPC-producing CPE are the most commonly occurring CPE in the United States. MBL-producing CPE have been most commonly associated with the Indian Subcontinent as well as with specific countries in Europe, including Romania, Denmark, Spain, and Hungary. The epicenter of OXA-48-like-producing is in Turkey and surrounding countries. Detailed knowledge of the epidemiology and molecular characteristics of CPE is essential to stem the spread of these pathogens.