Prevalence of Device-associated Nosocomial Infections Caused By Gram-negative Bacteria in a Trauma Intensive Care Unit in Libya

Medical Device-Associated Infections Caused by Biofilm-Forming Microbial Pathogens and Controlling Strategies

Hospital-acquired infections, also known as nosocomial infections, include bloodstream infections, surgical site infections, skin and soft tissue infections, respiratory tract infections, and urinary tract infections. According to reports, Gram-positive and Gram-negative pathogenic bacteria account for up to 70% of nosocomial infections in intensive care unit (ICU) patients. Biofilm production is a main virulence mechanism and a distinguishing feature of bacterial pathogens. Most bacterial pathogens develop biofilms at the solid-liquid and air-liquid interfaces. An essential requirement for biofilm production is the presence of a conditioning film. A conditioning film provides the first surface on which bacteria can adhere and fosters the growth of biofilms by creating a favorable environment. The conditioning film improves microbial adherence by delivering chemical signals or generating microenvironments. Microorganisms use this coating as a nutrient source. The film gathers both inorganic and organic substances from its surroundings, or these substances are generated by microbes in the film. These nutrients boost the initial growth of the adhering bacteria and facilitate biofilm formation by acting as a food source. Coatings with combined antibacterial efficacy and antifouling properties provide further benefits by preventing dead cells and debris from adhering to the surfaces. In the present review, we address numerous pathogenic microbes that form biofilms on the surfaces of biomedical devices. In addition, we explore several efficient smart antiadhesive coatings on the surfaces of biomedical device-relevant materials that manage nosocomial infections caused by biofilm-forming microbial pathogens.

Road Accidents, Polytrauma Patients, and Their Economic Burden

Trauma is a problem of global public health with economic, social and political extensions. It is constantly growing due to road accidents. The cost of hospitalization and the loss of working hours for those who managed to reach the hospital are huge for the national economy of each country. The purpose of the present study is to record the polytrauma patients of road accidents and to search for their economic cost. A total of 68 injured people were the study sample during the period 2014-2017. The study was conducted in a University hospital in Athens (Greece). The mean age of the patients was 36.67 years. The mortality was 13.2% and the mean cost of every polytrauma patient was 14.272 Euros. Nearly half of them had an infection, which increased the cost. Accident prevention, proper and timely treatment of injuries, monitoring, recording and controlling infections and reducing the length of hospitalization are some of the ways to reduce the financial cost of a traumatized person.

Nosocomial infections in the surgical intensive care unit: an observational retrospective study from a large tertiary hospital in Palestine

BACKGROUND

Nosocomial infections or hospital-acquired infections are a growing public health threat that increases patient morbidity and mortality. Patients at the highest risk are those in intensive care units. Therefore, our objective was to provide a pattern analysis of nosocomial infections that occurred in an adult surgical intensive care unit (ICU).

METHODS

This study was a retrospective observational study conducted in a 6-bed surgical intensive care unit (SICU) at An-Najah National University Hospital (NNUH) to detect the incidence of nosocomial infections from January 2020 until December 2021. The study group included 157 patients who received antibiotics during their stay in the SICU.

RESULTS

The incidence of nosocomial infections, either suspected or confirmed, in the SICU was 26.9% (95 out of 352 admitted patients). Pneumonia (36.8%) followed by skin and soft tissue infections (35.8%) were the most common causes. The most common causative microorganisms were in the following order: Pseudomonas aeruginosa (26.3%), Acinetobacter baumannii (25.3%), extended-spectrum beta lactamase (ESBL)-Escherichia coli (23.2%) and Klebsiella pneumonia (15.8%). The average hospital stay of patients with nosocomial infections in the SICU was 18.5 days.

CONCLUSIONS

The incidence of nosocomial infections is progressively increasing despite the current infection control measures, which accounts for an increased mortality rate among critically ill patients. The findings of this study may be beneficial in raising awareness to implement new strategies for the surveillance and prevention of hospital-acquired infections in Palestinian hospitals and health care centers.

Review and analysis of the overlapping threats of carbapenem and polymyxin resistant E. coli and Klebsiella in Africa

BACKGROUND

Carbapenem-resistant Enterobacterales are among the most serious antimicrobial resistance (AMR) threats. Emerging resistance to polymyxins raises the specter of untreatable infections. These resistant organisms have spread globally but, as indicated in WHO reports, the surveillance needed to identify and track them is insufficient, particularly in less resourced countries. This study employs comprehensive search strategies with data extraction, meta-analysis and mapping to help address gaps in the understanding of the risks of carbapenem and polymyxin resistance in the nations of Africa.

METHODS

Three comprehensive Boolean searches were constructed and utilized to query scientific and medical databases as well as grey literature sources through the end of 2019. Search results were screened to exclude irrelevant results and remaining studies were examined for relevant information regarding carbapenem and/or polymyxin(s) susceptibility and/or resistance amongst E. coli and Klebsiella isolates from humans. Such data and study characteristics were extracted and coded, and the resulting data was analyzed and geographically mapped.

RESULTS

Our analysis yielded 1341 reports documenting carbapenem resistance in 40 of 54 nations. Resistance among E. coli was estimated as high (> 5%) in 3, moderate (1-5%) in 8 and low (< 1%) in 14 nations with at least 100 representative isolates from 2010 to 2019, while present in 9 others with insufficient isolates to support estimates. Carbapenem resistance was generally higher among Klebsiella: high in 10 nations, moderate in 6, low in 6, and present in 11 with insufficient isolates for estimates. While much less information was available concerning polymyxins, we found 341 reports from 33 of 54 nations, documenting resistance in 23. Resistance among E. coli was high in 2 nations, moderate in 1 and low in 6, while present in 10 with insufficient isolates for estimates. Among Klebsiella, resistance was low in 8 nations and present in 8 with insufficient isolates for estimates. The most widespread associated genotypes were, for carbapenems, blaOXA-48, blaNDM-1 and blaOXA-181 and, for polymyxins, mcr-1, mgrB, and phoPQ/pmrAB. Overlapping carbapenem and polymyxin resistance was documented in 23 nations.

CONCLUSIONS

While numerous data gaps remain, these data show that significant carbapenem resistance is widespread in Africa and polymyxin resistance is also widely distributed, indicating the need to support robust AMR surveillance, antimicrobial stewardship and infection control in a manner that also addresses broader animal and environmental health dimensions.

Multidrug-resistant Acinetobacter baumannii in healthcare settings in Africa

The emergence of multidrug-resistant Acinetobacter baumannii is a major concern to healthcare providers and facilities in many parts of the world. This bacterial pathogen is commonly implicated in hospital-acquired infections, particularly in critically ill patients admitted to the intensive care unit (ICU). The extensive use of antibiotics, particularly in ICUs, and the lack of proper infection control interventions in many hospitals have led to an increased emergence of multidrug-resistant A. baumannii. Infections due to multidrug-resistant A. baumannii are associated with prolonged hospital stays and high morbidity and mortality, particularly among hospitalized ICU patients. The lack of antibiotic stewardship programmes in many healthcare facilities has exacerbated the burden of A. baumannii infections in many parts of Africa. This review discusses the prevalence and antibiotic-resistance pattern of the multidrug-resistant A. baumannii, and the possible ways to address or minimise its emergence in healthcare settings in Africa.

Mutations in AR or SRD5A2 Genes: Clinical Findings, Endocrine Pitfalls, and Genetic Features of Children with 46,XY DSD

OBJECTIVE

Androgen insensivity syndrome (AIS) and 5α-reductase deficiency (5α-RD) present with indistinguishable phenotypes among the 46,XY disorders of sexual development (DSD) that usually necessitate molecular analyses for the definitive diagnosis in the prepubertal period. The aim was to evaluate the clinical, hormonal and genetic findings of 46,XY DSD patients who were diagnosed as AIS or 5α-RD.

METHODS

Patients diagnosed as AIS or 5α-RD according to clinical and hormonal evaluations were investigated. Sequence variants of steroid 5-α-reductase type 2 were analyzed in cases with testosterone/dihydrotestosterone (T/DHT) ratio of ≥20, whereas the androgen receptor (AR) gene was screened when the ratio was <20. Stepwise analysis of other associated genes were screened in cases with no causative variant found in initial analysis. For statistical comparisons, the group was divided into three main groups and subgroups according to their genetic diagnosis and T/DHT ratios.

RESULTS

A total of 128 DSD patients from 125 non-related families were enrolled. Birth weight SDS and gestational weeks were significantly higher in 5α-RD group than in AIS and undiagnosed groups. Completely female phenotype was higher in all subgroups of both AIS and 5α-RD patients than in the undiagnosed subgroups. In those patients with stimulated T/DHT <20 in the prepubertal period, stimulated T/DHT ratio was significantly lower in AIS than in the undiagnosed group, and higher in 5α-RD. Phenotype associated variants were detected in 24% (n=18 AIS, n=14 5α-RD) of the patients, revealing four novel AR variants (c.94G>T, p.Glu32*, c.330G>C, p.Leu110=; c.2084C>T, p.Pro695Leu, c.2585_2592delAGCTCCTG, p.(Lys862Argfs*16), of these c.330G>C with silent status remained undefined in terms of its causative effects.

CONCLUSION

T/DHT ratio is an important hormonal criterion, but in some cases, T/DHT ratio may lead to diagnostic confusion. Molecular diagnosis is important for the robust diagnosis of 46,XY DSD patients. Four novel AR variants were identified in our study.

Trends of central line-associated bloodstream infections in the intensive care unit in the Kingdom of Bahrain: Four years’ experience

BACKGROUND

The central venous line is an essential component in monitoring and managing critically ill patients. However, it poses patients with increased risks of severe infections with a higher probability of morbidity and mortality.

AIM

To define the trends of the rates of central line-associated bloodstream infections (CLABSI) over four years, its predicted risk factors, aetiology, and the antimicrobial susceptibility of the isolated pathogens.

METHODS

The study was a prospective case-control study, performed according to the guidelines of the Center for Disease Control surveillance methodology for CLABSI in patients admitted to the adult intensive care unit (ICU) and auditing the implementation of its prevention bundle.

RESULTS

Thirty-four CLABSI identified over the study period, giving an average CLABSI rate of 3.2/1000 central line days. The infection's time trend displayed significant reductions over time concomitantly with the CLABSI prevention bundle's reinforcement from 4.7/1000 central line days at the beginning of 2016 to 1.4/1000 central line days by 2018. The most frequently identified pathogens causing CLABSI in our ICU were gram-negative organisms (59%). The most common offending organisms were Acinetobacter, Enterococcus, and Staphylococcus epidermidis, each of them accounted for 5 cases (15%). Multidrug-resistant organisms contributed to 56% of CLABSI. Its rate was higher when using femoral access and longer hospitalisation duration, especially in the ICU. Insertion of the central line in the non-ICU setting was another identified risk factor.

CONCLUSION

Implementing the prevention bundles reduced CLABSI significantly in our ICU. Implementing the CLABSI prevention bundle is crucial to maintain a substantial reduction in the CLABSI rate in the ICU setting.

Resistance patterns and clinical outcomes of Klebsiella pneumoniae and invasive Klebsiella variicola in trauma patients

Recent reclassification of the Klebsiella genus to include Klebsiella variicola, and its association with bacteremia and mortality, has raised concerns. We examined Klebsiella spp. infections among battlefield trauma patients, including occurrence of invasive K. variicola disease. Klebsiella isolates collected from 51 wounded military personnel (2009-2014) through the Trauma Infectious Disease Outcomes Study were examined using polymerase chain reaction (PCR) and pulsed-field gel electrophoresis. K. variicola isolates were evaluated for hypermucoviscosity phenotype by the string test. Patients were severely injured, largely from blast injuries, and all received antibiotics prior to Klebsiella isolation. Multidrug-resistant Klebsiella isolates were identified in 23 (45%) patients; however, there were no significant differences when patients with and without multidrug-resistant Klebsiella were compared. A total of 237 isolates initially identified as K. pneumoniae were analyzed, with 141 clinical isolates associated with infections (remaining were colonizing isolates collected through surveillance groin swabs). Using PCR sequencing, 221 (93%) isolates were confirmed as K. pneumoniae, 10 (4%) were K. variicola, and 6 (3%) were K. quasipneumoniae. Five K. variicola isolates were associated with infections. Compared to K. pneumoniae, infecting K. variicola isolates were more likely to be from blood (4/5 versus 24/134, p = 0.04), and less likely to be multidrug-resistant (0/5 versus 99/134, p<0.01). No K. variicola isolates demonstrated the hypermucoviscosity phenotype. Although K. variicola isolates were frequently isolated from bloodstream infections, they were less likely to be multidrug-resistant. Further work is needed to facilitate diagnosis of K. variicola and clarify its clinical significance in larger prospective studies.

Epidemiology of Multidrug-Resistant Pseudomonas aeruginosa in the Middle East and North Africa Region

Over the last decades, there has been a dramatic global increase in multidrug-resistant (MDR) pathogens particularly among Gram-negative bacteria (GNB). Pseudomonas aeruginosa is responsible for various health care-associated infections, while MDR P. aeruginosa causes significant morbidity and mortality. Middle East and North Africa (MENA) represent an unexplored geographical region for the study of drug resistance since many of these countries are at crossroads of high volume of travel, diverse expatriate populations, as well as high antibiotic consumption despite attempts to implement antimicrobial stewardship programs. This minireview analyzes epidemiology, microbiological, and genomic characteristics of MDR P. aeruginosa in the MENA region. Published data on MDR P. aeruginosa prevalence, antimicrobial resistance patterns, and genetic profiles from studies published during the past 10 years from 19 MENA countries have been included in this minireview. There is wide variation in the epidemiology of MDR P. aeruginosa in the MENA region in terms of prevalence, antimicrobial characteristics, as well as genetic profiles. Overall, there is high prevalence of MDR P. aeruginosa seen in the majority of the countries in the MENA region with similarities between neighboring countries, which might reflect comparable population and antibiotic-prescribing cultures. Isolates from critical care units are significantly resistant particularly from certain countries such as Saudi Arabia, Egypt, Libya, Syria, and Lebanon with high-level resistance to cephalosporins, carbapenems, and aminoglycosides. Colistin susceptibility patterns remains high apart from countries with high-level antibiotic resistance such as Saudi Arabia, Syria, and Egypt.

Incidence of Device Associated-Healthcare Associated Infections from a Neurosurgical Intensive Care Unit of a Tertiary Care Center: A Retrospective Analysis

Background:

Deviceassociated infections (DAIs) increase the morbidity and mortality in the intensive care unit (ICU). Studies from the neurosurgical ICU in developing countries are sparse.

Aims:

The aim of this study was to assess the incidence of device-associated healthcare associated infections, pathogens isolated, antibiotic resistance, and mortality in neurosurgical ICU.

Settings and Design:

A retrospective study was conducted in the neurosurgical ICU of a tertiary care center

Materials and Methods:

This study was done by analyzing data of patients admitted in a neurosurgical ICU with one or more devices during the period from January 2011 to July 2017.

Statistical Analysis:

Quantitative variables were expressed as mean and standard deviation; qualitative variables were expressed as frequency and percentage.

Results:

During this period, 6788 patients with devices were admitted in the ICU, and 316 patients developed DAI. Two hundred and forty-eight patients had catheter-associated urinary tract infection (CAUTI), 78 had ventilator-associated pneumonia (VAP), and 53 had central line-associated bloodstream infection (CLABSI). The incidence rate for CAUTI was 17.83, VAP – 16.83, and CLABSI – 4.39 per 1000 device days. The device utilization ratio was highest for urinary catheter – 0.76, followed by central line – 0.66 and ventilator – 0.25. Predominant pathogens were Klebsiella – 90, Escherichia coli – 77, Pseudomonas – 40, Candida – 39, Acinetobacter – 30, and Enterobacter – 21. Carbapenem resistance was found in Acinetobacter (73.4%), Pseudomonas (45%), and Enterobacter (38%). S. aureus isolated in six cases; four being MRSA (66.7%). Multidrug resistance was found in Acinetobacter (80%), Pseudomonas (60%), Enterobacter (52.3%), Klebsiella (42.3%), and E. coli (33.7%). No colistin resistant Gram negative bacilli or vancomycin resistant enterococci were isolated. During this period 124 patients with DAI died, of which 52 patients had sepsis. The crude mortality rate was 1.83%.

Conclusion:

The DAI with the highest incidence was CAUTI, followed by VAP and CLABSI. With the implementation of insertion bundles and adherence to aseptic precautions, the DAI rate had come down.

Risk factors, antimicrobial susceptibility pattern and patient outcomes of Pseudomonas aeruginosa infection: A matched case-control study

BACKGROUND

Pseudomonas aeruginosa is a leading nosocomial Gram-negative bacteria associated with prolonged hospitalization, and increased morbidity and mortality. Limited data exist regarding P. aeruginosa infection and outcome in patients managed in intensive care units (ICUs) in the Gulf countries. We aimed to determine the risk factors, antimicrobial susceptibility pattern and patient outcomes of P. aeruginosa infection in ICU.

METHODS

In this matched case-control study, all P. aeruginosa infections that occurred >48 h after hospital admission between January 31st 2016 and December 31st 2018 at ICUs affiliated with King Abdulaziz Medical City, Riyadh were included. P. aeruginosa was identified using MALDI-TOF (Vitek-MS) by biomérieux, and the antimicrobial susceptibility testing was performed using an automated biomérieux VITEK^®️ 2 Antimicrobial Susceptibility card.

RESULTS

The study included 90 cases and 90 controls. Compared with controls, cases had significantly higher mean ICU stay and higher proportions with previous history of antimicrobial therapy, coronary artery disease, malignancy, hemodialysis, previous surgery, use of central line, urethral catheterization, nasogastric tube, and tracheostomy. In a multivariate conditional logistic regression analysis, factors independently associated with P. aeruginosa infection were ICU duration [Odds Ratio (OR) 9.05, 95%CI 2.53-32.27, p = .001], previous surgery (OR = 7.33, 95%CI 1.66-32.36, p = .009), tracheostomy (OR = 11.13, 95%CI 1.05-118.59, p = .046), urethral catheterization (OR = 7.38, 95%CI 1.21-45.11, p = .030) and use of aminoglycosides (OR = 10.59, 95%CI 1.14-98.13, p = .038). Approximately 41% of P. aeruginosa isolates were resistant to imipenem, while 36.7% were multidrug-resistant. Mortality was similar in both groups: 54(60%) cases and 51(56.7%) controls; p = .650.

CONCLUSIONS

The study identifies several potentially modifiable factors associated with P. aeruginosa infection in ICUs. Identification of these factors could facilitate case identification and enhance control measures.

Antimicrobial resistance among GLASS pathogens in conflict and non-conflict affected settings in the Middle East: a systematic review

BACKGROUND

In spite of the evident general negative effects of armed conflict on countries' health systems and populations' health outcomes, little is known about similar impacts of conflicts on the spread of antimicrobial resistances (AMR). This review was to address this evidence gap and describe: 1. Patterns of AMR in the Middle East (ME) and resistance profiles of pathogens included in the Global AMR Surveillance System (GLASS) supported by the World Health Organization; 2. Differences in proportions of AMR isolates between conflict and non-conflict countries.

METHODS

A systematic literature review was conducted following PRISMA guidelines and searching five electronic databases. Subject heading and free text were searched for "antimicrobial resistances" and "Middle East", to identify observational studies on AMR published from January 2011 to June 2018. Data were extracted from included articles on a predefined set of variables. Percentages of AMR were analysed as median and interquartile ranges. Risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

A total of 132 articles met the inclusion criteria. Included studies showed heterogeneity in study design, laboratory methods and standards for interpretation of results, and an overall high risk of bias. Main findings were the following: 1. High proportions of carbapenem resistance in Acinetobacter spp. (median 74.2%), and both carbapenem resistance (median 8.1 and 15.4% for E. coli and K. pneumoniae respectively) and ESBL-production (median 32.3 and 27.9% for E. coli and K. pneumoniae respectively) amongst Enterobacteriaceae. S. aureus isolates showed a median methicillin resistance percentage of 45.1%, while vancomycin resistance was almost absent. A median of 50% of the strains of S. pneumoniae showed non-susceptibility to penicillin. 2. Similar trends were observed in conflict and non-conflict affected countries.

CONCLUSIONS

There is a lack of standardization in the methodological approach to AMR research in the Middle East. The proportion of antibiotic resistances among specific GLASS pathogens is high, particularly among Acinetobacter spp.

Suction Hoses of Dental Units as a Potential Source of Microbial Contamination

OBJECTIVES

Dental units are necessary tools for modern dentistry. Microbial contamination of dental units is thought to be the result of biofilm formation in various parts of the unit. We aimed to identify the total microbial count in the suction hose of dental units, and detect the presence of Pseudomonas aeruginosa.

METHODS

Random sampling of suction hoses of dental units in Birjand, Iran, was performed in dental clinics on the first (n = 115) and last (n = 115) working days of the week. Total viable counts of bacteria and detection of P. aeruginosa were performed on plate count agar and cetrimide agar, respectively. Plates were incubated at 37 °C for 48 hours.

RESULTS

None of the samples were free from bacterial contamination. P. aeruginosa was detected in 22.6% and 18.3% of samples taken on the first and last working days, respectively.

CONCLUSIONS

Suction hoses were heavily contaminated with bacteria, especially opportunistic pathogens, and current disinfection does not adequately control the contamination.

An Education-Based Text Messaging Program to Improve Nurses' Knowledge, Attitude, and Practice Related to Nosocomial Infections in Intensive Care Settings

BACKGROUND

Nosocomial infection (NI) is common in health care settings. Educational strategies such as mobile teaching methods for health care providers may help to resolve this problem. This pilot study assessed the influence of a text messaging program to improve intensive care unit nurses' knowledge, attitude, and practice related to NI prevention.

METHOD

In this single-group experimental study, 32 nurses received an educational intervention via short text messages on their cell phones. Information on knowledge, attitude, and practice regarding NI prevention was collected using a standard scale. Preventive messages about NI were prepared and sent to participants during a 2-month trial. Results were assessed 2 weeks after the intervention, and data were analyzed by paired t test.

RESULTS

Knowledge, attitude, and practice of participants increased by 17%, 3%, and 9%, respectively, from baseline to follow up. The average score on the knowledge dimension was lower than for other components. Knowledge components such as hand hygiene, work safety, and protective equipment increased to a lesser degree from pre- to posttest, compared with other aspects (p < .05 versus p < .001).

CONCLUSION

An education-based program operating through short text messages may be a useful in-service training strategy for intensive care unit nurses. [J Contin Educ Nurs. 2019;50(5):211-217.].

Healthcare-associated infections including neonatal bloodstream infections in a leading tertiary hospital in Botswana

Background: Healthcare-associated infections (HAIs) increase morbidity, mortality, length of hospital stay and costs, and should be prevented where possible. In addition, up to 71% of neonates are prone to bloodstream infections (BSI) during intensive care due to a variety of factors. Consequently, the objectives of this study were to estimate the burden of HAIs and possible risk factors in a tertiary hospital in Botswana as well as describe current trends in bacterial isolates from neonatal blood specimen and their antibiotic resistance patterns.Methods: Point Prevalence Survey (PPS) in all hospital wards and a retrospective cross-sectional review of neonatal blood culture and sensitivity test results, with data abstracted from the hospital laboratory database.Results: 13.54% (n = 47) of patients had HAIs, with 48.9% (n = 23) of them lab-confirmed. The highest prevalence of HAIs was in the adult intensive care unit (100% - n = 5), the nephrology unit (50% - n = 4), and the neonatal intensive care unit (41.9% - n = 13). One-fourth of HAIs were site unspecific, 19.1% (n = 9) had surgical site infections (SSIs), 17% (n = 8) ventilator-associated pneumonia/complications, and 10.6% (n = 5) were decubitus ulcer infections. There were concerns with overcrowding in some wards and the lack of aseptic practices and hygiene. These issues are now being addressed through a number of initiatives. Coagulase Negative Staphylococci (CoNS) was the commonest organism (31.97%) isolated followed by Enterococci spp. (18.03%) among neonates. Prescribing of third-generation cephalosporins is being monitored to reduce Enterococci, Pseudomonas and Acinetobacter spp. infections.Conclusions: There were concerns with the rate of HAIs and BSIs. A number of initiatives are now in place in the hospital to reduce these including promoting improved infection prevention and control (IPC) practices and use of antibiotics via focal persons of the multidisciplinary IPC committee. These will be followed up and reported on.

A systematic review of healthcare-associated infections in Africa: An antimicrobial resistance perspective

Background

Healthcare-associated infection (HCAI) is a global health challenge, not only as an issue of patient safety but also as a major driver of antimicrobial resistance (AMR). It is a major cause of morbidity and mortality with economic consequences.

Objective

This review provides an update on the occurrence of HCAI, as well as the contribution of emerging AMR on healthcare delivery in Africa.

Methods

We searched PubMed, Cochrane database, African Journals Online and Google Scholar for relevant articles on HCAI in Africa between 2010 and 2017. Preferred reporting items of systematic reviews and meta-analyses guidelines were followed for selection. Thirty-five eligible articles were considered for the qualitative synthesis.

Results

Of the 35 eligible articles, more than half (n = 21, 60%) were from East Africa. Klebsiella spp., Staphylococcus aureus, Escherichia coli and Pseudomonas spp. were the common pathogens reported in bloodstream infection, (catheter-associated) urinary tract infection, surgical site infection and healthcare-associated pneumonia. Among these various subtypes of HCAI, methicillin-resistant S. aureus (3.9% – 56.8%) and extended-spectrum beta-lactamase producing Gram-negative bacilli (1.9% – 53.0%) were the most reported antimicrobial resistant pathogens.

Conclusion

This review shows a paucity of HCAI surveillance in Africa and an emergence of AMR priority pathogens. Hence, there is a need for a coordinated national and regional surveillance of both HCAI and AMR in Africa.

A multi-center study on the risk factors of infection caused by multi-drug resistant Acinetobacter baumannii

BACKGROUND

Acinetobacter baumannii (AB) is critical for healthcare-associated infections (HAI) with significant regional differences in the resistance rate, but its risk factors and infection trends has not been well studied. We aimed to explore the risk factors, epidemiological characteristics and resistance of multidrug-resistant Acinetobacter baumannii (MDR-AB) in intensive care unit inpatients.

METHODS

Data of patients with MDR-AB (195 cases), and with antibiotic-sensitive AB infection (294 cases, control) during January to December, 2015 in three medical centers in Xiamen, China were conducted and analyzed in the present retrospective study.

RESULTS

Lower respiratory tract infection with AB accounted for 68.71%. MDR-AB was detected in 39.88% of all cases. Univariate analysis suggested that mechanical ventilation, indwelling catheter, cancer patients, length of hospitalization in intensive care unit (ICU) ≥15 d, Acute Physiology and Chronic Health Evaluation (APACHE) II score, combined using antibiotic before isolation of AB and use of third-lines cephalosporins were associated with the development of MDR-AB healthcare-associated infections. Dose-response relationship analysis suggested that the age and the days of mechanical ventilation were associated with increased infection with MDR-AB. Logistic regression analysis suggested that, mechanical ventilation, combined using antibiotic before isolation of AB, and indwelling catheter, were associated with MDR-AB infection, with odds ratios (OR) and 95% confidence intervals (CI) of 3.93 (1.52-10.14), 4.11 (1.58-10.73), and 4.15 (1.32-12.99), respectively.

CONCLUSIONS

MDR-AB infection was associated with mechanical ventilation, combined using antibiotic before isolation of AB, and indwelling catheter. Furthermore, the age and the days of mechanical ventilation were associated with increased infection with MDR-AB.

Multi-Drug-Resistant Gram-Negative Infections in Deployment-Related Trauma Patients

BACKGROUND

The contribution of multi-drug-resistant gram-negative bacilli infections (MDRGN-I) in patients with trauma is not well described. We present characteristics of MDRGN-Is among military personnel with deployment-related trauma (2009-2014).

PATIENTS AND METHODS

Data from the Trauma Infectious Disease Outcomes Study were assessed for infectious outcomes and microbial recovery. Infections were classified using standardized definitions. Gram-negative bacilli were defined as multi-drug-resistant if they showed resistance to ≥3 antibiotic classes or were producers of extended-spectrum β-lactamase or carbapenemases.

RESULTS

Among 2,699 patients admitted to participating U.S. hospitals, 913 (33.8%) experienced ≥1 infection event, of which 245 (26.8%) had a MDRGN-I. There were 543 MDRGN-I events (24.6% of unique 2,210 infections) with Escherichia coli (48.3%), Acinetobacter spp. (38.6%), and Klebsiella pneumoniae (8.4%) as the most common MDRGN isolates. Incidence of MDRGN-I was 9.1% (95% confidence interval [CI]: 8.0-10.2). Median time to MDRGN-I event was seven days with 75% occurring within 13 days post-trauma. Patients with MDRGN-Is had a greater proportion of blast injuries (84.1% vs. 62.5%; p < 0.0001), traumatic amputations (57.5% vs. 16.3%; p < 0.0001), and higher injury severity (82.0% had injury severity score ≥25 vs. 33.7%; p < 0.0001) compared with patients with either no infections or non-MDRGN-Is. Furthermore, MDRGN-I patients were more frequently admitted to the intensive care unit (90.5% vs. 48.5%; p < 0.0001), colonized with a MDRGN before infection (58.0% vs. 14.7%; p < 0.0001), and required mechanical ventilation (78.0% vs. 28.8% p < 0.0001). Antibiotic exposure before the MDRGN-I event was significantly higher across antibiotic classes except first generation cephalosporins and tetracyclines, which were very commonly used with all patients. Regarding outcomes, patients with MDRGN-Is had a longer length of hospitalization than the comparator group (53 vs. 18 days; p < 0.0001).

CONCLUSIONS

We found a high rate of MDRGN-I in our population characterized by longer hospitalization and greater injury severity. These findings inform treatment and infection control decisions in the trauma patient population.

Epidemiology and resistance features of Acinetobacter baumannii isolates from the ward environment and patients in the burn ICU of a Chinese hospital

Acinetobacter baumannii is an important opportunistic pathogen that causes severe nosocomial infections, especially in intensive care units (ICUs). Over the past decades, an everincreasing number of hospital outbreaks caused by A. baumannii have been reported worldwide. However, little attention has been directed toward the relationship between A. baumannii isolates from the ward environment and patients in the burn ICU. In this study, 88 A. baumannii isolates (26 from the ward environment and 62 from patients) were collected from the burn ICU of the Southwest Hospital in Chongqing, China, from July through December 2013. Antimicrobial susceptibility testing results showed that drug resistance was more severe in isolates from patients than from the ward environment, with all of the patient isolates being fully resistant to 10 out of 19 antimicrobials tested. Isolations from both the ward environment and patients possessed the β-lactamase genes bla OXA-51, bla OXA-23, bla AmpC, bla VIM, and bla PER. Using pulsed-field gel electrophoresis (PFGE) and multi-locus sequence typing (MLST), these isolates could be clustered into 4 major PFGE types and 4 main sequence types (ST368, ST369, ST195, and ST191) among which, ST368 was the dominant genotype. Epidemiologic and molecular typing data also revealed that a small-scale outbreak of A. baumannii infection was underway in the burn ICU of our hospital during the sampling period. These results suggest that dissemination of β-lactamase genes in the burn ICU might be closely associated with the high-level resistance of A. baumannii, and the ICU environment places these patients at a high risk for nosocomial infection. Cross-contamination should be an important concern in clinical activities to reduce hospitalacquired infections caused by A. baumannii.

Evaluation of Risk Factors for Intravenous Colistin Use-related Nephrotoxicity

OBJECTIVES

We investigated the incidence of and risk factors for nephrotoxicity in patients using intravenous colistin.

METHODS

This retrospective, observational study was conducted at Karadeniz Technical University, Faculty of Medicine, clinics and intensive care unit between 1 January 2009 and 1 January 2013. Intravenous colistin was administered to 133 patients at a dose of 2.5-5.0 mg/kg/day.

RESULTS

The patients mean age was 54.3±19.1 years and the mean duration of treatment was 13.5±3.6 days. Nephrotoxicity developed in 5.0±2.8 days in 38 (28.6%) patients. Based on RIFLE (risk, injury, failure, loss of kidney function, and end-stage kidney disease) criteria, 15 (39.5%) patients were class 1, 17 (44.7%) were class 2, six (15.8%) were class 3, and none were class 4. The mean duration of development of nephrotoxicity was 5.0±2.8 days. Hemodialysis requirement was observed in two (5.2%) of the 38 patients who developed nephrotoxicity. In these cases, colistin therapy was not discontinued. Nephrotoxicity was correlated with advanced age, high pretreatment serum creatinine levels, diabetes mellitus, and chronic obstructive pulmonary disease.

CONCLUSIONS

The use of colistin is relatively safe for patients that have normal renal functions. However, better standardization of the definition of nephrotoxicity in those patients with the use of scoring systems and close monitoring are necessary.