Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action

Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or "golden rules," for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice.

Molecular characterization and genotyping of isolates from cancer patients with Clostridioides difficile infection or asymptomatic colonization

Introduction. Cancer patients with Clostridioides difficile infection (CDI) are at a higher risk for adverse outcomes. In addition, a high prevalence of Clostridioides difficile asymptomatic colonization (CDAC) has been reported in this vulnerable population.Gap Statement. The molecular characteristics and potential role of CDAC in healthcare-related transmission in the cancer population have been poorly explored.Aim. We aimed to compare the molecular and genotypic characteristics of C. difficile isolates from cancer patients with CDAC and CDI.Method. We conducted a prospective cohort study of cancer patients with CDAC or CDI from a referral centre. Molecular characterization, typification and tcdC gene expression of isolates were performed.Results. The hospital-onset and community-onset healthcare facility-associated CDI rates were 4.5 cases/10 000 patient-days and 1.4 cases/1 000 admissions during the study period. Fifty-one C. difficile strains were isolated: 37 (72 %) and 14 (28 %) from patients with CDI or CDAC, respectively. All isolates from symptomatic patients were tcdA+/tcdB+, and four (10 %) were ctdA+/ctdB+. In the CDAC group, 10 (71 %) isolates were toxigenic, and none were ctdA+/ctdB+. The Δ18 in-frame tcdC deletion and two transition mutations were found in five isolates. After bacterial typing, 60 % of toxigenic isolates from asymptomatic carriers were clonal to those from patients with C. difficile-associated diarrhoea. No NAP1/027/BI strains were detected.Conclusions. We found a clonal association between C. difficile isolates from patients with CDAC and CDI. Studies are needed to evaluate the potential role of asymptomatic carriers in the dynamics of nosocomial transmission to support infection control measures and reduce the burden of CDI in high-risk groups.

Frequency of needle stick injuries among healthcare providers during large-scale SARS-CoV-2 vaccination brigades

The frequency of needle stick-related accidents in large-scale vaccination brigades during the COVID-19 pandemic is unknown. We determined the incidence of needle stick injuries (NIs) from the SARS-CoV-2 vaccination brigades in the Monterrey metropolitan area. We calculated the rate of NI by 100,000 doses administered from a registry of over 4 million doses.

Metagenomic Sequencing of Monkeypox Virus, Northern Mexico

Monkeypox virus (MPXV) has gained interest because of a multicountry outbreak of mpox (formerly monkeypox) cases with no epidemiologic link to MPXV-endemic regions. We sequenced the complete genome of MPXV isolated from a patient in northern Mexico. Phylogenetic analysis grouped the virus with isolates from Germany.

Bacterial incidence and drug resistance from pathogens recovered from blood, cerebrospinal and pleural fluids in 2019-2020. Results of the Invifar network

Background

Antimicrobial resistance is a global concern. Analysis of sterile fluids is essential because microorganisms are defined as significant in most cases. Blood, cerebrospinal, and pleural fluids are frequently received in the microbiology lab because they are associated with considerable rates of morbi-mortality. Knowledge of epidemiology in these samples is needed to choose proper empirical treatments due to the importance of reducing selection pressure.

Methods

We used retrospective laboratory data of blood, CSF, and pleural fluid collected from patients in Mexico between 2019 and 2020. Each laboratory identified the strains and tested susceptibility using its routine methods. For Streptococcus pneumoniae, a comparative analysis was performed with data from the broth microdilution method.

Results

Forty-five centers participated in the study, with 30,746 clinical isolates from blood, 2,429 from pleural fluid, and 2,275 from CSF. For blood and CSF, Staphylococcus epidermidis was the most frequent. For blood, among gram negatives, the most frequent was Escherichia coli. Among Enterobacterales, 9.8% of K. pneumoniae were carbapenem-resistant. For S. pneumoniae, similar resistance percentages were observed for levofloxacin, cefotaxime, and vancomycin. For CSF, the most frequent gram-negative was E. coli. In Acinetobacter baumannii, carbapenem resistance was 71.4%. The most frequent species detected for pleural fluid was E. coli; in A. baumannii, carbapenem resistance was 96.3%.

Conclusion

Gram-negative bacteria, with E. coli most prevalent, are frequently recovered from CSF, blood, and pleural fluid. In S. pneumoniae, the routine, conventional methods showed good agreement in detecting resistance percentages for erythromycin, levofloxacin, and vancomycin.

The global case fatality rate of coronavirus disease 2019 by continents and national income: A meta-analysis

The aim of this study is to provide a more accurate representation of COVID‐19's case fatality rate (CFR) by performing meta‐analyses by continents and income, and by comparing the result with pooled estimates. We used multiple worldwide data sources on COVID‐19 for every country reporting COVID‐19 cases. On the basis of data, we performed random and fixed meta‐analyses for CFR of COVID‐19 by continents and income according to each individual calendar date. CFR was estimated based on the different geographical regions and levels of income using three models: pooled estimates, fixed‐ and random‐model. In Asia, all three types of CFR initially remained approximately between 2.0% and 3.0%. In the case of pooled estimates and the fixed model results, CFR increased to 4.0%, by then gradually decreasing, while in the case of random‐model, CFR remained under 2.0%. Similarly, in Europe, initially, the two types of CFR peaked at 9.0% and 10.0%, respectively. The random‐model results showed an increase near 5.0%. In high‐income countries, pooled estimates and fixed‐model showed gradually increasing trends with a final pooled estimates and random‐model reached about 8.0% and 4.0%, respectively. In middle‐income, the pooled estimates and fixed‐model have gradually increased reaching up to 4.5%. in low‐income countries, CFRs remained similar between 1.5% and 3.0%. Our study emphasizes that COVID‐19 CFR is not a fixed or static value. Rather, it is a dynamic estimate that changes with time, population, socioeconomic factors, and the mitigatory efforts of individual countries.

Europe showed the highest COVID‐19 case fatality rate (CFR) until mid‐October 2020, and North America and South America follows.

Asia showed the highest CFR since the first confirmed case of COVID‐19 emerged, however, it had shown a declining tendency since March 2020.

CFRs in high‐income countries showed an explosive increase compared with those in low‐income countries, which can be interpreted as due to the under‐reporting of mortality cases from COVID‐19.

1014. Effect of Levofloxaclin and Trimethoprim-sulfamethoxazole on Planktonic and Biofilm Cells of Stenotrophomonas maltophilia Isolates Obtained from Blood and Respiratory Samples

Background

Stenotrophomonas maltophilia is a non-fermenting Gram-negative pathogen, which causes healthcare-associated infections and exhibits increasing drug resistance rates. In this study, we compared the effect of levofloxacin and trimethoprim-sulfamethoxazole on planktonic and biofilm cells of S. maltophilia isolates obtained from blood and respiratory samples.

Methods

S. maltophilia isolates were recollected from patients older than 18 years from 2018-2020 from Hospital Universitario Dr. Jose Eleuterio Gonzalez, a tertiary care hospital from Nuevo Leon, Mexico. Bacteria were dentified by MALDI-TOF MS. Biofilm formation was determined using the crystal violet staining method.Antimicrobial susceptibility in planktonic cells and biofilm cells were determined by the broth microdilution and the Calgary device, respectively.

Results

During the 3-year study period, 44 S. maltophilia isolates were identified, 28.8% of which were biofilm producers. Of those, 69.2% were obtained from blood cultures. Isolates were obtained from several wards: 25% infectious diseases ward, 18% nephrology, 18% intensive care units, 14% geriatric ward, 7% plastic surgery, and 18% from other wards. The majority of the studied subjects were men (34.6%), and the mean age was 41 years. The majority of the isolates were susceptible to levofloxacin (94.1%) and to trimethoprim-sulfamethoxazole (76.4%) in planktonic assays. All the isolates were resistant to both antibiotics when analyzing biofilm cells. Levofloxacin resistance was at least four-fold higher in biofilm cells compared to planktonic cells. Trimethoprim-sulfamethoxazole resistance was at least ten-fold higher in biofilm cells compared to planktonic cells.

Conclusion

The majority of S. maltophilia clinical isolates causing blood infections in a hospital in Mexico were able to produce biofilm. The production of biofilm in S. maltophilia strains enhanced resistance to levofloxacin and trimethoprim-sulfamethoxazole.

Disclosures

All Authors: No reported disclosures

Association between convalescent plasma treatment and mortality in COVID-19: a collaborative systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Convalescent plasma has been widely used to treat COVID-19 and is under investigation in numerous randomized clinical trials, but results are publicly available only for a small number of trials. The objective of this study was to assess the benefits of convalescent plasma treatment compared to placebo or no treatment and all-cause mortality in patients with COVID-19, using data from all available randomized clinical trials, including unpublished and ongoing trials (Open Science Framework, https://doi.org/10.17605/OSF.IO/GEHFX ).

METHODS

In this collaborative systematic review and meta-analysis, clinical trial registries (ClinicalTrials.gov, WHO International Clinical Trials Registry Platform), the Cochrane COVID-19 register, the LOVE database, and PubMed were searched until April 8, 2021. Investigators of trials registered by March 1, 2021, without published results were contacted via email. Eligible were ongoing, discontinued and completed randomized clinical trials that compared convalescent plasma with placebo or no treatment in COVID-19 patients, regardless of setting or treatment schedule. Aggregated mortality data were extracted from publications or provided by investigators of unpublished trials and combined using the Hartung-Knapp-Sidik-Jonkman random effects model. We investigated the contribution of unpublished trials to the overall evidence.

RESULTS

A total of 16,477 patients were included in 33 trials (20 unpublished with 3190 patients, 13 published with 13,287 patients). 32 trials enrolled only hospitalized patients (including 3 with only intensive care unit patients). Risk of bias was low for 29/33 trials. Of 8495 patients who received convalescent plasma, 1997 died (23%), and of 7982 control patients, 1952 died (24%). The combined risk ratio for all-cause mortality was 0.97 (95% confidence interval: 0.92; 1.02) with between-study heterogeneity not beyond chance (I2 = 0%). The RECOVERY trial had 69.8% and the unpublished evidence 25.3% of the weight in the meta-analysis.

CONCLUSIONS

Convalescent plasma treatment of patients with COVID-19 did not reduce all-cause mortality. These results provide strong evidence that convalescent plasma treatment for patients with COVID-19 should not be used outside of randomized trials. Evidence synthesis from collaborations among trial investigators can inform both evidence generation and evidence application in patient care.

Echocardiographic Characteristics of Subjects With COVID-19: A Case Series

Although coronavirus disease 2019 (COVID-19) manifests in most cases with respiratory symptoms, other presentations can occur. Direct damage to the cardiovascular system has been reported and recently, acute myocardial injury has been identified as a risk factor for mortality. Transthoracic echocardiography is a non-invasive tool that allows the detection of myocardial damage with validated markers (left ventricular ejection fraction and global longitudinal strain). Herein, we present the echocardiographic findings in four patients with COVID-19. All cases had acute respiratory distress syndrome (100%). Three out of four had elevated levels of creatine kinase and creatine kinase myocardial band. One case had ventricular concentric remodeling (25%). All cases (100%) had altered ventricular function: two had a reduced ejection fraction (50%) and, of those available for global longitudinal strain analysis, all had abnormal global longitudinal strain (100%). One case was found to have a tricuspid vegetation of 12 × 10 mm with no other manifestation of endocarditis. All of our cases had left ventricular dysfunction as assessed by echocardiography. One of our patients had a vegetation in the tricuspid valve. Two of our cases had a reduced ejection fraction. The importance of acute cardiac injury in COVID-19 has recently been established. A recent study found it to be an independent risk factor for mortality in patients with this disease. Information regarding echocardiographic characteristics of this population is scarce. Further research to elucidate the impact of these characteristics on morbidity and mortality is urgently needed.

2407. Overexpression of Virulence Factors in Biofilm from Recurrent Clostridium (Clostridioides) difficile Infection Isolates

Background

Recurrent Clostridium (Clostridioides) difficile infection (R-CDI) remains a significant healthcare problem. Our aim was to analyze virulence/colonization determinants including spore formation, and expression of quorum sensing factors and adhesion capability in C. difficile biofilms, which serve as a potential reservoir for C. difficile in R-CDI.

Methods

Isolates obtained from patients with R-CDI (n = 39) and non-recurrent CDI (NR-CDI) (n = 93) were analyzed. Isolates were identified by PCR and MALDI-TOF MS and ribotyped by 16S-RNA amplification and capillary electrophoresis.

Biofilm production in a C. difficile and in a C. difficile-microbiota (Enterococcus and Lactobacillus species) model was assessed by the crystal violet method. Spore counts were determined both in planktonic and biofilm growth.

RNA was extracted from a selection of strains from R-CDI (n = 10) and NR-CDI (n = 10) isolate biofilms and relative expression levels of: spo0A, sigH, slpA, cwp84, agrD1 and luxS were determined.

Results

All NR-CDI and R-CDI isolates were biofilm producers and most were strongly adherent (90.90%) and 027 ribotype (81.37%).

In the C. difficile biofilm model, spore formation was higher in R-CDI than in the NR-CDI isolates (P = 0.015). In the biofilm of C. difficile-microbiota, no difference was detected in spore formation between the R-CDI and NR-CDI isolates (P = 0.677).

Expression of sigH (p = 0.007), spo0A (p = 0.003), cwp84 (p = 0.001) and agrD1 (p = 0.001) was higher in R-CDI than NR-CDI isolates. No difference was shown in slpA (p = 0.066) and luxS (p = 0.400) expression between groups.

Conclusion

Our data suggest that expression of sporulating pathway genes, sigH, spo0A, the quorum sensing gene, agrD₁; and adhesion-associated gene, cwp84 is higher in R-CDI isolates, in addition to elevated spore formation, which may have an impact on the recurrence of the infection.

Disclosures

All authors: No reported disclosures.

2148. Performance of the BioFire FilmArray Gastrointestinal Panel in a Clinical Setting of Infectious Diarrhea

Background

Infectious diarrhea remains as one of the leading causes of morbidity and mortality worldwide among all age groups. Conventional methods for diagnosis are time consuming and expensive. The BioFire FilmArray gastrointestinal panel (FA-GIP) tests for 22 enteric pathogens, provides results in a few hours and improves healthcare costs. The impact on antibiotic stewardship is unknown.

Methods

We conducted a retrospective cohort, multi-center study to evaluate FA-GIP clinical performance in hospitalized patients with acute diarrhea. Patients from 3 hospitals from the Christus Muguerza health group were included between January 2017 and August 2018. The FA-GIP was ordered by the treating physician and was not influenced by the study. Duration of antibiotic therapy, length of hospital stay, and therapy modification were assessed. The comparison group consisted of patients with acute diarrhea in which no FA-GIP was ordered.

Results

Data from 130 patients with FA-GIP and 107 patients with conventional methods were collected. Pathogens were detected by FA-GIP in 72.3% of the cases. The median of duration of antibiotic therapy in FA-GIP group was 5 days (IQR 0–8) vs. 3 days (IQR 0–6) in conventional methods group, (P < 0.05). The mean length of stay was 3.3(SD ± 2.4) in FA-GIP group vs. 1.9 (SD ± 1.0) in the control group (P < 0.05). Patients in FA-GIP group had more days with diarrhea, lower hemoglobin levels, and higher creatinine levels at admission (Table 1). The most frequent pathogens detected were enteropathogenic Escherichia coli in 24.4%, norovirus in 19.1%, Clostridium difficile in 17.0% and Campylobacter jejuni in 15.9% (Table 2). Therapy modification after FA-GIP results was made in 51.1% of the patients with a detected pathogen, and in 42.8% of patients with no pathogen detected in FA-GIP the antibiotic was stopped.

Conclusion

Patients in the FA-GIP group had a more complex clinical scenario upon admission, they also had a longer duration of antibiotic therapies and longer length of stay. Although antibiotic therapy was positively influenced by the FA-GIP result, and no pathogen detection leads to withdrawal of unnecessary antibiotics.

Disclosures

All authors: No reported disclosures.

1789. Frequency of Chikungunya, Dengue, and Zika Virus in Acute Febrile Illness in Paired Urine and Serum Samples in Mexico

Background

Given the nonspecific clinical presentation that dengue (DENV), Zika (ZIKV), and chikungunya viruses (CHIKV) have, nucleic acid amplification tests have become the primary diagnostic tool. Multiplex real-time PCR assays have been approved for their use in the qualitative detection of ZIKV in urine but there are few data regarding CHIKV and DENV. We report the frequencies of PCR detection for DENV, ZIKV and CHIKV in paired urine and serum samples in Mexico.

Methods

We included patients with acute febrile illness from five centers, located in Guadalajara and Monterrey, from September 2016 to December 2018. Viral RNA was extracted from samples, reverse transcribed and subjected to real-time PCRs specific for DENV, CHIKV, and ZIKV. Patients were considered a positive case if any of the three tests were positive. The obtained data were analyzed using descriptive statistics.

Results

A total of 978 patients were included. A positive result was obtained in 331 patients (33.84%): 184 for ZIKV, 129 for DENV, and 18 for CHIKV. The tests were positive in both specimens in 56 (30.4%), 29 (22.4%), and 4 (22%) of the cases, respectively, while an isolated positive urine test was found in 74 (40%), 5 (3%) and 4 (22%) of the cases. Two patients were positive for both ZIKV and DENV, and two were positive for both ZIKV and CHIKV.

Conclusion

Acute febrile illness was potentially attributable to infection with one or two of the studied arboviruses in up to 34% of our patients. Out of all the cases, 25% were positive only in urine samples. Therefore, some diagnosis could be missed when analyzing only serum-based tests. Paired serum and urine sampling should be recommended when detecting arbovirus in acute febrile illness.

Disclosures

All authors: No reported disclosures.

2321. FluMex: A New Clinical Severity Index in Mexican Hospitalized Patients with Influenza

Background

Influenza virus infection is frequently characterized by a complex clinical behavior and outcomes can be fatal. There are many published scoring methods aimed for pulmonary infections and sepsis severity nevertheless they lack adequate sensitivity and specificity in patients with Influenza.

Methods

From 2013 to 2018, hospitalized patients from five hospitals from the Christus Muguerza health group from Monterrey, Mexico who had a positive rapid influenza-test and/or positive PCR for Influenza virus were enrolled. Risk factors for severity and mortality were evaluated calculating odds ratio with a binary logistic regression model and were adjusted for other factors. The new index was then compared with pneumonia severity scores by assessing area under the curve(AUC), sensitivity and specificity.

Results

We analyzed data from 125 patients hospitalized with confirmed Influenza infection. Less than 1% had received the corresponding seasonal influenza vaccine. Type 2 diabetes (T2D) and hypertension (HT) were the most prevalent comorbidities. Odds ratios were significant for age > 65 years, body mass index (BMI) > 30, T2D, HT, pulsoximetry < 90%, respiratory rate > 22 per minute, altered mental status, blood urea nitrogen (BUN) > 19 mg/dL, elevated lactate dehydrogenase (LDH), and an abnormal chest X-ray. The FluMex score was applied to a control group of 125 admitted patients with confirmed Influenza infection. AUC was 0.63 (CI 95%, 0.52–0.74; P < 0.05) for severity and 0.90 (IC 95%, 0.83–0.97; P < 0.05) for mortality, showing better predictive performance than other pneumonia and sepsis scores such as CURB-65, PSI, CROMI, SIRS, SOFA, qSOFA and ILI (Table 1).

Conclusion

The FluMex scoring system can be a useful tool for patients with suspected Influenza infection in predicting severity and mortality, helping to improve care and resource management.

Disclosures

All authors: No reported disclosures.

One-day point prevalence of healthcare-associated infections and antimicrobial use in four countries in Latin America

BACKGROUND AND AIMS

Experience in the region shows that in some countries there is very good surveillance of Healthcare-associated infections (HAIs) in health services, but there is no national data consistently in all countries. Therefore, we set to estimate the total burden of HAIs and antimicrobial use in acute care hospitals in Brazil, Venezuela, Mexico, and Colombia using the one-day point prevalence methodology.

METHODS

The survey was conducted between June and July 2016. In each ward or unit, HAIs and antimicrobial use data were collected on a single day by a trained team of researchers. Also, for each patient, we collected data on risk factors for infections.

RESULTS

One out of ten individuals surveyed had at least one healthcare-associated infection (HAI). Pneumonia and surgical site infections were the most relevant among the surveyed countries. Most of the surveyed participants, regardless of their HAI status, received antibiotics except the individuals managed in Brazil. Carbapenems and third-generation Cephalosporins were among the most frequently used antibiotics.

CONCLUSION

Our results add to WHO's recent efforts to understand HAIs prevalence and antibiotic consumption in low and middle-income countries, of which we studied three that were not included in their last report.

Consensus on the prevention, diagnosis, and treatment of Clostridium difficile infection

In recent decades, Clostridium difficile infection (CDI) has become a worldwide health problem. Mexico is no exception, and therefore the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, endoscopists, internists, infectious disease specialists, and microbiologists) to carry out the "Consensus on the prevention, diagnosis, and treatment of Clostridium difficile infection", establishing useful recommendations (in relation to the adult population) for the medical community. Said recommendations are presented herein. Among them, it was recognized that CDI should be suspected in subjects with diarrhea that have a history of antibiotic and/or immunosuppressant use, but that it can also be a community-acquired infection. A 2-step diagnostic algorithm was proposed, in which a highly sensitive test, such as glutamate dehydrogenase (GDH), is first utilized, and if positive, confirmed by the detection of toxins through immunoassay or nucleic acid detection tests. Another recommendation was that CDI based on clinical evaluation be categorized as mild-moderate, severe, and complicated severe, given that such a classification enables better therapeutic decisions to be made. In mild-moderate CDI, oral vancomycin is the medication of choice, and metronidazole is recommended as an alternative treatment. In addition, fecal microbiota transplantation was recognized as an efficacious option in patients with recurrence or in the more severe cases of infection, and surgery should be reserved for patients with severe colitis (toxic megacolon), in whom all medical treatment has failed.

502. Enhanced Sporulation and Vancomycin Resistance Associated With Clostridium difficile From Recurrent Infections

Background

Recurrent Clostridium difficile infection (R-CDI) remains a significant healthcare problem. Our aim was to analyze sporulation and antimicrobial resistance of C. difficile in biofilms as a potential reservoir for recurrence.

Methods

C. difficile isolates obtained from patients with initial CDI (I-CDI) (n = 93) and from patients with R-CDI (n = 39) were analyzed. Isolates were identified by PCR and MALDI-TOF MS and ribotyped using 16S RNA amplification and capillary electrophoresis. Biofilm production was assessed by the crystal violet microtiter-plate method. Susceptibilities to vancomycin and linezolid were determined both in planktonic and in biofilm cells and total viable cells and spore were quantified in biofilm cells.

Results

All I-CDI and R-CDI isolates were biofilm producers and >75% were ribotype 027. MICs for vancomycin and linezolid were higher in biofilm than in planktonic cells in both I-CDI and R-CDI isolates (P < 0.05) (Table 1). Isolates recovered from R-CDI showed a higher vancomycin resistance (MIC >2 mg/L) and sporulated 2 log₁₀ higher than isolates from I-CDI (P < 0.01 and P = 0.086, respectively).

Conclusion

C. difficile isolates in biofilms were 100-fold more resistant to vancomycin than planktonic cells. Isolates recovered from patients with R-CDI showed higher sporulation capacities than C. difficile recovered from I-CDI patients. Our data suggest that biofilm formation ability may play a key role in R-CDI by contributing to vancomycin resistance/tolerance. Furthermore, C. difficile from recurrent episodes sporulated to a greater capacity which may facilitate prolonged C. difficile persistence in the gut following therapy for R-CDI.

Disclosures

All authors: No reported disclosures.

2026. Phenotypic and Molecular Characterization of Drug Resistance and Biofilm Production in Stenotrophomonas maltophilia Obtained in a 10-Year Period from a Mexican Hospital

Background

Stenotrophomonas maltophilia is an emerging drug-resistant opportunistic pathogen related with healthcare-associated infections. The aim was to perform a phenotypic and molecular characterization of drug resistance and biofilm formation in S. maltophilia obtained in a 10-year period from a Mexican Hospital.

Methods

S. maltophilia isolates from a 10-year period from a tertiary care hospital in Mexico were identified by MALDI-TOF MS. Antimicrobial susceptibility was determined by the broth microdilution method. Drug resistance-associated genes were analyzed by PCR. Biofilm formation and its composition was assessed by crystal violet staining, and detachment assays, respectively. Biofilm production-associated genes were analyzed by PCR. MALDI-TOF mass spectra patterns were analyzed to search markers of drug resistance and biofilm production using the ClinProTools software.

Results

In the 10-year study period, 258 S. maltophilia isolates were identified, with high resistance detected for ceftazidime (48.4%), cefepime (31.6%), ciprofloxacin (25.0%), trimethoprim-sulfamethoxazole (18.8%), and lower resistance to chloramphenicol (13.6%) and levofloxacin (2.2%). Drug resistance was not associated to the presence of the sul1 (4.1%), sul2 (0.5%), sul3 (0.0%) or ISCR (0.0%) genes. Overexpression of the SmeABC efflux pump was associated to higher drug resistance (P < 0.05). Overall, 97.7% isolates were biofilm producers, i.e., 41.7% were strong producers; 32.0% were moderate, and 26.2% were weak producers. Biofilm composition analysis showed similar percentages for carbohydrates, proteins and DNA in all isolates (36.0, 39.7 and 40.9%, respectively). Biofilm-associated genes fsnR, rmlA, rpfF, xanB and spgM were detected in 94.0, 75.3, 28.6, 17.2% and 0.0% of isolates, respectively. Four potential biomarker peaks were detected in rmlA positive biofilm-producing isolates (P < 0.05).

Conclusion

Most of S. maltophilia clinical isolates showed high antimicrobial resistance levels and were able to produce biofilm. Biofilm biomass composition of these isolates showed a similar proportion of polysaccharides, proteins, and DNA. The presence of the rmlA gene was associated with biofilm production. Four potential markers of the presence of the biofilm production-associated rmlA gene were detected by mass spectrometry.

Disclosures

All authors: No reported disclosures.

A Global Declaration on Appropriate Use of Antimicrobial Agents across the Surgical Pathway

This declaration, signed by an interdisciplinary task force of 234 experts from 83 different countries with different backgrounds, highlights the threat posed by antimicrobial resistance and the need for appropriate use of antibiotic agents and antifungal agents in hospitals worldwide especially focusing on surgical infections. As such, it is our intent to raise awareness among healthcare workers and improve antimicrobial prescribing. To facilitate its dissemination, the declaration was translated in different languages.

The Global Alliance for Infections in Surgery: defining a model for antimicrobial stewardship-results from an international cross-sectional survey

BACKGROUND

Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world.

METHODS

A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery.

RESULTS

The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p < 0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%).

CONCLUSION

The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.

Erratum to: Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

[This corrects the article DOI: 10.1186/s13017-016-0089-y.].

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

One-year surveillance of ESKAPE pathogens in an intensive care unit of Monterrey, Mexico

BACKGROUND

Bacterial species from the ESKAPE group (i.e. Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter species) are frequently resistant to antibiotics. The purpose of this study was to monitor the incidence of ESKAPE pathogens at the intensive care unit (ICU) of a tertiary care hospital in Monterrey, Mexico.

METHODS

All clinically relevant organisms isolated from June 2011 to June 2012 were included. Identification and susceptibility testing was performed using panels from Sensititre. Resistance to oxacillin, for S. aureus, and the production of extended spectrum β-lactamases (ESBLs), for K. pneumonia, were determined as defined by the Clinical Laboratory Standards Institute. Also, the presence of vanA and vanB genes was determined in E. faecium vancomycin (VAN)-resistant isolates.

RESULTS

The majority of pathogens (64.5%) isolated in the ICU unit were from the ESKAPE group. The organisms most frequently isolated were A. baumannii (15.8%) and P. aeruginosa (14.3%). A high resistance to carbapenems was detected for A. baumannii (75.3%) while 62% of S. aureus isolates were confirmed to be methicillin resistant. Of the K. pneumoniae isolates, 36.9% were ESBL producers. We detected three E. faecium VAN-resistant isolates, all of which contained the vanA gene.

CONCLUSION

The presence of the ESKAPE group of pathogens is a major problem in the ICU setting. The results of this study support the implementation of special antimicrobial strategies to specifically target these microorganisms.

Case report: Transient success using prolonged treatment with miltefosine for a patient with diffuse cutaneous leishmaniasis infected with Leishmania mexicana mexicana

Leishmania sp. is an intracellular parasite that causes a variable degree of clinical manifestations, especially in the skin. We present the case of a 38-year-old male with a chronic history of mucocutaneous disease present since childhood that generated deformity, loss of cartilage in the ears and nose, and scarring that limited his range of motion. The parasite was identified as L. mexicana mexicana. The patient was treated with a 3-month course of oral miltefosine with overwhelming results.

Risk factors associated with extended-spectrum β-lactamase-producing Enterobacteriaceae nosocomial bloodstream infections in a tertiary care hospital: a clinical and molecular analysis

AIM

To describe the risk factors and molecular epidemiology of nosocomial bloodstream infections caused by extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in a tertiary care hospital.

METHODS

Patients with enterobacteria-positive blood cultures were included. ESBL expression in the isolates was detected using the combination disk method. Antimicrobial susceptibility testing was performed using the disk diffusion method. bla(SHV), bla(TEM), and bla(CTX-M) genes were identified in the isolated strains by PCR and sequencing. Klebsiella pneumoniae isolates were genotyped by PFGE.

RESULTS

Of the 90 isolates recovered, half were found to express ESBLs. Twenty-eight (62%) of these isolates were K. pneumoniae, 8 (18%) were Escherichia coli, 6 (13%) were Enterobacter cloacae, and 3 (7%) were Serratia marcescens. Multivariate logistic regression analysis showed that the only independent risk factor associated with infection by ESBL-producing strains was use of broad-spectrum cephalosporins. None of the isolates was resistant to imipenem. The bla(SHV5) gene was detected in 84% of isolates, followed by bla(CTX-M15) (27%), bla(SHV2) (9%), and bla(SHV12) (7%). PFGE identified six clones among the 28 ESBL-producing K. pneumoniae isolates.

CONCLUSIONS

ESBL-producing K. pneumoniae clones were detected throughout the hospital. Use of broad-spectrum cephalosporins is the most important risk factor associated with the proliferation of ESBL-producing strains.