The impact of discontinuing single-room isolation of patients with vancomycin-resistant enterococci: a quasi-experimental single-centre study in South Korea

OBJECTIVES

There is limited data on the effects of discontinuing single-room isolation while maintaining contact precautions, such as the use of gowns and gloves. In April 2021, our hospital ceased single-room isolation for patients with vancomycin-resistant enterococci (VRE) because of single-room unavailability. This study assessed the impact of this policy by examining the incidence of hospital-acquired VRE bloodstream infections (HA-VRE BSI).

METHODS

This retrospective quasi-experimental study was conducted at a tertiary-care hospital in Seoul, South Korea. Time-series analysis was used to evaluate HA-VRE BSI incidence at the hospital level and in the haematology unit before (phase 1) and after (phase 2) the policy change.

RESULTS

At the hospital level, HA-VRE BSI incidence level (VRE BSI per 1000 patient-days per month) and trend did not change significantly between phase 1 and phase 2 (coefficient -0.015, 95% confidence interval (CI): -0.053 to 0.023, P=0.45 and 0.000, 95% CI: -0.002 to 0.002, P=0.84, respectively). Similarly, HA-VRE BSI incidence level and trend in the haematology unit (-0.285, 95% CI: -0.618 to 0.048, P=0.09 and -0.018, 95% CI: -0.036 to 0.000, P = 0.054, respectively) did not change significantly across the two phases.

CONCLUSIONS

Discontinuing single-room isolation of VRE-colonized or infected patients was not associated with an increase in the incidence of VRE BSI at the hospital level or among high-risk patients in the haematology unit. Horizontal intervention for multi-drug-resistant organisms, including measures such as enhanced hand hygiene and environmental cleaning, may be more effective at preventing VRE transmission.

Nutritional Strategies To Improve VRE Control

The rise of Vancomycin-resistant enterococci (VRE) strains among cellular therapy recipients raises concerns due to increased morbidity, mortality, and hospitalization costs, particularly impacting transplanted patients with diminished survival expectations. Recent research linking lactose to Enterococcus growth and graft-versus-host disease (GVHD) emphasizes the need for data on reducing lactose in the diets of VRE-carrying patients, especially in cellular therapy contexts like CAR-T or allogeneic hematopoietic stem cell transplantation. Responding to elevated VRE positivity rates in rectal swabs among patients in our BMT Unit, a unique nutritional strategy was implemented, introducing lactose-free milk and strictly enforcing lactose-free diets. This approach resulted in a significant reduction in VRE carriers, with a 16% positivity rate in the Lactose Group versus 3.6% in the Lactose-Free Group, as of June 2023. These results indicate the potential efficacy of this innovative nutritional strategy in high-risk departments, such as BMT Units and Intensive Care Units, with implications for reducing isolation strategies and inappropriate antibiotic use in cases of VRE colonization.

Vancomycin-resistant Enterococcus faecium: impact of ending screening and isolation in a Danish University hospital

BACKGROUND

Substantial resources are used in hospitals worldwide to counteract the ever-increasing incidence of vancomycin-resistant and vancomycin-variable Enterococcus faecium (VREfm and VVEfm), but it is important to balance patient safety, infection prevention, and hospital costs.

AIM

To investigate the impact of ending VREfm/VVEfm screening and isolation at Odense University Hospital (OUH), Denmark, on patient and clinical characteristics, risk of bacteraemia, and mortality of VREfm/VVEfm disease at OUH. The burden of VREfm/VVEfm bacteraemia at OUH and the three collaborative hospitals in the Region of Southern Denmark (RSD) was also investigated.

METHODS

A retrospective cohort study was conducted including first-time VREfm/VVEfm clinical isolates (index isolates) detected at OUH and collaborative hospitals in the period 2015-2022. The intervention period with screening and isolation was from 2015 to 2021, and the post-intervention period was 2022. Information about clinical isolates was retrieved from microbiological databases. Patient data were obtained from hospital records.

FINDINGS

At OUH, 436 patients were included in the study, with 285 in the intervention period and 151 in the post-intervention period. Ending screening and isolation was followed by an increased number of index isolates. Besides a change in van genes, only minor non-significant changes were detected in all the other investigated parameters. Mortality within 30 days did not reflect the VREfm/VVEfm-attributable deaths, and in only four cases was VREfm/VVEfm infection the likely cause of death.

CONCLUSION

Despite an increasing number of index isolates, nothing in the short follow-up period supported a reintroduction of screening and isolation.

Opioid exposure as a potential risk factor for vancomycin-resistant enterococci colonization in the absence of antimicrobial exposure

BACKGROUND

Antimicrobial exposure leads to an increased risk of colonization and spread of vancomycin-resistant enterococci. Studies have also implicated exposure to nonantimicrobial medications as a potential risk factor for an increased risk of colonization with these pathogens.

METHODS

A matched case-control study was performed to determine specific nonantimicrobial medications associated with vancomycin-resistant enterococci rectal colonization. Cases and controls were defined as persons who were not exposed to antimicrobials in the preceding 12 months and in whom vancomycin-resistant enterococci rectal colonization was and was not detected at hospital admission, respectively. Matching was performed by the date of admission. Data were extracted from electronic medical records and included patient demographics, clinical data, and exposure to non-antimicrobial medications in the preceding 90 days.

RESULTS

Vancomycin-resistant enterococci colonization was identified among 2,919 (4.8%) patients during their first admission among 59,986 admissions. Among these patients, 27 cases were identified and were matched to 63 controls. Exposure to opioids was the only independent risk factor associated with colonization (adjusted odds ratio 3.8 [95% confidence interval 1.4-10.8], P-value = .01).

CONCLUSIONS

Opioid exposure may increase the risk of vancomycin-resistant enterococci colonization. Preventing the acquisition of these pathogens may require infection-prevention efforts targeting persons exposed to opioids.

Are Cutibacterium acnes delivered from skin to deep tissues in primary reverse shoulder arthroplasty? A prospective study

INTRODUCTION

The objective of this study is to determine whether the deep tissues are inoculated during surgery with the Cutibacterium acnes still present in the skin after the surgical preparation in reverse shoulder arthroplasties.

MATERIALS AND METHODS

Prospective study including patients undergoing surgery with reverse shoulder arthroplasty. All the patients received preoperative antibiotic prophylaxis with cefazolin (2 g IV) and the skin was prepared with 2% chlorhexidine gluconate and 70% isopropyl alcohol. From all the patients, 9 cultures were obtained after the antibiotic was administrated and the skin surgically prepared. The cultures were sent to isolate C. acnes. DNA was extracted from the C. acnes isolated colonies. Isolate nucleotide distances were calculated using the Genome-based distance matrix calculator from the Enveomics collection toolbox.

RESULTS

The study included 90 patients. C. acnes was isolated in 24 patients (26.6%) with a total of 61 positive cultures. There were 12 phylotype II, 27 IB and 22 IA. In 9 patients, C. acnes was present in both skin and deep tissues, and they constituted the sample to be studied by means of genomic analysis. In 7 out of the 9 patients, deep tissue samples clustered closer to at least one of its corresponding skin isolates when compared to the other independent bacterial ones.

CONCLUSIONS

The C. acnes present in the skin at the beginning of the surgery are the same as those found in the deep tissues at the end of the surgery. This result strengthens the possibility that the C. acnes is delivered from the skin to the deep tissues.

Perioperative daptomycin for prophylaxis of vancomycin-resistant Enterococcus infection in colonized liver transplant recipients

BACKGROUND

Infection with vancomycin-resistant Enterococcus (VRE) in liver transplant recipients (LTR) has been associated with extended hospital stays, increased readmission rates, graft failure, and death. A tailored perioperative surgical prophylaxis regimen targeting VRE may reduce postoperative infections in VRE-colonized patients. This study investigated the outcomes of perioperative daptomycin in this patient population.

METHODS

This retrospective, single-center cohort study included LTR ≥ 18 years old who were VRE-colonized from June 2018 to November 2022. VRE colonization was identified by a VRE rectal swab screen or a positive VRE culture prior to transplant. Two groups were analyzed: daptomycin versus no daptomycin. All LTR received perioperative piperacillin-tazobactam for 24 h. If VRE-colonized, one dose of daptomycin (6 mg/kg) was given pre- and postoperatively. Demographics, clinical characteristics, risk factors for VRE infection, and daptomycin dose were collected. The primary outcome was VRE infection at 14 days and 90 days post-transplant.

RESULTS

There were 36 VRE-colonized LTR; 19 received daptomycin and 17 did not. Baseline characteristics and risk factors for VRE infection were similar between groups. More VRE infections occurred in the no daptomycin group within 14 days post-transplant (24% vs. 0%, p = .04), but at 90 days posttransplant there was no significant difference (29% vs. 16%, p = .43). The average daptomycin dose was 7.1 mg/kg.

CONCLUSION

Perioperative daptomycin reduced the rate of VRE infections in VRE-colonized LTR within 14 days posttransplant but not at 90 days. Future studies should evaluate if higher doses and/or longer duration of perioperative daptomycin can reduce VRE infections beyond 14 days post-transplant.

Enterococcal Membrane Vesicles as Vaccine Candidates

Enterococcus faecium is a leading cause of nosocomial infections, particularly in immunocompromised patients. The rise of multidrug-resistant E. faecium, including Vancomycin-Resistant Enterococci (VRE), is a major concern. Vaccines are promising alternatives to antibiotics, but there is currently no vaccine available against enterococci. In a previous study, we identified six protein vaccine candidates associated with extracellular membrane vesicles (MVs) produced by nosocomial E. faecium. In this study, we immunized rabbits with two different VRE-derived MV preparations and characterized the resulting immune sera. Both anti-MV sera exhibited high immunoreactivity towards the homologous strain, three additional VRE strains, and eight different unrelated E. faecium strains representing different sequence types (STs). Additionally, we demonstrated that the two anti-MV sera were able to mediate opsonophagocytic killing of not only the homologous strain but also three unrelated heterologous VRE strains. Altogether, our results indicate that E. faecium MVs, regardless of the purification method for obtaining them, are promising vaccine candidates against multidrug-resistant E. faecium and suggest that these naturally occurring MVs can be used as a multi-antigen platform to elicit protective immune responses against enterococcal infections.

Carbapenemase-producing Enterobacteriaceae and vancomycin-resistant Enterococcus faecium: The value of a computerized monitoring system to limit their spread

OBJECTIVE

To quickly implement Infection Prevention and Control measures ("search and isolate" strategy), a computerized monitoring system for carbapenemase-producing Enterobacteriaceae (CPE) and Vancomycin-resistant Enterococcus faecium (VRE) carrier and contact patients has been developed in our hospital since 2014. The objectives were to assess the value of a computerized monitoring system in CPE and VRE management and to evaluate the relevance of extended monitoring of all contact patients.

METHODS

Using the data extracted from the computerized system, we conducted a descriptive analysis of CPE and VRE carriers detected from 2004 to 2019 and CPE and VRE extensive contact patients (when hospital stay overlapped with the stay of a carrier in the same unit) from 2014 to 2019.

RESULTS

Between 2015 and 2019 (microbiological data only available during this period), 113 CPE and 558 VRE carriers were registered in the database (DB). Among them, 33.9% CPE and 12.8% VRE carriers were infected (p = 0.02). The most frequent infections were urinary tract infections (52.0%), bloodstream infections (20.0%) and pneumonia (16.0%). Close to 8000 (7679) extended contact patients were exposed. Only 26.2% of them were removed from the DB because of appropriate negative post-exposure rectal screenings. No rectal screening was performed in 33.5% of contact patients. Between 2014 and 2019, 16 outbreaks occurred. The proportion of infected carriers differed significantly between outbreaks (index cases) and non-epidemic episodes (50.0% and 20.5% respectively, p = 0.03). The detection system was able to control diffusion in 99.7% of readmissions of known carriers. Among the 360 readmissions detected by the system, only one was involved in an outbreak due to non-compliance with infection control measures.

CONCLUSION

Given the low screening completion rate (26.2%) and the low detection rate (1.3%), extended monitoring of contact patients does not seem relevant. After five years of use, the computerized monitoring system has demonstrated its effectiveness in terms of responsiveness and limitation of the spread of multidrug-resistant organisms.

Impact of a new hospital with close to 100% single-occupancy rooms on environmental contamination and incidence of vancomycin-resistant Enterococcus faecium colonization or infection: a genomic surveillance study

BACKGROUND

Vancomycin-resistant Enterococcus faecium (VRE) is a leading cause of nosocomial infection, driven by its ability to spread between patients and persist in the hospital environment.

AIM

To investigate the impact of a long-established cardiothoracic hospital moving to new premises with close to 100% single-occupancy rooms on the rates of environmental contamination and infection or colonization by VRE.

METHODS

Prospective environmental surveillance for VRE was conducted at five time-points between April and November 2019, once in the original building, and four times in the new building. Incidence rate ratios (IRRs) of VRE infection/colonization were determined for the one-year period before and after the hospital move, and compared to a nearby hospital.

FINDINGS

In the original location, the first environmental screen found 29% VRE positivity. The following four screens in the new location showed a significant reduction in positivity (1-6%; P<0.0001). The VRE infection/colonization rates were halved in the new location (IRR: 0.56; 95% confidence interval: 0.38-0.84), compared to the original location, contrasting with an increase in a nearby hospital (1.62; 1.17-2.27) over the same time-period. Genomic analysis of the environmental isolates was consistent with reduced transmission in the new hospital.

CONCLUSION

The use of single-occupancy rooms was associated with reduced environmental contamination with VRE, and lower transmission and isolation of VRE from clinical samples. The cost-effectiveness of single-occupancy room hospitals in reducing healthcare-associated infections should be reassessed in the context of operational costs of emerging pandemic and increasing antimicrobial resistance threats.

Impact of discontinuing isolation in a private room for patients infected or colonized with vancomycin-resistant enterococci (VRE) on the incidence of healthcare-associated VRE bacteraemia in a hospital with a predominantly shared-room setting

BACKGROUND

Isolating patients infected or colonized with vancomycin-resistant enterococci (VRE) in a private room or cohort room to prevent hospital transmission is controversial.

AIM

To evaluate the effect of a relaxed isolation policy for VRE-infected or colonized patients on healthcare-associated (HA) VRE bacteraemia in an acute care hospital with a predominantly shared-room setting.

METHODS

The incidence of HA VRE bacteraemia was compared during a private isolation era (October 2014-September 2017), a cohort isolation era (October 2017-June 2020), and a no isolation era (July 2020-June 2022). Using Poisson regression modelling, an interrupted time-series analysis was conducted to analyse level changes and trends in incidences of HA VRE bacteraemia for each era.

FINDINGS

The proportion of VRE-infected or -colonized patients staying in shared rooms increased from 18.3% in the private isolation era to 82.6% in the no isolation era (P < 0.001). There was no significant difference in the incidences of HA VRE bacteraemia between the private isolation era and the cohort isolation era (relative risk: 1.01; 95% confidence interval: 0.52-1.98; P = 0.977) or between the cohort isolation era and the no isolation era (0.99; 0.77-1.26; P = 0.903). In addition, there was no significant slope increase in the incidence of HA VRE bacteraemia between any of the eras.

CONCLUSION

In a hospital with predominantly shared rooms, the relaxation of isolation policy did not result in increased HA VRE bacteraemia, when other infection control measures were maintained.

Discontinuing MRSA and VRE contact precautions: Defining hospital characteristics and infection prevention practices predicting safe de-escalation

OBJECTIVE

To define conditions in which contact precautions can be safely discontinued for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE).

DESIGN

Interrupted time series.

SETTING

15 acute-care hospitals.

PARTICIPANTS

Inpatients.

INTERVENTION

Contact precautions for endemic MRSA and VRE were discontinued in 12 intervention hospitals and continued at 3 nonintervention hospitals. Rates of MRSA and VRE healthcare-associated infections (HAIs) were collected for 12 months before and after. Trends in HAI rates were analyzed using Poisson regression. To predict conditions when contact precautions may be safely discontinued, selected baseline hospital characteristics and infection prevention practices were correlated with HAI rate changes, stratified by hospital.

RESULTS

Aggregated HAI rates from intervention hospitals before and after discontinuation of contact precautions were 0.14 and 0.15 MRSA HAI per 1,000 patient days (P = .74), 0.05 and 0.05 VRE HAI per 1,000 patient days (P = .96), and 0.04 and 0.04 MRSA laboratory-identified (LabID) events per 100 admissions (P = .57). No statistically significant rate changes occurred between intervention and non-intervention hospitals. All successful hospitals had low baseline MRSA and VRE HAI rates and high hand hygiene adherence. We observed no correlations between rate changes after discontinuation and the assessed hospital characteristics and infection prevention factors, but the rate improved with higher proportion of semiprivate rooms (P = .04).

CONCLUSIONS

Discontinuing contact precautions for MRSA/VRE did not result in increased HAI rates, suggesting that contact precautions can be safely removed from diverse hospitals, including community hospitals and those with lower proportions of private rooms. Good hand hygiene and low baseline HAI rates may be conditions permissive of safe removal of contact precautions.

The effect of an isolation-coping programme on patients isolated for colonization or infection with multidrug-resistant organisms: a quasi-experimental study

BACKGROUND

The global increase in the prevalence of vancomycin-resistant enterococci (VRE) and carbapenem-resistant Enterobacterales (CRE) among multidrug-resistant organisms (MDROs) has necessitated contact precaution and isolation in medical institutions. Contact isolation has a negative effect on the mental health of patients, but few interventions have addressed this issue.

AIM

This study evaluated an isolation-coping programme developed for patients colonized or infected with VRE or CRE.

METHODS

To mitigate the negative effects of isolation due to having MDRO, an infection control nurse in the present study 1) developed an isolation-coping programme and 2) validated the programme's effect on the uncertainty, anxiety, depression, and knowledge of patients isolated because of MDRO (VRE or CRE) using a pre-post quasi-experimental design.

FINDINGS

The experimental group (n=56) received education and emotional support via the isolation-coping programme, while the control group (n=55) received only verbal isolation guidelines provided by the medical institution. Compared with the control group, the experimental group showed a reduction in uncertainty (t=-8.925), anxiety (Z=-6.131), and depression (Z=-5.379), and better knowledge (Z=-8.372) (p<.001 for all).

CONCLUSION

The novel isolation-coping programme is an effective intervention to improve uncertainty, anxiety, depression, and knowledge in patients isolated with VRE or CRE.

Comparison of individual hive and apiary-level sample types for spores of Paenibacillus larvae in Saskatchewan honey bee operations

Three commercial honey bee operations in Saskatchewan, Canada, with outbreaks of American foulbrood (AFB) and recent or ongoing metaphylactic antibiotic use were intensively sampled to detect spores of Paenibacillus larvae during the summer of 2019. Here, we compared spore concentrations in different sample types within individual hives, assessed the surrogacy potential of honey collected from honey supers in place of brood chamber honey or adult bees within hives, and evaluated the ability of pooled, extracted honey to predict the degree of spore contamination identified through individual hive testing. Samples of honey and bees from hives within apiaries with a recent, confirmed case of AFB in a single hive (index apiaries) and apiaries without clinical evidence of AFB (unaffected apiaries), as well as pooled, apiary-level honey samples from end-of-season extraction, were collected and cultured to detect and enumerate spores. Only a few hives were heavily contaminated by spores in any given apiary. All operations were different from one another with regard to both the overall degree of spore contamination across apiaries and the distribution of spores between index apiaries and unaffected apiaries. Within operations, individual hive spore concentrations in unaffected apiaries were significantly different from index apiaries in the brood chamber (BC) honey, honey super (HS) honey, and BC bees of one of three operations. Across all operations, BC honey was best for discriminating index apiaries from unaffected apiaries (p = 0.001), followed by HS honey (p = 0.06), and BC bees (p = 0.398). HS honey positively correlated with both BC honey (r_s = 0.76, p < 0.0001) and bees (r_s = 0.50, p < 0.0001) and may be useful as a surrogate for either. Spore concentrations in pooled, extracted honey seem to have predictive potential for overall spore contamination within each operation and may have prognostic value in assessing the risk of future AFB outbreaks at the apiary (or operation) level.

Impact of single-room contact precautions on acquisition and transmission of vancomycin-resistant enterococci on haematological and oncological wards, multicentre cohort-study, Germany, January-December 2016

BackgroundEvidence supporting the effectiveness of single-room contact precautions (SCP) in preventing in-hospital acquisition of vancomycin-resistant enterococci (haVRE) is limited.AimWe assessed the impact of SCP on haVRE and their transmission.MethodsWe conducted a prospective, multicentre cohort study in German haematological/oncological departments during 2016. Two sites performed SCP for VRE patients and two did not (NCP). We defined a 5% haVRE-risk difference as non-inferiority margin, screened patients for VRE, and characterised isolates by whole genome sequencing and core genome MLST (cgMLST). Potential confounders were assessed by competing risk regression analysis.ResultsWe included 1,397 patients at NCP and 1,531 patients at SCP sites. Not performing SCP was associated with a significantly higher proportion of haVRE; 12.2% (170/1,397) patients at NCP and 7.4% (113/1,531) patients at SCP sites (relative risk (RR) 1.74; 95% confidence interval (CI): 1.35-2.23). The difference (4.8%) was below the non-inferiority margin. Competing risk regression analysis indicated a stronger impact of antimicrobial exposure (subdistribution hazard ratio (SHR) 7.46; 95% CI: 4.59-12.12) and underlying disease (SHR for acute leukaemia 2.34; 95% CI: 1.46-3.75) on haVRE than NCP (SHR 1.60; 95% CI: 1.14-2.25). Based on cgMLST and patient movement data, we observed 131 patient-to-patient VRE transmissions at NCP and 85 at SCP sites (RR 1.76; 95% CI: 1.33-2.34).ConclusionsWe show a positive impact of SCP on haVRE in a high-risk population, although the observed difference was below the pre-specified non-inferiority margin. Importantly, other factors including antimicrobial exposure seem to be more influential.

Does the removal of contact precautions for MRSA and VRE infected patients change health care-associated infection rate?: A systematic review and meta-analysis

OBJECTIVE

Update existing meta-analysis to analyze if discontinuation of contact precautions (CPs) for Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin resistant Enterococcus (VRE) colonization or infection affects hospital-associated MRSA or VRE infection rates.

METHODS

We conducted a systematic review of 17 studies evaluating discontinuation of CPs for MRSA and VRE. Random-effects and fixed-effects models were used to determine the pooled risk ratios (RR) of preincidence hospital-associated infection rate to postincidence rate. Subgroup analysis was used to assess sources of heterogeneity.

RESULTS

No significant difference between rates of hospital-associated MRSA infection before and after stopping the CPs was observed (RR, 0.84; 95% confidence internal [CI], 0.71-1.01; P = .06). An inverse association was observed between discontinuation of CPs and rates of hospital-associated VRE infection (RR, 0.82; 95% CI, 0.72-0.94; P = .005). A subgroup analysis of 6 studies that used chlorhexidine, showed no difference between rates of hospital-associated MRSA infection with discontinuation of CPs (RR, 0.83; 95% CI, 0.69-1.00; P = .05). In 5 studies that did not use chlorhexidine, there was no difference between rates of hospital-associated MRSA infection with discontinuation of CPs (RR, 1.02; 95% CI, 0.55-1.88; P= .95).

CONCLUSIONS

There was no significant difference in rates of hospital-associated MRSA infection before and after removing CPs. Additionally, there were decreased rates of hospital-associated VRE infection following stoppage of CPs.

Effectiveness of Contact Precautions to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococci in Intensive Care Units

BACKGROUND

Contact precautions for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are under increasing scrutiny, in part due to limited clinical trial evidence.

METHODS

We retrospectively analyzed data from the Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) trial to model the use of contact precautions in individual intensive care units (ICUs). Data included admission and discharge times and surveillance test results. We used a transmission model to estimate key epidemiological parameters, including the effect of contact precautions on transmission. Finally, we performed multivariate meta-regression to identify ICU-level factors associated with contact precaution effects.

RESULTS

We found that 21% of admissions (n = 2194) were placed on contact precautions, with most for MRSA and VRE. We found little evidence that contact precautions reduced MRSA transmission. The estimated change in transmission attributed to contact precautions was -16% (95% credible interval, -38% to 15%). VRE transmission was higher than MRSA transmission due to contact precautions, but not significantly. In our meta-regression, we did not identify associations between ICU-level factors and estimated contact precaution effects. Importation and transmission were higher for VRE than for MRSA, but clearance rates were lower for VRE than for MRSA.

CONCLUSIONS

We found little evidence that contact precautions implemented during the STAR*ICU trial reduced transmission of MRSA or VRE. We did find important differences in the transmission dynamics between MRSA and VRE. Differences in organism and healthcare setting may impact the efficacy of contact precautions.

Efficacy of a formalin-inactivated Lactococcus garvieae vaccine in farmed grey mullet (Mugil cephalus)

Lactococcosis [Lactococcus garvieae (LG)] is one of the most prevalent bacterial diseases affecting grey mullet (Mugil cephalus) aquaculture. Therefore, the present research evaluated the efficacy of formalin-killed LG vaccine with an oil-based adjuvant in grey mullet under laboratory and field trials. The laboratory evaluation for LG vaccine and its cross-protection upon challenge in grey mullet found that single-dose immunization of formalin-killed LG with adjuvant resulted in 91.4% and 100% relative per cent survival (RPS) when challenged with homologous and heterologous strains. The levels of specific antibody titre and lysozyme activity increased significantly in the vaccinated group. Immune gene expression at 24 hr after challenge showed an increase in levels of pro-inflammatory and anti-inflammatory cytokines. A parallel field trial experiment was conducted to investigate the long-term effectiveness of the LG vaccine. Results demonstrated that at one month and three months post-immunization with heterologous strain, 100% RPS was recorded in the vaccinated group. The findings suggested that the formalin-inactivated LG vaccine strain (S3) protected grey mullet against LG infection for a period of three months.

Stopping the routine use of contact precautions for management of MRSA and VRE at three academic medical centers: An interrupted time series analysis

BACKGROUND

Contact precautions (CP) are a widely adopted strategy to prevent cross-transmission of organisms, commonly methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Some hospitals have discontinued CP for patients with MRSA or VRE; however, the impact on hospital-acquired infection rates (HAI) has not been assessed systematically.

METHODS

Retrospective multicenter interrupted time series between 2002 and 2017 at three academic hospitals. Participating hospitals discontinued CP for patients with contained body fluids who were colonized or infected with MRSA or VRE. The primary intervention was stopping the use of CP. Secondary interventions were horizontal infection prevention strategies. The primary outcomes were rates of central line-associated bloodstream infections, catheter-associated urinary tract infections, mediastinal surgical site infection, and ventilator-associated pneumonia due to MRSA, VRE, or any organism using Centers for Disease Control and Prevention National Healthcare Safety Network surveillance definitions.

RESULTS

Central line-associated bloodstream infections, catheter-associated urinary tract infections, mediastinal surgical site infection, and ventilator-associated pneumonia rates trended down at each institution. There were no statistically significant increases in these infections associated with discontinuing CP. Individual horizontal infection prevention strategies variably impacted HAI outcomes.

CONCLUSIONS

Stopping the routine use of CP for patients with contained body fluids who are colonized or infected with MRSA or VRE did not result in increased HAIs. Bundled horizontal infection prevention strategies resulted in sustained HAI reductions.

An adjunctive therapy administered with an antibiotic prevents enrichment of antibiotic-resistant clones of a colonizing opportunistic pathogen

A key challenge in antibiotic stewardship is figuring out how to use antibiotics therapeutically without promoting the evolution of antibiotic resistance. Here, we demonstrate proof of concept for an adjunctive therapy that allows intravenous antibiotic treatment without driving the evolution and onward transmission of resistance. We repurposed the FDA-approved bile acid sequestrant cholestyramine, which we show binds the antibiotic daptomycin, as an 'anti-antibiotic' to disable systemically-administered daptomycin reaching the gut. We hypothesized that adjunctive cholestyramine could enable therapeutic daptomycin treatment in the bloodstream, while preventing transmissible resistance emergence in opportunistic pathogens colonizing the gastrointestinal tract. We tested this idea in a mouse model of Enterococcus faecium gastrointestinal tract colonization. In mice treated with daptomycin, adjunctive cholestyramine therapy reduced the fecal shedding of daptomycin-resistant E. faecium by up to 80-fold. These results provide proof of concept for an approach that could reduce the spread of antibiotic resistance for important hospital pathogens.

Nanosilver gel as an endodontic alternative against Enterococcus faecalis in an in vitro root canal system in Mexican dental specimens

Nanotechnology has become a research area with promising results for technological innovation. Endodontics can benefit from this field of research by increasing the success rate of the treatment, which currently ranges between 86% and 98% and has varied very little over the years. One of the causes of endodontic treatment failure is based on the presence of Enterococcus faecalis. The objective of this investigation is to evaluate the antibacterial effect of a gel preparation containing silver nanoparticles (Ag-NP) against E. faecalis present in the walls of the root canal. 60 extracted human uniradicular teeth that were instrumented with Wave One Gold (Denstplay/USA) and subsequently contaminated with Enterococcus faecalis. For antibacterial evaluation, intra-canal conducting was placed, and several groups were formed: a) Ag-NP 300 ug/MI gel; b) Ag-NP 500 ug/MI gel; c) Ca (OH) 2 (Ultracal from Ultradent/USA) and the control group. They were incubated at 37°C and a sample was taken every 24 h for 7 days. The Ag-NP gel showed antimicrobial activity against E. faecalis with a value of minimum inhibitory concentration and minimum bactericidal concentration of 300 g/ml and 900 g/ml, respectively. When the Ag-NP gel was used as an intra-canal conducting drug in an in-vitro model, its antimicrobial effect at 300 g/ml and 500 g/ml was equivalent to the action of Ca(OH)2.

Effect of Ticagrelor on Reducing the Risk of Gram-Positive Infections in Patients With Acute Coronary Syndrome

In light of recent studies describing the antibacterial properties of ticagrelor, the association between treatment with ticagrelor and subsequent risk for infection following acute coronary syndrome (ACS) is taking on increased importance. A single center, retrospective, matched cohort analysis was performed. All patients older than 30 years of age admitted between January 1, 2013 and November 1, 2019 for an ACS and discharged with dual antiplatelet therapy (DAPT) were included. The primary outcome was defined as hospital admissions due to infections likely caused by gram-positive bacteria up to 1 year following the ACS hospitalization. The base cohort included 3,909 patients. About 2,035 (52.1%) were treated with ticagrelor and 1,874 (47.9%) with clopidogrel. Patients treated with ticagrelor had a 64% lower risk of gram-positive infection during the first year following hospitalization after adjusting for demographic and co-morbidity factors compared with those treated with clopidogrel (hazard ratio [HR], 0.36; 95% confidence interval [CI], 0.21 to 0.61; p <0.001). In a cohort starting from 1 year (conclusion of DAPT period) and up to 3 years following ACS hospitalization, the risk of gram-positive infection was comparable in both groups (HR, 0.70; 95% CI, 0.41 to 1.19; p = 0.182). Treatment with ticagrelor was not associated with a reduced risk of gram-negative infections (HR, 0.48; 95% CI, 0.21 to 1.06; p = 0.07). In conclusion, DAPT regimen that includes aspirin and ticagrelor is associated with reduced risk of gram-positive infection compared with the combination of aspirin and clopidogrel.

Long-Lasting Decrease of the Acquisition of Enterococcus faecium and Gram-Negative Bacteria Producing Extended Spectrum Beta-Lactamase (ESBL) by Transient Application of Probiotics

Previously it was shown that application of probiotics stopped the acquisition of vancomycin-resistant Enterococcus faecium (VRE) by patients in an early rehabilitation ward. Once the application of probiotics ended, we examined whether acquisition of VRE reoccurred. Furthermore, we examined whether probiotics altered prevalence of vancomycin-susceptible E. faecium (VSE) and Gram-negative bacteria, which produce extended spectrum beta-lactamase (ESBL). Although probiotic application ceased in April 2018, VRE-colonized patients rarely presented on that ward until 2019. Probiotic treatment also resulted in a decreased number of patients with VSE and ESBL. While decreased incidence of VRE occurred immediately, decreased VSE and ESBL numbers occurred months later. A probiotic-mediated decrease of VSE and ESBL incidence cannot be explained when assuming bacterial transmission exclusively as a linear cause and effect event. The decrease is better understood by considering bacterial transmissions to be stochastic events, which depend on various driving forces similar to an electric current. We hypothesize that VRE, VSE and ESBL uptake by patients and by staff members mutually reinforced each other, leading staff members to form a bacterial reservoir, similar to a condenser that stores electrical energy. Probiotic treatment then inhibited regeneration of that store, resulting in a breakdown of the driving force.

Enterococcus faecium: from microbiological insights to practical recommendations for infection control and diagnostics

Early in its evolution, Enterococcus faecium acquired traits that allowed it to become a successful nosocomial pathogen. E. faecium inherent tenacity to build resistance to antibiotics and environmental stressors that allows the species to thrive in hospital environments. The continual wide use of antibiotics in medicine has been an important driver in the evolution of E. faecium becoming a highly proficient hospital pathogen.For successful prevention and reduction of nosocomial infections with vancomycin resistant E. faecium (VREfm), it is essential to focus on reducing VREfm carriage and spread. The aim of this review is to incorporate microbiological insights of E. faecium into practical infection control recommendations, to reduce the spread of hospital-acquired VREfm (carriage and infections). The spread of VREfm can be controlled by intensified cleaning procedures, antibiotic stewardship, rapid screening of VREfm carriage focused on high-risk populations, and identification of transmission routes through accurate detection and typing methods in outbreak situations. Further, for successful management of E. faecium, continual innovation in the fields of diagnostics, treatment, and eradication is necessary.

Antibacterial and antibiofilm activities of thyme oil against foodborne multiple antibiotics-resistant Enterococcus faecalis

The inhibitory and bactericidal activities of thyme oil against the foodborne multiple antibiotics-resistant Enterococcus faecalis biofilm were evaluated in this study. Gas chromatography-mass spectrometry revealed that more than 70% of the composition of thyme oil is thymol. Crystal violet staining assay showed that 128 and 256 μg/mL thyme oil significantly inhibited the biofilm formation of E. faecalis. The cell adherence of E. faecalis, as shown by its swimming and swarming motilities, was reduced by thyme oil. The exopolysaccharide (EPS) quantification assay showed that thyme oil inhibited the EPS synthesis in E. faecalis biofilms. The 3D-view observations through confocal laser scanning and scanning electron microscopy suggested that cell adherence and biofilm thickness were decreased in thyme oil–treated biofilms. Quantitative real-time analyses showed that the transcription of ebp and epa gene clusters, which were related to cell mobility and EPS production, was inhibited by thyme oil. Thus, thyme oil effectively inhibited the biofilm formation of E. faecalis by affecting cell adherence and EPS synthesis. Furthermore, 2,048 and 4,096 μg/mL thyme oil can effectively inactivate E. faecalis population in the mature E. faecalis biofilms by 5.75 and 7.20 log CFU/mL, respectively, after 30 min of treatment. Thus, thyme oil at different concentrations can be used as an effective antibiofilm or germicidal agent to control E. faecalis biofilms.

Is Cutibacterium acnes early surgical site infection rate related to the duration of antibiotic prophylaxis in adolescent idiopathic scoliosis surgery?

PURPOSE

Cutibacterium acnes (C. acnes) is a gram-positive anaerobic bacillus located in pilosebaceous glands, usually responsible for late postoperative surgical site infections (SSI). A recent study performed in our institution highlighted an unexpected emergence of C. acnes early SSI. One potential explanation was the change of the perioperative antibioprophylaxis (ATB) protocol, which switched from 48 h postoperative cefamandole to intraoperative only cefazoline. The aim of this study was therefore to investigate the influence of the ATB duration on the occurrence of C. acnes early SSI, by comparing the incidence rates during 3 consecutive ATB protocols.

METHODS

Between January 2007 and September 2017, all patients who underwent posterior fusion for AIS were retrospectively reviewed. Early C. acnes SSI were reported and compared between 3 periods, during which the ATB protocols were modified. January 2007-February 2012: Intraoperative Cefamandole continued 48 h (protocol 1) March 2012-August 2016: Single shot of intraoperative Cefazoline (protocol 2) September 2016-September 2017: Intraoperative Cefazoline continued 48 h (protocol 3).

RESULTS

Fifty-three early SSI (7.2%) were reported among the 732 posterior AIS fusions included. Global incidence of C. acnes infection was 2.9%. The incidence of C. acnes in early SSI increased from 0 to 4.9% between protocol 1 and 2, but was reduced to 1.7% with protocol 3.

CONCLUSIONS

Early C acnes SSI can be explained by the difficulty to eradicate this pathogen with current skin preparation procedures and some Beta-lactam antibiotics tolerance. Longer duration antibioprophylaxis is preferable to prevent from early C. acnes SSI.

High efficacy and economical procedure of oral vaccination against Lactococcus garvieae/Streptococcus iniae in rainbow trout (Oncorhynchus mykiss)

The present study was aimed to examine the efficacy of chitosan-alginate coated vaccines against pathogenicity of Lactococcus garvieae and Streptococcus iniae in rainbow trout. Fish were divided into four groups including: Group A: fish immunized by chitosan-alginate coated vaccine, Group B: fish immunized by non-coated vaccine, Group C: fish feed by chitosan-alginate coated pellets without vaccine and Group D: fish feed by basic diet (non-coated and without vaccine). In groups A and B, the vaccination was carried out for 14 days and after that supplemented with fundamental diet (control diet). Comparable to groups A and B, fish of group C were also fed 14 days with test diets and after that fed control food. On day 0, 20, 40 and 60 of the experiment, serum samples were given. Fish have been challenged with live L. garvieae and S. iniae after 60 days. The levels of bactericidal activity and complement activity among innate immunity components extended on day 20 of the research and after that decreased in group A and B (P < 0.05) all through the examination. The relative expression of IL-6 and IgM in groups A and B extended on examination day 20. The expression of these genes illustrated no advancements in different groups in during the examination (P > 0.05). In group A, the serum antibody titer against L. garvieae and S. iniae broadly raised on day 40 and 60 of examination, whereas in group B, the immune response titer against S. iniae and L. garvieae illustrated a significant elevation on day 60 of the trial (P < 0.05). After challenge with live bacteria, survival rate of 83 ± 9.1%(challenged with S. iniae) and 72.18 ± 9.8% (challenged with L. garvieae) were gotten independently in group A, which were higher than survival of other exploratory groups (P < 0.05). In conclusion, the results of the present examination appear that the orally vaccination of rainbow trout with chitosan-alginate covered vaccine stimulates immunity system and also efficiently protects rainbow trout against Lactococcus garvieae and Streptococcus iniae.

The impact of discontinuing contact precautions for multidrug resistant organisms at a less than 400-bed level II teaching hospital and a community hospital: A 3-month pilot study

BACKGROUND

The impact of discontinuing contact precautions (CPs) for patients with select multidrug-resistant organisms on bacteremia infection rates was evaluated in this quality improvement project.

METHODS

The removal of use of CPs, with increased focus on standard precautions, for all patients with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) colonization/infection was piloted via a quality improvement project over a 3-month period.

RESULTS

CP was discontinued in December 2018. Comparing 3 months pre- and postchange, the overall incidence density rate decreased for hospital-onset (HO) laboratory-identified (LabID) MRSA bacteremia (0.07 vs 0.02; P = .52), whereas HO LabID VRE bacteremia rates remained the same (0.00 vs 0.00). Overall estimated financial savings, including personal protective equipment ($15,375) and staff time ($17,165), was $32,540 for the project period, with annualized estimated savings of $130,160.

CONCLUSIONS

In this pilot study evaluating the discontinuance of CPs, there was no evidence of an increase in HO MRSA or VRE LabID bacteremia incidence density rates. This practice change may be safely implemented at similar health care facilities.

Profiling the transcriptome response of Atlantic salmon head kidney to formalin-killed Renibacterium salmoninarum

Renibacterium salmoninarum is a Gram-positive, intracellular bacterial pathogen that causes Bacterial Kidney Disease (BKD) in Atlantic salmon (Salmo salar). The host transcriptomic response to this immune-suppressive pathogen remains poorly understood. To identify R. salmoninarum-responsive genes, Atlantic salmon were intraperitoneally injected with a low (5 × 10⁵ cells/kg, Low-Rs) or high (5 × 10⁷ cells/kg; High-Rs) dose of formalin-killed R. salmoninarum bacterin or phosphate-buffered saline (PBS control); head kidney samples were collected before and 24 h after injection. Using 44K microarray analysis, we identified 107 and 345 differentially expressed probes in response to R. salmoninarum bacterin (i.e. High-Rs vs. PBS control) by Significance Analysis of Microarrays (SAM) and Rank Products (RP), respectively. Twenty-two microarray-identified genes were subjected to qPCR assays, and 17 genes were confirmed as being significantly responsive to the bacterin. There was an up-regulation in expression of genes playing putative roles as immune receptors and antimicrobial effectors. Genes with putative roles as pathogen recognition (e.g. clec12b and tlr5) or immunoregulatory (e.g. tnfrsf6b and tnfrsf11b) receptors were up-regulated in response to R.salmoninarum bacterin. Also, chemokines and a chemokine receptor showed opposite regulation [up-regulation of effectors (i.e. ccl13 and ccl) and down-regulation of cxcr1] in response to the bacterin. The present study identified and validated novel biomarker genes (e.g. ctsl1, lipe, cldn4, ccny) that can be used to assess Atlantic salmon response to R. salmoninarum, and will be valuable in the development of tools to combat BKD.

Significant reduction of vancomycin resistant E. faecium in the Norwegian broiler population coincided with measures taken by the broiler industry to reduce antimicrobial resistant bacteria

Vancomycin resistant enterococci (VRE) belong to the most common causes of nosocomial infections worldwide. It has been reported that use of the glycopeptide growth promoter avoparcin selected for a significant livestock-reservoir of VRE in many European countries, including Norway. However, although avoparcin was banned as a feed-additive in 1995, VRE have for unknown reasons consistently been reported in samples from Norwegian broilers. When avoparcin was banned, broiler-feed was supplemented with the polyether ionophore narasin in order to control the diseases coccidiosis and the frequent sequela necrotic enteritis. A potential link between transferrable vancomycin resistance and reduced susceptibility to narasin was recently reported. The use of narasin as a feed additive was abolished by the Norwegian broiler industry in 2016 and since then, broilers have been reared without in-feed antibacterial supplements. In this study, we demonstrate that all VRE isolates from Norwegian broilers collected in 2006–2014 displayed reduced susceptibility to narasin. Surveillance data collected two years after the narasin abolishment show a significant reduction in VRE, below the detection limit of the surveillance method, and a concurrent marked reduction in Enterococcus faecium with reduced susceptibility to narasin. The significant decline of E. faecium with reduced susceptibility to these antimicrobial compounds also coincided with an increased focus on cleaning and disinfection between broiler flocks. Furthermore, data from a controlled in vivo experiment using Ross 308 broilers indicate that the proportion of E. faecium with reduced susceptibility to narasin was heavily reduced in broilers fed a narasin-free diet compared to a diet supplemented with narasin. Our results are consistent with that the abolishment of this feed additive, possibly in combination with the increased focus on cleaning and disinfection, has had a substantial impact on the occurrence of VRE in the Norwegian broiler population.

The protective effect of fish-derived cathelicidins on bacterial infections in zebrafish, Danio rerio

Antibiotic-resistant bacteria are severe threats to aquaculture industry. Boosting and modulating host immune responses has been proved to be an effective strategy to combat with bacterial infections and there is an urgent need for novel immunomodulators. Cathelicidins is an important family of host defense peptides (HDPs) that possess direct antimicrobial activities and potent immunomodulatory properties. Several cathelicidins have been identified and characterized from diverse fish species. Considering the relatively conserved immune systems between different fish species, it is reasonable to speculate that cathelicidins from different fish species possess immunomodulating functions on the other fish species. In the present study, two fish-derived cathelicidins (CATH_BRALE and codCath1) were selected to investigate their protective effect on zebrafish with bacterial infections. They exhibited potent and broad-spectrum antimicrobial activities against the tested aquatic Gram-positive and Gram-negative pathogenic bacteria, with MIC values ranging 2.34-18.75 μg/ml for CATH_BRALE and 2.34-37.5 μg/ml for codCath1. And their antimicrobial effect is so rapid that they killed the bacteria within 60 min. Unlike conventional antibiotics, they kill bacteria by inducing bacterial membrane permeabilization and cell disruption. Besides direct antimicrobial activity, CATH_BRALE and codCath1 exhibited potent immunomodulatory functions by both inhibiting bacteria induced zebrafish pro-inflammatory cytokine gene (TNF-α, IL-1β, and IL-6) expression and stimulating zebrafish chemokine gene IL-8 expression. In vivo challenge test proved that they could significantly decrease the bacterial numbers and enhance the survival rates of zebrafish. All the results above imply the great potential of CATH_BRALE and codCath1 as novel peptide immunomodulators in fish aquaculture industry.

Levofloxacin versus Cefpodoxime for Antibacterial Prophylaxis in Allogeneic Stem Cell Transplantation

National guidelines recommend antimicrobial prophylaxis for allogeneic stem cell transplant patients during the pre-engraftment period because of increased infection risk during neutropenia. Fluoroquinolones have demonstrated lower rates of bacteremias and incidence of neutropenic fever, but there is limited evidence in the use of alternative antibacterials such as cefpodoxime. The primary objective of this study is to compare the rates of antibiotic prophylaxis failure between levofloxacin and cefpodoxime in allogeneic stem cell transplant recipients. Secondary objectives include comparing and characterizing number and type of infections, mortality at day 100 post-transplant, and hospitalizations for infectious causes in the first 100 days of transplant. This is a single-center, retrospective chart review of adult patients who received an allogeneic stem cell transplant from matched related and matched unrelated donors and antibacterial prophylaxis with levofloxacin or cefpodoxime from January 1, 2011, to October 1, 2014. A total of 142 patients were evaluated (71 levofloxacin, 71 cefpodoxime). Both levofloxacin and cefpodoxime groups had similar rates of neutropenic fever and antibiotic prophylaxis failure (58% versus 58%, P = NS). There were similar incidences of Clostridioides difficile and Multi-drug resistant (MDR) infections among both levofloxacin and cefpodoxime groups. Rates of infections, hospitalizations, and mortality in the first 100 days were similar among both groups. Cefpodoxime can be used as an alternative to levofloxacin for antibiotic prophylaxis in allogeneic stem cell transplant patients.

Valuable method for production of oral vaccine by using alginate and chitosan against Lactococcus garvieae/Streptococcus iniae in rainbow trout (Oncorhynchus mykiss)

The effectiveness of ionotropic gelation method (by combining alginate and chitosan) vaccine against Lactococcus garvieae and Streptococcus iniae was examined in rainbow trout. Fish were separated into four groups and fed the distinctive examined feeds. Our groups were included: A) fish immunized by chitosan-alginate coated vaccine, B) fish immunized by non-coated vaccine, C) fish feed by chitosan-alginate coated pellets without vaccine and D) fish feed by basic diet (non-coated and without vaccine). In groups A and B, the vaccination was carried out for 14 days. Fish of group C, like groups A and B were fed 14 days with pellets covered with chitosan-alginate without vaccine and a short time later they were fed with control diet. On day 0, 20, 40 and 60 of the trial, serum samples were extracted. Fish were challenged with L. garvieae and S. iniae after 60 days of research. Innate immunity components containing complement activity, total protein and IgM appeared no significant changes nearly in all groups during the 60 days that the examination finished. Although, bactericidal activity and lysozyme activity demonstrated a significant increase on days 20, 40 and 60 in group A compared to control groups (C and D) (P < 0.05) and similar results about the blood respiratory burst activity just on days 20 and 40 were obtained. Also, the relative expression of IL-6 of group A, was significantly higher compared to all of other groups (B, C and D) on days 20 and 60 of experiment (P < 0.05). The same results were obtained about the relative expression of IgM. The serum ELISA antibody titer against L. garvieae, increased significantly on days 20 and 40 of experiment in fish immunized by chitosan-alginate coated vaccine (Group A) compared to control groups (C and D)(P < 0.05) while the result of ELISA test against S. iniae was significantly higher on days 40 and 60 of experiment in group A compared to groups B, C and D (P < 0.05). After challenge with these two live bacteria (S. iniae and L. garvieae), a survival rates of 76.67 ± 5.77% (challenged with S. iniae) and 66.67 ± 5.77% (challenged with L. garvieae) were seen in group immunized with chitosan-alginate coated vaccine (Group A), which were higher than survival rates gotten in other trial groups (P < 0.05). The consequences of the present experiment show that the oral vaccination of rainbow trout with improved chitosan-alginate (via ionotropic procedure) (group A) properly secures this important fish against Lactococcus garvieae and Streptococcus iniae.

Efficacy of Injectable and Immersion Polyvalent Vaccine against Streptococcal Infections in Broodstock and Offspring of Nile tilapia (Oreochromis niloticus)

A vaccine against streptococcosis, lactococcosis and enterococcosis in tilapia was formulated, ME-VAC Aqua Strept, as a polyvalent inactivated vaccine containing Streptococcus agalactiae, S. iniae, Lactococcus garvieae and Enterococcus faecalis along with a nano-particulate adjuvant. Use of ME-VAC Aqua Strept by injection or immersion resulted in an improved non-specific and adaptive immunity of broodstock and offspring. Intra-peritoneal vaccination of tilapia broodstock increased the total leukocyte count, phagocytosis, lysozyme activity, antibody titer, number of seeds/vaccinated broodstock, seeds quality and survival rates. Also, immersion mass vaccination of tilapia larvae provided a long period of protection up to three months, with a relative percent of survivability (RPS) not less than 60% at this time. To our knowledge, this vaccine may be the first to offer a combined protection against streptococcosis, lactococcosis and enterococcosis in tilapia. The results support the use of this vaccine as an effective tool for disease control and well-being of fish.

From Culturomics to Clinical Microbiology and Forward

Culturomics has permitted discovery of hundreds of new bacterial species isolated from the human microbiome. Profiles generated by using matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry have been added to the mass spectrometer database used in clinical microbiology laboratories. We retrospectively collected raw data from MALDI-TOF mass spectrometry used routinely in our laboratory in Marseille, France, during January 2012-March 2018 and analyzed 16S rDNA sequencing results from misidentified strains. During the study period, 744 species were identified from clinical specimens, of which 21 were species first isolated from culturomics. This collection involved 105 clinical specimens, accounting for 98 patients. In 64 cases, isolation of the bacteria was considered clinically relevant. MALDI-TOF mass spectrometry was able to identify the species in 95.2% of the 105 specimens. While contributing to the extension of the bacterial repertoire associated with humans, culturomics studies also enlarge the spectrum of prokaryotes involved in infectious diseases.

Intervertebral disc penetration by antibiotics used prophylactically in spinal surgery: implications for the current standards and treatment of disc infections

PURPOSE

The presence of Propionibacterium acnes in a substantial component of resected disc specimens obtained from patients undergoing discectomy or microdiscectomy has led to the suggestion that this prominent human skin and oral commensal may exacerbate the pathology of degenerative disc disease. This hypothesis, therefore, raises the exciting possibility that antibiotics could play an important role in treating this debilitating condition. To date, however, little information about antibiotic penetration into the intervertebral disc is available.

METHODS

Intervertebral disc tissue obtained from 54 microdiscectomy patients given prophylactic cefazolin (n = 25), clindamycin (n = 17) or vancomycin (n = 12) was assayed by high-performance liquid chromatography, with cefaclor as an internal standard, to determine the concentration of antibiotic penetrating into the disc tissue.

RESULTS

Intervertebral disc tissues from patients receiving the positively charged antibiotic clindamycin contained a significantly greater percentage of the antibacterial dose than the tissue from patients receiving negatively charged cefazolin (P < 0.0001) and vancomycin, which has a slight positive charge (P < 0.0001).

CONCLUSION

Positively charged antibiotics appear more appropriate for future studies investigating potential options for the treatment of low-virulence disc infections. These slides can be retrieved under Electronic Supplementary Material.

Effectiveness of ultraviolet disinfection in reducing hospital-acquired Clostridium difficile and vancomycin-resistant Enterococcus on a bone marrow transplant unit

OBJECTIVE

To determine the effectiveness of ultraviolet (UV) environmental disinfection system on rates of hospital-acquired vancomycin-resistant enterococcus (VRE) and Clostridium difficile.

DESIGN

Using active surveillance and an interrupted time-series design, hospital-acquired acquisition of VRE and C. difficile on a bone marrow transplant (BMT) unit were examined before and after implementation of terminal disinfection with UV on all rooms regardless of isolation status of patients. The main outcomes were hospital-based acquisition measured through (1) active surveillance: admission, weekly, and discharge screening for VRE and toxigenic C. difficile (TCD) and (2) clinical surveillance: incidence of VRE and CDI on the unit.

SETTING

Bone marrow transplant unit at a tertiary-care cancer center.ParticipantsStem cell transplant (SCT) recipients.InterventionTerminal disinfection of all rooms with UV regardless of isolation status of patients.

RESULTS

During the 20-month study period, 579 patients had 704 admissions to the BMT unit, and 2,160 surveillance tests were performed. No change in level or trend in the incidence of VRE (trend incidence rate ratio [IRR], 0.96; 95% confidence interval [CI], 0.81-1.14; level IRR, 1.34; 95% CI, 0.37-1.18) or C. difficile (trend IRR, 1.08; 95% CI, 0.89-1.31; level IRR, 0.51; 95% CI, 0.13-2.11) was observed after the intervention.

CONCLUSIONS

Utilization of UV disinfection to supplement routine terminal cleaning of rooms was not effective in reducing hospital-acquired VRE and C. difficile among SCT recipients.

Efficacy of a Eudragit L30D-55 encapsulated oral vaccine containing inactivated bacteria (Lactococcus garvieae/Streptococcus iniae) in rainbow trout (Oncorhynchus mykiss)

The efficacy of a Eudragit L30D-55 encapsulated vaccine against Lactococcus garvieae and Streptococcus iniae was investigated in rainbow trout. Fish were divided into four groups and fed the different experimental feeds. Groups were: A) fish immunized by Eudragit-coated pellets containing vaccine, B) fish immunized by vaccine-coated pellets without Eudragit, C) fish fed Eudragit-coated pellets without vaccine and D) fish fed pellets without vaccine orEudragit (control group). In groups A and B, the vaccination was conducted for 14 days. Similar to groups A and B, fish of group C were fed 14 days with pellets coated with Eudragit and afterwards they were fed control diet. Serum samples were taken on day 0, 20, 40 and 60 of the experiment. After 60 days, fish were challenged with L. garvieae and S. iniae. In almost all groups, innate immunity components including alternative complement activity, lysozyme activity, bactericidal activity, IgM and total protein showed no significant changes during the 60 days that the experiment lasted. However, the blood respiratory burst activity and lysozyme activity showed a significant increase on day 20 of experiment in groups B and D respectively (P < 0.05). The relative expression of immune-related genes including IL-6 and IgM genes was higher in vaccinated fish, with the highest expression in those immunized by Eudragit-coated pellets (Group A). In addition, the relative expression of IL-6 and IgM peaked on day 20 but decreased on day 60 in vaccinated groups. The ELISA antibody titer against L. garvieae increased from day 20 and peaked on day 60 of experiment (P < 0.05). Also, the antibody titer against L. garvieae was higher in fish immunized by Eudragit-coated pellets (Group A) compared to fish of group C and control. After bacterial challenge, a survival percentages of % 85 ± 7.07% (challenged with S. iniae) and % 72.21 ± 7.8% (challenged with L. garvieae) were observed respectively in groups immunized with pellets coated with Eudragit L30D-55 (Group A), which were higher than survival percentages obtained in other experimental groups (P < 0.05). The results of the present study demonstrate that the oral administration of Eudragit L30D-55-encapsulated vaccine appropriately protects rainbow trout against Lactococcus garvieae and Streptococcus iniae.

Vancomycin-resistant enterococci (VRE): a reason to isolate?

In recent years, an increase in invasive VRE infections has been reported worldwide, including Germany. The most common gene encoding resistance to glycopeptides is VanA, but predominant VanB clones are emerging. Although neither the incidence rates nor the exact routes of nosocomial transmission of VRE are well established, screening and strict infection control measures, e.g. single room contact isolation, use of personal protective clothing by hospital staff and intensified surface disinfection for colonized individuals, are implemented in many hospitals. At the same time, the impact of VRE infection on mortality remains unclear, with current evidence being weak and contradictory. In this short review, we aim to give an overview on the current basis of evidence on the clinical effectiveness of infection control measures intended to prevent transmission of VRE and to put these findings into a larger perspective that takes further factors, e.g. VRE-associated mortality and impact on patient care, into account.

[Vancomycin-resistant enterococci]

The review describes important bacterial pathogens, namely enterococci, focusing on their resistance to glycopeptides. Presented are the basic phenotypes and genotypes of vancomycin-resistant enterococci and options for antibiotic therapy of infections with their etio-logical role. At the same time, their prevalence in the Czech Republic is characterized based on data from the EARS-Net and studies available in the literature. Finally, potential approaches to preventing the spread of these dangerous multidrug-resistant bacteria are defined.

Long-Term Impact of Universal Contact Precautions on Rates of Multidrug-Resistant Organisms in ICUs: A Comparative Effectiveness Study

OBJECTIVETo evaluate the impact of universal contact precautions (UCP) on rates of multidrug-resistant organisms (MDROs) in intensive care units (ICUs) over 9 yearsDESIGNRetrospective, nonrandomized observational studySETTINGAn 800-bed adult academic medical center in New York CityPARTICIPANTSAll patients admitted to 6 ICUs, 3 of which instituted UCP in 2007METHODSUsing a comparative effectiveness approach, we studied the longitudinal impact of UCP on MDRO incidence density rates, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and carbapenem-resistant Klebsiella pneumoniae. Data were extracted from a clinical research database for 2006-2014. Monthly MDRO rates were compared between the baseline period and the UCP period, utilizing time series analyses based on generalized linear models. The same models were also used to compare MDRO rates in the 3 UCP units to 3 ICUs without UCPs.RESULTSOverall, MDRO rates decreased over time, but there was no significant decrease in the trend (slope) during the UCP period compared to the baseline period for any of the 3 intervention units. Furthermore, there was no significant difference between UCP units (6.6% decrease in MDRO rates per year) and non-UCP units (6.0% decrease per year; P=.840).CONCLUSIONThe results of this 9-year study suggest that decreases in MDROs, including multidrug-resistant gram-negative bacilli, were more likely due to hospital-wide improvements in infection prevention during this period and that UCP had no detectable additional impact.Infect Control Hosp Epidemiol 2018;39:534-540.

Prolonged antibiotic treatment for infected low flow vascular malformations

BACKGROUND

Infection in low flow malformations is difficult to diagnose and treat. Initial presentation can be followed by cycles of recurrent infection lasting several years. The optimal duration of antibiotic therapy to prevent recurrence of infection has not been established.

METHODS

All cases of infection in low flow malformations at the Royal Children's Hospital over a ten-year period were reviewed. Clinical markers of infection and duration of initial antibiotic treatment were correlated with the development of recurrent episodes of infection.

RESULTS

Twenty-one patients met criteria for inclusion. Nineteen were diagnosed as lymphatic malformations and two as venous malformations. The majority of patients (13 or 62%) received a prolonged course of six weeks or more of antibiotics. Eleven (52%) patients went on to have recurrent infections, but these were significantly less likely to be in those treated with a long course of antibiotics (Fisher's exact test, p=0.026). In only 12 of 21 cases could a bacterium be grown. Elevated CRP was the most consistent abnormal laboratory finding in infection.

CONCLUSIONS

Longer courses of antibiotics reduce the risk of recurrent infection in low-flow vascular malformations. We recommend an antibiotic course of three months or more at the initial presentation of infection in a low flow malformation. Elevated CRP is the most sensitive test for diagnosis of infection in low-flow malformations.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

III.

In vitro assessment of the antimicrobial activity of silver and zinc oxide nanoparticles against fish pathogens

BACKGROUND

Antibiotic resistance is a global issue that threatens public health. The excessive use of antibiotics contributes to this problem as the genes of antibiotic resistance can be transferred between the bacteria in humans, animals and aquatic organisms. Metallic nanoparticles could serve as future substitutes for some conventional antibiotics because of their antimicrobial activity. The aim of this study was to evaluate the antimicrobial effects of silver and zinc oxide nanoparticles against major fish pathogens and assess their safety in vitro. Silver nanoparticles were synthesized by chemical reduction and characterized with UV-Vis spectroscopy, transmission electron microscopy and zeta sizer. The concentrations of silver and zinc oxide nanoparticles were measured using inductively coupled plasma-mass spectrometry. Subsequently, silver and zinc oxide nanoparticles were tested for their antimicrobial activity against Aeromonas hydrophila, Aeromonas salmonicida subsp. salmonicida, Edwardsiella ictaluri, Edwardsiella tarda, Francisella noatunensis subsp. orientalis, Yersinia ruckeri and Aphanomyces invadans and the minimum inhibitory concentrations were determined. MTT assay was performed on eel kidney cell line (EK-1) to determine the cell viability after incubation with nanoparticles. The interaction between silver nanoparticles and A. salmonicida was investigated by transmission electron microscopy.

RESULTS

The tested nanoparticles exhibited marked antimicrobial activity. Silver nanoparticles inhibited the growth of both A. salmonicida and A. invadans at a concentration of 17 µg/mL. Zinc oxide nanoparticles inhibited the growth of A. salmonicida, Y. ruckeri and A. invadans at concentrations of 15.75, 31.5 and 3.15 µg/mL respectively. Silver nanoparticles showed higher cell viability when compared to zinc oxide nanoparticles in the MTT assay. Transmission electron microscopy showed the attachment of silver nanoparticles to the bacterial membrane and disruption of its integrity.

CONCLUSIONS

This is the first study on inhibitory effects of silver and zinc oxide nanoparticles towards A. salmonicida and A. invadans. Moreover, zinc oxide nanoparticles inhibited the growth of Y. ruckeri. In low concentrations, silver nanoparticles were less cytotoxic than zinc oxide nanoparticles and represent an alternative antimicrobial compound against A. hydrophila, A. salmonicida and A. invadans.

Cooperating Commensals Restore Colonization Resistance to Vancomycin-Resistant Enterococcus faecium

Antibiotic-mediated microbiota destruction and the consequent loss of colonization resistance can result in intestinal domination with vancomycin-resistant Enterococcus (VRE), leading to bloodstream infection in hospitalized patients. Clearance of VRE remains a challenging goal that, if achieved, would reduce systemic VRE infections and patient-to-patient transmission. Although obligate anaerobic commensal bacteria have been associated with colonization resistance to VRE, the specific bacterial species involved remain undefined. Herein, we demonstrate that a precisely defined consortium of commensal bacteria containing the Clostridium cluster XIVa species Blautia producta and Clostridium bolteae restores colonization resistance against VRE and clears VRE from the intestines of mice. While C. bolteae did not directly mediate VRE clearance, it enabled intestinal colonization with B. producta, which directly inhibited VRE growth. These findings suggest that therapeutic or prophylactic administration of defined bacterial consortia to individuals with compromised microbiota composition may reduce inter-patient transmission and intra-patient dissemination of highly antibiotic-resistant pathogens.

Reducing Pediatric Sternal Wound Infections: A Quality Improvement Project

OBJECTIVES

To evaluate whether a quality improvement intervention reduces sternal wound infection rates in children after cardiac surgery.

DESIGN

This is a pre- and postintervention quality improvement study.

SETTING

A 16-bed cardiac ICU in a university-affiliated pediatric tertiary care children's hospital.

PATIENTS

All patients undergoing cardiac surgery via median sternotomy from January 2010 to December 2014 are included. The sternal wound infection rates for primary closure and delayed sternal closure are reported per 100 sternotomies. The hospital-acquired infection records were used to identify preintervention cases, while postintervention cases were collected prospectively.

INTERVENTION

Implementation of a sternal wound prevention bundle during the preoperative, intraoperative, and postoperative periods for cardiac surgical cases.

MEASUREMENTS AND MAIN RESULTS

During the preintervention period, 32 patients (3.8%) developed sternal wound infection, whereas only 19 (2.1%) developed sternal wound infection during the postintervention period (p = 0.04). The rates of sternal wound infection following primary closure were not significantly different pre- and postintervention (2.4% vs 1.6%; p = 0.35). However, patients with delayed sternal closure had significantly lower postintervention infection rates (10.6% vs 3.9%; p = 0.02).

CONCLUSIONS

Implementation of a sternal wound prevention bundle during the perioperative period was associated with lower sternal wound infection rates in surgeries with delayed sternal closure.

Lactococcus garvieae outbreaks in Brazilian farms Lactococcosis in Pseudoplatystoma sp. - development of an autogenous vaccine as a control strategy

This study evaluated the control of streptococcosis outbreaks in Brazil, isolated from diseased sorubim and identified as Lactococcus garvieae by genetic sequencing. This report determined the potential for lactococcosis control in sorubim Pseudoplatystoma sp. with two vaccines: an aqueous-based, whole-cell inactivated vaccine (bacterin) and an oil-adjuvanted bacterin. Their efficacy was evaluated at 30 days post-vaccination (d.p.v.) by challenge with L. garvieae, and the antibody production response at 15, 30 and 60 d.p.v. and the non-specific immune response were compared amongst treatments. High protection levels (P < 0.05) were achieved with the oil-adjuvanted vaccine with a relative percentage survival value of 81.7% at 30 d.p.v. Additionally, the oil-adjuvanted vaccine increased the immunogenicity of the bacterin as indicated by greater agglutination antibody titres from 15 until 60 d.p.v. This is the first report of a positive effect of vaccine administration on the specific immunity of sorubim, and the study showed that a specific antibody plays an important role in sorubim defence against lactococcosis because the innate immune responses were similar in all of the studied animals. These results demonstrated that oil-adjuvanted vaccine can be an effective alternative for the protection of sorubim from L. garvieae disease.