A loophole in soap dispensers mediates contamination with Gram-negative bacteria

Bloodstream infections by multidrug-resistant Pluralibacter gergoviae in premature neonates in Central-West Brazil: Report of two cases

Two cases of bloodstream infections caused by multidrug-resistant Pluralibacter gergoviae (KPC+) in premature neonates hospitalized in a neonatal intensive care unit in Brazil are presented. Strains from these cases were confirmed by 16S rRNA sequencing and matrix assisted laser desorption ionization-time of flight/mass spectrometry using MALDI Biotyper®, with further typing using Fourier-transform infrared spectroscopy using IR Biotyper®. The cases were unrelated, as evidenced by clustering analysis. Both neonates displayed risk factors including prolonged hospitalization, invasive device use, and prior antibiotic treatments. Case 1 exhibited clinical recovery following treatment with polymyxin B and amikacin, whereas Case 2 resulted in death despite multiple antibiotic regimens. Isolated strains showed resistance to carbapenems and harbored the blaKPC, highlighting the critical need for targeted diagnostics and stringent infection control in neonatal intensive care units. These findings underscore the significance of monitoring emerging pathogens like P. gergoviae, which possess high multidrug resistance and limited therapeutic options.

Healthcare-associated bloodstream infections caused by bacterial and fungal contamination of intravenous fluids and medicines in healthcare facilities in low- and middle-income countries: a scoping review

INTRODUCTION

We reviewed culture-confirmed healthcare-associated outbreaks linked to bacterial and fungal contamination of intravenous fluids and medicines (further "infusates") in low-income countries and lower and upper middle-income countries (LIC, Lower-MIC and Upper-MIC). We assessed the scope, impact, risks, and gaps in knowledge.

METHODOLOGY

Literature search including PubMed, Web of Science, Worldwide Database for Nosocomial Outbreaks, Global Health, and Google Scholar. National essential medicine lists (NEMLs) of sub-Saharan countries were searched for listing of pediatric infusates.

RESULTS

Between 1975 and 2023, 50 articles were retrieved. Median (range) number of patients affected was 12 (3-185); 74.2% (761/1025) of all patients affected were children. All patients presented with bloodstream infections; median case fatality ratio was 21.1% (0.0-87.5%). Upper-MIC, Lower-MIC and LIC accounted for 21, 25 and 4 articles, respectively. Most frequently affected wards were neonatal and adult intensive care units (19 and 6 articles). The 50 articles revealed 59 contaminated infusates: IV fluids (n = 37), including TPN (n = 10, of which 8 were from Upper-MIC), and IV medicines (n = 22), comprising amongst others propofol (n = 4) and Water for Injection (n = 3). The 63 isolates included Enterobacterales (46.0% (29/63) of isolates), non-fermentative Gram-negative bacteria (NFGNB, 47.6% (30/63)), fungi (4.8%, 3/63)) and Bacillus circulans (1.6% (1/63)). Among the Enterobacterales, the genera Serratia, Klebsiella, and Enterobacter represented 82.8% (24/29) of isolates. Burkholderia cepacia was the most frequent NFGNB (53.3% (16/30) isolates). Excluding TPN, 18 IV fluids and 7 IV medicines (representing half (51.0%, (25/49) of these infusates) were incorrectly used as multidose vial. A third (33.9%, 20/59) of infusates in 40.0% (20/50) of articles was intrinsically contaminated. In LIC and LMIC, staff in neonatology units turned to in-ward preparation of infusates because of lack of access to pediatric IV formulations and sizes. Less than a third (31.8%, 18/44) of the NEMLs listed neonatal IV premixtures.

CONCLUSION

Infusate contamination is a serious, underreported risk especially for children in LICs and Lower-MIC. Outstanding issues are access to pediatric infusates and preventing in-ward preparation of IV medicines in LIC and Lower-MIC, and safe preparation and administration of TPN in Upper-MIC.

Bacterial contamination of mobile handwashing stations in hospital settings in the Democratic Republic of the Congo

BACKGROUND

As part of the containment of the COVID-19 pandemic, mobile handwashing stations (mHWS) were deployed in healthcare facilities in low-resource settings. We assessed mHWS in hospitals in the Democratic Republic of the Congo for contamination with Gram-negative bacteria.

METHODS

Water and soap samples of in-use mHWS in hospitals in Kinshasa and Lubumbashi were quantitatively cultured for Gram-negative bacteria which were tested for antibiotic susceptibility. Meropenem resistant isolates were assessed for carbapenemase enzymes using inhibitor-based disk and immunochromatographic tests. Mobile handwashing stations that grew Gram-negative bacteria at counts > 10,000 colony forming units/ml from water or soap were defined as highly contaminated.

RESULTS

In 26 hospitals, 281 mHWS were sampled; 92.5% had the "bucket with hand-operated tap" design, 50.5% had soap available. Overall, 70.5% of mHWS grew Gram-negative bacteria; 35.2% (in 21/26 hospitals) were highly contaminated. Isolates from water samples (n = 420) comprised 50.3% Enterobacterales (Klebsiella spp., Citrobacter freundii, Enterobacter cloacae), 14.8% Pseudomonas aeruginosa and 35.0% other non-fermentative Gram-negative bacteria (NFGNB, including Chromobacterium violaceum and Acinetobacter baumannii). Isolates from soap samples (n = 56) comprised Enterobacterales (67.9%, including Pluralibacter gergoviae (n = 13)); P. aeruginosa (n = 12) and other NFGNB (n = 6). Nearly one-third (31.2%, 73/234) of Enterobacterales (water and soap isolates combined) were multi-drug resistant; 13 isolates (5.5%) were meropenem-resistant including 10 New Delhi metallo-beta-lactamase (NDM) producers. Among P. aeruginosa and the other NFGNB, 7/198 (3.5%) isolates were meropenem resistant, 2 were NDM producers. Bacteria listed as critical or high priority on the World Health Organization Bacterial Priority Pathogens List accounted for 20.3% of isolates and were present in 12.0% of all mHWS across 13/26 hospitals. Half (50.5%) of highly contaminated mHWS were used by healthcare workers and patients as well as by caretakers and visitors.

CONCLUSIONS

More than one third of in-use mobile handwash stations in healthcare facilities in a low resource setting were highly contaminated with clinically relevant bacteria, part of which were multidrug resistant. The findings urge a rethink of the place of mobile handwash stations in healthcare facilities and to consider measures to prevent their contamination.

Characterization of antibiotic and disinfectant susceptibility in biofilm-forming Acinetobacter baumannii: A focus on environmental isolates

The clinical role of Acinetobacter baumannii has been highlighted in numerous infectious syndromes with a high mortality rate, due to the high prevalence of multidrug-resistant (MDR) isolates. The treatment and eradication of this pathogen is hindered by biofilm-formation, providing protection from noxious environmental factors and antimicrobials. The aim of this study was to assess the antibiotic susceptibility, antiseptic susceptibility and biofilm-forming capacity using phenotypic methods in environmental A. baumannii isolates. One hundred and fourteen (n = 114) isolates were collected, originating from various environmental sources and geographical regions. Antimicrobial susceptibility testing was carried out using the disk diffusion method, while antiseptic susceptibility was performed using the agar dilution method. Determination of biofilm-forming capacity was carried out using a microtiter-plate based method. Resistance in environmental A. baumannii isolates were highest for ciprofloxacin (64.03%, n = 73), levofloxacin (62.18%, n = 71) and trimethoprim-sulfamethoxazole (61.40%, n = 70), while lowest for colistin (1.75%, n = 2). Efflux pump overexpression was seen in 48.25% of isolates (n = 55), 49.12% (n = 56) were classified as MDR. 6.14% (n = 7), 9.65% (n = 11), 24.65% (n = 28) and 59.65% (n = 68) of isolates were non-biofilm producers, weak, medium, and strong biofilm producers, respectively. No significant differences were observed between non-MDR vs. MDR isolates regarding their distribution of biofilm-producers (P = 0.655). The MIC ranges for the tested antiseptics were as follows: benzalkonium chloride 16-128 μg mL-1, chlorhexidine digluconate 4-128 μg mL-1, formaldehyde 64-256 μg mL-1 and triclosan 2-16 μg mL-1, respectively. The conscientious use of antiseptics, together with periodic surveillance, is essential to curb the spread of these bacteria, and to maintain current infection prevention capabilities.

Eye infection risks from Pseudomonas aeruginosa via hand soap and eye drops

Eye infections from bacterial contamination of bulk-refillable liquid soap dispensers and artificial tear eye drops continue to occur, resulting in adverse health outcomes that include impaired vision or eye enucleation. Pseudomonas aeruginosa (P. aeruginosa), a common cause of eye infections, can grow in eye drop containers and refillable soap dispensers to high numbers. To assess the risk of eye infection, a quantitative microbial risk assessment for P. aeruginosa was conducted to predict the probability of an eye infection for two potential exposure scenarios: (i) individuals using bacteria-contaminated eye drops and (ii) contact lens wearers washing their hands with bacteria-contaminated liquid soap prior to placing the lens. The median risk of an eye infection using contaminated eye drops and hand soap for both single and multiple exposure events (per day) ranged from 10-1 to 10-4, with contaminated eye drops having the greater risk. The concentration of P. aeruginosa was identified as the parameter contributing the greatest variance on eye infection risk; therefore, the prevalence and level of bacterial contamination of the product would have the greatest influence on health risk. Using eye drops in a single-use container or with preservatives can mitigate bacterial growth, and using non-refillable soap dispensers is recommended to reduce contamination of hand soap. Given the opportunistic nature of P. aeruginosa and its ability to thrive in unique environments, additional safeguards to mitigate bacterial growth and exposure are warranted.IMPORTANCEPseudomonas aeruginosa (P. aeruginosa) is a pathogen that can persist in a variety of unusual environments and continues to pose a significant risk for public health. This quantitative microbial risk assessment (QMRA) estimates the potential human health risks, specifically for eye infections, associated with exposure to P. aeruginosa in bacteria-contaminated artificial tear eye drops and hand soap. This study applies the risk assessment framework of QMRA to evaluate eye infection risks through both consumer products. The study examines the prevalence of this pathogen in eye drops and soap, as well as the critical need to implement measures that will mitigate bacterial exposure (e.g., single-use soap dispensers and eye drops with preservatives). Additionally, limitations and challenges are discussed, including the need to incorporate data regarding consumer practices, which may improve exposure assessments and health risk estimates.